Asthma and ageing: an end user's perspective--the perception and problems with the management of asthma in the elderly

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.

Cellular senescence in the lung across the age spectrum

Cellular senescence results in cell cycle arrest with secretion of cytokines, chemokines, growth factors, and remodeling proteins (senescence-associated secretory phenotype; SASP) that have autocrine and paracrine effects on the tissue microenvironment. SASP can promote remodeling, inflammation, infectious susceptibility, angiogenesis, and proliferation, while hindering tissue repair and regeneration. While the role of senescence and the contributions of senescent cells are increasingly recognized in the context of aging and a variety of disease states, relatively less is known regarding the portfolio and influences of senescent cells in normal lung growth and aging per se or in the induction or progression of lung diseases across the age spectrum such as bronchopulmonary dysplasia, asthma, chronic obstructive pulmonary disease, or pulmonary fibrosis. In this review, we introduce concepts of cellular senescence, the mechanisms involved in the induction of senescence, and the SASP portfolio that are relevant to lung cells, presenting the potential contribution of senescent cells and SASP to inflammation, hypercontractility, and remodeling/fibrosis: aspects critical to a range of lung diseases. The potential to blunt lung disease by targeting senescent cells using a novel class of drugs (senolytics) is discussed. Potential areas for future research on cellular senescence in the lung are identified.

Caveolae, caveolin-1 and lung diseases of aging

INTRODUCTION

Flask-shaped plasma membrane (PM) invaginations called caveolae and their constitutive caveolin and cavin proteins regulate cellular function via plasma membrane and intracellular signal transduction pathways. Caveolae are present in a variety of cells in the lung including airway smooth muscle (ASM) where they interact with other proteins, receptors, and ion channels and thereby have the potential to affect both normal and disease processes such as inflammation, contractility, and fibrosis. Given their involvement in cell signaling, caveolae may play important roles in mediating and modulating aging processes, and contribute to lung diseases of aging. Areas covered: This review provides a broad overview of the current state of knowledge regarding caveolae and their constituent proteins in lung diseases in the elderly and identifies potential mechanisms that can be targeted for future therapies. Expert Commentary: Caveolin-1 may play a protective role in lung disease. What is less clear is whether altered caveolin-1 with aging is a natural process, or a biomarker of disease progression in the elderly.

Fall episodes in elderly patients with asthma and COPD - A pilot study

OBJECTIVE

Evidence of an increased risk of falls in patients with chronic obstructive pulmonary disease (COPD) exists; however, this has not been studied in elderly asthmatic patients. The aim of the study was to determine the incidence of falls in elderly patients who were diagnosed with bronchial asthma compared to subjects with COPD.

METHODS

A 12-month prospective observational study in elderly outpatients with diagnosis of either asthma or COPD was conducted. All of the participants were monitored on the following parameters: falls, comorbidities, drug therapy, and The Berg Balance Scale. The rate of falls was shown as an incidence ratio. Cluster analysis for subgroups with similar features was performed on all patients included in the study. Two clusters of frequent fallers were determined.

RESULTS

The fall incidence rate in falls per person per year was 1.41 (95% CI: 0.86-1.96) in asthmatic patients and 1.49 (95% CI: 1.05-2.11) in the COPD group. Frequent fallers were more prevalent in the COPD group, with 32% in this group compared to 28% in the groups of patients with asthma. In cluster analysis, frequent fallers were grouped into two models characterized by polytherapy, depression symptoms, hospitalizations, coronary disease, dementia, and diagnosis of COPD or asthma.

CONCLUSION

Elderly asthmatic patients presented a high rate of falls, which is comparable to that of patients with COPD.

Effectiveness of psychological interventions to improve quality of life in people with long-term conditions: rapid systematic review of randomised controlled trials

Background

Long-term conditions may negatively impact multiple aspects of quality of life including physical functioning and mental wellbeing. The rapid systematic review aimed to examine the effectiveness of psychological interventions to improve quality of life in people with long-term conditions to inform future healthcare provision and research.

Methods

EBSCOhost and OVID were used to search four databases (PsychInfo, PBSC, Medline and Embase). Relevant papers were systematically extracted by one researcher using the predefined inclusion/exclusion criteria based on titles, abstracts, and full texts. Randomized controlled trial psychological interventions conducted between 2006 and February 2016 to directly target and assess people with long-term conditions in order to improve quality of life were included. Interventions without long-term condition populations, psychological intervention and/or patient-assessed quality of life were excluded.

Results

From 2223 citations identified, 6 satisfied the inclusion/exclusion criteria. All 6 studies significantly improved at least one quality of life outcome immediately post-intervention. Significant quality of life improvements were maintained at 12-months follow-up in one out of two studies for each of the short- (0–3 months), medium- (3–12 months), and long-term (≥ 12 months) study duration categories.

