Asthma in Older Adults 

• Author: Praveen Buddiga, MD; Chief Editor: Michael A Kaliner, MD

Asthma is a chronic inflammatory disease characterized by hyper-responsiveness of airways to various stimuli. This complex disease affects patients of all ages. Although asthma has an equal incidence across all age groups, asthma in the elderly is often underdiagnosed and undertreated. A case-control cohort study showed that older adults with asthma have a higher rate of allergic sensitization, decreased lung function, and significantly worse quality of life when compared with controls.^[1]

Some of the stimuli or triggers may generally be subdivided into allergic (allergens such as pollen, molds and fungi, dust mites, pet dander, and insects) or nonallergic (eg, cold air, infections, diesel exhaust, indoor/outdoor air pollution, perfume, tobacco smoke, and other irritants). See the image below.

Allergic triggersNon-allergic triggers

Medical conditions such as rhinosinusitis, gastroesophageal reflux, and aspirin or nonsteroidal anti-inflammatory agent (NSAID) sensitivity may also trigger or exacerbate asthma.

Elderly patients with asthma face disproportionate morbidity, mortality and cost when compared with younger patient groups. They represent a higher number of unscheduled outpatient visits, emergency room visits, and asthma-related hospitalizations; once hospitalized, the death rate attributable to asthma for patients older than 65 years is 14 times higher than patients aged 18-35 years.^{[2, 3, 4, 5]}

Some of the independent risk factors for asthma in older adults include house dust mite sensitization and maternal smoking.^[1]

Anatomy

Normal lung tissue and constricted lung tissue are demonstrated in the image below.

Lung tissue normal vs. constricted

Pathophysiology

Airway inflammation, smooth muscle contraction, epithelial sloughing, mucous hypersecretion, bronchial hyperresponsiveness, and mucosal edema are some of the common pathophysiological mechanisms seen in asthma. The chronic persistent inflammation may result in airway remodeling and structural changes of the airway wall. These changes include an epithelial thickening and subepithelial fibrosis; changes of extracellular matrix are linked to deposition of collagen and fibronectin in the subepithelial basement membrane.

Various stimuli and factors may trigger asthma; this is evident by the recruitment and infiltration of proinflammatory cells within the airways. Cells such as eosinophils, neutrophils, lymphocytes, and degranulated mast cells, lead to occlusion of the bronchial lumen by mucus. See the image below.

Allergic triggersNon-allergic triggers

Etiology

Allergic triggers include the following:

• Pollen - Trees, grasses, weeds
• Mold – Fungi
• Dust mites
• Animal proteins

Allergic triggers usually cause asthma symptoms by dimerizing or bridging the high affinity immunoglobulin E (IgE) receptors located on the mast cells in the lungs. See the image below.

Allergic triggersNon-allergic triggers

Non-allergic triggers include the following:

• Cold air
• Infections – Influenza, Mycoplasma pneumonia, viruses/upper respiratory infections
• Tobacco smoke
• NSAIDS or aspirin
• Exercise
• Irritants - Perfumes, paint
• Pollutants - Diesel exhaust, industrial chemicals
• Occupational exposures

Epidemiology

Over the past 40 years, the incidence rate of asthma has increased across all age groups. The incidence rate of asthma in adults older than 65 years is similar to that found in other age groups (approximately 100 cases per 100,000 population annually).^[2]

Patient Education

Adult patients with asthma often stop their medications when they feel well. These patients must be monitored on a regular basis to assess symptoms and to intervene for appropriate asthma control. Adults generally expect to be treated as adults, with a respect and an appreciation for the skills they bring to the table as they have different educational levels, backgrounds, life experiences, and expectations. Adults have established values, beliefs and opinions that must be identified and respected in order to set goals for managemen