Aging & Asthma

Helping Seniors Cope: Symptoms, Treatment, Equipment and Compliance Strategies

One of the best kept secrets in respiratory is that seniors develop asthma.

In the course of a lifetime, the respiratory system takes quite a beating. As a person gets older, the long-term effects of air pollution, smoking, passive smoking and allergens weaken the airways. Though the root cause is unknown, these factors may contribute to asthma in adulthood.

“You have to wonder if they didn’t have something underlying to begin with that maybe just wasn’t diagnosed, wasn’t severe enough, and now that they’ve gotten older, all of these things sort of come together like a switchboard that’s overloaded,” says Carol Proctor, RRT, RPFT, AE-C, The Lung Center, Clearwater, Fla.

Approximately 6 to 10 percent of seniors in the United States have asthma, according to the American Academy of Allergy, Asthma and Immunology (AAAAI). Asthma diagnosed in childhood can reappear later in life. Yet new asthma diagnosis among seniors is not uncommon.

Different Symptoms for Different Generations
Because asthma is typically thought of as a childhood disease, it is often misdiagnosed or overlooked in seniors.

“Sometimes a nighttime cough may be the only symptom,” says Marianne Frieri, M.D., Ph.D., FAAAAI, FACAAI, chief of Allergy Immunology, Department of Medicine at Nassau University Medical Center; professor of Medicine, Pathology at SUNY, Stony Brook; private practice at North Shore Allergy & Asthma Institute, Long Island, N.Y.

If patients don’t hear wheezing, many attribute their symptoms to something else entirely, such as the effects of aging. “As we get older, we think it’s because we’re out of shape or we’ve picked up weight. We don’t realize there’s really something going on, especially if we don’t hear a wheeze,” Proctor says.

In fact, pursuing a healthier lifestyle might reveal asthma symptoms previously overlooked, especially if a senior quits smoking or begins an exercise program. Also, seniors’ immune systems are weaker and the muscle-to-fat ratio decreases as a person ages, which makes seniors more fragile, Proctor says.

Even if seniors notice a problem, they don’t always report it. “There’s still stigma attached to having illnesses, especially if they’ve had a smoking history and they feel guilty about everything they have. They may try to minimize it,” Proctor says. “People of my parent’s generation and older, they didn’t complain about things. You just went through it because often as children, (you) didn’t see physicians and you didn’t go to the hospital unless you were dying.”

Treatment Variables
Once asthma is identified, the treatment varies somewhat from childhood asthma. For one thing, inhaled steroids play a larger role.

Proctor says older patients have stronger parasympathetic nervous systems than younger patients. As a result, inhaled steroids are more effective than bronchodilators.

“It’s a little different emphasis for them as they get older,” Proctor says. “Their responses are different.”

One challenge to treatment is that seniors often take multiple medications to manage co-morbidities. Some conditions prevalent among seniors can worsen asthma symptoms or prevent diagnosis, including gastric reflux disease, thyroid problems, heart disease, hypertension and sinusitis. Also, medications for these conditions could interact with asthma medications.

Frieri outlines the following factors that must be considered when treating asthma in seniors:
• Natural decline in lung function, which might lower goals
• Adverse medication side-effects and potential drug interactions
• Therapy for co-existing conditions, which can worsen asthma
• Cognitive or physical limitations that might limit a patient’s ability to participate fully in treatment.

As a result, treatment may need to be individualized to account for physical, social and emotional changes, according to Frieri.

“You have to look at the complete patient,” Proctor says. “Of course, that’s more complicated when they get older. They come to us with more history; they come to us with co-morbidities.”

Allergies also play a less clear role in older asthmatics. Frieri reports that the prevalence of allergic asthma in seniors is lower than in younger asthmatics. Still, seniors must pay careful attention to triggers. Some triggers might go unnoticed, such as bedroom carpets, passive smoke and ozone air pollution, Frieri says.

“Asthma patients should avoid exercise outside with pollen count,” Frieri recommends. Also, “ozone exposure has been associated with poorly controlled asthma in elderly adults,” she continues. “What’s really interesting is ozone exposure can sometimes even link with the pollen, and if someone is allergic to pollen, the ozone and the pollen together could be a co-factor.”

As with children, an asthma action plan is vital. The plan, separated into three zones, outlines a specific strategy for worsening asthma symptoms, such as going to the hospital when peak flow readings hit certain levels.

Teaching Compliance
Getting seniors on the right track with treatment can be difficult. For starters, the learning curve can present a challenge.

Proctor says it’s important that clinicians make sure patients understand as much as possible about their medications and condition, specifically the purpose of medications, the effects (and side effects) of medications and the effects of asthma on the lungs.

Education is essential to patient compliance, and clinicians must take care in how they deliver information. “Especially with older people, you have to have a demonstration, have them return the demonstration, explain it, give them written instructions, usually give them something that’s pictorial also,” Proctor says. “Often the equipment that we give them to use has pictures on it in addition to something that they can read, depending on how they actually get information.”

Proctor says she tries to present information in different ways to meet the learning styles of different patients. Frequent, shorter sessions are better, she says. As patients repeat equipment demonstrations, she also helps fine-tune their technique and reinforces what they do correctly.

Proctor says any information that is distributed must be printed large enough for seniors to read. “Some places put things on green or blue paper. You can’t do that because as people get older they can’t make those differentiations,” she says. “Some of the more exotic looking types are difficult for seniors to read. The instructions need to be clear. The key points need to be brought out.”

