Asthma in the elderly: a different disease?

Risk factors and clinical outcomes associated with fixed airflow obstruction in older adults with asthma

BACKGROUND

Asthma in older adults is associated with increased morbidity and mortality compared with asthma in younger patients. Fixed airflow obstruction (FAO) is associated with decreased survival in younger patients, but its significance remains unclear in older adults with asthma.

OBJECTIVE

To identify risk factors and outcomes related to FAO in older adults with asthma.

METHODS

Subjects older than 55 years with a physician diagnosis of persistent asthma were evaluated. Collected data included participant demographic information, medications, asthma exacerbations, Asthma Control Test (ACT) score, Asthma Quality of Life (AQLQ) score, comorbidities, spirometry, atopic status, and fractional exhaled nitric oxide. Clinical characteristics and outcomes associated with FAO (defined as post-bronchodilator ratio of forced expiratory volume in 1 second to forced vital capacity ≤70%) were assessed.

RESULTS

A total of 186 participants were analyzed (48 men and 138 women, mean age 66 years). FAO was demonstrated in 30% of participants. Using regression analysis, predictors of FAO included advanced age, African American race, male sex, and longer duration of asthma. In outcomes analysis, FAO was associated with worsened ACT and AQLQ scores; however, after controlling for confounding factors, logistic regression showed no association. No significant association was found between FAO and exacerbations, fractional exhaled nitric oxide, atopy, rhinitis, education level, depression, smoking, or body mass index.

CONCLUSION

Risk factors associated with FAO in older adults with asthma include advanced age, African American race, increased asthma duration, and male sex. Unlike younger patients, FAO is not independently associated with worsened asthma control, quality of life, or exacerbations in older patients with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01979055.

Comorbidity, disease burden and mortality across age groups in a Swedish primary care asthma population: An epidemiological register study (PACEHR)

BACKGROUND

Asthma is often associated with other diseases. To identify and manage comorbidities is important, as these conditions may increase the disease burden.

OBJECTIVE

To describe the prevalence of comorbidities, disease burden and mortality across age groups in a large Swedish primary care real-life asthma population.

METHODS

Observational cohort study of asthma patients, all ages, identified from electronic medical records by ICD-10-CM code, data from 36 primary care centers. Data were linked to national mandatory Swedish health registers. Comorbidities were identified by ICD-10-CM codes and collected from electronic medical records and the National Patient Registers, mortality data from the Cause of Death Register. Exacerbations were defined as hospitalizations due to asthma, and/or emergency visits at hospital and/or prescription claims of oral steroids.

RESULTS

In total 33,468 patients (58% women) were included. The most prevalent comorbidities were acute upper respiratory tract infection (53%), rhinitis (25%), acute lower respiratory tract infection (25%), hypertension (21%), anxiety and depression (20%). The comorbidities associated with highest risk for an exacerbation were COPD OR 1.98 (95%CI: 1.80-2.19), nasal polyps OR 1.75 (95%CI: 1.49-2.05) and rhinitis OR 1.52 (95%CI: 1.41-1.63). All-cause mortality was similar to the Swedish population, 1011 deaths per 100,000 person/year compared with 1058 deaths (standardized risk = 0.99 [95%CI:0.95-1.04]). The pulmonary related death rate was greater in the study population versus the Swedish population (122 versus 72 per 100,000person/year).

CONCLUSION

Comorbid disease was frequent in this large real-life asthma population with an impact on exacerbations. To identify and treat comorbidities with impact on asthma outcomes are essential to improve asthma care.

The Contribution of Oxidative Stress and Inflamm-Aging in Human and Equine Asthma

Aging is associated with a dysregulation of the immune system, leading to a general pro-inflammatory state of the organism, a process that has been named inflamm-aging. Oxidative stress has an important role in aging and in the regulation of immune responses, probably playing a role in the development of age-related diseases. The respiratory system function physiologically declines with the advancement of age. In elderly asthmatic patients, this may contribute to disease expression. In this review, we will focus on age-related changes affecting the immune system and in respiratory structure and function that could contribute to asthma occurrence, and/or clinical presentation in the elderly. Also, naturally occurring equine asthma will be discussed as a possible model for studying the importance of oxidative stress and immun-aging/inflamm-aging in humans.

Atopy Is Associated with Age at Asthma Onset in Elderly Patients

BACKGROUND

Asthma in the elderly population (60 years of age and older) is frequently underdiagnosed, as well as atopy. Atopy, although more prevalent in younger patients, can be a major cause of asthma in the elderly. Chronic obstructive pulmonary disease (COPD) and cardiovascular disease are common differential diagnoses, especially in elderly smokers.

OBJECTIVE

The objective of this study was to assess atopy and comorbidities in elderly patients with asthma.

METHODS

This was an observational and retrospective study involving elderly asthmatic patients followed up at a tertiary center. Patients were assessed for severity of asthma, frequency of atopy, and frequency of comorbidities concomitant with asthma. Then, they were classified according to their age at asthma onset and the groups compared with each other for atopy, spirometric parameters, and comorbidities.