Conclusions

All 6 psychological intervention studies significantly improved at least one quality of life outcome immediately post-intervention, with three out of six studies maintaining effects up to 12-months post-intervention. Future studies should seek to assess the efficacy of tailored psychological interventions using different formats, durations and facilitators to supplement healthcare provision and practice.

Predictors of asthma control in elderly patients

PURPOSE OF REVIEW

We are in the era of rapid aging of the global population. Elderly asthmatic patients have an increased frequency of hospitalization and a high mortality rate. In this review, we focus on comorbidities and treatment issues in terms of the predictors of asthma control in the elderly.

RECENT FINDINGS

Some frequent comorbidities, such as chronic obstructive pulmonary disease, chronic sinusitis, obesity, and depression, are associated with uncontrolled asthma in elderly asthmatic patients. Smoking status in elderly asthmatic patients was associated with more frequent exacerbations. Management of comorbidities should be taken into account when we treat elderly asthmatic patients. Low treatment adherence, which is common in elderly asthmatic patients, predicts poor asthma control status. A poor knowledge about asthma, cognitive function impairment, and inappropriate inhaler technique result in low treatment adherence. Polypharmacy is associated with low treatment adherence, adverse drug reactions, and drug-drug interactions, and it is supposed to be a predictor of asthma control.

SUMMARY

Multifactorial assessments, including comorbidities, treatment adherence, and polypharmacy, are important for better asthma control in elderly asthmatic patients. Further studies on the strategy for the management of elderly asthmatic patients in a real-world setting are warranted.

Asthma in intellectual disability: are we managing our patients appropriately?

People with intellectual disability are a vulnerable group of people with asthma that has, to date, largely been ignored in the medical literature. Although guidelines for medication management for people with intellectual disability suggest asthma is treated as for other populations, there are special considerations that should be taken into account when managing asthma in this group. Due to their cognitive impairment as well as comorbidities, they are likely to require support with asthma self-management, including inhaler use. Their varying degrees of autonomy mean that there is often a need to provide education and information to both the person and their caregivers.

People with intellectual disability can require special support for asthma self-management, including inhaler usehttp://ow.ly/mAuR305vrGq

Addressing the misdiagnosis of asthma in adults: where does it go wrong?

INTRODUCTION

Asthma is diagnosed based on patients' respiratory symptoms of wheeze, cough, chest tightness and/or dyspnea together with physiologic evidence of variable and reversible expiratory airflow limitation. A high prevalence of overdiagnosis, underdiagnosis and misdiagnosis of adult asthma has been reported in the literature. Areas covered: Misdiagnosis of asthma in adults can occur in the community due to physicians' failure to confirm airflow limitation using spirometry, the relatively poor sensitivity of spirometry to absolutely rule in asthma, the complexity of multiple asthma phenotypes and endotypes, and the inherent day to day variability of asthma symptoms and airflow limitation. Consequences of asthma misdiagnosis to the patient and to the healthcare system include increased medication costs, increased potential side effects related to unnecessary use of medications and lost opportunities to diagnose the true cause of patients' respiratory symptoms. Expert commentary: Here we provide a review of the problem of misdiagnosis of adult asthma and suggestions for how to decrease the risk of misdiagnosis.

Factors affecting ability to achieve asthma control in adult patients with moderate to severe persistent asthma

OBJECTIVE

Despite the use of optimal therapy and guidelines, the rate of asthma control is suboptimal in adult populations. Purpose of this study is to describe factors associated with ability to achieve well-controlled asthma over time for adult patients treated in a tertiary medical center-based asthma outpatient specialty clinic.

METHODS

Existing clinical data collected for 320 adult patients enrolled in a hospital-based outpatient asthma specialty clinic from July 1, 2003 through June 30, 2011 evaluated time to achieve well-controlled asthma and factors associated with well-controlled asthma such as adherence and lack of previous exacerbations.

RESULTS

Adherence to prescribed therapy (p = 0.004) and no previous asthma related ED visits (p = 0.004) were associated with well-controlled asthma for moderate persistent baseline. BMI on a continuous spectrum (p = 0.120) and the diagnosis of allergic rhinitis (p = 0.769) were not independently significant. Body-mass-index (BMI) in combination with adherence did influence ability to achieve well-controlled asthma (p < 0.05). Adherence (p = 0.615), allergic rhinitis (p = 0.172), BMI continuous scale (p = 0.074) and visit interval <90 days (p = 0.653) were not independently associated with likelihood of achieving well-controlled asthma in severe persistent asthmatics. Significance of particular factors in combination (adherence, allergic rhinitis, sex, BMI) showed dependency on other variables in achieving well-controlled asthma.

CONCLUSIONS

Different factors are associated with asthma control for different patient subpopulations. Adherence to standard therapy did not improve obese (BMI > 30) patients' ability to achieve asthma control. Female patients were less likely to obtain well-controlled asthma per unit increase of BMI. Multiple factors must be addressed to optimize attaining asthma control.

