This month’s issue includes a clinical review of asthma diagnosis and management in geriatric patients by Charles Reed, MD. Dr. Reed discusses the NAEPP Expert Panel Report 3 (2007) guidelines for diagnosing and managing asthma in the context of the different presentation of late-in-life asthma.
The author points out that clinicians have additional considerations trying to diagnose asthma in geriatric patients. These confounders include decrease in lung function that results from structural compromise associated with aging, comorbid lung disease such as COPD and bronchiectasis, and increased IgE levels that are not allergen specific. Structural changes associated with aging negatively affect pulmonary function testing and often manifest as irreversibility with bronchodilators and increased residual volume.
NAEPP asthma management guidelines can be complicated by a number of characteristics associated with the elderly asthma patients. Drug therapy may be less effective in light of structural changes to the lungs, thus bronchodilators may not be fully effective. Short-acting bronchodilators have the risk of increasing cardiac symptoms and should be avoided, especially in patients with heart disease. Corticosteroid therapy may be effective, but comes with significant side effects such as osteoporosis and hyperglycemia, which are of particular concern in the elderly asthma patient. Furthermore, Dr Reed points out that elderly patients often have difficulty using inhalers effectively, and their inhalation technique needs to be checked at every visit. It may be necessary to switch to old-fashioned pressure nebulizers or oral medications.
Careful assessment of the home environment also remains an important part of management. Dr. Reed emphasizes that, even though elderly patients may not have IgE antibody to aeroallergens, mites, molds and bacteria can cause airway inflammation through innate immune pathways. He notes, “In many elderly asthmatic patients' records, information about the environment is the major omission” (unpublished correspondence). Additionally, anti-fungal medications should be considered if sputum cultures are positive for fungi.
In summary, Dr. Reed revisits the importance of following the guidelines by assessment and control of environmental triggers, effective use of inhaled corticosteroids and oral medications, close evaluation of drug side-effects, and management of comorbid lung disease.
Do you have any questions for Dr. Reed, or comments about this study? We want to hear from you. Please feel free to post your own questions or comments. All questions and comments will be forwarded to the authors for a response.
Do any of the readers have experience with low dose theophylline in older adult asthmatics? I would be willing to try this in a few of my older asthmatics that have not responded to ICS/LABA, or LTRA's.
ReplyDeleteWe asked the author to response to your question: "This is a critically important point. It raises two issues about medical decision making. First, there have been very few studies targeting treatment of asthma in elderly adults. I suspect that there never will be funding for investigation of this old generic drug. Second, when specific experimental studies are lacking (as they often are) decisions must be individualized and based on logical application of available information. When theophyline was considered a bronchodilator acting through inhibition of phosphodieaterase, the large doses required were unacceptably toxic in elderly patients. However many studies in younger patients showed that low doses reduced symptoms and improved lung funtion. Now it is known that theophylline acts through pathways additional to inhibition of phosphodiesterase. Specifially, low doses inhibit the action of NFkappa B in away different from and presumably additive to the action of corticosteroids. We should take advantage of the simplicity of the oral route for elderly patients. Especially when the oral route is more effective in reaching small airways. The physician would find detailed information in Peter Barnes' chapter on theophylline in the seventh edition of Allergy Principles and Practice."
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