RESULTS

This study included 243 elderly asthmatic patients, 71.8% of them presenting severe disease and 82.3% forced expiratory volume in 1 second (FEV₁) < 80%. Gastroesophageal reflux disease, obesity, and asthma-COPD overlap syndrome were observed, respectively, in 64%, 37%, and 13% of these patients. Atopy was observed in 63%, mainly in those with early onset disease, and its frequency decreased as the age of asthma onset increased (P < .05). Total serum IgE was higher for allergic patients and FEV₁ values were lower for patients with long-term asthma. Aspirin-exacerbated respiratory disease was more frequent in patients with nonallergic asthma.

CONCLUSIONS

Most elderly asthmatic patients followed up in our tertiary center were atopic and higher values of total serum IgE suggest atopy. Atopy was inversely correlated with age of asthma onset. The diagnosis of allergic asthma in the elderly population is essential to treat patients more properly, improving their quality of life and decreasing asthma morbidity and mortality.

Leukotriene Receptor Antagonists for the Treatment of Asthma in Elderly Patients

Elderly asthma (EA) is regarded as a distinct phenotype of asthma and is associated with age-related changes in airway structure and alterations in lung function and immune responses. EA is difficult to diagnose because of aging and co-morbidities, and overlaps with fixed airway obstructive disease. Novel modalities to differentiate between EA and chronic obstructive pulmonary disease (COPD) are necessary. A multifaceted approach, including clinical history, smoking habits, atopy, and measurement of lung function, is mandatory to differentiate asthma from COPD. There are a variety of co-morbidities with EA, of which COPD, upper airway diseases, depression, obesity, and hypertension are the most common, and these co-morbidities can affect the control status of EA. However, leukotriene receptor antagonists (LTRAs) can facilitate the management of EA, and thus addition of an LTRA to inhaled corticosteroid (ICS) monotherapy or ICS plus long-acting β₂-agonist therapy improves symptoms in EA patients. LTRA treatment is safe and beneficial in patients who are unable to use inhalation devices properly or who have co-morbid diseases. Therefore, clinical studies targeting a specific population of EA patients are warranted to help achieve a better therapeutic strategy in EA patients.

Late-Onset Asthma: A Diagnostic and Management Challenge

Late-onset asthma is common, associated with poor outcome, underdiagnosed and undertreated, possibly due to the modifying effect of ageing on disease expression. Although the diagnostic work-up in elderly individuals suspected of having asthma follows the same steps as in younger individuals (case history and spirometry), it is important to acknowledge that elderly individuals are likely to have diminished bronchodilator reversibility and some degree of fixed airflow obstruction. Elderly individuals, therefore, often require further objective tests, including bronchial challenge testing, to objectively confirm asthma. If necessary, a trial of oral or inhaled corticosteroid might be necessary. Asthma can be diagnosed when increased airflow variability is identified in a symptomatic patient, and if the patient does not have a history of exposure, primarily smoking, known to cause chronic obstructive pulmonary disease, the diagnosis is asthma even if the patient does not have fully reversible airflow obstruction. Pharmacological therapy in patients with late-onset asthma follows international guidelines, including treatment with the lowest effective dose of inhaled corticosteroid to minimize the risk of systemic effects. However, most recommendations are based on extrapolation from findings in younger patients. Comorbidities are very common in patients with late-onset asthma and need to be taken into account in the management of the disease. In conclusion, late-onset asthma is poorly recognized and sub-optimally treated, the latter not least because elderly patients are excluded from most randomized controlled trials. Future studies should focus on the development of evidence-based guidelines for diagnosis and the pharmacological therapy of asthma in the elderly, including late-onset asthma.

Effects of omalizumab in severe asthmatics across ages: A real life Italian experience

BACKGROUND

This retrospective study aimed at evaluating long-term effects of Omalizumab in elderly asthmatics in a real-life setting.

METHODS

105 consecutive severe asthmatics (GINA step 4-5; mean FEV₁% predicted:66 ± 15.7) treated with Omalizumab for at least 1 year (treatment mean duration 35.1 ± 21.7 months) were divided into 3 groups according to their age at Omalizumab treatment onset: 18-39, 40-64 and ≥ 65 years.

RESULTS

Comorbidities, number of overweight/obese subjects and patients with late-onset asthma were more frequent among older people. A similar reduction of inhaled corticosteroids dosage and SABA on-demand therapy was observed in all groups during Omalizumab treatment; a similar FEV₁ increased was also observed. Asthma Control Test (ACT) improved significantly (p < 0.001) in the three groups, increasing from 15 [IQR:12-18] to 24 [IQR:22-25] in younger subjects, from 14 [IQR:10-16] to 21 [IQR:20-23] in the 40-64-year-group and from 15 [IQR:12-16] to 20 [IQR:18-22] in elderly patients where improvement was lower (p = 0.039) compared to younger people. Asthma exacerbations decreased significantly after Omalizumab but the percentage of exacerbation-free patients was higher in younger people (76.9%) compared to middle aged patients (49.2%) and the elderly (29%) (p = 0.049). After Omalizumab treatment, the risk for exacerbations was lower in subjects aged 40-64 (OR = 0.284 [CI95% = 0.098-0.826], p = 0.021) and 18-39 (OR = 0.133 [CI95% = 0.026-0.678], p = 0.015), compared to elderly asthmatics. Also, a significantly reduced ACT improvement (β = -1.070; p = 0.046) passing from each age class was observed.

CONCLUSION

Omalizumab improves all asthma outcomes independently of age, although the magnitude of the effects observed in the elderly seems to be lower than in the other age groups.