Asthma in the elderly patient

Asthma affects a significant proportion of elderly patients, but unfortunately, it is responsible for a high asthma-related morbidity and mortality in this population. This may be related not only to the development of a more severe asthma phenotype compared to younger patients, with more marked airway obstruction and a more neutrophilic type of airway inflammation, but also to the presence of many co-morbid conditions. Furthermore, in older patients, asthma is often under-diagnosed, undertreated and poorly managed. Unfortunately, elderly patients have usually been excluded of clinical trials on asthma and there is an urgent need to perform more research on the optimal management of asthma in this population.

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

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.

Enhanced allergic airway disease in old mice is associated with a Th17 response

BACKGROUND

The prevalence of asthma in the elderly is increasing and associated with higher mortality than in children or young adults. However, the effects of age on the development and character of allergic asthma have been understudied. It has been suggested that mixed Th2/Th17 responses cause more severe forms of asthma, but the role of Th17 response in allergic airway disease and aging is not well understood.

OBJECTIVE

To investigate age-dependent characteristics and Th17 immune response in allergic airway disease in a murine house dust mite (HDM)-allergen model.

METHODS

Twelve-week-old and 15-month-old male BALB/c mice were sensitized and challenged with HDM. Bronchoalveolar lavage fluid (BALF), airway inflammation and hyperresponsiveness (AHR), serum immunoglobulin and splenic T cells were assessed. Age-related T cell activation was analyzed in a co-culture with bone marrow-derived dendritic cells (BMDC) and splenic CD4(+) T cells from young and old mice.

RESULTS

Features of allergic airway disease such as mucous cell hyperplasia, infiltration of airway eosinophils and lymphocytes, Th2 cytokine expression and serum IgG1 levels were greater in old compared to young mice. In contrast to the more marked inflammatory/immune responses to HDM in old mice, AHR was greater in young HDM-treated mice. Only the old mice developed airway neutrophil infiltration and a Th17 immune response upon HDM exposure, with increases in BALF cytokines IL-17A and KC, and Th17 cytokine producing T cells in the spleen. Stimulation of CD4(+) T cells and BMDC co-cultures with HDM, resulted in an enhanced Th17 cytokine response in cells isolated from old mice.

CONCLUSIONS AND CLINICAL RELEVANCE

Our findings in mice suggest that the severity and character of allergic airway disease are age dependent, with a bias towards a Th17 immune response with aging. Elderly, asthmatics may be prone to develop severe allergic airway inflammation with a mixed Th2/Th17 immune response.

Predictors of Asthma Control by Stepwise Treatment in Elderly Asthmatic Patients

The geriatric population is increasing, and asthma severity increases with age. We determined the predictors of asthma control, exacerbation, and the factors that affect asthma-specific quality of life (A-QOL) in elderly asthmatic patients. This was a prospective, multicenter, real-life study for 6 months with stepwise pharmacologic treatment based on the Global Initiative for Asthma (GINA) guideline. A total of 296 asthmatic patients aged ≥ 60 yr were recruited from 5 university centers in Korea. The improved-asthma control group was defined as the group of patients who maintained well-controlled or improved disease and the not-improved asthma control group was defined as the remaining patients. Fewer number of medications for comorbidities (2.8 ± 3.3 in the improved vs. 4.5 ± 4.4 in the control) and higher physical functioning (PF) scale (89.8 ± 14.2 in the improved vs. 82.0 ± 16.4 in the control) were significant predictors in the improved-asthma control group (OR = 0.863, P = 0.004 and OR = 1.028, P = 0.018, respectively). An asthma control test (ACT) score of ≤ 19 at baseline was a significant predictor of asthma exacerbation (OR = 3.938, P = 0.048). Asthma duration (F = 5.656, P = 0.018), ACT score (F = 12.237, P = 0.001) at baseline, and the presence of asthma exacerbation (F = 5.565, P = 0.019) were significant determinants of changes in A-QOL. The number of medications for comorbidities and performance status determined by the PF scale may be important parameters for assessing asthma control in elderly asthmatic patients.

Sintomas respiratórios em pacientes atendidos em uma unidade básica de saúde de Goiânia-GO

