Vol. 11 •Issue 6 • Page 14
Allergy & Asthma
Improving Asthma Management for Seniors
If you were on a search for asthma patients, bingo halls and senior centers would probably be the last places where you would look.
Traditionally, asthma is thought of as a childhood disease. But statistics from the Centers for Disease Control and Prevention show that 4 percent to 5 percent of asthma sufferers are 65 and older, and up to 10 percent of asthma diagnoses occur in this age group.1 It’s likely that many more seniors go undiagnosed.2
Because the elderly have limited respiratory and cardiac reserves, respiratory clinicians need to ensure prompt asthma diagnosis and effective treatment decisions in this age group.
No matter what the patient’s maturity, asthma is characterized by chronic inflammation of the airways and reversible airway obstruction. However, identifying asthma in seniors isn’t always straightforward. Physicians may wrongly assume that cough, wheezing, shortness of breath and chest tightness are simply signs of aging, or they may attribute these symptoms to comorbidity.
“Asthma can be mimicked by other disease processes,” said Kay Wolfson, MD, of the Ochsner Clinic, New Orleans. Among them are chronic obstructive pulmonary disease, bronchiectasis, congestive heart failure and other cardiac and pulmonary problems.
COPD is probably the most common condition that asthma is confused with in the elderly, Dr. Wolfson said. One way clinicians can distinguish the two is that a history of smoking most always is associated with cases of COPD; it’s less often attributed to asthma. Also, a history of episodic wheeze, nocturnal dyspnea and allergies are more common to asthma than to COPD.
Doctors have several diagnostic tools at their fingertips, including spirometry, chest X-ray, electrocardiogram and complete blood count with differential. A diagnosis of asthma is usually confirmed when airflow obstruction is demonstrated by an FEV1 less than 80 percent and FEV1/FVC ratio less than 70 percent.3 Asthma also may be indicated if airflow obstruction is reversible (greater than 12 percent FEV1 and 200 mL FVC)3 following bronchodilator treatment or after a course of corticosteroids.
Spirometry standards can be difficult to meet in older patients. Clinicians need to recognize poor testing technique as some patients’ weakness or lack of coordination can skew results. Furthermore, severe airflow obstruction and bronchoconstriction caused by forced expiratory efforts can interfere with patient performance. In these situations, a consistent pattern of decreasing FEV1 readings is a good indicator of asthma.3
TAKING AN ACTIVE ROLE
Once an asthma diagnosis is established, patient education is vital. A good clinician will coach patients through the management process, including planning, implementing and evaluating a successful treatment program.
Stella Henry, RN, director of Vista Del Sol, a long-term care center in Culver City, Calif., encourages her elderly patients to be in charge of their asthma, which fosters a sense of control over their disease. “Patients need to be active players,” she said. “If they have the right diagnosis and management, this is a disease that’s reversible, but if they’re nervous or anxious they’ll feel overwhelmed and immobilized.”
A good way to involve patients is to ask them to establish goals for their asthma therapy. These goals can be individualized according to patients’ interests. One patient may want to tend to her garden, while another wants to travel to see his grandchildren. They should focus on living independently and maintaining quality of life. Clinicians can assist patients in setting realistic goals; unrealistic goals are an indicator that a patient hasn’t accepted his or her diagnosis or doesn’t understand the disease.
Clinicians also must teach patients to become more aware of their asthma symptoms, Dr. Wolfson said. Home peak flow monitoring is helpful for some patients, but its use may be limited for those patients with physical or cognitive disabilities that deter them from using the peak flow meter accurately.
Doctors should instruct elderly patients to watch symptoms that could signify lung deterioration and the need for therapeutic changes. These signs include nocturnal or early morning awakenings with cough, increase in use or diminished response to inhaled beta2-agonists, and changes in the intensity of dyspnea.
Keeping an asthma action plan listing a patient’s symptoms and steps to take in case of an asthma flare-up is essential. For the elderly, an action plan printed in large type kept in a public area of the house, such as on the refrigerator, also should include medications and emergency phone numbers. Close relatives and family should have a copy of these plans in case an attack occurs in their presence.
A primary way asthmatics can prevent an exacerbation is by identifying and controlling their asthma triggers. Clinicians can suggest that their patients keep a journal to record symptoms, peak flow measurements and how they correspond to certain conditions.
Respiratory infections are prevalent asthma triggers for older adults. The NAEPP recommends immunization against pneumococcal infections every five to seven years for adults ages 60 to 75, and every three to four years for adults over 75.3 The elderly should be immunized against influenza annually.
