Aging with Asthma
‘You’re Never Too Old to be Well’
By Francie Scott
A rail-thin woman consults her physician about her breathing difficulty. She wheezes and coughs. She frequently catches colds and sometimes feels her breathing gets worse when she plays with her cat.
Does the woman have asthma, COPD or chronic bronchitis?
She may well have asthma, but many physicians overlook this diagnosis because of her age and focus on COPD or chronic bronchitis, which are more common among older adults. As a result, many older asthmatics do not receive the medication they need to control their disease, and their quality of life plunges accordingly. Some studies show older adults are more likely to die of asthma than younger patients are.
A 69-year-old woman who lives in Vermont knows the scenario well. She struggled with bronchitis and bouts of pneumonia throughout her childhood and adult years until she was diagnosed with asthma at age 65. Armed with asthma drugs and a care plan, she now enjoys good health.
“I feel incredible,” she says. The woman, who asked that her name not be published, credits her new life to her specialist, Thomas Plaut, MD, an asthma consultant and author based in Amherst, Mass., who also helped her grandson get his asthma under control.
“I think management is the whole deal,” she says. “You get the right doctor and the right medication.”
How can physicians polish their diagnostic skills when they examine older adults with respiratory symptoms?
Albert L. Sheffer, MD, of Harvard Medical School in Brookline, Mass., suggests a spirometry test to make a diagnosis. “If a patient has asthma, the spirometry will improve after a bronchodilator,” he explains.
Although this test sounds simple, elderly people with asthma frequently are underdiagnosed and undertreated. A recent report from the Cardiovascular Health Study1 found only 4 percent of a community sample of 4,581 people over 65 years reported a current diagnosis of asthma. Another 4 percent said they had experienced at least one attack of wheezing accompanied by a tight chest and dyspnea during the previous year, indicating probable asthma.
When smokers and people with congestive heart failure were removed from the study (leaving 2,527 subjects) investigators found that 39 percent of subjects who had a definite diagnosis of asthma took no asthma medications at all. Data from other members of the asthma group showed that 40 percent were taking a bronchodilator, 30 percent took inhaled steroids, 21 percent took theophylline and 15 percent took oral steroids.
Overall, subjects who had definite asthma or probable asthma reported poor general health, symptoms of depression, and limitations in their daily living activities more often than subjects who reported no asthma symptoms. They also were more likely to report a family history of asthma, childhood respiratory problems, workplace exposures, dyspnea associated with exertion, hay fever, chronic bronchitis, nocturnal symptoms and daytime sleepiness.
“The large number of elderly persons who have asthma symptoms identified by this study but have not received a diagnosis of asthma is disturbing because they are experiencing a reduced quality of life and considerable morbidity associated with their asthma, which may be largely preventable,” study authors concluded.
Lead author, Paul Enright, MD, of the University of Arizona in Tucson, notes in an interview that “primary care providers need to realize asthma is as much a problem in the elderly as it is in young children.” He suggests a “high index of suspicion” when patients present with a history of chronic cough, wheezing episodes and shortness of breath on exertion.
Dr. Enright also suggests office spirometry as the best tool for diagnosis: a baseline test followed by a bronchodilator treatment and a second test. “If a patient with asthma symptoms has airway obstruction on spirometry and their FEV1 improves by more than 12 percent and 200 ml following a bronchodiolator, the diagnosis of asthma is usually confirmed,” he explains.
The doctor and his colleagues note in their study that 92 participants who reported “definite asthma” had normal spirometry results. Dr. Enright did not express surprise at this finding because many patients with asthma have intermittent or mild disease. When their asthma is controlled they often have normal spirometry.
SORTING OUT ASTHMA
Some pulmonary specialists who see elderly people are well aware that an asthma diagnosis often is missed. “It can be difficult to separate out (from other pulmonary diseases) in later life,” suggests David E. Ciccolella, MD, director of the Asthma Center at Temple University Hospital in Philadelphia.
When clinicians consider a diagnosis for elderly patients who have trouble breathing, they tend to think of COPD, reactive airways or perhaps asthmatic bronchitis, especially if they are smokers. “These are fairly difficult areas to sort out,” Dr. Ciccolella says, noting, “It’s hard to make sure you are dealing just with asthma.” Dr. Sheffer agrees, adding that emphysema may have a bronchospastic component. He also suggests many of these elderly patients had “low-grade asthma all their lives.”
