Features of asthma in the elderly

Long-term predictors of severe exacerbations and mortality in a cohort of well-characterised adults with asthma

Background

We aimed to explore long-term predictors of severe exacerbations and mortality in adults with well-characterised asthma.

Study design and methods

Adults (aged ≥ 15) with an objectively verified diagnosis of asthma were recruited from a Danish respiratory outpatient clinic between 1974 and 1990. All individuals were followed in Danish registries for vital status, hospital admissions for asthma and cause of death until end of 2017. Predictors of exacerbations were obtained from a repeated measures model. Standardised mortality rates (SMR) for all-causes were compared with the Danish background population. Hazard ratios for mortality were obtained from a cox proportional hazards model in a two-step process.

Results

At baseline, the cohort comprised 1071 patients (mean age 38, SD 16, 61% women), of whom 357 (33%) died during follow-up, with 93 (26%) dying from asthma (primary diagnosis). We found an SMR of 1.24 (95% CI 1.11–1.37, p < 0.001) for all-cause mortality. Baseline predictors for asthma-related death and repeated severe exacerbations were increasing age, ever smoker, FEV₁ < 80% pred., high blood eosinophils, longer duration of symptoms and use of SABA > twice daily. Being non-atopic, having a positive histamine challenge test and symptoms more than twice a week were also predictors of repeated exacerbations.

Conclusions

Markers of poor asthma control, including high use of SABA, are predictors of long-term exacerbation rate and mortality over 30 years in patients with well-characterised asthma. Improving asthma control, including lung function and reducing use of reliever medication, is vital for improving the long-term outcome of asthma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01864-z.

Insomnia and Daily Function in Older Adults With Asthma

The current study examined the prevalence of insomnia and its relationship with daily function in older adults with asthma. Data on 278 older adults with asthma (aged ≥60 years) from the 2005-2008 National Health and Nutrition Examination Survey were analyzed. Insomnia was present in 40% of the study sample and was associated with a greater number of activities of daily living (ADL) and instrumental ADL (IADL) limitations. In multivariate analyses accounting for covariates including depressive symptoms, insomnia was not associated with having at least two ADL/IADL limitations. However, those with co-occurring insomnia and depressive symptoms were more likely to have at least two ADL/IADL limitations compared to those with either condition singly. Insomnia in the presence of depressive symptoms may impede one's ability to perform ADL/IADL. Current findings suggest that assessment and treatment of insomnia and depression in older adults with asthma may be important for maintaining active, independent living. [Journal of Gerontological Nursing, 46(11), 28-36.].

Asthma Across the Ages: Adults

Asthma is a common disease affecting approximately 300 million people worldwide, across all age ranges. Despite advances in asthma outcomes of the last few decades, there remains room for improvement in asthma management and for patient outcomes, particularly in older patients. The heterogeneity of asthma is now well recognized, and is known to complicate response to treatment and patient behavior and impact health outcomes. Asthma and its heterogeneity change according to age. Asthma affects people differently across the life span. In adults, prevalence is highest among those in middle age; however, mortality is greater in the older age group. In this clinical commentary, we describe how age impacts asthma prevalence and incidence, outcomes, disease expression, and approach to management in adulthood and in older patients.

Is asthma in the elderly different? Functional and clinical characteristics of asthma in individuals aged 65 years and older

BACKGROUND

The prevalence of chronic diseases in the elderly (> 65 years), including asthma, is growing, yet information available on asthma in this population is scarce.Our objective is to determine the differential clinical and functional characteristics of the population > 65 years old with asthma included in the Integrated Research Programs of Asthma Databank of the Spanish Society of Pneumology and Thoracic Surgery (www.bancodatosasma.com).

METHODS

Retrospective comparative descriptive study of demographic, clinical and functional variables for 1713 patients with asthma categorized into 3 age groups as follows: adults aged < 65 years (A), younger elderly aged 65-74 years (B) and older elderly aged ≥75 years (C).

RESULTS

Predominant features of elderly patients with asthma (N = 471) were the female sex, fewer smokers, greater obesity, poorer lung function, and lower values of nitric oxide in exhaled air (p < 0.01). The most frequently associated comorbidity was gastroesophageal reflux. The highest doses of inhaled corticosteroids were by group A (60.8%). For the sample overall, 23.2% (N = 398) were being treated with omalizumab and 8.2% (N = 140) were corticosteroid-dependent (10.6% in group B). The highest percentage of patients receiving antileukotriene agents was in group B (42.9%).

