Asthma in the elderly: diagnosis and management

The National Asthma Education and Prevention Program's "Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma" apply to all ages. This review discusses additional specific points for elderly patients. These patients are very heterogeneous. Their asthma can have begun at any time and can vary greatly in severity. It is frequently associated not only with any of the diseases that affect older persons but also with comorbid lung diseases. Many patients have irreversible airway obstruction, which is due to severe airway remodeling, chronic obstructive pulmonary disease, or bronchiectasis. Diagnosis should include chest radiography and computed tomographic scanning to diagnose other lung diseases if FEV₁ remains low after treatment. Asthma pathogenesis includes not only IgE-mediated allergy but also innate immune inflammation from endotoxin and trypsin-like proteases, and therefore evaluation and control of environmental exposures is an important part of management. Pharmacologic treatment, too, is adjusted to achieve and maintain control and is basically the same for all ages, except that elderly patients have reduced response to bronchodilators and increased side effects from beta adrenergic agonists and glucocorticoids. Many elderly patients have difficulty inhaling aerosols, and therefore nebulizers might be a better delivery system. Oral medications have the benefit of greater ease of administration and greater efficacy on the peripheral airways. Leukotriene antagonists and low-dose theophylline are often helpful additives to aerosol glucocorticoids. Oral glucocorticoids might be indicated for severe asthma.