Management of asthma in adults over 65 years of age

Development group: Gruffydd-Jones, McArthur, Murphy, Russell & Wise.
This management algorithm was developed by a multidisciplinary expert panel: Gruffydd-Jones K et al with the support of a grant from Teva UK Limited.


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This management algorithm was developed by a multidisciplinary expert panel: Gruffydd-Jones K et al with the support of a grant from Teva UK Limited.

Algorithm for the management of asthma in adults over 65 years of age

Diagnosis

  • A diagnosis of asthma is based on clinical assessment supported by objective tests to demonstrate variable airflow obstruction and the presence of airway inflammation
  • Although typical age of onset <20 years, asthma can present at any age, including in the elderly
  • Asthma is often under-diagnosed and under-treated in elderly patients, who may:
    • underestimate their respiratory impairment, mistakenly putting their symptoms down to their age
    • be unable to provide a clear history
  • Lung function tests typically show variable airflow limitation, but it is important to consider that in the elderly a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio <0.7 in the absence of symptoms may be normal
  • When diagnosing asthma, other conditions that can cause breathing difficulties should be excluded, in elderly patients it is especially important to consider: anaemia; anxiety/depression; cardiac disease; deconditioning and obesity; and other respiratory conditions, particularly chronic obstructive pulmonary disease

Assessment

Assess current control

  • Assess control using an appropriate tool, preferably the Royal College of Physicians (RCP) ‘3 questions’ or Asthma Control Test (ACT):
    • well-controlled asthma = 0 (RCP) or 25 (ACT)
    • poor control = 2–3 (RCP) or <20 (ACT)
      • use of short-acting β2-agonist (SABA) 2–3 times a week is also indicative of poor control
    • further information (e.g. positive exacerbation history in the last year or presence of reduced FEV1) is needed to assess control if score is 1 (RCP) or 20–25 (ACT) 
  • Elderly patients may underestimate their own impairment, so ask carers for an indication of day-to-day control

Assess future risk

  • Increased future risk of near-fatal or fatal asthma in older adults may be indicated by:
    • non-adherence, or erratic adherence, with treatment, monitoring, and follow-up appointments 
    • uncontrolled symptoms
    • high use of SABAs:
      • ≥12 SABA inhalers in 12 months
    • inadequate inhaled corticosteroid (ICS) use (not prescribed; poor adherence; sub-optimal inhaler technique)
    • low forced expiratory volume in one second (FEV1), especially <60% predicted
    • major psychological or socioeconomic problems, including:
      • social isolation
      • unstable social circumstances—these will vary in the elderly and may be difficult to ascertain
      • depression
    • exposure to triggers—including respiratory infection
    • co-morbidities (e.g. obesity, rhinosinusitis)
    • blood or sputum (>3%) eosinophilia
    • past admission to an intensive care unit for asthma
    • any contact with a healthcare professional because of asthma symptoms, including visits to the emergency department

Education

  • Educate the patient (including carers, if appropriate) on:
    • self-management
    • personalised asthma action plan and reinforce with every contact
    • lifestyle changes (e.g. smoking cessation)
    • avoidance of potential triggers
    • adherence to medication, particularly ICS
  • To support elderly patients it may be helpful to consider:
    • use of larger print and pictures for patients with visual or cognitive impairment
    • large print labels, patient reminder cards, and tablet compliance aids (e.g. dosette box), to aid adherence 

Pharmacological management

Increasing therapy

  • Increase therapy (step up) in accordance with British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) recommendations

Decreasing therapy

  • Decrease therapy (step down) in accordance with BTS/SIGN recommendations; consider decreasing therapy by 25–50% when symptoms have been well controlled for 3–6 months

Choosing an appropriate treatment

  • Initiate treatment with a low-dose ICS as regular preventer therapy
  • Choose an appropriate treatment in a device that the patient is able to use successfully and consistently
  • Specific considerations for older patients include:
    • cognition, including ability to remember to take medicines at the correct time
    • inhaler technique, including ability to use different types of inhalers
    • hand or manual dexterity, which may affect ability to:
      • use different inhalers—consider use of an aid device  
      • push pills out of blister packaging and open medicine bottles with child-safe lids
    • co-morbidities, which may affect the patient’s asthma or may be an underlying cause of their breathlessness, such as cardiac disease, osteoporosis, depression, diabetes, obstructive sleep apnoea, obesity/metabolic syndrome, and arthritis
    • choice of drug, taking into account existing conditions and drugs and potential risks, such as repeat episodes of pneumonia and potential for cataracts with ICS
    • polypharmacy—increased risk of side-effects, such as dry mouth, tremor, oral thrush, glaucoma, osteoporosis, and osteopenia, and of interactions, e.g. with β-blockers, including eye drops

Long-term management

  • Follow up patients at least annually unless control worsens
  • Refer patients for specialist review if:
    • they are using high dose therapies, as defined by BTS/SIGN
    • there is uncertainty over the diagnosis, for example due to atypical pattern of symptoms
    • there is lack of response to treatment

Useful resources


References

about this management algorithm…

sponsor—

This algorithm has been developed by MGP Ltd, the publisher of Guidelines, and the working party was convened by them. Final editorial decisions rested with the Chair. Teva UK had the opportunity to comment on the technical accuracy of this guideline but the content is independent of and not influenced by Teva UK.

group members

Dr Kevin Gruffydd-Jones (Chair, general practitioner with special interest in respiratory conditions), Ruth McArthur (practice nurse with special interest in allergy and respiratory disease and Education for Health trainer), Dr Anna Murphy (consultant respiratory pharmacist), Dr Richard Russell (consultant respiratory physician), Dr Elspeth Wise (general practitioner)

further information

call MGP Ltd (01442 876100)



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