CONCLUSIONS

Asthma in adults aged> 65 is more severe and associated with greater comorbidity, which would indicate the need for a more integrated and multidimensional approach to asthma treatment for these patients.

Asthma Over the Age of 65: All's Well That Ends Well

Asthma in older adults (often classified as those 65 years or older) is relatively common, underdiagnosed, and suboptimally treated. It is an important health problem, as the population of the United States continues to age. Unfortunately, asthma morbidity and mortality rates are highest in this age group. Alterations in the innate and adaptive immune responses occur with aging, and contribute to pathophysiologic differences and subsequent treatment challenges. The symptoms of asthma may differ from those in younger populations, and often include fatigue. There are unique factors that can complicate asthma management among older adults, including comorbidities, menopause, caregiver roles, and depression. Pharmacologic therapies are often not as effective as in younger populations, and may have greater side effects. Spirometry, peak flow measurements, and asthma education are typically underused, and may contribute to delays in diagnosis as well as worse outcomes. There are specific strategies that health care providers can take to improve the care of older adults with asthma.

Asthma in the elderly and late-onset adult asthma

Elderly asthmatics are at a higher risk for morbidity and mortality from their asthma than younger patients. There are important age-related physiologic and immunologic changes that complicate the presentation, diagnosis, and management of asthma in the aged population. Evidence suggests that elderly asthmatics are more likely to be underdiagnosed and undertreated. Additionally, elderly patients with asthma have highest rates of morbidity and mortality from their disease than younger patients. The underlying airway inflammation of asthma in this age group likely differs from younger patients and is felt to be non-type 2 mediated. While elderly patients are underrepresented in clinical trials, subgroup analysis of large clinical trials suggests they may be less likely to respond to traditional asthma therapies (ie, corticosteroids). As the armamentarium of pharmacologic asthma therapies expands, it will be critical to include elderly asthmatics in large clinical trials so that therapy may be better tailored to this at-risk and growing population.

Exacerbation risk and characterisation of the UK's asthma population from infants to old age

BACKGROUND

Few studies have examined the characteristics of a general asthma population; most have focused on more severe patients or severe exacerbations.

METHODS

This population-based cohort study, from April 2007 to September 2015, used linked primary and secondary care electronic healthcare records (Clinical Practice Research Datalink, Hospital Episode Statistics). Characteristics of four age cohorts, 'Under 5s', '5 to 17s', '18 to 54s', '55+', were described. Exacerbation risk factors, including asthma severity (measured by the British Thoracic Society (BTS) stepwise approach), were assessed using Poisson regression.

RESULTS

424 326 patients with current asthma were eligible (n, median follow-up: 'Under 5s'=17 320, 1 year; '5 to 17s'=82 707, 3.3 years; '18 to 54s'=210 724, 4 years; '55+'=113 575, 5.1 years). Over 60% of the total study population had mild asthma (BTS steps 1/2). There were differences between the cohort's characteristics, including by gender, disease severity and exacerbation pattern. The rate of exacerbations was highest in the oldest cohort and lowest in the '5 to 17s' cohort (rate per 10 person-years (95% CI), 'Under 5s'=4.27 (4.18 to 4.38), '5 to 17s'=1.48 (1.47 to 1.50), '18 to 54s'=3.22 (3.21 to 3.24), '55+'=9.40 (9.37 to 9.42)). In all cohorts, exacerbation rates increased with increasing asthma severity, after adjusting for confounders including gender, socioeconomic status, smoking, body mass index, atopy, rhinitis, gastro-oesophageal reflux, anxiety, depression and COPD.

CONCLUSION

The majority of UK patients with asthma had mild asthma and did not experience an exacerbation during follow-up. Patients aged ≥55 years had the lowest proportion with mild asthma and highest rate of exacerbations; the opposite was found in patients aged between 5 and 18 years.

Pathways linking health literacy, health beliefs, and cognition to medication adherence in older adults with asthma

BACKGROUND

Limited health literacy is associated with low adherence to asthma controller medications among older adults.

OBJECTIVE

We sought to describe the causal pathway linking health literacy to medication adherence by modeling asthma illness and medication beliefs as mediators.

METHODS

We recruited adults aged 60 years and older with asthma from hospital and community practices in New York, New York, and Chicago, Illinois. We measured health literacy and medication adherence using the Short Test of Functional Health Literacy in Adults and the Medication Adherence Rating Scale, respectively. We used validated instruments to assess asthma illness and medication beliefs. We assessed cognition using a cognitive battery. Using structural equation modeling, we modeled illness and medication beliefs as mediators of the relationship between health literacy and adherence while controlling for cognition.