Objetivo: verificar a prevalência de sintomas respiratórios em indivíduos que procuram uma unidade básica de saúde, descrevendo as distribuições desses sintomas e dos fatores de risco relacionados com doenças respiratórias. Métodos: estudo transversal em uma unidade básica de saúde de Goiânia-GO. Durante um ano, 44 observações, escolhidas de forma aleatória, foram realizadas, onze em cada estação do ano. Para análise dos dados, foram utilizados teste do qui-quadrado, ANOVA, correlação e regressão robusta univariada. Resultados: dentre os 3.354 indivíduos avaliados, 13,7% (458/3.354) possuíam sintomas respiratórios. A tosse foi o sintoma respiratório mais prevalente, ocorrendo em 91% (417/458) dos casos. Em relação aos que procuraram a unidade de saúde, 4,8% (161/3354) apresentavam tosse por duas semanas ou mais. A proporção dos diferentes sintomas respiratórios (tosse, dispneia e chiado) foi semelhante entre as estações, e as prevalências de sintomas respiratórios encontradas nas quatros estações (inverno, outono, verão e primavera) foram, respectivamente, 20%, 14%, 11,9% e 7,4%. A média do tempo de tosse para idosos foi estatisticamente maior que nos demais grupos (p=0,004). Os tabagistas, ex-tabagistas, portadores de baixo peso, pessoas que referiam pneumonia prévia, asma ou DPOC apresentaram médias de tempo de tosse maiores, mas essas diferenças não foram estatisticamente significativas. O modelo de regressão mostrou aumento do tempo de tosse com aumento da idade (r2=0,08; p=0,0001). Conclusão: as doenças respiratórias perfazem uma importante parcela dos atendimentos da unidade básica de saúde. A prevalência de sintomas respiratórios é maior no inverno e o tempo médio de tosse aumenta com a idade.

Asthma control in elderly asthmatics. An Italian observational study

BACKGROUND

The exponential increase of individuals aged >64 yrs is expected to impact the burden of asthma. We aimed to explore the level of asthma control in elderly subjects, and factors influencing it.

METHODS

A multicenter observational study was performed on consecutive patients >64 years old with a documented physician-diagnosis of asthma. Sixteen Italian centers were involved in this 6-month project.

FINDINGS

A total of 350 patients were enrolled in the study. More than one-third of elderly asthmatic patients, despite receiving GINA step 3-4 antiasthmatic therapy, had an Asthma Control Test score ≤19, with a quarter experiencing at least one severe asthma exacerbation in the previous year. Twenty-nine percent of patients (n = 101) were classified as having Asthma-COPD Overlap Syndrome (ACOS) due to the presence of chronic bronchitis and/or CO lung diffusion impairment. This subgroup of patients had lower mean Asthma Control Test scores and more exacerbations compared to the asthmatic patients (18 ± 4 compared to 20 ± 4, p < 0.01, and 43% compared to 18%, p < 0.01, respectively). Modified Medical Research Council dyspnea mMRC scores and airway obstruction, assessed on the basis of a FEV(1)/FVC ratio below the lower limit of normal, were more severe in ACOS than in asthma, without any difference in responses to salbutamol. In a multivariate analysis, the mMRC dyspnea score, FEV(1)% of predicted and the coexistence of COPD were the only variables to enter the model.

INTERPRETATION

Our results highlight the need to specifically evaluate the coexistence of features of COPD in elderly asthmatics, a factor that worsens asthma control.

Asthma in the elderly: what we know and what we have yet to know

In the past, asthma was considered mainly as a childhood disease. However, asthma is an important cause of morbidity and mortality in the elderly nowadays. In addition, the burden of asthma is more significant in the elderly than in their younger counterparts, particularly with regard to mortality, hospitalization, medical costs or health-related quality of life. Nevertheless, asthma in the elderly is still been underdiagnosed and undertreated. Therefore, it is an imperative task to recognize our current challenges and to set future directions. This project aims to review the current literature and identify unmet needs in the fields of research and practice for asthma in the elderly. This will enable us to find new research directions, propose new therapeutic strategies, and ultimately improve outcomes for elderly people with asthma. There are data to suggest that asthma in older adults is phenotypically different from young patients, with potential impact on the diagnosis, assessment and management in this population. The diagnosis of AIE in older populations relies on the same clinical findings and diagnostic tests used in younger populations, but the interpretation of the clinical data is more difficult. The challenge today is to encourage new research in AIE but to use the existing knowledge we have to make the diagnosis of AIE, educate the patient, develop a therapeutic approach to control the disease, and ultimately provide a better quality of life to our elderly patients.

[Asthma in the elderly]

Asthma is a common condition in the elderly although often confounded with chronic obstructive pulmonary disease (COPD) in this population. Asthma in the elderly seems to represent a specific phenotype characterized by more severe, but often less perceived, airway obstruction, a neutrophilic or mixed-type of airway inflammation and frequent comorbidities. Patients aged 65 years and over have an increased asthma-related morbidity and mortality compared to younger patients, probably due to difficulties in regard to diagnosis, assessment of the disease severity and treatment. Research is urgently needed to determine the optimal treatment of the aged patient. In this document we will review the state of knowledge on this topic and discuss the challenges of multidisciplinary asthma management in the elderly.

