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• Asthma in the elderly is under-diagnosed
• Diagnosis of asthma in older patients
• Suggested diagnostic steps in the elderly
• Indentifying patients with airflow limitations
• Excluding diagnoses other than asthma and COPD
• Distinguishing asthma from COPD
• Spirometry in the elderly
• The role of diagnostic treatment trial in the elderly
• Managing asthma in elderly patients
• References

Summary of practice points	Level of evidence
Always attempt to make the distinction between asthma and COPD, or determine that both are present, so that the optimal treatment can be prescribed	[√]
Spirometry is mandatory for detecting airflow limitation in both asthma and COPD	[√]
The possibilities of both asthma and COPD must be considered in all patients with cough or unexplained breathing difficulty during physical activity	[√]
Demonstration of a small degree of acute reversibility to bronchodilators alone does not distinguish asthma from COPD.	[√]
Avoid the use of oral corticosteroids in treatment trials in elderly patients.	[√]
Warn patients that delay of effective treatment during an acute episode through over-reliance on nebulisers increases the risk of life-threatening asthma	[√]
Be aware that perception of airflow limitation is reduced in older people. Always ask "Can you feel any difference after the reliever?" before measuring post-bronchodilator FEV1	[√]
Check inhaler technique and adherence whenever asthma is reviewed.	[√]
Set up an effective recall process to ensure annual influenza re-vaccination and review of pneumococcal vaccination status in all elderly patients with asthma, even in those with mild asthma.	[√]
Consider a PEF-based asthma action plan for patients who have shown poor perception of airflow limitation.	[√]

Asthma in elderly patients is more common than previously understood.^1-5

• The lifetime asthma prevalence among middle-aged and older Australians is approximately 15%.^4,6 Asthma prevalence in the general adult population is estimated at approximately 10-12%.^7,8
• Emerging international evidence suggests that the prevalences of both asthma and chronic obstructive pulmonary disease (COPD) are increasing.^9-11

The risk of dying from asthma increases with age. The majority of asthma deaths occur in people aged 65 and over, particularly during the winter months.⁷

Asthma in the elderly is under-diagnosed

It has been estimated that up to one-third of elderly people with asthma are not identified by their doctors.^5,12

• Lack of awareness of the possibility of new-onset asthma in the elderly may be a factor in both under-reporting and misdiagnosis.¹³
• Patients and doctors often attribute respiratory symptoms to ageing or common diseases of the elderly.^14,15
• Elderly people may be unaware of reduced respiratory function when activities of daily living are limited by other conditions, or when perception of breathlessness is reduced.¹⁶
• Comorbidity may make the diagnosis of asthma in older people more difficult.

Identifying asthma in elderly patients is clinically important:

• Asthma tends to be more severe in older patients than younger adults, based on spirometric lung function parameters, clinical features of asthma (emergency visits and hospitalisation rates) and comorbidities.^{1,12,17- 21}
• Mortality rates are higher in elderly patients than in younger age groups, and acute asthma attacks more rapidly fatal.²²
• Asthma is associated with significant disability, depression and impairment of mobility in older patients.^1,12,17,18
• In the general population, long-term delay in the diagnosis of respiratory symptoms can lead to progressive and irreversible loss of pulmonary function,²³ while the benefits of prompt treatment are clear, even for mild asthma.^24-27Similar benefits may be expected in the elderly.

Diagnosis of asthma in older patients

As for younger adults, the diagnosis of asthma in older patients is based on:

• history
• physical examination
• supportive diagnostic testing (e.g. spirometry).

For more information, see Diagnosis in Adults.

Diagnostic difficulties in the elderly are listed in Table 1. Despite these difficulties, always attempt to make the distinction between asthma and COPD, because they have different natural histories and expected response to therapy.²⁸

There are many asthma phenotypes, and no single item or procedure can definitively determine the presence of asthma. Diagnosis involves an overall assessment of the patient's medical history, physical examination, laboratory test results and observation over time.

Spirometry is the most effective diagnostic tool available to assist general practitioners in the accurate diagnosis of asthma. Spirometry is mandatory for detecting airflow limitation in both asthma and COPD,^29,30 and helps distinguish between these diseases.

For more information, see COPD and asthma.

