Asthma Over the Age of 65: All's Well That Ends Well

Worse lung function, more allergic sensitization but less blood eosinophilia in elderly patients with long-standing versus late-onset asthma

BACKGROUND

Asthma in the elderly is usually considered homogeneous and non-atopic.

OBJECTIVE

To compare clinical, functional and immunological features between elderly asthmatics with long-standing asthma (LSA) and those with late-onset asthma (LOA).

METHODS

Eighty-two asthmatics older than 64 were included into LSA (asthma onset before age 40; n = 46) and LOA (asthma onset from 40 years of age on; n = 36) groups. Asthma treatment and comorbidities were recorded. All individuals underwent the asthma control questionnaire-7 (ACQ-7) and cognitive impairment screening (Mini-Mental State Examination). Inhaler technique was assessed by checklists; the Morisky Medication Adherence Scale-8 was used to assess adherence to treatment. Spirometry, skin prick tests (SPTs), induced sputum and blood eosinophil counts were performed.

RESULTS

We found high frequencies of cognitive impairment, poor inhaler technique and low adherence to treatment in both groups, which had good disease control (ACQ-7 scores: 1.20 ± 0.74 versus 1.11 ± 0.89; p = 0.67, respectively). The LSA group had more severe airway obstruction (FEV1(% predicted): 62.04 ± 19.50 versus 77.15 ± 18.74, p < 0.01; FEV1/FVC: 0.59 ± 0.10 versus 0.69 ± 0.09, p < 0.01); higher frequency of positive SPTs (65.6% versus 18.8%, p = 0.001); and lower frequency of blood eosinophilia (45.7% versus 77.1%, p = 0.004) than the LOA group. No differences in sputum cell counts or inflammatory profiles were found between the groups. Ninety percent of the individuals studied had at least one feature of Type 2 asthma.

CONCLUSION

LSA and LOA phenotypes differ substantially. That should be accounted for in research and clinical practice grounds.

Patient-Centric Approach for the Treatment of Rheumatoid Arthritis-Associated Interstitial Lung Disease in Older People

PURPOSE OF REVIEW

The purpose of this review is to outline considerations for treating older adults with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) as it relates to infection, comorbidities, cancer, and quality of life.

RECENT FINDINGS

The recent 2023 American College of Rheumatology/American College of Chest Physicians guideline conditionally recommended specific disease-modifying antirheumatic drugs (DMARDs), antifibrotics, and short-term glucocorticoids to treat RA-ILD. Since RA-ILD often affects older adults, we contextualize these pharmacologic options related to infection, gastrointestinal (GI) effects, cancer, cardiovascular disease, and quality of life. Nearly all DMARDs and glucocorticoids are immunosuppressive and increase infection risk. Rituximab, mycophenolate, cyclophosphamide, and glucocorticoids may have particularly high infection risk. Many therapies recommended for treating RA-ILD have potential GI side effects. Antifibrotics have a high rate of nausea and diarrhea. Janus kinase inhibitors may increase risk of cancer and cardiovascular disease in older people. In older individuals, decisions must weigh the risks and benefits of drug options while considering clinical and social factors such as polypharmacy, adherence, cost, convenience, and social support. Management of RA-ILD in older individuals is complex and should consider risks and benefits, while optimizing quality and quantity of life through a shared decision-making process.

The usefulness of the forced oscillation technique in the diagnosis of bronchial asthma in seniors

BACKGROUND

Obstructive pulmonary diseases are common in the elderly but often remain underdiagnosed due to limited spirometry availability or challenges with patient cooperation during testing. This study evaluated the potential of the forced oscillation technique (FOT) as a diagnostic tool for bronchial asthma in individuals over 60 years old.

RESEARCH DESIGN AND METHODS

A total of 189 patients diagnosed with asthma after age 60 and a control group of nonasthmatic seniors were included. Participants underwent spirometry, FOT, and bronchial reversibility testing using both methods. The primary outcomes were correlations between positive results from resting spirometry and FOT in asthmatics and the agreement between reversibility test results across the two methods.

RESULTS

FOT parameters (FEV1, V5, R5) effectively distinguished asthmatics from nonasthmatics. Positive reversibility test results were observed in 71 (73.2%) patients using FOT and 68 (70.1%) using spirometry, with both methods aligning in 64 (66%) cases.

CONCLUSION

These results highlight the value of FOT, particularly for bronchial reversibility testing, in improving asthma diagnosis in seniors. FOT offers a practical alternative for patients who face difficulties performing spirometry, addressing a critical need in this population.

Adherence Challenges and Strategies in Specific Groups With Asthma: Adolescents, Pregnancy, and Older Adults

Poor adherence to controller therapies is a universal challenge to asthma control. Several high-risk groups, including adolescents, pregnant women, and older adults, have their own unique challenges to adherence. The rates of asthma controller therapy use are low in each of these populations, but secondary to different causes. Adolescents have increased independence and a transition to new self-management responsibilities; pregnant women may be concerned about adverse effects of medications to the fetus; and older adults may have age-related physical and cognitive challenges to effectively taking medication. Only by understanding the nuances of care in these populations can health care professionals develop strategies to address barriers to adherence. Tailored education focused on empowering patients and dispelling misconceptions can serve as tools to improve adherence and ultimately asthma control.

Implementation of a remote behavioral intervention for older adults with asthma - a pilot study

OBJECTIVE

Older adults with asthma (OAA) have elevated asthma morbidity rates. A six-session intervention based on self-regulation theory was shown to improve outcomes. However, wide-spread implementation was difficult due to the in-person design. Our objective was to determine the feasibility and acceptability of an updated intervention for OAA that is completely remote, includes a physician component, and utilizes shared decision-making (SDM).