RESULTS

Our study included 433 patients with a mean age of 67 ± 6.8 years. The sample had 84% women, 31% non-Hispanic blacks, and 39% Hispanics. The 36% of patients with limited health literacy were more likely to have misconceptions about asthma (P < .001) and asthma medications (P < .001). Health literacy had a direct effect (β = 0.089; P < .001) as well as an indirect effect on adherence mediated by medications concerns (β = 0.033; P = .002). Neither medication necessity (β = 0.044; P = .138) nor illness beliefs (β = 0.007; P = .143) demonstrated a mediational role between health literacy and adherence.

CONCLUSIONS

Interventions designed to improve asthma controller medication adherence in older adults may be enhanced by addressing concerns about medications in addition to using communication strategies appropriate for populations with limited health literacy and cognitive impairments.

'Get Your Life Back': process and impact evaluation of an asthma social marketing campaign targeting older adults

Background

Asthma in older adults is underdiagnosed and poorly self-managed. This population has little knowledge about the key symptoms, the prevalence among older adults, and the serious consequences of untreated asthma. The purpose of this study was to undertake a multifaceted evaluation of a social marketing campaign to increase asthma awareness among older adults in a regional Australian community.

Methods

A cohort of older adults in an intervention region (n = 316) and a control region (n = 394) were surveyed immediately prior to and following the social marketing campaign. Campaign awareness, message recall, materials recognition, and actions taken as a result of the campaign were assessed in both regions. Asthma knowledge and perceptions, experience of asthma symptoms, and general health were also assessed in both regions at baseline and follow-up. Analyses were conducted to explore the effects of the campaign in the intervention region, and to examine outcomes among different audience segments.

Results

The survey data showed that those in the target segments (Wheezers and Strugglers) had better message recall, and were more likely to report having taken action to control their respiratory symptoms. The campaign significantly increased the number of calls to an asthma information line from the target audience in the intervention community.

Conclusions

A theory-based social marketing campaign conducted over 3-months increased the asthma information seeking behaviours of older adults in the intervention community compared to the control community. Recommendations are outlined for future community health promotion campaigns targeting older adults.

The association of health literacy with illness and medication beliefs among older adults with asthma

OBJECTIVE

Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs.

METHODS

Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n=420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models.

RESULTS

Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2-2.82; OR: 2.22, 95% CI: 1.29-3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (β=0.92, p=.05), despite recognizing their necessity (β=-1.36, p=.01).

CONCLUSIONS

Older asthmatics with low HL endorse erroneous asthma beliefs.

PRACTICE IMPLICATIONS

Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.

The asthma knowledge and perceptions of older Australian adults: implications for social marketing campaigns

OBJECTIVE

The purpose of this research is to gain an understanding of the asthma perceptions of older adults and identify gaps in their asthma knowledge.

METHODS

In regional New South Wales, Australia, a stratified, random sample of 4066 adults, aged 55 years and over, both with and without an asthma diagnosis, completed a survey based on the Health Belief Model about asthma knowledge and perceptions.

RESULTS

Almost half of the sample had experienced symptoms of breathlessness in the past four weeks. Breathlessness was a predictor of lower health ratings and poorer mood. Older adults reported low susceptibility to developing asthma. The sample demonstrated poor knowledge of key asthma symptoms including shortness of breath, tightness in the chest and a cough at night.

CONCLUSION

There is a general lack of asthma awareness in this age group. This could result in not seeking medical help, and thus a reduced quality of life.

PRACTICAL IMPLICATIONS

Older adults should be made aware of key symptoms and the prevalence of asthma in the older adult population, and be empowered to take control of their respiratory health. Audience segmentation for an intervention should be based on recent experience of breathlessness and asthma diagnosis.

The effect of oral tolerance on the allergic airway response in younger and aged mice

BACKGROUND

The effect of increased age on the induction of oral tolerance by low-dose antigen feeding and its effect on the response to antigen airway challenge in aged mice have not been well characterized.

OBJECTIVE

To determine whether oral tolerance can be induced in aged mice and its impact on the development of allergic airway inflammation.