Table 1. Diagnostic difficulties in the elderly

Complex differential diagnosis - symptoms of asthma are non-specific and overlap with other conditions that are relatively common among older adults, including COPD, heart failure and lung cancer (e.g. it may be very difficult to distinguish between asthma and COPD in a smoker with a history of asthma) Poor recognition of symptoms - physiological changes of ageing can results in reduced perception of airflow limitation by patient.16 Limited utility of direct tests of airway hyperresponsiveness - these are much less sensitive in people aged over 50 years than in younger adults.31 Comorbidity - deafness, frailty, physical deconditioning and the presence of other chronic conditions (e.g. arthritis, heart disease) can contribute to problems in interpreting symptoms and performing lung function tests. Cognitive impairment may be a barrier to obtaining a clear and thorough history. Social isolation may delay presentation to medical services.

Suggested diagnostic steps in the elderly

A useful diagnostic approach in elderly patients with suspected respiratory disease is:

1. Aim to identify all patients with airflow limitation (either COPD or asthma)
2. Exclude other conditions
3. Distinguish COPD from asthma
4. Consider the possibility that asthma and COPD are both present and overlap.

Practice tip A useful diagnostic approach in elderly patients with suspected respiratory disease is: first: aim to identify all patients with airflow limitation (either COPD or asthma) second: exclude other conditions third: distinguish COPD from asthma and determine whether one or both are present.

Identifying patients with airflow limitation

Helpful questions to ask when taking a history in older adults with suspected airflow limitation (asthma, COPD or both) are listed in Table 2.

Consider symptoms, smoking history and allergies when taking the history.  

Symptoms

The possibilities of asthma and COPD must both be considered in all patients with cough.

• In adults up to 75 years presenting with cough, around half may have asthma or COPD.^32,33
• In patients aged 65 and over with new-onset asthma, the symptoms most frequently experienced are cough, wheeze and dyspnoea. Onset of symptoms commonly coincides with upper respiratory tract infection.³⁴

Smoking history

Smoking history should be taken in all older patients with suspected respiratory disease. Smoking history is a major risk factor for COPD, but cannot rule out the diagnosis of asthma, especially in cases that overlap.

Allergy

History should include questions about history of allergy (hay fever, eczema).

• Atopy has been identified as an important predictor of asthma in the elderly as well as in other age groups^12,35,36
• Ask about previous history of allergies and about seasonal response to environmental, household or animal allergens.¹²
• However, the absence of atopy or other immunological markers of asthma does not rule out an asthma diagnosis. Asthma may be triggered more often by respiratory tract viruses than allergies in older people.³⁴
• Ask about family history as well as past history and of respiratory symptoms. Older people with current asthma symptoms commonly have a family history of asthma and childhood respiratory problems.³⁶

For more information about allergic rhinitis, see Asthma and Allergy.

Table 2. Useful questions for identifying airflow limitation in older adults

Diagnostic questions Have you had any wheezing or whistling in your chest in the last 12 months? Have you had this wheezing whistling when you did not have a cold? Have you woken at night with feeling of tightness in chest in the last 12 months? Have you been woken by an attack of shortness of breath in the last 12 months? Have you been woken by an attack of coughing in the last twelve months? Have you had an attack of asthma in the last 12 months? Are you currently taking any medicine for asthma? Do you have any nasal allergies including hay fever? Risk factors Are you a smoker or ex-smoker? Did you have any allergies as a child? What type of work have you done for most of your life?

Excluding diagnoses other than asthma and COPD

A differential diagnosis for respiratory symptoms in older adults is set out in Table 3.

Where there in any uncertainty as to the cause of new symptoms, a chest X-ray should be done to rule out other significant morbidity or complications (eg pneumothorax) or other diagnoses (e.g. congestive heart failure or lung carcinoma).^35,37,38

Table 3. Important causes for respiratory symptoms in the elderly

Pulmonary	Asthma Chronic obstructive pulmonary disease Bronchiectasis Pulmonary emboli Pulmonary fibrosis Pneumonia, bronchitis Pleural effusion Pneumothorax Malignant disease Aspiration pneumonitis
Cardiac	Arrhythmias Ischaemic heart disease Valvular heart disease Cardiomyopathies Pericardial disease
Neurological	Respiratory muscle weakness Motor neurone disease Myasthenia gravis
Drug-related	Oral and topical beta2 adrenergic receptor antagonists Nonsteroidal anti-inflammatory drugs Angiotensin converting enzyme (ACE) inhibitors
Other	Vocal cord dysfunction Gastroesophageal reflux disease Anaemia Anxiety Tracheal stenosis