METHODS

A pilot study of 12 OAA with uncontrolled asthma and their asthma providers was conducted at three health centers. The remote intervention (titled SOAR) consisted of 4 sessions (2 groups and 2 individual). Asthma providers (both specialists and primary care) were sent updates of progress along with information on how to incorporate SDM into the visit. Implementation (feasibility, acceptability, and appropriateness) and clinical (asthma control, asthma quality of life, perceived control, depression, and self-confidence) outcomes were measured.

RESULTS

SOAR was found to be feasible, acceptable, and appropriate, with values on validated implementation scales similar to those of in-person behavioral interventions. Asthma providers found the program helpful and intended to change care based on the updates. Asthma control scores improved significantly from baseline (14.2 to 16.8, p = 0.04), as did asthma quality of life (4.2 to 4.9, p = 0.03) and self-confidence to manage asthma (7.1 to 8.5, p = 0.02). There was no change in depression nor perceived control scores.

CONCLUSION

A remote behavioral intervention appeared feasible and acceptable for OAA and their health care providers, and can improve outcomes. Larger scale implementation trials are warranted.

Weight-adjusted waist index is an independent predictor of all-cause and cause-specific mortality in patients with asthma

BACKGROUND

There is a close relationship between obesity and the occurrence of asthma.The weight-adjusted waist index (WWI) is a relatively novel anthropometric parameter that reflects obesity.

OBJECTIVE

We aimed to explore the association between WWI and mortality in the asthma population.

METHODS

We included adult with asthma from NHANES 1999-2018. WWI = Waist circumference (cm)/square root of body weight (kg). Current asthma was determined by the participant's responses in standardized questionnaires. All-cause, cardiovascular disease (CVD), cancer, and respiratory disease mortality information was obtained by prospectively matching these data to the National Death Index. Multivariate-adjusted Cox proportional hazards regression analyses, Kaplan Meier survival analyses, restricted cubic spline (RCS) analyses, stratified analyses, and sensitivity analyses were used to clarify these associations.

RESULTS

A total of 101,316 participants were included in the study, and 3223 were diagnosed with asthma.WWI was independently and positively associated with all-cause and all factor-specific mortality in asthma. In fully adjusted models, each unit increase in WWI was associated with 43 % (hazard ratio [HR] and 95 % confidence interval [CI] = 1.43 [1.25,1.64], p < 0.0001), 58 % (1.58 [1.25, 1.99], p < 0.001), 50 % (1.50 [1.19, 1.90], p < 0.001), and 79 % (1.79 [1.34, 2.39], p < 0.0001) increased all-cause, CVD, cancer, and respiratory disease mortality, respectively. RCS analyses showed largely linear associations between WWI and all mortality risks. Stratified analyses indicated that these associations were influenced by multiple factors, and that age was consistently the effect modifier across all associations.

CONCLUSIONS

WWI is an independent predictor of all-cause, CVD, cancer, and respiratory-related mortality in the adult asthma population. These findings highlight that WWI may have novel prognostic value as a simple and easily accessible obesity parameter in asthma patients.

The Status of Asthma in the United States

Introduction

Asthma imposes a substantial health and economic burden on patients and their families and on the health care system. An assessment of the status of asthma in the US may lead to effective strategies to improve health and quality of life among people with asthma. The objective of our study was to assess the historical trends and current state of asthma illness and death among children and adults in the US.

Methods

We assessed asthma-related emergency department visits and hospitalizations among children and adults by using data from the 2010-2021 National Health Interview Survey (NHIS), the 2010-2020 Nationwide Emergency Department Sample (NEDS), the National (Nationwide) Inpatient Sample (NIS), the Healthcare Cost and Utilization Project (HCUP), and the Agency for Healthcare Research and Quality (AHRQ). Asthma death rates were calculated by using 2010-2021 National Vital Statistics System data.

Results

Asthma prevalence increased significantly among adults from 2013 through 2021 (P = .04 for the annual percentage change [APC] slope) and decreased among children from 2010 through 2021 (P values for slopes: 2010-2017, P = .03; 2017-2021, P = .03). Prevalence of current asthma was higher among non-Hispanic Black people (children, 12.5%; adjusted prevalence ratio [APR] = 2.19; 95% CI, 1.68-2.84 and adults, 10.6%; APR = 1.25; 95% CI, 1.09-1.43) compared with non-Hispanic White people (children, 5.7%; adults, 8.2%). Prevalence of asthma attacks and use of asthma-related health care declined among adults and children. Asthma prevalence and asthma-related emergency department visits, hospitalization, and death rates differed by select characteristics.

Conclusions

Although asthma attacks, ED visits, hospitalizations, and deaths have declined since 2010 among all ages, current asthma prevalence declined only among children, and significant disparities in health and health care use still exist.

Climate change and its impact on asthma

ABSTRACT

Earth's climate is changing at an unprecedented pace, primarily due to anthropogenic causes including greenhouse gas emissions. Evidence shows a strong link between climate change and its effects on asthma. Healthcare professionals must be educated to advocate for and lead effective strategies to reduce the health risks of climate change.

PPARγ attenuates cellular senescence of alveolar macrophages in asthma-COPD overlap

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents a complex condition characterized by shared clinical and pathophysiological features of asthma and COPD in older individuals. However, the pathophysiology of ACO remains unexplored. We aimed to identify the major inflammatory cells in ACO, examine senescence within these cells, and elucidate the genes responsible for regulating senescence.

METHODS

Bioinformatic analyses were performed to investigate major cell types and cellular senescence signatures in a public single-cell RNA sequencing (scRNA-Seq) dataset derived from the lung tissues of patients with ACO. Similar analyses were carried out in an independent cohort study Immune Mechanisms Severe Asthma (IMSA), which included bulk RNA-Seq and CyTOF data from bronchoalveolar lavage fluid (BALF) samples.

