What’s the treatment for asthma in the elderly?
Diagnosis and treatment of asthma can be more complicated in people age 65 and older than in those who are younger. Health professionals have to consider that older people. Older people tend to have worse asthma symptoms and a higher risk of death from asthma than younger people. Older people may not be as able to determine when they are having breathing discomfort as younger people. This can lead to delays in seeking treatment and to undertreatment of airway
inflammation. They may be more prone to side effects from asthma medications or may be at risk for reactions between medications they are taking. They may also have difficulty using inhalers properly and remembering to take medications.
Older persons often have other types of obstructive lung disease, such as chronic bronchitis or emphysema. This makes it important to know to what extent the symptoms are caused by asthma. Giving steroids for two to three weeks can help determine this. Side-effects from beta-receptor agonist drugs (including a speeding heart and tremor) may be more common in older patients. These patients may benefit from receiving an anti-cholinergic drug, along with the beta-receptor agonist. If theophylline is given, the dose should be limited, as older patients are less able to clear this drug from their blood. Steroids should be avoided, as they often make elderly patients confused and agitated. Steroids may also further weaken the bones.
All patients need to have regular visits scheduled for their asthma. Older people need to have a written Asthma Action Plan that tells them exactly what to do to prevent and treat asthma symptoms. The plan should be in large print, if necessary, and reviewed at each office visit.
Elderly patients may need assistance in order to keep their asthma under control. They may have difficulty with transportation, prescription costs or emotional stress. To help them find resources that can assist them, click on their county of residence at “Local Info” on the home page. Because compliance with multiple therapies – for both asthma and coexisting diseases and conditions – may be difficult, elderly patients often need special education and training in using asthma medications and devices.
The potential for drug interactions is greater in elderly patients with asthma because these patients are likely to be on multiple medications for other conditions, particularly heart disease. Certain asthma medications may be prescribed to avoid making other medical problems worse. Desired therapeutic and clinical outcomes may be more difficult to achieve in elderly patients with asthma. Normal lung function may either be unattainable or be attainable only with potentially dangerous, high pharmacologic doses. It is important, therefore, to set realistic goals for therapy. Treatment goals may need to be modified to maintain a desirable quality of life. Beta2-agonists and theophylline use should be monitored carefully because they can cause tachyarrhythmias and aggravate ischemic heart disease. If theophylline is used, it should be used with caution, especially in patients with congestive heart failure. Systemic corticosteriods may aggravate congestive heart failure and lower serum potassium with potentially adverse cardiac effects. Corticosteroids in high doses may reduce bone mineral content and may accelerate development of osteoporosis. Sympathomimetics is an effective bronchodilator that does not affect heart rate is an important consideration for seniors with heart disease. However, the common mode of administration, which uses a hand-activated inhaler, may be difficult for some elderly people to use. For example, use of the inhaler may be made more difficult by arthritis, tremors, stroke or muscle coordination problems. Some breath-actuated MDIs are available (Maxaire). There are also special devices for inhalers for people with severe arthritis. Steroids (inhaled and oral) are available as an inhaled medication and usually recommended when asthma is persistent. Inhaled steroids usually are started in moderate to high doses and tapered to the minimal dose to control symptoms and normalize peak-flow determinations. Recommendations for oral steroid use include initial high doses, rapid tapering off and then use of alternate-day oral steroids or inhaled steroids if needed. Oral steroid use is sometimes associated with confusion in the elderly. Methylxanthines (aminophylline, theophylline) are potent bronchodilators, but with equally powerful side effects including nausea, rapid heart rate, headache and seizures. Variable metabolism makes them particularly toxic in seniors if not monitored closely, usually with blood levels.
Peak expiratory flow (PEF) monitoring can contribute significantly to management. It may also help distinguish asthma symptoms from symptoms of coexisting heart and lung diseases. However, the usefulness of PEF monitoring may be limited by age-related factors that compromise the effort and perceptual and motor skills required for accurate measurements. Assistance from a caretaker may be useful. Avoidance of environmental triggers, including tobacco smoke and other airborne irritants to which the patient is sensitive, is useful for many elderly patients with asthma. It is important that physicians have a regular follow-up visit with their patients with asthma. This should be done at least yearly. The following chart provides the basic elements of a follow-up visit for asthma with a doctor or asthma counselor.
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