Adapted from Dow L, 1998¹⁴

Distinguishing asthma from COPD

Practice points

Always attempt to make the distinction between asthma and COPD, or determine that both are present, so that the optimal treatment can be prescribed. [√] Spirometry is mandatory for detecting airflow limitation in both asthma and COPD. [√] The possibilities of both asthma and COPD must be considered in all patients with cough or unexplained breathing difficulty during physical activity. [√] Demonstration of a small degree of acute reversibility to bronchodilators alone does not distinguish asthma from COPD. [√]

Asthma in the elderly is often difficult to distinguish from COPD. Clinical signs of asthma and COPD overlap. Discriminating between asthma and COPD (Table 4), or concluding that both diseases are present and overlapping, is based on the following:

• symptom information
• degree of reversibility of airflow limitation
• peak expiratory flow (PEF) variability
• bronchial hyperresponsiveness
• history of allergy.

Note that:

• single symptoms do not discriminate between asthma and COPD.³⁹
• maximal relevant diagnostic information is obtained when spirometry is performed before and after bronchodilator and before and after a treatment trial.
• the diagnosis might be made with confidence only after observing and collecting clinical data for weeks or months.

For more information, see COPD and Asthma.

Table 4. Factors that distinguish asthma from COPD

Factor	Asthma	COPD
Young age at onset	Often	Almost never
Sudden onset of disease	Often	Almost never
Smoking history	Sometimes	Almost always
Allergy	Often	Sometimes
Dyspnoea	Often	Often
Wheezing	Often	Sometimes
Coughing	Sometimes	Often
Sputum production	Seldom	Often
Chronic airflow limitation	Seldom	Almost always
Variable airflow limitation	Almost always	Seldom
Reversible airflow limitation	Almost always	Almost never
Airway hyperresponsiveness	Almost always	Sometimes
Diurnal peak expiratory flow variability	Almost always	Sometimes

Adapted from Van Schayck C, 1996⁴⁰ These factors can help distinguish between asthma and COPD, but be aware that both conditions may be present.

Spirometry in the elderly

As in younger adults, spirometry findings must be interpreted carefully, with reference to clinical findings. Clinicians should be aware of potential pitfalls in the interpretation of spirometry in the elderly, listed in Table 5.

• The diagnosis of asthma can be made with a high degree of confidence when post-bronchodilator FEV₁/FVC ratio is greater than 70% and acute reversibility is demonstrated after administration of bronchodilator (a postbronchodilator increase of ≥200 ml and ≥ 12% in FEV₁ or FVC).
• The diagnosis of probable asthma can be made by demonstrating acute reversibility after bronchodilator, even when post-bronchodilator FEV₁/FVC ratio is less than 70%.
• Reversibility of airflow limitation after a therapeutic trial helps confirm the diagnosis of asthma.

For more information on criteria for reversibility of airflow limitation, see Diagnosis in Adults.

COPD

• Spirometry is mandatory for the detection of early stages of COPD in general practice, and at least doubles the proportion of patients identified.³⁰
• The diagnosis of COPD is based on a demonstration of airflow limitation (post-bronchodilator FEV₁/FVC ratio of less than 70%), together with lack of acute reversibility after administration of bronchodilator. This criterion may result in false positives in older people,⁴¹ but that is preferable to under-diagnosis, given the potential poor health outcomes in older people.
• Lack of full reversibility after a therapeutic trial helps confirm the diagnosis.

See COPD and Asthma.

Overlap of asthma and COPD

The presence of overlapping COPD and asthma is a strong possibility in a patient whose clinical profile includes all of the following features:

• Age over 45 years
• A history of smoking
• Reversibility of airflow limitation acutely after bronchodilator or over time
• Post-bronchodilator FEV₁/ FVC <70%.

Table 5. Spirometry pitfalls in the elderly

Spirometry does not rule out asthma

Spirometry (especially post-bronchodilator readings) may be normal in people with asthma. Among older people with respiratory symptoms, spirometry is a sensitive tool for finding COPD cases, but is less sensitive for identifying those with asthma.