RESULTS

The analysis of the scRNA-Seq data revealed that monocytes/ macrophages were the predominant cell type in the lung tissues of ACO patients, constituting more than 50% of the cells analyzed. Lung monocytes/macrophages from patients with ACO exhibited a lower prevalence of senescence as defined by lower enrichment scores of SenMayo and expression levels of cellular senescence markers. Intriguingly, analysis of the IMSA dataset showed similar results in patients with severe asthma. They also exhibited a lower prevalence of senescence, particularly in airway CD206 + macrophages, along with increased cytokine expression (e.g., IL-4, IL-13, and IL-22). Further exploration identified alveolar macrophages as a major subtype of monocytes/macrophages driving cellular senescence in ACO. Differentially expressed genes related to oxidation-reduction, cytokines, and growth factors were implicated in regulating senescence in alveolar macrophages. PPARγ (Peroxisome Proliferator-Activated Receptor Gamma) emerged as one of the predominant regulators modulating the senescent signature of alveolar macrophages in ACO.

CONCLUSION

The findings suggest that senescence in macrophages, particularly alveolar macrophages, plays a crucial role in the pathophysiology of ACO. Furthermore, PPARγ may represent a potential therapeutic target for interventions aimed at modulating senescence-associated processes in ACO.Key words ACO, Asthma, COPD, Macrophages, Senescence, PPARγ.

PPARγ Attenuates Cellular Senescence of Alveolar Macrophages in Asthma- COPD Overlap

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents a complex condition characterized by shared clinical and pathophysiological features of asthma and COPD in older individuals. However, the pathophysiology of ACO remains unexplored. We aimed to identify the major inflammatory cells in ACO, examine senescence within these cells, and elucidate the genes responsible for regulating senescence. Bioinformatic analyses were performed to investigate major cell types and cellular senescence signatures in a public single-cell RNA sequencing (scRNA-Seq) dataset derived from the lung tissues of patients with ACO. Similar analyses were carried out in an independent cohort study Immune Mechanisms Severe Asthma (IMSA), which included bulk RNA-Seq and CyTOF data from bronchoalveolar lavage fluid (BALF) samples. The analysis of the scRNA-Seq data revealed that monocytes/ macrophages were the predominant cell type in the lung tissues of ACO patients, constituting more than 50% of the cells analyzed. Lung monocytes/macrophages from patients with ACO exhibited a lower prevalence of senescence as defined by lower enrichment scores of SenMayo and expression levels of cellular senescence markers. Intriguingly, analysis of the IMSA dataset showed similar results in patients with severe asthma. They also exhibited a lower prevalence of senescence, particularly in airway CD206 + macrophages, along with increased cytokine expression (e.g., IL-4, IL-13, and IL-22). Further exploration identified alveolar macrophages as a major subtype of monocytes/macrophages driving cellular senescence in ACO. Differentially expressed genes related to oxidation-reduction, cytokines, and growth factors were implicated in regulating senescence in alveolar macrophages. PPARγ (Peroxisome Proliferator-Activated Receptor Gamma) emerged as one of the predominant regulators modulating the senescent signature of alveolar macrophages in ACO. Collectively, the findings suggest that senescence in macrophages, particularly alveolar macrophages, plays a crucial role in the pathophysiology of ACO. Furthermore, PPARγ may represent a potential therapeutic target for interventions aimed at modulating senescence-associated processes in ACO.

Clinical, functional, and inflammatory characteristics of asthma among adults aged over 60 years old: a case-control study

ObjectiveThis observational case-control study analyzed the clinical, functional, inflammatory profile, and treatment data of a cohort of patients with asthma who were followed up at the outpatient clinic of a teaching hospital.MethodsPatients who visited the clinic between January 2008 and February 2020 and diagnosed with asthma according to the Global Initiative for Asthma (GINA) criteria were included in the study. Patients were broadly classified into two groups: age <60 or age ≥60 years. The patients were evaluated for asthma control and severity, medications used, comorbidities, smoking status, occurrence of exacerbation, spirometry at the first and last visits, sputum cytology, allergic prick test, and inflammatory cytokine levels.ResultsPatients over 60 years of age had lower asthma control test (ACT) scores, required higher doses of inhaled corticosteroids to achieve asthma control and had worse lung function with fixed airway obstruction, higher number of comorbidities, greater exposure to tobacco, and longer outpatient follow-up than younger patients with asthma. Furthermore, older patients presented with neutrophilia and higher levels of TNFα in the induced sputum as compared to younger patients.ConclusionsThese findings suggest that patients aged ≥60 years of age had a more severe asthma profile and poorer lung function than younger patients with asthma. Furthermore, aging, long-term asthma, comorbidities, and tobacco exposure contributed to an accelerated decline in lung function.

Phenotype overlap in the natural history of asthma

The heterogeneity of asthma makes it challenging to unravel the pathophysiologic mechanisms of the disease. Despite the wealth of research identifying diverse phenotypes, many gaps still remain in our knowledge of the disease's complexity. A crucial aspect is the impact of airborne factors over a lifetime, which often results in a complex overlap of phenotypes associated with type 2 (T2), non-T2 and mixed inflammation. Evidence now shows overlaps between the phenotypes associated with T2, non-T2 and mixed T2/non-T2 inflammation. These interconnections could be induced by different determinants such as recurrent infections, environmental factors, T-helper plasticity and comorbidities, collectively resulting in a complex network of distinct pathways generally considered as mutually exclusive. In this scenario, we need to abandon the concept of asthma as a disease characterised by distinct traits grouped into static segregated categories. It is now evident that there are multiple interplays between the various physiologic, cellular and molecular features of asthma, and the overlap of phenotypes cannot be ignored.

Characterization and cluster analyses of elderly asthma in comparison with nonelderly patients with asthma in Japan

BACKGROUND

Asthma is a heterogeneous disease with multiple phenotypes that are useful in precision medicine. As the population ages, the elderly asthma (EA, aged ≥ 65 years) population is growing, and EA is now a major health problem worldwide.

OBJECTIVE

To characterize EA and identify its phenotypes.