Usability testing of AsthmaWise with older adults

There are many reasons why online self-management education is attractive to both patients and providers. AsthmaWise, an online self-management program, was developed using a Moodle platform, to enable older adults to learn asthma self-management skills. This study aimed to improve AsthmaWise through conducting: usability testing with a sample of end users; a cognitive walk-through undertaken by an independent health researcher; and assessment of content readability. A Perceived Health Web Site Usability Questionnaire score of 67% was achieved, indicating that there were usability issues that needed to be addressed. The cognitive walk-through and readability assessment identified unique issues that were not identified through usability testing with end users. The testing process allowed issues to be identified and rectified before piloting AsthmaWise, creating a more accessible and refined end product. The involvement of the site designer in the testing process was valuable and is highly recommended. This study shows that usability testing involving both end users and experts is an essential part of the design process that is relatively easy and inexpensive to undertake and can be effectively conducted by a nonexpert.

Self-Management of Wellness and Illness in an Aging Population

In this chapter, we review the last 10 years of literature on self-management of illnesses (acute/episodic and chronic) and wellness (e.g., health promotion). We focus on health self-management in the context of an aging population, wherein middle-aged adults are more likely to be managing wellness activities and older adults are often managing both maintenance of health and chronic illnesses. The critical issues related to self-management of health are discussed, including those imposed by health care demands and those stemming from individual differences in general abilities (e.g., motor, perception, cognition) and socioemotional characteristics. The dynamic relationship between theory and practice is highlighted. Health care demands reflect the nature of the illness or wellness activity and include managing comorbidities, symptoms, and medications; engaging in health promotion activities (e.g., exercise, diet); the required use of health technologies; the need for health-related information; and coordination of the care network. Individual differences in motor, perceptual, and cognitive abilities, as well as in the severity and complexity of the illness and the consequent demands, also impact how a person self-manages health. Cognitive abilities, such as decision making, knowledge, literacy (i.e., general, health, and e-health literacy), and numeracy are particularly implicated in the process of managing one’s own health and are especially important in the context of an aging population; therefore we give these cognitive abilities special attention in this chapter. Socioemotional characteristics, and attitudes and beliefs about one’s health, impact an individual’s self-management of health as well, impacting his or her motivation and goal-setting behaviors. Moreover, we discuss literature on interventions that have been used to improve self-management of health, and we examine the potential for technology. We conclude with guidelines for technology design and instruction, and discuss emerging themes.

'Get Your Life Back': process and impact evaluation of an asthma social marketing campaign targeting older adults

Background

Asthma in older adults is underdiagnosed and poorly self-managed. This population has little knowledge about the key symptoms, the prevalence among older adults, and the serious consequences of untreated asthma. The purpose of this study was to undertake a multifaceted evaluation of a social marketing campaign to increase asthma awareness among older adults in a regional Australian community.

Methods

A cohort of older adults in an intervention region (n = 316) and a control region (n = 394) were surveyed immediately prior to and following the social marketing campaign. Campaign awareness, message recall, materials recognition, and actions taken as a result of the campaign were assessed in both regions. Asthma knowledge and perceptions, experience of asthma symptoms, and general health were also assessed in both regions at baseline and follow-up. Analyses were conducted to explore the effects of the campaign in the intervention region, and to examine outcomes among different audience segments.

Results

The survey data showed that those in the target segments (Wheezers and Strugglers) had better message recall, and were more likely to report having taken action to control their respiratory symptoms. The campaign significantly increased the number of calls to an asthma information line from the target audience in the intervention community.

Conclusions

A theory-based social marketing campaign conducted over 3-months increased the asthma information seeking behaviours of older adults in the intervention community compared to the control community. Recommendations are outlined for future community health promotion campaigns targeting older adults.

Differences between asthma in young and elderly: results from the COREA study

BACKGROUND

There has been no large-scale and comprehensive study of the differences between asthma in elderly asthmatics (EA) and non-elderly (i.e. young) asthmatics (NEA).

METHODS

We performed principal component analysis (PCA) using 2067 asthmatics (434 EA and 1633 NEA) from the Korean Cohort for Reality and Evolution of adult Asthma (COREA). EA was defined as asthmatics with the chronological age of 65 or more and eleven clinical variables measured at enrollment were used for PCA; symptom score, symptom duration, number of exacerbation during previous one year, smoking pack year, number of controller medications, body mass index, predicted % of FEV1, predicted % FVC, post-bronchodilator FEV1/FVC ratio, atopy index and number of eosinophils in peripheral blood.

RESULTS

PCA of all asthmatics showed that EA and NEA were distinctly separated by the first and second principal component on the plot of individual asthmatics according to their scores. For further analysis, we divided all asthmatics into the EA and the NEA group and performed PCA again in each group. The first four principal components with eigenvalues ≥ 1.0 were identified in both groups and they explained 55.5% of the variance in the EA group and 52.4% in the NEA group respectively. Clinical variables showed distinctly different patterns of loading on the first four principal components between the EA and the NEA group.

