Under-diagnosed Asthma in the Elderly: Part II

The American College of Chest Physicians reported that asthma has been under-diagnosed in the elderly (Medical Herald, Nov. 1999). This report was based on a population-based research project (the Cardiovascular Health Study) which was designed to assess the epidemiological risks associated with cardiovascular disease in the elderly.

As part of the Cardiovascular Health Study, two thousand, five hundred and twenty seven individuals were studied with spirometry and standardized questions regarding asthma conditions and possible triggers of asthma. A sleep questionnaire was also used. A Spirometer is a machine that measures exhaled airflow and is a good indicator of lung functioning.

The report stated: "…our results suggest that not only is asthma under-diagnosed in elderly persons in the United States and associated with considerable morbidity. But most of those who have had an asthma diagnosis and manifest current symptoms are not being treated properly." They estimate that there is a 15% under-diagnosed rate of asthma in the elderly.

It is reported that 15 million people in the United States including more than one million Americans over 65 suffer from asthma. Results from this study indicate that the one million elderly figure is a minimum figure at best.

The common triggers of asthma include allergens, infections, irritants, cold air and exercise. It tends to flare up most often at night or early morning hours and after an exposure to one of the triggers. It involves the constriction of the air-passages in the lungs.

If you have trouble breathing at certain times, you should see your doctor who may in turn refer you to a pulmonary specialist. This author has recently had that experience following what was diagnosed as the flu, despite having taken flu shots. Symptoms included difficulty in talking, coughing with no phlegm and some fatigue when doing my daily walking. Cardiovascular problems were ruled out. My pulmonary specialist put me through a series of tests, including spirometry and determined I had "probable asthma". He recommended two measured inhalers to be taken daily as well as a steroid to be taken for five days. None of this routine has interfered with my daily routine, except that I try to talk less to preserve my voice.

I will be visiting my pulmonologist once per year regardless of whether I am experiencing symptoms or not. I expect my treating physician to adjust my treatment regimen specifically to my current needs. My HMO covers all this. It is in my best interest to follow this plan to enable me to live a healthy and active lifestyle.

Elderly individuals with asthma are reported to be more likely to have impairments with activities of daily living. As a result they are more negative toward life and may show some symptoms of depression. The daily use of anti-inflammatory medications such as inhaled corticosteroids, plus long acting bronchodilators for more serious cases is now standard therapy. Oral corticosteroids can have untoward side effects, especially in the elderly. Check with your physician if you suspect this condition. It can help the quality of your life.

While there has been improvement in the treatment of asthma, indications are that the improvement has been due to earlier identification of the condition, and the wide spread use of inhaled corticosteroids. Asthma can be seen as either a mild, moderate or severe disease. Each calls for a different approach to its treatment. Mild asthma is usually controlled by use of low dosages of corticosteroid inhalers. Moderate asthma is treated with adding a long-acting beta agonist or a low dose of theophylline. The severe cases may require high doses of corticosteroid inhalers or oral corticosteroid, the long-term use of which is associated with adverse side effects.

A potentially new type of treatment was reported in the Dec. 23, 1999 New England Journal of Medicine. An antibody is injected into the body and is believed to suppress the late-phase reaction of asthma, which is associated with bronchial inflammation followed by bronchococonstriction. It is a recombinant humanized monoclonal antibody called rhuMAb-E25. Henry Milgrom, M.D. and his group at The National Jewish Medical and Research Center as well as other sites throughout the country carried out this study. The study concluded "A recombinant humanized monoclonal antibody directed against IgE has potential as a treatment for subjects with moderate or severe allergic asthma." It would drastically reduce the need for bronchodilators as a rescue medication. The use of the injection may increase compliance with long term therapy, a not uncommon problem in the elderly. Dr. Peter Barnes of the National Heart and Lung Institute, London, United Kingdom, in an editorial in the same Journal where the study was reported states "Further studies…are needed to explore the potential of this exciting new therapeutic approach." It does not have FDA approval.

See also: Part I- Asthma and the Elderly


Harold Rubin, MS, ABD, CRC, Guest Lecturer

December 25, 1999

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