METHODS

Younger (6 weeks old) and aged (18 months old) mice were fed ovalbumin (OVA) prior to sensitization to induce antigen tolerance. Serum antigen-specific immunoglobulins (Igs), bronchoalveolar lavage fluid (BALF), lung histology, enumeration of CD4 + Foxp3+ Treg cells, and airway hyperresponsiveness (AHR) were determined after the final antigen challenge.

RESULTS

Feeding antigen to aged mice prior to sensitization induced oral tolerance as determined by a decrease in antigen-specific IgE and IgG(1); however, the effect was greater in younger mice. Induction of oral tolerance was associated with a greater increase in airway Treg cells in the younger mice. Despite these differences, oral tolerance significantly suppressed features of asthma in aged mice, including BALF total cell and eosinophil numbers, cytokine production, and AHR.

CONCLUSIONS

Aged mice developed oral tolerance to antigen, which suppressed several features of allergic airway inflammation.

Differentiating the treatment of asthma and chronic obstructive pulmonary disease in the elderly patient

The focus of this case is a 70-year-old female who was admitted to an assisted living community following a hospitalization for a severe asthma exacerbation. The diagnosis of asthma in the geriatric patient is often under-recognized, misdiagnosed, and improperly managed. Several factors may explain the misclassification and the undertreatment of asthma in the older patient. This case discusses the pharmacotherapeutic management of asthma in the geriatric patient and differentiates the clinical features of asthma from that of chronic obstructive lung disease. The comprehensive management of asthma should include an interprofessional approach because the consultant pharmacist is an essential member of the health care team.

The predictors of poorly controlled asthma in elderly

Purpose

To evaluate asthma control in elderly individuals and identify the factors that predict poor control.

Methods

A retrospective, observational study evaluating 108 elderly individuals with asthma (59 females: ≥60 years, mean age: 70.5 years) was conducted at Ajou University Hospital from October 2010 to March 2011. Subjects were classified into two groups according to scores on the asthma control test (ACT). Group I consisted of 38 patients with ACT scores ≤19 (poor controllers) and group II included 70 patients with ACT scores >19 (controllers). Clinical data was analyzed. Spirometry was performed, and the ACT and asthma quality-of-life survey were completed. Medication possession ratios were calculated to evaluate compliance.

Results

Of the 108 enrolled subjects, 54.6% were female, 7.5% were obese, and 49.0% were atopic. The mean age of the patients was 70.5, and the average of time patients had suffered from asthma was 15.5 years. Comorbid conditions were found in more than 80% of the patients. Allergic rhinitis was most common comorbid condition; this was followed by cardiovascular disease and degenerative arthritis (76.9%, 65.7%, and 51.9%, respectively). Many patients (35.2%) were in poorly controlled states characterized by significantly lower asthma quality of life scores (P<0.001) and higher admission rates (P=0.034). Multivariate logistic regression analysis showed that a history of pulmonary tuberculosis was a predictor of poorly controlled asthma in elderly individuals even after adjusting for age, sex, smoking, lung function and other comorbidities (OR=4.70, CI=1.06-20.81, P=0.042).

Conclusions

The asthma of more than one-third of elderly individuals with this condition was poorly controlled, and a history of pulmonary tuberculosis may have contributed to this outcome. Proper evaluation and management of comorbid conditions in elderly patients with asthma is essential for the achievement of better control of the disease and a higher quality of life for those who suffer from it.

Epidemiology and management of common pulmonary diseases in older persons

Pulmonary disease prevalence increases with age and contributes to morbidity and mortality in older patients. Dyspnea in older patients is often ascribed to multiple etiologies such as medical comorbidities and deconditioning. Common pulmonary disorders are frequently overlooked as contributors to dyspnea in older patients. In addition to negative impacts on morbidity and mortality, quality of life is reduced in older patients with uncontrolled, undertreated pulmonary symptoms. The purpose of this review is to discuss the epidemiology of common pulmonary diseases, namely pneumonia, chronic obstructive pulmonary disease, asthma, lung cancer, and idiopathic pulmonary fibrosis in older patients. We will review common clinical presentations for these diseases and highlight differences between younger and older patients. We will also briefly discuss risk factors, treatment, and mortality associated with these diseases. Finally, we will address the relationship between comorbidities, pulmonary symptoms, and quality of life in older patients with pulmonary diseases.