CONCLUSION

EA and NEA have different compositional patterns underlying their clinical variables. These observations helped in understanding the differences between EA and NEA from the integrated view covering various clinical aspects.

The asthma knowledge and perceptions of older Australian adults: implications for social marketing campaigns

OBJECTIVE

The purpose of this research is to gain an understanding of the asthma perceptions of older adults and identify gaps in their asthma knowledge.

METHODS

In regional New South Wales, Australia, a stratified, random sample of 4066 adults, aged 55 years and over, both with and without an asthma diagnosis, completed a survey based on the Health Belief Model about asthma knowledge and perceptions.

RESULTS

Almost half of the sample had experienced symptoms of breathlessness in the past four weeks. Breathlessness was a predictor of lower health ratings and poorer mood. Older adults reported low susceptibility to developing asthma. The sample demonstrated poor knowledge of key asthma symptoms including shortness of breath, tightness in the chest and a cough at night.

CONCLUSION

There is a general lack of asthma awareness in this age group. This could result in not seeking medical help, and thus a reduced quality of life.

PRACTICAL IMPLICATIONS

Older adults should be made aware of key symptoms and the prevalence of asthma in the older adult population, and be empowered to take control of their respiratory health. Audience segmentation for an intervention should be based on recent experience of breathlessness and asthma diagnosis.

Developments in the field of allergy in 2011 through the eyes of Clinical and Experimental Allergy

As in previous years, we felt it would be of value to our readership to summarize the new information provided by the authors who have published in Clinical and Experimental Allergy in 2011 and set this in the context of recent advances in our understanding of the pathogenesis and management of allergic disease in all its many manifestations. In 2011, about 210 articles were published in Clinical and Experimental Allergy including editorials, reviews, opinion articles, guidelines, letters, book reviews and of course at the heart of the journal, papers containing original data. As before, this review is divided into sections based on the way the journal is structured, although this year we have grouped together all the papers dealing with mechanisms of allergic disease, whether they involve patients (clinical mechanisms), pure in vitro studies (basic mechanisms) or animal models (experimental models), as we felt this was a more coherent way to deal with the subject. In the field of asthma and rhinitis, the relationship between airway inflammation and airway dysfunction was of perennial interest to investigators, as were phenotypes and biomarkers. Aspirin hypersensitivity appeared in studies in several papers and there was new interest in asthma in the elderly. The mechanisms involved in allergic disease describe advances in our understanding of T cell responses, the relationship between inflammation and disease, mast cell and basophil activation, steroid resistance and novel therapies. In the section dealing with epidemiology, studies seeking to identify risk factors for allergic disease including vitamin D are prominent, as once again are studies investigating gene-environment interactions. The clinical allergy section focuses on drug allergy, food allergy and immunotherapy. The area of oral immunotherapy for food allergy is well covered and we were grateful to Stephen Durham for guest editing an outstanding special issue on immunotherapy in the centenary year of Leonard Noon's pioneering work. Lastly, in the field of allergens, the interest in component-resolved diagnosis continues to grow and there are also articles describing important novel cultivars and the effect of food processing on the allergenic properties of foods. Another terrific year, full of important and high-quality work,which the journal has been proud to bring to the allergy community.

A randomized controlled trial of a self-regulation intervention for older adults with asthma

OBJECTIVES

To evaluate a self-regulation intervention for asthma for older adults.

DESIGN

A blinded randomized controlled trial.

SETTING

Single-center tertiary care academic center.

PARTICIPANTS

Seventy older adults aged 65 and older with persistent asthma randomized to an intervention or control group.

INTERVENTION

Participants participate in a six-session program conducted over the telephone and in group sessions. Participants selected an asthma-specific goal, identified problems, and addressed potential barriers.

MEASUREMENTS

Outcomes were assessed at 1, 6, and 12 months and included the mini-Asthma Quality of Life Questionnaire (mAQLQ), Asthma Control Questionnaire (ACQ), healthcare utilization, exhaled nitric oxide (FENO), and percentage of predicted forced expiratory volume in 1 second (FEV1%).

RESULTS

The mAQLQ score was significantly higher in the intervention group at 1, 6, and 12 months, even after controlling for confounding factors. The between-group difference decreased over time, although at 12 months, it remained greater than 0.5 points. The ACQ was better in the intervention group than in the control group at 1, 6, and 12 months. At 12 months, those in the intervention group were 4.2 times as likely as those in the control group to have an ACQ score in the controlled range. Healthcare utilization was lower in the intervention group, although no difference was observed in FENO or predicted FEV1%.

CONCLUSION

A self-regulation intervention can improve asthma control, quality of life, and healthcare utilization in older adults.