Marking the key elements for success can help seniors, Proctor says.

Sometimes seniors are resistant to taking long-acting medications and instead try to rely on rescue inhalers. “I’ll say take it three weeks just like the doctor has ordered you to take it, and then if you don’t feel it’s helping you, try a day or two without it,” she says. “Usually that’s enough time for it to build up in their system for them to very slowly start to feel better, and then when they stop it, they notice the change. Sometimes that’s the only way you can convince them.”

The National Heart, Lung and Blood Institute lists the following barriers to treatment, which can serve as a guideline for clinicians:
• Decreased ability to handle multiple stimuli
• Memory problems
• Loss of coordination and muscle strength
• Hearing and visual difficulties
• Sleep disturbances that may impair cognitive function
• Depression.

Equipment Connection
Frieri says that oftentimes a co-existing condition, such as arthritis, can prevent a senior from using a metered-dose inhaler. As a result many seniors require nebulizers.

“A lot of times they don’t use the device properly and they don’t open their airway and then let it go in,” she says. “They may just puff it in and it doesn’t get down. It doesn’t reach the lower part of their lungs and that’s a problem. It gets caught in their mouth.”

Proctor says that while seniors with arthritis may have trouble with inhalers, she sees more seniors who prefer inhalers.

“Some of the newer inhalers are easier to use,” Proctor says. “You still have some folks that will cling to the nebulizer, but usually if they’re active, they don’t want to be tied down to that.”

If seniors prefer a nebulizer, Proctor says it’s essential that they clean it regularly because contamination could be a problem.

A spacer can assist seniors who use an inhaler. “The spacers are nice because they have that harmonic tone that tells them if they’re taking it in too fast,” Proctor says.

One critical component of asthma management is a peak flow meter. The inexpensive, easy-to-use device provides a “real-life measurement,” says Frieri. “Some elderly don’t want to do it because they have to blow three times and take an average. But it helps guide (them); it’s like a poor man’s choice of looking at the large airway.”

The peak flow goals differ slightly from children, and with co-existing conditions, like emphysema, using the device may be less meaningful. Peak flow can help distinguish asthma symptoms from co-existing heart and lung diseases, however. It’s important to take the individual’s abilities and limitations into consideration when recommending a peak flow meter.

Proctor cautions that peak flow meters are a monitoring tool only and should not be used for diagnosis. For a patient with a large asthmatic component to their disease, a peak flow meter can help identify symptoms, she says. For example, someone who doesn’t sleep well may have trouble breathing. A peak flow meter can help determine if the breathing problems are a result of fatigue or an asthma attack. “I now have something objective that I can look at and compare,” Proctor says. “It’s not like when you cut yourself and you can see that you’re bleeding. It’s a much more subtle thing.”

RT Toolbox
Respiratory therapists play a critical role in helping patients manage their asthma. RTs can help patients succeed by following these tips:
• Be sensitive to possible illiteracy. “Sometimes, there’s a literacy issue and often they’re embarrassed to admit (it),” Proctor says. “Some of these people did not have the opportunity to go through more than maybe elementary school at the most, and they’re embarrassed by that. That’s another reason for going through things orally and giving pictorial instructions.”
• Recommend that patients use diaries. The diary helps patients keep track of important information, such as how to do peak flow and the information they’ll need when they call the doctor. Plus, patients can record daily peak flow measurements for comparison and jot down asthma triggers.
• Show patients breathing techniques. Proctor says she instructs patients to use their hands as cues to feel how they’re breathing. “Have them practice things at home for short periods. Never have them do it for long periods,” she says. A commercial break while watching TV is a perfect time to practice breathing techniques. “If I’m teaching them pursed or diaphragmatic breathing, I show them and I have them put it with going up steps, going up a hill, walking on a treadmill,” Proctor says. “You can practice this sitting down or lying down, (but) it doesn’t do you any good if you can’t use it when you’re moving.”
• Remind patients to rinse their mouths. If a steroid is being used, seniors can develop a yeast infection in their mouth if they aren’t rinsing afterward, Frieri says.

Remodeling Airways
According to Marianne Frieri, M.D., Ph.D., elderly asthma patients may experience airway remodeling, a condition where the physiological characteristics of the airway changes, thereby creating irreversible effects. With persistent and severe asthma, especially, obstruction in the bronchial tubes may not be reversible, and could be difficult to differentiate from COPD or other lung conditions.

According to an article published in the American Journal of Respiratory Critical Care Medicine, injured tissues typically respond with acute inflammation. In healing, those tissues regenerate and replace connective tissues that eventually turn into scar tissue. Usually, this process is beneficial, but in asthma, a chronic inflammatory process, airways sometimes heal in a way that alters the structure of those tissues.

The structural changes could manifest as a thickened airway, involving increased muscle mass, mucous glands and vessel area, which permanently reduces the airway’s caliber. The result is reduced airflow and increased mucous secretion, which could close the airway.

Remodeling occurs in both children and adults. Studies show that FEV1 decreases mainly in those with persistent asthma, but remodeling is more prevalent in severe asthma cases. Studies suggest that irreversible airway obstruction is usually associated with the frequency of wheezing and ongoing asthma, according to the journal. In addition, it appears that patients whose asthma appears after age 50 usually experience steeper declines in lung function.

This article originally appeared in the Respiratory Management April 2008 issue of HME Business.

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