Asthma diagnosis and management

Asthma is a chronic inflammatory airway disease that is commonly seen in the emergency department (ED). This article provides an evidence-based review of diagnosis and management of asthma. Early recognition of asthma exacerbations and initiation of treatment are essential. Treatment is dictated by the severity of the exacerbation. Treatment involves bronchodilators and corticosteroids. Other treatment modalities including magnesium, heliox, and noninvasive ventilator support are discussed. Safe disposition from the ED can be considered after stabilization of the exacerbation, response to treatment and attaining peak flow measures.

Asthma in the elderly: Current understanding and future research needs--a report of a National Institute on Aging (NIA) workshop

Asthma in the elderly is underdiagnosed and undertreated, and there is a paucity of knowledge on the subject. The National Institute on Aging convened this workshop to identify what is known and what gaps in knowledge remain and suggest research directions needed to improve the understanding and care of asthma in the elderly. Asthma presenting at an advanced age often has similar clinical and physiologic consequences as seen with younger patients, but comorbid illnesses and the psychosocial effects of aging might affect the diagnosis, clinical presentation, and care of asthma in this population. At least 2 phenotypes exist among elderly patients with asthma; those with longstanding asthma have more severe airflow limitation and less complete reversibility than those with late-onset asthma. Many challenges exist in the recognition and treatment of asthma in the elderly. Furthermore, the pathophysiologic mechanisms of asthma in the elderly are likely to be different from those seen in young asthmatic patients, and these differences might influence the clinical course and outcomes of asthma in this population.

Asthma and ageing: an end user's perspective--the perception and problems with the management of asthma in the elderly

Despite the high prevalence of asthma in the elderly, its development, diagnosis, and treatment are under-researched. This paper provides a comprehensive review of the current state of knowledge in relation to management of asthma in the elderly - focusing on barriers to diagnosis and treatment and the central role of self-management. Asthma prevalence increases with age, as does the risk of dying from asthma, and with the ageing of the population and increasing life expectancy, the prevalence of (diagnosed and undiagnosed) asthma in older adults is expected to increase drastically, placing an increasing burden on sufferers, the community and health budgets. Asthma sufferers are more likely to be psychologically distressed and at a higher risk of anxiety and depression, more likely to experience a sense of lack of control over their health and to have lower self-reported quality of life. Asthma is under-diagnosed, and under-treated, in the elderly, further exacerbating these negative consequences. The review concludes, among other things, that there is a need to better understand the development and impact of asthma in the elderly, to increase community awareness of asthma in the elderly, to improve both 'medical management' and 'self-management' in this population and to develop more effective tools for diagnosis and treatment of asthma in the elderly. The paper concludes with key recommendations for future research and practice in this area.

Inadequate health literacy is associated with suboptimal health beliefs in older asthmatics

OBJECTIVES

To examine the relationship between suboptimal asthma beliefs and inadequate health literacy among older adults with asthma.

METHODS

The authors interviewed 100 English- and Spanish-speaking asthmatics (ages >or=50 years) in a New York City primary care clinic (response, 83%). Outcomes included the belief that one does not have asthma when symptoms are absent (no symptoms-no asthma), that asthma is temporary, is curable, and that medications work better if not used all the time. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Belief and health literacy associations were measured with multivariable logistic regression adjusting for age, sex, and race.

RESULTS

The mean age was 61 years; 35% had inadequate health literacy. Those with inadequate literacy were more likely than those with adequate or marginal literacy to have suboptimal beliefs: no symptoms-no asthma, 60% versus 34%, p = .01; temporary, 23% versus 9%, p = .07; curable, 54% versus 25%, p = .004; medication use, 44% versus 21%, p = .03. These relationships remained statistically significant in multivariable analyses that adjusted for age, sex, and race.

CONCLUSIONS

Suboptimal asthma beliefs were more common among older asthmatics with inadequate health literacy. Interventions to improve asthma self-management in older adults should address both belief and health literacy barriers.

'You have to learn to live with it': a qualitative and quantitative study of older people with asthma

INTRODUCTION

Asthma mortality has declined overall because of a range of public health initiatives. In western countries, the majority of asthma deaths now occur in people over the age of 50. The reasons for the poorer response of older age groups to public health asthma initiatives are not known.

OBJECTIVES

We undertook a study to investigate the disease perspectives of older people with asthma and barriers which may exist and prevent optimal asthma care.

METHODS

Fifty-five participants (16 male and 39 female) aged over 50 from an inner city, suburban area and a rural region were recruited. Lung function was measured, and questionnaire data on asthma symptoms, knowledge and control, medication use and respiratory health were collected. Participants were also interviewed in-depth, and the quantitative and qualitative data were triangulated.

