Professor Monroe J. King

Clinical Associate Professor Monroe J. King, D.O., University of South Florida College of Medicine

Asthma is often overlooked in older patients, but why?

We asked two leading experts to weigh in. Dr. Charles E. Reed is a former head of the division of allergic diseases at the Mayo Clinic in Rochester, Minn. Dr. Monroe King is an associate professor of medicine in the division of allergy and immunology at the University of South Florida and a consultant to the National Institute on Aging for asthma and allergic diseases. This story represents an edited version of their remarks, made in separate interviews.

Q Can people get asthma for the first time later in life?

Reed: Yes. Our epidemiologic studies in Rochester showed us that asthma can start at all ages, even in the elderly. At the same time, people continue to recover from asthma even after age 65. We're not sure exactly why, but we think it's because something in their environment changes.

King: There are two peaks of asthma onset: One, in children and younger adults; the other, in people middle age and older.

Q What distinguishes people who get asthma later?

Reed: When older people get asthma, they seem to have more severe disease. When I reviewed the elderly asthmatics we saw at the Mayo Clinic — at least 1,000 a year — over 40 percent of them had irreversible lung diseases such as chronic obstructive pulmonary disease or chronic lung infections.

Many of these individuals smoked at one point. Exposure to bad things in the environment — cigarette smoke, moldy houses, contaminated air conditioning systems, nasty workplaces — doesn't just cause asthma, it causes other lung diseases.

King: Older people who get asthma tend to have fewer allergies. The course of their illness is stormier — they tend to have more exacerbations of asthma, more hospitalizations and the highest rate of death of any age group. That may be because older people's immune systems aren't as robust as younger adults. Also, older people tend to get more respiratory infections.

Q What about treatment of older adults with asthma?

Reed: Older adults often tend to have a poorer response to treatment. Also, they often have other conditions that can make it difficult for a physician to sort out all the details. Young people with asthma are all pretty much similar. Older folks with asthma, each one is different.

King: Older people may also have more difficulty using asthma inhalers if they have arthritis or problems with coordination.

The asthma medications we use for older adults are the same. But because patients frequently have co-occurring conditions and are taking other drugs, there is more risk of adverse reactions.

Take, for example, older people with tremors. Asthma medicines can increase tremors sometimes. There are safety questions about some of the beta-agonists (medicines that help open the airways). The FDA has a black box warning for those drugs that applies to everybody, but there are concerns that older people might be at greater risk, especially for heart troubles. Also, beta blockers and ACE inhibitors for hypertension can make asthma worse.

Q I know there are gender differences with asthma. Is this true of older adults?

King: Yes. In studies by both the Centers for Disease Control and the New York State Health Department, epidemiologists have shown that women at menopause and older are three times more likely to be hospitalized as men with asthma. Women over the age of 65 are twice as likely to be hospitalized and twice as likely to die of asthma as men.

Q What's going on?

King: We don't know if hormones directly affect asthma. But we do know that boys under the age of 12 have twice as much asthma as girls do. By age 20, girls have twice as much asthma as boys. This reaches a ratio of three to one by the age of menopause.

Q You mentioned that fewer older adults have allergy-induced asthma. Can you tell me more about this?

Reed: It's really quite unusual for someone over the age of 40 to develop an allergy to something unless it's something that they haven't been exposed to before. Yet, people still develop asthma in later middle age and beyond, even though they're not getting allergies. This is called "intrinsic asthma" as contrasted to "allergic asthma."

The cause of intrinsic asthma has not been established. The pathology and physiology is similar to allergic asthma, but the environment exposures and molecular processes that lead to airway inflammation have not been identified.

Q Is getting an asthma diagnosis hard for older adults?

King: This condition is under-diagnosed, and patients don't think of asthma as a disease older people can get. So, frequently older people attribute difficulty with breathing to aging. They just decrease their level of activity to accommodate it.

Q What would you advise an elderly person who's having problems breathing?

King: Have a pulmonary function test. And if your primary doctor can't do one, get referred to a pulmonologist or an allergist who can.

Seniors and asthma

Prevalence: Six percent to 10 percent of seniors may have asthma — a chronic inflammatory condition that affects airways in the lungs.

Symptoms: Coughing, chest tightness, shortness of breath, wheezing.

Diagnosis: Can be difficult, as asthma can co-exist with conditions that have similar symptoms, including chronic bronchitis, congestive heart failure, sinusitis, gastrointestinal reflux and chronic obstructive pulmonary disease.

Concerns: Drugs used to treat asthma can exacerbate osteoporosis. Drugs used to treat other conditions — beta-blockers, ACE inhibitors, aspirin, non-steroidal anti- inflammatory medications — can trigger or worsen asthma.

Treatment: Eliminate environmental triggers such as dust mites or mold. Use medications to reduce inflammation and open inflamed airways.

SOURCE: American Academy of Allergy, Asthma & Immunology