METHODS

In adult patients with asthma (aged ≥ 18 years) who had been diagnosed with having asthma at least 1 year before study enrollment, 1925 were included in the NHOM-Asthma (registered in UMIN-CTR; UMIN000027776), and the data were used for this study, JFGE-Asthma (registered in UMIN-CTR; UMIN000036912). Data from EA and non-EA (NEA) groups were compared, and Ward's minimum-variance hierarchical clustering method and principal component analysis were performed.

RESULTS

EA was characterized by older asthma onset, longer asthma duration and smoking history, more comorbidities, lower pulmonary function, less atopic, lower adherence, and more hospital admissions because of asthma. In contrast, the number of eosinophils, total immunoglobulin E level, oral corticosteroid use, and asthma control questionnaire scores were equivalent between EA and NEA. There were 3 distinct phenotypes in EA, which are as follows: EA1: youngest, late onset, short duration, mild; EA2: early onset, long duration, atopic, low lung function, moderate; and EA3: oldest, eosinophilic, overweight, low lung function, most severe. The classification factors of the EA phenotypes included the age of onset and asthma control questionnaire-6. Similarities were observed between EA and NEA phenotypes after principal component analysis.

CONCLUSION

The EA in Japan may be unique because of the population's high longevity. Characterization of EA phenotypes from the present cohort indicated the need for distinct precision medicine for EA.

TRIAL REGISTRATION

JFGE-Asthma registered in UMIN-CTR (https://www.umin.ac.jp/ctr/); UMIN000036912.

Management of Elderly Asthma: Key Questions and Tentative Answers

The aging lung undergoes structural changes, immunosenescence, and inflammation, rendering the elderly more susceptible to developing obstructive airway disease. Thus, asthma in those of chronological age ≥ 65 years is not rare. Elderly asthma (EA) imposes considerable burdens in terms of mortality and morbidity, and expenditure. However, clinicians lack knowledge of EA and thus often prescribe inappropriate management. In this review, we ask 3 key questions frequently encountered during EA diagnosis and treatment: 1) Is EA different?; 2) How can we appropriately diagnose EA?; 3) Are there management strategies specific to EA? Based on recent studies, we provide tentative answers as follows: 1) late-onset EA differs in clinical features and pathogenetic mechanisms from non-EA, and thus further phenotypic and endotypic characterization of EA is needed; 2) both over- and under-diagnosis of asthma in the elderly can be reduced if the objective diagnostic tests are appropriately performed; 3) cautious prescription of ICS to selected EA patients should be encouraged, and a multifaceted approach which involves increasing medical awareness and inhaler use proficiency and adherence, seeking the assistance of caregivers, and correcting micronutrient deficiencies is required to reduce acute exacerbations in EA patients.

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

Uncontrolled asthma in the elderly is a public health issue recognized in developed countries such as the United States and among the European Union, both from patient safety and economic perspectives. Variations in the cutoff, which defines elderly age, contribute to epidemiological study difficulties. Nonetheless, the relevance of elderly asthma from a socioeconomic perspective is inarguable. The projected growth of the enlarging geriatric population in the United States portends an impending national health burden that may or may not be preventable with pharmacologic and non-pharmacologic treatments. Asthma in the elderly might be a consequence of uncontrolled disease that is carried throughout a lifetime. Or elderly asthmatics could suffer from uncontrolled asthma, which overlaps with other ailments common with advancing ages that merit consideration, eg, COPD, heart disease, OSA, diabetes mellitus, and other comorbidities. Because of the heterogeneity of asthma phenotypes and other conditions that could mimic the symptoms of elderly asthma, further cohort studies are needed to elucidate the elderly asthmatic pathophysiology and management. More studies to characterize elderly asthma can help address these patients' unmet need for evidence-based guidelines. We introduce the 5 "Ps" (phenotypes, partnership, pharmacology, practice in acute exacerbations, and problems or barriers for the elderly asthmatics) that establish a framework approach for clinical practice.

Asthma Prevalence and Phenotyping in the General Population: The LEAD (Lung, hEart, sociAl, boDy) Study

Background

Asthma is a chronic heterogeneous respiratory disease involving differential pathophysiological pathways and consequently distinct asthma phenotypes.

Objective and Methods

In the LEAD Study, a general population cohort (n=11.423) in Vienna ranging from 6-82 years of age, we addressed the prevalence of asthma and explored inflammatory asthma phenotypes that included allergic and non-allergic asthma, and within these phenotypes, an eosinophilic (eosinophils ≥300 cells/µL, or ≥150 cells/µL in the presence of ICS medication) or non-eosinophilic (eosinophils <300 cells/µL, or <150 cells/µL in the presence of ICS) phenotype. In addition, we compared various factors related to biomarkers, body composition, lung function, and symptoms in control subjects versus subjects with current asthma (current doctor's diagnosis of asthma).

Results

An overall prevalence of 4.6% was observed for current asthma. Furthermore, an age-dependent shift from allergic to non-allergic asthma was found. The non-eosinophilic phenotype was more prominent. Obesity was a prevalent condition, and body composition including visceral adipose tissue (VAT), is affected in current asthma versus controls.

Conclusion

This broad-aged and large general population cohort identified differential patterns of inflammatory asthma phenotypes that were age-dependent. The presence of eosinophilia was associated with worse asthma control, increased asthma medication, increased VAT, and lower lung function, the opposite was found for the presence of an allergic asthma.

Global trends in the incidence and mortality of asthma from 1990 to 2019: An age-period-cohort analysis using the global burden of disease study 2019

Background

Asthma is a major global health challenge. The global strategic management and prevention of asthma report has been published, but health system planning for asthma requires a careful assessment of asthma epidemiology. This study described the incidence and mortality of global asthma from 1990 to 2019.

Methods

Based on data from the global burden of disease study (GBD) 2019, we present spatial and temporal trends in asthma incidence and mortality for the world and its 204 countries and territories from 1990 to 2019. Meanwhile, age-period-cohort analysis was used to explore factors influencing asthma incidence and mortality.