The woman from Vermont fits this profile. She remembers spending her fourth birthday in bed with a cough. An active child who rode bikes and horses, she tried to avoid dust because she had trouble breathing. The woman recalls muggy nights with her nose pressed up against the window screen in order “to get more air.”
Investigators analyzing data from the Nurses Health Study2 also suggest that many cases of adult-onset asthma actually reflect the return of asthma symptoms in patients who had asthma symptoms as children.
Investigators noted that subjects might not remember a diagnosis of asthma because doctors could have diagnosed their condition as “wheezy bronchitis” when they were children. Clinicians now agree that their counterparts often missed an asthma diagnosis in past decades when the disease was not well understood.
Congestive heart failure is another confounding factor in diagnosing pulmonary diseases because symptoms may include a constrictive defect, making a spirometry test difficult to interpret accurately. Both diseases should be included in the differential diagnosis of episodes of wheezing with shortness of breath.
Dr. Enright and his colleagues excluded patients with congestive heart failure and also excluded heavy smokers to refine their diagnosis of patients with asthma.
Dr. Sheffer noted that “cardiac asthma” symptoms are not due to inflammation of the airways, and patients with this condition would not respond to asthma medication.
As people grow older, they are exposed to new and more allergens, and their airways are less tolerant of the irritation. Changes in lifestyle choices, such as remarriage to someone with a cat or a dog or moving into a house that is heavy with dust mites, also can precipitate late-onset asthma, according to Dr. Sheffer.
Other precipitating factors for late-onset asthma may include weight gain; clinicians are finding a stronger link between obesity and the development of asthma.
Some suggest hormone replacement therapy may play a role in the late development of asthma in elderly women. Dr. Sheffer cited the Nurses Health Study as an example of establishing the estrogen link to asthma.
However, Dr. Enright cites an unpublished analysis of data from 2,353 post-menopausal women in the Cardiovascular Health Study that indicates an opposite response. These investigators found women on hormone replacement therapy had better lung function than women in a control group.
Medications, such as beta blockers for hypertension, also may produce asthma symptoms, according to Dr. Plaut.
While Dr. Enright agrees that some medications complicate an asthma diagnosis, he and his colleagues found no association between beta blockers and asthma symptoms in the Cardiovascular Health Study. He is familiar with the phenomenon in younger patients.
The woman from Vermont stresses the importance of educating older patients about their technique for taking inhaled drugs. “They should bring all their medication to their doctor’s office and have him watch them use it,” she suggests.
A fan of self-management, the woman happily describes how she avoided an asthma exacerbation by taking her medication on recent visit to Morocco, where swirling dust caused her airways to constrict. Before her asthma diagnosis, the woman once ended up in the hospital with pneumonia when dust triggered her asthma in Chile. Knowing how to respond to an emergency “gives me a great deal of freedom,” she says.
Elderly asthmatic adults who are undiagnosed or poorly managed pay a high price. Their quality of life is impaired, and LTC Michael J. Morris, MC, of Fort Sam Houston in Texas noted in his CHEST editorial,3 that older adults are more likely to die of asthma than younger people with the disease are.
For example, a 1987 report4 claims a mortality rate ranging between 3.0 and 4.9 percent per 100,000 for 65-year-olds to 74-year-olds with active asthma, while the mortality rate per 100,000 for asthmatics under 35 years ranged between 0.5 and 0.6 percent.
This finding was confirmed by an English study that found 58 percent of female patients and 71 percent of male patients who died of asthma were older than 70 years. Dr. Morris cited other studies from the 1980s that demonstrate the trend.
“There is little evidence that clinicians are doing well with the management of asthma in the elderly,” Dr. Morris agreed. He urged clinicians to consult established guidelines to improve their performance.
Because so many elderly asthmatics are not receiving appropriate medication and consequently suffer losses in their quality of life, clinicians need to sharpen their diagnosis and management of this patient population. “You’re never too old to be well,” the woman from Vermont says.
1. Enright P. et al. “Underdiagnosis and undertreatment of asthma in the elderly.” CHEST. 1999;116:603-613.
2. Troisi RJ, et al. “A prospective study of diet and adult-onset asthma.” Amer J Resp Crit Care Med. 1995;151:1401-1408.
3. Morris MJ. “Difficulties with diagnosing asthma in the elderly.” CHEST. 1999;116:591-593.
4. Evans R, et al. “National trends in the morbidity and mortality of asthma in the U.S.” CHEST. 1987;91 (Supplement) 65S-74s.
Francie Scott is senior editor of ADVANCE.