Promoting Asthma Awareness to Older Adults

The limited existing research on the asthma perceptions of older adults suggests that this population perceives asthma to be a childhood disease and, therefore, believe that they are not susceptible to developing the condition as an adult. The asthma mortality rate is much higher for older adults than for children, and there is considerable negative impact on health-related quality of life. However, health promotion regarding asthma is rarely aimed at this population. To address this issue, social marketing campaign messages and materials about asthma were developed for an older adult population based on quantitative survey data. Through a series of community focus groups, these messages and materials were pretested with older adults to establish the types of asthma health promotion messages, taglines, and images that engage this target audience. Materials that conveyed a “human element” appealed most to older adults, enabling them to relate to the individuals and situations depicted in the images. Positive, empowering messages containing novel information and asking questions of the target population resonated best with older adults. These features should be considered in the development of health promotion campaign materials about chronic disease targeting older adult populations.

Microbes and mucosal immune responses in asthma

The substantial increase in the worldwide prevalence of asthma and atopy has been attributed to lifestyle changes that reduce exposure to bacteria. A recent insight is that the largely bacterial microbiome maintains a state of basal immune homoeostasis, which modulates immune responses to microbial pathogens. However, some respiratory viral infections cause bronchiolitis of infancy and childhood wheeze, and can exacerbate established asthma; whereas allergens can partly mimic infectious agents. New insights into the host’s innate sensing systems, combined with recently developed methods that characterise commensal and pathogenic microbial exposure, now allow a unified theory for how microbes cause mucosal inflammation in asthma. The respiratory mucosa provides a key microbial interface where epithelial and dendritic cells interact with a range of functionally distinct lymphocytes. Lymphoid cells then control a range of pathways, both innate and specific, which organise the host mucosal immune response. Fundamental to innate immune responses to microbes are the interactions between pathogen-associated molecular patterns and pattern recognition receptors, which are associated with production of type I interferons, proinflammatory cytokines, and the T-helper-2 cell pathway in predisposed people. These coordinated, dynamic immune responses underlie the differing asthma phenotypes, which we delineate in terms of Seven Ages of Asthma. An understanding of the role of microbes in the atopic march towards asthma, and in causing exacerbations of established asthma, provides the rationale for new specific treatments that can be assessed in clinical trials. On the basis of these new ideas, specific host biomarkers might then allow personalised treatment to become a reality for patients with asthma.

Development and validation of the Patient Asthma Concerns Tool (PACT) to identify the needs of older people with asthma

BACKGROUND

Tools which assist practitioners to identify patient concerns and increase understanding of their needs can improve both the delivery of care and adherence to treatment. The aim of this study was to test the validity and reliability of a 14-item tool, to identify the unmet needs and concerns of older people with asthma.

METHODS

The Patient Asthma Concerns Tool (PACT) was developed from a pool of 55 items derived from a comprehensive literature review. After pilot and field testing, the initial 55 item questionnaire was administered to a community sample (n = 193), psychometrically tested, and refined to a 14 item PACT tool which was evaluated by a group of clinicians.

RESULTS

The PACT was shown to have good content and construct validity and was well received by clinicians. The PACT also correlated well with the Juniper ACQ and Brooks' adherence score on related variables and showed good reliability with good-excellent Kappa and ICC scores. Internal consistency of factors was high, and the overall Cronbach's α was 0.70.

CONCLUSION

The PACT questionnaire was shown to be a valid and reliable tool clinically and psychometrically. We intend to test it in primary care settings and anticipate that its use will assist health professionals to identify the needs and concerns of older patients with asthma and direct tailored asthma management accordingly.

Association of allergic asthma emergency room visits with the main biological and chemical air pollutants

Joint effect of biological (pollen) and chemical air pollutants on asthma emergency room (ER) visits was analyzed for Szeged region of Southern Hungary. Our database of a nine-year period (1999-2007) includes daily number of asthma emergency room (ER) visits, and daily mean concentrations of CO, PM(10), NO, NO(2), O(3) and SO(2), furthermore two pollen variables (Ambrosia and total pollen excluding Ambrosia), as well. The analysis was performed for ER visits of asthma bronchiale using two age groups (adults and the elderly) of males and females for three seasons. Factor analysis was performed in order to clarify the relative importance of the pollutant variables affecting asthma ER visits. Asthma ER visits denote notably stronger associations with the pollutants in adult male than in adult female patients both for the pollen season of Ambrosia and the pollen-free season. Furthermore, adults are substantially more sensitive to severe asthma attack than the elderly for the season of total pollen excluding Ambrosia pollen. The joint effect of the chemical and pollen variables is the highest for the asthma ER cases in the pollen season of Ambrosia, basically due to the extra impact of the total pollen excluding Ambrosia pollen and partly due to Ambrosia pollen. A nonparametric regression technique was applied to discriminate between events of ER visit-no ER visit using pollen and chemical pollutants as explaining variables. Based on multiple correlations, the strongest relationships between ER visits and pollutants are observed during the pollen-free season. The elderly group with asthma bronchiale is characterized by weaker relationships between ER visits and pollutants compared to adults. Ratio of the number of correct decisions on the events of ER visit-no ER visit is lowest for the season of total pollen excluding Ambrosia pollen. Otherwise, similar conclusions hold as those received by multiple correlations.

