Asthma in the older adult: presentation, considerations and clinical management

Abstract

Asthma affects older adults to the same extent as children and adolescents. However, one is led to imagine that asthma prevalence decreases with aging and becomes a rare entity in the elderly. From a clinical perspective, this misconception has nontrivial consequences in that the recognition of the disease is delayed and the treatment postponed. The overall management of asthma in the elderly population is also complicated by specific features that the disease develops in the most advanced ages, and by the difficulties that the physician encounters when approaching the older asthmatic subjects. The current review article aims at describing the specific clinical presentations of asthma in the elderly and highlights the gaps and pitfalls in the diagnostic and therapeutic approaches. Relevant issues with regard to the clinical management of asthma in the elderly are also discussed.

Keywords:

• aging
• asthma
• asthma diagnosis
• asthma physiopathology
• comorbidity
• elderly

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Asthma can start at any age. The age of asthma onset may affect the clinical presentation of asthma in the elderly. Early onset asthma is easier to recognize, when a well-documented history of asthma in childhood or adolescence is present. However, it may show features of chronic persistent airflow obstruction.

• Asthma may coexist with chronic obstructive pulmonary disease (asthma–COPD overlap syndrome); in many cases, a clear distinction between asthma and COPD is possible with an accurate clinical history and appropriate lung function tests. Nevertheless, the proper diagnosis is often a challenge in daily clinical practice.

• Several comorbidities are associated with asthma in the elderly, and this association differs from that observed in younger patients.

• In clinical practice, physicians should treat comorbidities strictly correlated with asthma physiopathology (i.e., rhinitis or GORD), assess comorbidities that may influence asthma outcomes (i.e., depression or cognitive impairment) and try to prevent comorbidities related to drug-associated side effects (i.e., cataracts, arrhythmias or osteoporosis).

• The diagnosis of airway obstruction in the elderly can represent a challenge. The use of FEV₁/FVC as a fixed ratio is suitable to define the presence of airway obstruction in adults in clinical practice. In the elderly populations, the threshold value of FEV_1/FVC should be lowered from 0.70 (applied in adults) to 0.65 to avoid the risk of overdiagnoses. In this scenario, the use of lower limit of normal is to be preferred.

• The prevalence of allergic sensitizations is lower in the most advanced ages due to the phenomenon of immunosenescence. However, this component worsens the clinical manifestations of asthma and should be properly assessed and treated.

• Although obesity is a risk factor for asthma also in older adults, malnutrition (e.g., undernutrition) could play the most relevant role.

• Achieving asthma controls is often a difficult task in the elderly. Depression and cognitive impairment may play an important role and need to be regularly checked and managed.

Notes