Results

From 1990 to 2019, the incidence of asthma decreased from 601.20 per 1,00,000 to 477.92 per 1,00,000, and the mortality of asthma decreased from 8.60 per 1,00,000 to 5.96 per 1,00,000. High sociodemographic index (SDI) areas have higher age-standardised asthma incidence and low sociodemographic index areas have higher age-standardised asthma mortality. The age-period-cohort analysis results showed that the relative risk (RR) of incidence was high in children and the RR of mortality was high in elderly individuals. The RR of both asthma incidence and mortality showed a decreasing trend over time. The RR of asthma incidence in the recent birth cohort was higher than that in the previous birth cohort. The RR of asthma mortality continued to decline with the change in the birth cohort.

Conclusions

Global asthma incidence and mortality decreased from 1990 to 2019. The decline in asthma incidence was mainly attributed to age effects and period effects, and the decline in asthma mortality was mainly attributed to period effects and cohort effects. Focusing on the risk of incidence in children and the risk of mortality in the elderly, promoting healthy lifestyles and controlling environmental risk factors can help to better control asthma.

Vitamin D status and asthma, lung function, and hospitalization among British adults

Background

Vitamin D has been known to be associated with asthma. However, the association between vitamin D status and asthma, lung function as well as hospitalization among adults remains unclear.

Objective

To investigate the role of serum vitamin D in asthma prevalence, lung function, and asthma control in adults.

Methods

Multivariable logistic regression was applied to assess the relationship between serum vitamin D and asthma prevalence, lung function (FEV1, FVC, and FEV1/FVC), current wheeze, and asthma-linked hospitalizations in a cross-sectional study of 435,040 adults aged 37-73 years old from the UK Biobank.

Results

Compared to vitamin D deficiency, the odds of asthma were decreased by 6.4% [adjusted odds ratio (aOR) = 0.936; 95% CI: 0.911-0.962; p < 0.001] and 9.8% (aOR = 0. 0.902; 95% CI: 0.877-0. 0.927; p < 0.001) in individuals with insufficient and optimal vitamin D concentration, respectively, in the fully adjusted model. In total asthmatic patients, serum vitamin D was obviously and positively related with FEV1 (β = 1.328 ml, 95% CI = 0.575-2.080), FVC (β = 2.018 ml, 95% CI = 1.127-2.908), and FEV1/FVC (β = 0.006%, 95% CI = 0.002-0.010). Asthmatic patients whose vitamin D level was in the deficient category had 9.3-19.9% higher odds of current wheeze than insufficient categories (aOR = 0.907; 95% CI: 0.861-0.957; p < 0.001) and optimal categories (aOR = 0.801; 95% CI: 0.759-0.845; p < 0.001), but the relationship between vitamin D and asthma hospitalization was not significant.

Conclusion

Vitamin D deficiency was related to higher odds of asthma and current wheeze, and lower lung function in a large sample size study of British adults. Our results indicate a potential positive impact of serum vitamin D on asthma occurrence and disease control in adults.

Expert consensus recommendations for the management of asthma in older adults

Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6-10%, with a higher prevalence among women aged 64 to 75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting.

Trends in asthma among adults in the United States, National Health and Nutrition Examination Survey 2005 to 2018

BACKGROUND

Asthma is a common chronic disease in American adults. The prevalence of asthma has varied over time, but there are few studies on the long-term trend of asthma in American adults.

OBJECTIVE

To describe the prevalence and trend of asthma in American adults from 2005 to 2018 and analyze the risk factors for asthma.

METHODS

Data collection was performed from National Health and Nutrition Examination Survey 2005 to 2018. The unweighted number and weighted percentages of normal participants and patients with asthma and the trends of asthma were calculated. Weighted univariate logistic regression was used to analyze the risk factors for asthma.

RESULTS

A total of 39,601 adults were included in this study. From 2005 to 2018, the overall prevalence of asthma in American adults was 8.41%, whereas that in young, middle-aged, and elderly adults was 8.30%, 8.70%, and 7.92%, respectively. The estimated prevalence of asthma in the overall adults and young adults increased with time (P for trend = .03, difference = 0.023 and P for trend = .007, difference = 0.060, respectively), and the estimated prevalence of middle-aged and elderly adults remained stable with time (P for trend = .33, difference = 0.015 and P for trend = .80, difference = -0.024, respectively).

CONCLUSION

Asthma in American adults was on the rise. Female sex, non-Hispanic Blacks, individuals with low annual household income, active smokers, obese patients, patients with hypertension, patients with diabetes, and individuals with positive asthma family history were associated with a higher risk for developing asthma.

Characterisation of the Australian Adult Population Living with Asthma: Severe - Exacerbation Frequency, Long-Term OCS Use and Adverse Effects

Introduction

Asthma poses a significant burden for the Australian population. Understanding severe exacerbation rates, and steroid-related burden for adults diagnosed with asthma stands to offer insights into how this could be reduced.

Methods

Electronic medical records (EMR) and questionnaires from the Optimum Patient Care Research Database Australia (OPCRDA) were utilised retrospectively. OPCRDA is a real-world database with >800,000 medical records from Australian primary care practices. Outcomes were severe asthma exacerbations in Australian adults, over a 12-month period, stratified by Global Initiative for Asthma (GINA) treatment intensity steps, and steroid associated comorbidities.

Results

Of the 7868 adults treated for asthma, 19% experienced at least one severe exacerbation in the last 12-months. Severe exacerbation frequency increased with treatment intensity (≥1 severe exacerbation GINA 1 13%; GINA 4 23%; GINA 5a 33% and GINA 5b 28%). Questionnaire participants reported higher rates of severe exacerbations than suggested from their EMR (32% vs 23%) especially in steps 1, 4 and 5. Patients repeatedly exposed to steroids had an increased risk of osteoporosis (OR 1.95, 95% CI 1.43–2.66) and sleep apnoea (OR 1.78, 95% CI 1.30–2.46).