Acute reversibility of airflow limitation alone does not rule out COPD

Demonstration of a small degree of acute reversibility to bronchodilators does not, on its own, distinguish asthma from COPD.42 Reversibility of airflow limitation can be demonstrated in people with COPD who do not have a concurrent diagnosis of asthma.43,44 Measuring bronchodilator response on different occasions may result in differing results for reversibility.45,46 Response may differ according to the medication (e.g. salbutamol vs oral corticosteroids), or reversibility criteria used.47

The role of a diagnostic treatment trial in the elderly

A treatment trial attempting to reduce airflow limitation and symptoms can provide valuable diagnostic information.

• An appropriate trial regimen for most patients is ICS given at a dose of 500-1000 mcg fluticasone or 800-1600 mcg budesonide (or equivalent). For safety reasons, ICS is preferable to a short trial of oral corticosteroids.
• For most patients, 4-8 weeks is an appropriate length for a treatment trial.⁴⁸
• The delivery device should be selected individually, based on ease of use and cost.
  - Dry powder inhalers may be easier for older patients to use.
  - When a metered dose inhaler (MDI) is chosen, a spacer should be used.

The response should be monitored according to asthma control, symptoms and spirometry. For more information on monitoring asthma control, see Ongoing Care.

Managing asthma in elderly patients

Drug treatment

As for patients of all age groups:

• the choice of initial treatment is guided by the severity of untreated asthma at the time of diagnosis
• subsequent modifications of the treatment regimen will depend on the degree of symptom control achieved at regular ongoing review.
• the diagnosis should be reconsidered in a patient whose symptoms respond poorly to therapy.⁴⁹

Factors affecting the choice of delivery device in older patients

Comorbidities in older patients will influence the choice of delivery devices:

• Patients who are frail, weak, or have arthritis affecting the hands may need to use additional aids or undergo a trial of various devices to determine the optimal delivery method
• Patients with cognitive disorders may require a carer to help them use MDIs and spacers
• Delivery of drugs by nebuliser may be necessary in some patients.

Prescribing issues

When prescribing asthma medications for elderly patients, choose doses cautiously and monitor closely for adverse effects. Clinical trials conducted for registration purposes have generally included few elderly patients.

Consider these issues and consult the Approved Product Information as necessary:

• When prescribing oral corticosteroids, consider the possibility of reactivation of tuberculosis and monitor closely, particularly in those born in countries with high prevalences.
• Lower initial doses (compared with general adult doses) are recommended for some drugs (e.g. salbutamol).
• Clearance of some drugs (e.g. theophylline) is decreased in the elderly and in those with impaired liver function.
• Consider potential interactions with other drugs, e.g:
  • The risk of hypokalaemia is increased by the concomitant use of beta₂ agonists and diuretics
  • Theophylline and aminophylline interact with a range of agents. If these are used, start with a low dose and monitor closely for drug-drug interactions.
• Elderly patients with multiple comorbidities may experience difficulties taking complex medication regimens correctly. A Home Medicines Review may be useful. For more information, see The role of the community pharmacist.

Asthma and diabetes

The early use of high-dose inhaled corticosteroids in response to potential exacerbations might be considered in patients with diabetes, in order to avoid the use of oral corticosteroids.

Patients with diabetes need to understand how to control hyperglycaemia, should it be necessary to initiate a short course of oral prednisolone during an asthma exacerbation.

Patient education

As for other age groups, offer patients and carers self-management education, and not only information. This education should be aim to help them integrate previous ideas and beliefs about asthma with current knowledge. For more information, see Provide Asthma Self-management Education.

• Cognitive status, dexterity and eyesight must be taken into account when educating patients about the roles and correct use of medicines, and use of inhalation devices (Table 6).
• Ensure that patients and carers are given clear information on when to call emergency services. Inappropriate reliance on nebulisers may delay effective treatment.

Practice points

Avoid the use of oral corticosteroids in treatment trials in elderly patients. [√] Warn patients that delay of effective treatment during an acute episode through over-reliance on nebulisers increases the risk of life-threatening asthma. [√] Be aware that perception of airflow limitation is reduced in older people. Always ask "Can you feel any difference after the reliever?" before measuring post-bronchodilator FEV1. [√] Check inhaler technique and adherence whenever asthma is reviewed. [√]

Table 6. Patient-related factors to consider when choosing a delivery system

Aspects to consider	Delivery system notes
Strength to operate the device Inspiratory flow rate Coordination Agility	MDI versus breath-activated devices Spacers
Visual acuity and ability to judge fill status	Dose counters require good eyesight
Strength and function of hands	Haleraids for patients with arthritis or disability
Cognitive status Understanding of the roles of each medication	Where possible, don't mix inhaler types within a treatment regimen Reinforce when each medication should be taken Reinforce role of nebulisers