Smoking and exposure to environmental tobacco smoke should be avoided, as well as other common allergy triggers, such as cockroaches and animal dander. However, control measures should be feasible and benefit asthma management without having a negative effect on a patient’s quality of life. For example, a pet could potentially exacerbate a patient’s condition, but if that animal is a longtime companion removing it may cause psychological consequences. A home visit by a care provider can rule out triggers and help a patient make the changes needed to increase their comfort.
CHOOSING A COURSE OF THERAPY
Another issue unique to elderly patients is medication problems. Doctors can prescribe the same inhaled and oral medicines for elderly patients as they do for younger patients, but they must be aware of possible drug interactions and adverse medical effects, Dr. Wolfson said.
The recommended treatment for mild intermittent asthma in the elderly is inhaled beta2-agonist taken as needed, according to the NAEPP. This treatment is increased if the need for medication rises. In patients with moderate asthma without COPD, daily chronic maintenance therapy with anti-inflammatory medication is recommended. A long-acting inhaled beta2-agonist, ipratropium bromide or sustained-release theophylline may be used to control nighttime symptoms.1
When choosing the appropriate drug, clinicians must consider the type of delivery device, Henry said. Elderly patients encounter physical disabilities with aging, such as arthritis, that can make using inhalers difficult. Other elderly patients have poor coordination and are unable to pump the medicine and inhale it simultaneously. Spacers and improved inhaler devices are now available that combine bronchodilators and inhaled steroids in one device, making drug delivery easier for older patients to manage.
Risks of adverse effects from asthma treatments can limit the choice, dosage and frequency of medication in older patients. Physicians need to review their asthma patients’ drug histories at each office visit to ensure a patient hasn’t changed his or her course of therapy.
According to the NAEPP, these asthma drugs may have the following effects:3
• Inhaled corticosteroids: At high doses, these drugs can cause dermal thinning and bruising. Also, in older women especially, bone loss and acceleration of osteoporosis can occur, and calcium and vitamin D supplements are recommended.
• Systemic corticosteroids: Metabolic clearance rates are lower for these drugs in geriatric patients. Long-term use can cause cardiovascular and metabolic disturbances, musculoskeletal changes, ophthalmologic diseases and depression.
• Theophylline: Older patients are more susceptible to theophylline’s side effects, which include cardiac arrhythmia, nausea, insomnia and liver disease. Drugs used concomitantly with theophylline can affect its elimination within the body, causing higher theophylline levels in the blood. Patients should be monitored routinely for toxicity.
• Inhaled beta2-agonists: In long-term asthma care, clinicians need to consider electrocardiogram changes, hypokalemia, hypoxemia and tremor. Effects need to be monitored continually in patients with acute severe asthma with comorbid cardiac problems.
• Oral long-acting beta2-agonists: These medications should be avoided in older patients due to possible tremors and increased heart rate and blood pressure.
Drugs taken by elderly patients for coexisting medical conditions can cause adverse effects when take alongside asthma medicines.1
Beta-adrenergic blocking agents, taken for hypertension, cardiac arrythmias and glaucoma, can place elderly patients at risk for bronchospasm. Generally, patients with asthma shouldn’t use these drugs, but if use is necessary a selective agent should be administered.
Geriatric patients commonly use nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, for cardiovascular and musculoskeletal conditions linked to aging. However, some patients may experience sudden, severe bronchospasm with NSAIDs. In those cases, physicians recommend acetaminophen for pain therapy.
Diuretics, used by some patients for hypertension and ventricular failure, can increase risk of cardiac arrhythmias when combined with beta2-agonists. Patients using both medications should be monitored for electrolyte imbalance and treated with magnesium or potassium supplementation.
Angiotensin-converting enzyme (ACE) inhibitors can produce coughing in some patients who have hypertension, causing confusion to the diagnosis and treatment of asthma. Discontinuing use of the ACE inhibitor will reduce coughing if the drug is causing it.
Some elderly patients have sinusitis and rhinitis and need to take antihistamines, but nonsedating antihistamines can cause arrhythmias if the patient is also taking a diuretic or beta2-agonist.
Through the management process, clinicians need to inform their patients about risks associated with their medicines and how to control their asthma properly without disrupting therapy for other health conditions.
Elderly patients with asthma present a unique set of challenges. With correct diagnosis and management, seniors have the opportunity to lead fulfilling and active lives.
For a list of references, please call Debra Yeminijian at (610) 278-1400, ext. 1153, or visit www.Respiratory-care-sleep-medicine.advanceweb.com/mrreflist.html.
Debra Yemenijian is editorial assistant of ADVANCE.