Conclusion

The Australian population living with GINA 1, 4, 5a and 5b asthma have high severe exacerbation rates and steroid-related burden, especially when compared to other first world countries, with these patients needing alternative strategies or possibly specialist assessment to better manage their condition.

Vitamin D Attenuates Airway Inflammation in Asthmatic Guinea Pigs Using Mammalian Target of Rapamycin-Mediated Autophagy

The purpose of this experiment is to find out the function of Vitamin D (VD) in airway inflammation in asthmatic guinea pigs by regulating mammalian target of rapamycin (mTOR)-mediated autophagy. A total of 40 male guinea pigs were randomly assigned into the Con group, the ovalbumin (OVA)-sensitized group, the VD group, the VD + dimethyl sulfoxide group, and the VD + rapamycin (mTOR inhibitor) group. Then, serum from all groups was harvested for the measurement of immunoglobulin E (IgE), interleukin (IL)-4, and IL-5 levels. Next, bronchoalveolar lavage fluid was collected for cell counting. Moreover, lung tissues were extracted to assess levels of p-mTOR and autophagy factors (LC3B, Beclin1, Atg5, and P62). Compared with the Con group, the OVA group showed elevated levels of IgE, IL-4, and IL-5, increased contents of eosinophils, neutrophil, and lymphocytes, and declined monocytes. And the VD group improved inflammatory reactions in the guinea pigs. Besides, the OVA group showed lower levels of p-mTOR and P62 and higher autophagy levels than the Con group, while the VD group had opposite results. Rapamycin annulled the suppressive role of VD to airway inflammation in asthmatic guinea pigs. VD might inhibit OVA-induced airway inflammation by inducing mTOR activation and downregulating autophagy in asthmatic guinea pigs.

Short palate, lung, and nasal epithelial clone 1 (SPLUNC1) level determines steroid-resistant airway inflammation in aging

Asthma and its heterogeneity change with age. Increased airspace neutrophil numbers contribute to severe steroid-resistant asthma exacerbation in the elderly, which correlates with the changes seen in adults with asthma. However, whether that resembles the same disease mechanism and pathophysiology in aged and adults is poorly understood. Here, we sought to address the underlying molecular mechanism of steroid-resistant airway inflammation development and response to corticosteroid (Dex) therapy in aged mice. To study the changes in inflammatory mechanism, we used a clinically relevant treatment model of house-dust mite (HDM)-induced allergic asthma and investigated lung adaptive immune response in adult (20-22 wk old) and aged (80-82 wk old) mice. Our result indicates an age-dependent increase in airway hyperresponsiveness (AHR), mixed granulomatous airway inflammation comprising eosinophils and neutrophils, and Th1/Th17 immune response with progressive decrease in frequencies and numbers of HDM-bearing dendritic cells (DC) accumulation in the draining lymph node (DLn) of aged mice as compared with adult mice. RNA-Seq experiments of the aged lung revealed short palate, lung, and nasal epithelial clone 1 (SPLUNC1) as one of the steroid-responsive genes, which progressively declined with age and further by HDM-induced inflammation. Moreover, we found increased glycolytic reprogramming, maturation/activation of DCs, the proliferation of OT-II cells, and Th2 cytokine secretion with recombinant SPLUNC1 (rSPLUNC1) treatment. Our results indicate a novel immunomodulatory role of SPLUNC1 regulating metabolic adaptation/maturation of DC. An age-dependent decline in the SPLUNC1 level may be involved in developing steroid-resistant airway inflammation and asthma heterogeneity.

Mitochondrial Dysfunction in Chronic Respiratory Diseases: Implications for the Pathogenesis and Potential Therapeutics

Mitochondria are indispensable for energy metabolism and cell signaling. Mitochondrial homeostasis is sustained with stabilization of mitochondrial membrane potential, balance of mitochondrial calcium, integrity of mitochondrial DNA, and timely clearance of damaged mitochondria via mitophagy. Mitochondrial dysfunction is featured by increased generation of mitochondrial reactive oxygen species, reduced mitochondrial membrane potential, mitochondrial calcium imbalance, mitochondrial DNA damage, and abnormal mitophagy. Accumulating evidence indicates that mitochondrial dysregulation causes oxidative stress, inflammasome activation, apoptosis, senescence, and metabolic reprogramming. All these cellular processes participate in the pathogenesis and progression of chronic respiratory diseases, including chronic obstructive pulmonary disease, pulmonary fibrosis, and asthma. In this review, we provide a comprehensive and updated overview of the impact of mitochondrial dysfunction on cellular processes involved in the development of these respiratory diseases. This not only implicates mechanisms of mitochondrial dysfunction for the pathogenesis of chronic lung diseases but also provides potential therapeutic approaches for these diseases by targeting dysfunctional mitochondria.

Sex, Cells, and Asthma

There are marked sex differences in asthma prevalence and severity. Sex hormones play a central role in these sex biases and directly interact with multiple key cells involved in the pathogenesis of asthma. Here we review the known effects of estrogen, progesterone, and testosterone on airway epithelial cells, airway smooth muscle cells, the mononuclear phagocyte system, innate lymphoid cells, eosinophils, mast cells, T cells, and B cells, all in the context of asthma. Furthermore, we explore unresolved clinical questions, such as the role of sex hormones in the link between asthma and obesity.