RESULTS

Participants with a duration of asthma for >30 years reported significantly fewer symptoms and better quality of life irrespective of asthma severity, indicating less appreciation of symptoms in those with a long asthma duration. Interviews revealed this was related to previous asthma management strategies when treatment options were limited. Participants with a recent diagnosis sought understanding of asthma and the reason for their illness. Initiatives to improve asthma care in older people need to reflect these findings.

CONCLUSIONS

Self-management strategies for older people need to be tailored according to the time of disease onset and the duration of disease.

Asthma in older adults

Asthma is underdiagnosed and undertreated in older adults. The classic symptoms, including episodic wheezing, shortness of breath, and chest tightness, are nonspecific in this age group. Older patients may underrate symptoms, and other diseases, such as chronic obstructive pulmonary disease, congestive heart failure, and angina, may have similar presentations. Objective measurements of lung function always should complement the history taking and physical examination. Management of asthma in older adults should include careful monitoring, controlling triggers, optimizing and monitoring pharmacotherapy, and providing appropriate asthma education. Adverse effects to commonly used asthma medications are more common in older adults, and careful monitoring of their use and adverse effects is important.

Socioeconomic status and hospitalization in the very old: a retrospective study

Background

Socioeconomic status could affect the demand for hospital care. The aim of the present study was to assess the role of age, socioeconomic status and comorbidity on acute hospital admissions among elderly.

Methods

We retrospectively examined the discharge abstracts data of acute care hospital admissions of residents in Rome aged 75 or more years in the period 1997–2000. We used the Hospital Information System of Rome, the Tax Register, and the Population Register of Rome for socio-economic data. The rate of hospitalization, modified Charlson's index of comorbidity, and level of income in the census tract of residence were obtained. Rate ratios and 95% confidence limits were computed to assess the relationship between income deciles and rate of hospitalization. Cross-tabulation was used to explore the distribution of the index of comorbidity by deciles of income. Analyses were repeated for patients grouped according to selected diseases.

Results

Age was associated with a marginal increase in the rate of hospitalization. However, the hospitalization rate was inversely related to income in both sexes. Higher income was associated with lower comorbidity. The same associations were observed in patients admitted with a principal diagnosis of chronic condition (diabetes mellitus, heart failure, chron obstructive pulmonary disease) or stroke, but not hip fracture.

Conclusion

Lower social status and associated comorbidity, more than age per se, are associated with a higher rate of hospitalization in very old patients.

General principles of asthma management: symptom monitoring

The first step in optimal asthma care is identifying and properly diagnosing patients who have asthma then classifying asthma severity carefully and accurately to ensure proper treatment. Objective monitoring of pulmonary function using spirometry and peak flow monitoring, subjective assessment using symptom identification, and physicians' acceptance of National Asthma Education Program's Expert Panel guidelines are needed to diminish the consequences of undertreatment of asthma. Persistent asthma requires continuous long-term controller therapy. Erratic and insufficient use of medication must be addressed. Clinicians should encourage patients to manage their asthma using routine peak flow monitoring and symptom assessment then intervene according to their asthma action plan. These efforts allow patients to take charge of their asthma instead of the asthma taking charge of them.

The diagnosis and management of asthma is much tougher in older patients

Half the elderly individuals with asthma have not been diagnosed, yet their quality of life is substantially impaired. Primary care physicians should, therefore, be encouraged to ask about respiratory symptoms in elderly patients, and then perform office spirometry for those with symptoms. Airway obstruction increases the likelihood of asthma, but the lack of a 'significant' acute bronchodilator response is clinically meaningless. Methacholine challenge testing is safe and useful for detecting asthma in patients with normal baseline spirometry. Only one in five life-long smokers ever develops chronic obstructive pulmonary disease, so elderly smokers should also be evaluated for reversible airways obstruction. A normal diffusing capacity test will rule out emphysema in current and former smokers. Elderly individuals whose asthma has been diagnosed are often receiving sub-optimal treatment, resulting in poor asthma control and a high death rate. Co-morbidities (recognized or not) are the rule in elderly patients, and these conditions, or the drugs taken to treat them, may exacerbate asthma. Conversely, bronchodilators and corticosteroids used to treat asthma often worsen co-morbid conditions, such as osteoporosis, ocular disease, and cardiac arrhythmias. Therefore, extra caution is needed when treating elderly asthmatic patients, and objective monitoring of their response to each new asthma medication is important.