A comparison of the clinical and induced sputum characteristics of early- and late-onset asthma

BACKGROUND

There are few studies describing the phenotype of late-onset asthma (LOA). We sought to investigate the clinical and induced sputum characteristics of patients with LOA.

METHODS

Nineteen patients with LOA diagnosed after the age of 40 years and 19 patients with early-onset asthma (EOA) diagnosed before the age of 20 years were recruited. Subjects performed lung function, reversibility, asthma control questionnaire (ACQ), exhaled nitric oxide (NO), and sputum induction.

RESULTS

The FEV(1) % predicted was lower in EOA compared to LOA (87.6 % vs. 103 %, respectively, p = 0.02), while ACQ scores were significantly higher in EOA (1.46 vs. 0.89, respectively, p = 0.03). NO was not different between the groups, but the percentage neutrophil counts were lower in the EOA group compared to the LOA group (36.6 vs. 57.3, respectively, p = 0.02). Asthma duration, but not age, was negatively associated with lung function (r = -0.4, p = 0.01). Neutrophil counts in healthy age-matched controls (n = 10) were similar to EOA and lower than LOA.

CONCLUSION

Raised sputum neutrophils in LOA are not an indicator of severe disease and could be a characteristic feature of this asthma phenotype. Duration of asthma influences lung function.

The predictors of poorly controlled asthma in elderly

Purpose

To evaluate asthma control in elderly individuals and identify the factors that predict poor control.

Methods

A retrospective, observational study evaluating 108 elderly individuals with asthma (59 females: ≥60 years, mean age: 70.5 years) was conducted at Ajou University Hospital from October 2010 to March 2011. Subjects were classified into two groups according to scores on the asthma control test (ACT). Group I consisted of 38 patients with ACT scores ≤19 (poor controllers) and group II included 70 patients with ACT scores >19 (controllers). Clinical data was analyzed. Spirometry was performed, and the ACT and asthma quality-of-life survey were completed. Medication possession ratios were calculated to evaluate compliance.

Results

Of the 108 enrolled subjects, 54.6% were female, 7.5% were obese, and 49.0% were atopic. The mean age of the patients was 70.5, and the average of time patients had suffered from asthma was 15.5 years. Comorbid conditions were found in more than 80% of the patients. Allergic rhinitis was most common comorbid condition; this was followed by cardiovascular disease and degenerative arthritis (76.9%, 65.7%, and 51.9%, respectively). Many patients (35.2%) were in poorly controlled states characterized by significantly lower asthma quality of life scores (P<0.001) and higher admission rates (P=0.034). Multivariate logistic regression analysis showed that a history of pulmonary tuberculosis was a predictor of poorly controlled asthma in elderly individuals even after adjusting for age, sex, smoking, lung function and other comorbidities (OR=4.70, CI=1.06-20.81, P=0.042).

Conclusions

The asthma of more than one-third of elderly individuals with this condition was poorly controlled, and a history of pulmonary tuberculosis may have contributed to this outcome. Proper evaluation and management of comorbid conditions in elderly patients with asthma is essential for the achievement of better control of the disease and a higher quality of life for those who suffer from it.

Asthma diagnosis and management

Asthma is a chronic inflammatory airway disease that is commonly seen in the emergency department (ED). This article provides an evidence-based review of diagnosis and management of asthma. Early recognition of asthma exacerbations and initiation of treatment are essential. Treatment is dictated by the severity of the exacerbation. Treatment involves bronchodilators and corticosteroids. Other treatment modalities including magnesium, heliox, and noninvasive ventilator support are discussed. Safe disposition from the ED can be considered after stabilization of the exacerbation, response to treatment and attaining peak flow measures.

Asthma in the Elderly: Can We Distinguish It from COPD?

Asthma in older adults affects quality of life and results in a higher hospitalization rate and mortality. In common clinical practice, asthma in the elderly is underdiagnosed and undertreated or overdiagnosed and mistreated. The age-related reduction in perception of shortness of breath and the high incidence of comorbidities make the diagnosis and management more difficult and challenging for the physicians. Chronic obstructive pulmonary disease (COPD) is usually easy to distinguish from asthma, but sometimes the distinction from late-onset asthma in older patients, particularly in cigarette smokers, is difficult and may be impossible. Both diseases are characterized by the presence of airflow obstruction but have distinct pathogenesis, inflammatory pattern, and prognosis. The distinction between Asthma and COPD based simply on spirometric parameters is difficult especially in the elderly asthmatics. The combination of lung function testing, bronchial hyperresponsiveness (BHR) and atopy status, HRCT scans, and the newly developed biological techniques, allowing the assessment of biomarker profiles, could facilitate the distinction between these diseases.