Ginsenoside Rh1 attenuates ovalbumin-induced asthma by regulating Th1/Th2 cytokines balance

Ginsenoside Rh1 (Rh1) has anti-inflammatory effects in asthma mice, but the underlying mechanism remains unclear. BALB/c mice were sensitized and challenged with ovalbumin (OVA) to construct asthma model. Mice received Rh1 or tiotropium bromide 0.5 h before OVA challenge. Airway morphology and airway remodeling were assessed by HE staining and Masson's trichrome staining, respectively. Th1/Th2 cytokines in serum or broncho alveolar lavage fluid (BALF) were measured by ELISA kits. Rh1 significantly alleviated the lung resistance and airway resistance, and reduced the number of total inflammation cells, eosinophils, neutrophils, and lymphocytes in BALF of the asthmatic mice. The morphological changes and collagen deposition of airway were also reduced by Rh1 in asthmatic mice. The increase of Eotaxin, IL-4, IL-5, IL-13, and IL-33 and the decrease of IL-12 and IFN-γ in both BALF and serum of OVA exposed mice were reversed by Rh1. Rh1 attenuates OVA-induced asthma in the mice model by regulating Th1/Th2 cytokines balance.

Ventilatory defects and treatable traits in very elderly patients

Though the approach used to classify chronic respiratory diseases is changing to a treatable-traits (TT) approach, data regarding very elderly patients is lacking. The objectives of this study were to assess TT frequency in very elderly patients and to study the link between extrapulmonary TT and ventilatory defects. Individuals (≥75 years) residing in elderly care centres answered a standardised questionnaire, underwent spirometry, atopy and fractional exhaled nitric oxide assessments and had their blood pressure and peripheral pulse oximetry measured. Pulmonary, extrapulmonary and behavioural TT were evaluated. Outcome variables were an airflow limitation (post-bronchodilator z-score FEV1/FVC<-1.64) and a restrictive spirometry pattern (z-score FEV1/FVC ≥ +1.64 and z-score FVC<-1.64). Seventy-two percent of the individuals who took part in the study (n = 234) were women, and the median age of participants was 86 (IQR: 7.4). At least one pulmonary TT was identified in 105 (44.9%) individuals. The most frequent extrapulmonary TTs were: persistent systemic inflammation (47.0%), anaemia (34.4%), depression (32.5%) and obesity (27.4). Airflow limitation was exclusively associated with smoking (OR 5.03; 95% CI 1.56-16.22). A restrictive spirometry pattern was associated with cognitive impairment (OR: 3.89; 95% CI: 1.55-9.79). A high frequency of various TTs was found. The novel association between a restrictive spirometry pattern and cognitive impairment highlights the urgency of clinical research on this vulnerable age group.

Home environment allergen exposure scale in older adult cohort with asthma

OBJECTIVES

Home environmental exposures are a primary source of asthma exacerbation. There is a gap in decision support models that efficiently aggregate the home exposure assessment scores for focused and tailored interventions. Three development methods of a home environment allergen exposure scale for persons with asthma (weighted by dimension reduction, unweighted, precision biomarker-based) were compared, and racial disparity tested.

METHODS

Baseline measures from a longitudinal cohort of 187 older adults with asthma were analyzed using humidity and particulate matter sensors, allergy testing, and a home environment checklist. Weights for the dimension reduction scale were obtained from factor analysis, applied for loadings > 0.35. Scales were tested in linear regression models with asthma control and asthma quality of life outcomes. Racial disparities were tested using t tests. Scale performance was tested using unadjusted regression analyses with asthma control and asthma quality of life outcomes, separately.

RESULTS

The 7-item empirically weighted scale demonstrated best performance with asthma control associations (F = 4.65, p = 0.03, R2 = .02) and quality of life (F = 6.45, p = 0.01, R2 = .03) as follows: evidence of roach/mice, dust, mold, tobacco smoke exposure, properly venting bathroom fan, self-report of roach/mice/rats, and access to a HEPA filter vacuum. Pets indoors loaded on a separate scale. Racial differences were observed (t = - 3.09, p = 0.004).

CONCLUSION

The Home Environment Allergen Exposure Scale scores were associated with racial disparities. Replicating these methods in populations residing in high-risk/low-income housing may generate a clinically meaningful, tailored assessment of asthma triggers. Further consideration for variables that address allergic reactivity and biomarker results is indicated to enhance the potential for a precision prevention score.

Cost-Effectiveness of Tiotropium in Elderly Patients with Severe Asthma Using Real-World Data

BACKGROUND

Tiotropium has the potential to alleviate asthmatic symptoms caused by the aging of lungs. However, few studies have focused on specific treatments for elderly patients with asthma.

OBJECTIVES

To estimate the cost-effectiveness of adding tiotropium to inhaled corticosteroids and long-acting beta-agonists in elderly patients with severe asthma using real-world data.

METHODS

Phase I was a retrospective cohort study using the National Health Insurance claims data to measure clinical and economic outcomes. In phase II, a Markov model was constructed to evaluate cost-effectiveness from Korean health care system perspective, based on phase I, including 2 health states, and an asthma exacerbation event. We estimated cost given in 2018 US dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Subgroup analyses for patients with poorly controlled symptoms (frequent short-acting beta-agonist users; frequent exacerbators) were performed.

RESULTS

In elderly patients with severe asthma, the incremental cost and effectiveness in the tiotropium group compared with the inhaled corticosteroid and long-acting beta-agonist group were $2281 and 0.038 QALYs, respectively. The incremental cost-effectiveness ratio was $60,074/QALY, indicating that the addition of tiotropium is not a cost-effective alternative. Meanwhile, 2 subgroups with poorly controlled symptoms showed that adding tiotropium is a cost-effective alternative (frequent short-acting beta-agonist users $4078/QALY; frequent exacerbators $8332/QALY).

CONCLUSIONS

Tiotropium shows a higher cost-effectiveness profile when applied to elderly patients with uncontrolled symptoms. These results using real-world evidence provide information beyond the clinical outcomes reported by randomized controlled trials, providing a complementary ground in establishing the reimbursement criteria of tiotropium for elderly patients with severe asthma.

Outcome measures to be considered on asthma in elderly

PURPOSE OF REVIEW

Asthma is a chronic heterogeneous respiratory disease which is characterized by airflow limitation and variable respiratory symptoms. Asthma in patients more than 65 years of age has an important negative impact on quality of life. The pathophysiology and treatment of asthma in older patients are not as well identified as in younger groups of ages. In this review we intend to outline characteristics found in elderly adults which distinguish them from other age groups of patients with asthma.