Review of asthma in the elderly patient

Practice points
Set up an effective recall process to ensure annual influenza re-vaccination and review of pneumococcal vaccination status in all elderly patients with asthma, even in those with mild asthma. [√] Consider a PEF-based asthma action plan for patients who have shown poor perception of airflow limitation. [√]

The principles of asthma review in the elderly patient are the same as for other age-groups with asthma. The appropriate frequency of review depends on severity e.g, weekly review may be appropriate in a patient with a recent life-threatening asthma attack; review every 6 or 12 months may be suitable for someone with stable mild persistent asthma.

• Ask whether the patient has experienced any problems with asthma, medication or monitoring.
• Ask about night waking with asthma, morning symptoms, asthma-related limit of normal activity, shortness of breath, wheeze and short-acting beta₂ agonist (SABA) use. For questionnaires available for use in monitoring asthma, see Ongoing Care.
• Ask whether there have been any changes in the use of medications.
• Ask about adherence to the treatment plan.
• Ask about any changes in the environment.
• Ask whether there are any aggravating factors (e.g. gastric reflux).
• Ask whether the person took his or her reliever bronchodilator medication.
• Perform spirometry before and after bronchodilator, and check perception of post-bronchodilator effect.
• Check device technique.
• Check the patient's (and/or carer's) understanding of the asthma action plan by asking "What would you do if ...?".

Factors that commonly complicate the monitoring of asthma control in older people include:

• reduced perception of airflow limitation
• comorbidities (e.g. poor eyesight, hearing impairment, weakness due to osteoarthritis, cognitive deficits, neurological deficits secondary to cerebrovascular disease)
• psychosocial issues (e.g. lack of carer, dependence, lack of confidence, depression, perceived and actual financial barriers, resistance to accepting the diagnosis, low motivation).

Consider these strategies to overcome common difficulties:

• For patients with impaired grip strength, add a device to a standard inhaler to make actuation easier (e.g. Haleraid).
• Put a large, easily visible marker on the PEF meter to make it easier for a person with poor eyesight to judge PEF relative to best recorded value (compared with reading from the scale)
• For patients who cannot perform PEF monitoring (e.g. due to stroke or dementia), teach a carer to observe for signs that indicate increased respiratory work:
  • inability to speak in sentences of more than a few words between breaths
  • respiratory distress or marked anxiety
  • acute cognitive impairment compared with usual status.

Perception of airflow limitation

Assessment of the patient's ability to perceive changes in airway function is an important part of the assessment of older patients, both when initiating treatment and at each subsequent review.

Perception of airway function can be assessed in two ways:

1. Asking about the use of SABAs

An elderly patient who gives a history of using SABAs in response to asthma symptoms probably has reasonably good perception of airflow limitation.

2. Checking whether the person is aware of a change in symptoms or ease of breathing when a large post-bronchodilator response in FEV₁ (or PEF) is measured.

• Routinely ask "Can you feel any difference after the reliever?" before measuring post-bronchodilator FEV₁. If other staff (e.g. practice nurses) are performing spirometry, train them to include this question with all older patients.
• If the patient has not perceived any change despite a large response (e.g. an increase in FEV₁ of > 20% and > 400 mLs), it is advisable to write a PEF-based asthma action plan.

Practice tip Schedule a consultation specifically to assess asthma if possible, because: It is difficult to check all these aspects of asthma at one review Asthma control can only be assessed when exacerbations are absent.

Vaccination

Check the status of influenza and pneumococcal vaccination every year in February-March. Ensure that an effective recall process is in place to ensure annual influenza re-vaccination in all elderly patients with asthma - even in those with mild asthma - and that initial pneumococcal vaccination and subsequent revaccination occurs in line with NHMRC recommendations.

Acute exacerbations and action plans in elderly patients

Comorbidity must be considered when planning management of asthma exacerbations in the elderly.

• Where feasible, a PEF-based asthma action plan should be considered for patients who have shown poor perception of airflow limitation.
• A large-print (or handwritten) action plan, or an audiotape of the action plan may benefit visually impaired patients.
• Patients whose first language is not English may need an audiotape of the action plan in their native language.

See Asthma Action Plans.