Asthma Care in the Elderly: Practical Guidance and Challenges for Clinical Management - A Framework of 5 “Ps”

Figures & data

Table 1 Mimickers of Asthma in the Elderly

Diagnosis	Symptoms	Tests	Hallmarks that Can Help Distinguish from Asthma
COPD with or without bronchiectasis	Dyspnea, cough, and sputum production	Spirometry, CXR	Smoking history, DLCO, imaging studies (CXR or CT showing emphysema or bullae or a flattened diaphragm)
ACOS	Cough, shortness of breath, wheezing, sputum production	PFT, CT chest, methacholine challenge testing	ACOS patients have lower diffusion capacity and higher blood neutrophil levels^Citation67,Citation70,Citation71
Heart failure	Dyspnea, fatigue, ± cough	BNP, ECHO, CXR	Symptoms of fluid overload: leg edema, orthopnea, PND. Imaging showing pleural effusions or pulmonary edema
Bronchiectasis	Productive cough with exacerbations, fatigue	CT chest, Aspergillus testing, testing for CF, CXR	Productive cough most days of the week. Imaging characteristic
GERD	Dry Cough, heartburn, hoarseness, sore throat, dysphagia, wheezing, abnormal taste, frequent clearing of the throat	EGD, barium swallow, manometry, pH	Association with other laryngeal symptoms, worse in the morning
Hyperventilation/panic disorder	SOB, palpitations, chest tightness, tachypnea	Diagnosis of exclusion	Normal lab and diagnostic tests, history of other mental health conditions like history of anxiety or depression, able to exercise and work without limitations.
ACE-Inhibitor induced cough	Dry Cough	None; diagnosis of exclusion	Dry, “hacking” cough.
Rhinosinusitis	Nasal congestion, runny nose, postnasal drip, and cough	Clinical diagnosis	Frequent history of allergies, recurrent URI symptoms/viral URIs
Vocal Cord Dysfunction	Stridor, wheezing, choking sensation, coughing, wheezing, hoarseness, throat tightness	Laryngoscopy	Sudden onset and inability to speak or ability to speak with a hoarse voice; inhaler typically do not help
Tracheobronchomalacia and EDAC	Wheezing, chronic cough, mucus production	Bronchoscopy, CT chest	Recurrent infections, responsive to positive airway pressure^Citation65
Anemia	DOE, fatigue	CBC	Pallor on physical examination, new progressive symptoms, intense fatigue

Abbreviations: ACE-I, Angiotensin-converting enzyme inhibitor; ACOS, asthma chronic obstructive lung disease overlap; ASA, aspirin; BNP, B-natriuretic peptide; CXR, chest radiograph; COPD, chronic obstructive pulmonary disease; CBC, complete blood count; CT, computed tomography; CF, cystic fibrosis; DLCO, diffusion limitation for carbon monoxide; DOE, dyspnea on exertion; ECHO, echocardiogram; EGD, esophagogastroduodenoscopy; EDAC, excessive dynamic airway collapse; GERD, gastroesophageal reflux disease; NSAID, non-steroidal anti-inflammatory drug; PFT, pulmonary function testing; PND, paroxysmal nocturnal; SOB, shortness of breath; URI, upper respiratory tract infection; dyspnea.

Figure 1 Discussion points in communicating with elderly patients.

Abbreviations: MDI, metered dose inhaler; DPI, dry powdered inhaler.

Figure 2 Key Principles (“5 Ps”) in Approaching Asthma in the Elderly.

Abbreviations: SABA, short acting-beta agonist; ICS, inhaled corticosteroid; LABA, long acting-beta agonist, LTRA, leukotriene receptor antagonists; LAMA, long-acting muscarinic antagonists.

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