RECENT FINDINGS

With increasing age, there are alterations in the innate and adaptive immune responses, known as 'immunosenescence.' These age-associated modifications include an altered response after a pathogenic exposure or tissue injury, moderately mediated through an irreversible loss of cellular replication and defective tissue repair.

SUMMARY

Asthma is a consequence of complex gene-environment interactions, with diversity in clinical presentation and the type and intensity of airway inflammation and remodeling. Age-associated changes in lung physiology and morphology may occur and contribute to asthma. Aging is correlated with a notable decrease in elastic recoil, greater chest wall rigidity, and poor respiratory muscle strength. Underreporting of symptoms by elderly patients is common because of multiple underlying causes. VIDEO ABSTRACT: http://links.lww.com/COAI/A17.

Race and Asthma Outcomes in Older Adults: Results from the National Asthma Survey

BACKGROUND

The number of older adults with asthma continues to rise, yet the effects of race and ethnicity on asthma outcomes in this population are unknown.

OBJECTIVE

To characterize the effect of race and ethnicity on asthma outcomes in a large national sample of older adults and to identify factors that are associated with disparities found.

METHODS

Data from the 2015 Behavioral Risk Factor Surveillance Survey and Asthma Call-Back Survey were analyzed. Respondents were included if they had a current asthma diagnosis, were aged ≥55, and self-identified as non-Hispanic white, African American, or Hispanic. Demographic variables, health care access, comorbidities, and asthma history were correlated with asthma outcomes (health care utilization and asthma control). Asthma outcome variables were further analyzed using multivariable logistic regression.

RESULTS

A total of 4700 individuals were included. Compared with non-Hispanic white respondents, African American and Hispanic respondents had lower incomes, greater impaired access to health care due to cost, and increased reliance on rescue medications. After controlling for factors including income, education, comorbidities, and health insurance, African American and Hispanic respondents were twice as likely to visit the emergency room (ER) for asthma (P < .001 for both) and 40% less likely to report uncontrolled daytime symptoms (P = .002 and .008).

CONCLUSIONS

Racial differences in asthma outcomes persist despite controlling for multiple social determinants of health and access to health insurance through Medicare. Minority patients were more likely to visit the ER but less likely to report frequent daytime symptoms. These findings indicate that comprehensive strategies to address assessment, monitoring, and treatment are needed to decrease health disparities.

A Comparison of Leukotriene Receptor Antagonists to Low-Dose Inhaled Corticosteroids in the Elderly with Mild Asthma

BACKGROUND

Although elderly patients with asthma have clinical characteristics different from those of young adults, few studies or guidelines have focused on specific treatments for this population.

OBJECTIVE

This study compared the effectiveness of leukotriene receptor antagonists (LTRAs) versus inhaled corticosteroids (ICSs) in elderly patients with asthma in real-world settings.

METHODS

We extracted records for elderly patients with asthma who were newly prescribed LTRAs or low-dose ICSs from January 2003 to December 2010 from National Sample Cohort data of Korea. We defined the first prescription date for each medication as the index date. We compared the risks of asthma exacerbation between the 2 groups using Cox proportional-hazard regression after propensity score-based inverse probability of treatment weighting to balance covariates between treatment groups. We also compared asthma-related health care resource utilization and medication compliance in both groups using chi-square test and t test.

RESULTS

The number of identified patients newly treated with LTRAs and low-dose ICSs was 1571 and 121, respectively. The risks of asthma exacerbation in the LTRA and low-dose ICS groups after weighting were not significantly different (hazard ratio, 0.98; 95% CI, 0.65-1.54). The proportion with high compliance (medication possession ratio ≥ 80%) in the LTRA group was higher than that in the low-dose ICS group.

CONCLUSIONS

The effectiveness of LTRAs was not different from that of low-dose ICSs regarding the risk of asthma exacerbation in elderly patients with asthma in real-world settings. Given the practical benefits gained from convenient administration, LTRAs can be considered a reasonable alternative first-line therapy for elderly patients with mild asthma.

Neighborhood air pollution and household environmental health as it relates to respiratory health and healthcare utilization among elderly persons with asthma

Objective: The study investigated the associations between fine particulate matter (PM_2.5; <2.5 μm in diameter), indoor environment, pulmonary function, and healthcare utilization in a vulnerable group of elderly persons with asthma. We hypothesized that environmental conditions were associated with adverse pulmonary health outcomes. Methods: The study involved elderly (n = 76; mean age 64.6 years; 48 women) vulnerable persons in Detroit, Michigan, USA, with physician-diagnosed asthma. Exposure variables included measured outdoor PM_2.5, self-rated outdoor and household environmental pollutants. Outcome variables were self-rated and measured pulmonary function, and asthma-related healthcare utilization. Results: Mean ambient PM_2.5 concentrations during the study was 14.14 ± (S.D. 6.36) µg/m³ during the summer and 14.20 (6.33) during the winter (p = 0.95). In multiple regression analyses, adjusting for age and gender, mean 6-month concentration of PM_2.5 was related to shortness of breath (SHOB; standardized β = 0.26, p = 0.02) and inversely with self-rated respiratory health (SRRH; β = 0.28, p = 0.02). However, PM_2.5 did not predict lung function (FEV₁% predicted and FEV₁/FVC). However, PM_2.5 was related to use of asthma controller drugs (β = 0.38, p = 0.001). Participants' air pollution ratings predicted total healthcare utilization (β = 0.33, p = 0.01). Conclusions: In elderly persons with asthma, living near heavy industry and busy highways, objective and perceived environmental pollution relate to participants' respiratory health and healthcare utilization. Importantly, air pollution might increase use of asthma controller drugs containing corticosteroids with implication for elderly persons' risk to develop osteoporosis and cardiovascular disease.