Characterization of leukotrienes in a pilot study of older asthma subjects

Immunosenescence, Inflammaging, and Lung Senescence in Asthma in the Elderly

Prevalence of asthma in older adults is growing along with increasing global life expectancy. Due to poor clinical consequences such as high mortality, advancement in understanding the pathophysiology of asthma in older patients has been sought to provide prompt treatment for them. Age-related alterations of functions in the immune system and lung parenchyma occur throughout life. Alterations with advancing age are promoted by various stimuli, including pathobionts, fungi, viruses, pollutants, and damage-associated molecular patterns derived from impaired cells, abandoned cell debris, and senescent cells. Age-related changes in the innate and adaptive immune response, termed immunosenescence, includes impairment of phagocytosis and antigen presentation, enhancement of proinflammatory mediator generation, and production of senescence-associated secretory phenotype. Immnunosenescence could promote inflammaging (chronic low-grade inflammation) and contribute to late-onset adult asthma and asthma in the elderly, along with age-related pulmonary disease, such as chronic obstructive pulmonary disease and pulmonary fibrosis, due to lung parenchyma senescence. Aged patients with asthma exhibit local and systemic type 2 and non-type 2 inflammation, associated with clinical manifestations. Here, we discuss immunosenescence’s contribution to the immune response and the combination of type 2 inflammation and inflammaging in asthma in the elderly and present an overview of age-related features in the immune system and lung structure.

Perioperative stroke: A perspective on challenges and opportunities for experimental treatment and diagnostic strategies

Perioperative stroke is an ischemic or hemorrhagic cerebral event during or up to 30 days after surgery. It is a feared condition due to a relatively high incidence, difficulties in timely detection, and unfavorable outcome compared to spontaneously occurring stroke. Recent preclinical data suggest that specific pathophysiological mechanisms such as aggravated neuroinflammation contribute to the detrimental impact of perioperative stroke. Conventional treatment options are limited in the perioperative setting due to difficult diagnosis and medications affecting coagulation in may cases. On the contrary, the chance to anticipate cerebrovascular events at the time of surgery may pave the way for prevention strategies. This review provides an overview on perioperative stroke incidence, related problems, and underlying pathophysiological mechanisms. Based on this analysis, we assess experimental stroke treatments including neuroprotective approaches, cell therapies, and conditioning medicine strategies regarding their potential use in perioperative stroke. Interestingly, the specific aspects of perioperative stroke might enable a more effective application of experimental treatment strategies such as classical neuroprotection whereas others including cell therapies may be of limited use. We also discuss experimental diagnostic options for perioperative stroke augmenting classical clinical and imaging stroke diagnosis. While some experimental stroke treatments may have specific advantages in perioperative stroke, the paucity of established guidelines or multicenter clinical research initiatives currently limits their thorough investigation.

Race and Asthma Outcomes in Older Adults: Results from the National Asthma Survey

BACKGROUND

The number of older adults with asthma continues to rise, yet the effects of race and ethnicity on asthma outcomes in this population are unknown.

OBJECTIVE

To characterize the effect of race and ethnicity on asthma outcomes in a large national sample of older adults and to identify factors that are associated with disparities found.

METHODS

Data from the 2015 Behavioral Risk Factor Surveillance Survey and Asthma Call-Back Survey were analyzed. Respondents were included if they had a current asthma diagnosis, were aged ≥55, and self-identified as non-Hispanic white, African American, or Hispanic. Demographic variables, health care access, comorbidities, and asthma history were correlated with asthma outcomes (health care utilization and asthma control). Asthma outcome variables were further analyzed using multivariable logistic regression.

RESULTS

A total of 4700 individuals were included. Compared with non-Hispanic white respondents, African American and Hispanic respondents had lower incomes, greater impaired access to health care due to cost, and increased reliance on rescue medications. After controlling for factors including income, education, comorbidities, and health insurance, African American and Hispanic respondents were twice as likely to visit the emergency room (ER) for asthma (P < .001 for both) and 40% less likely to report uncontrolled daytime symptoms (P = .002 and .008).

CONCLUSIONS

Racial differences in asthma outcomes persist despite controlling for multiple social determinants of health and access to health insurance through Medicare. Minority patients were more likely to visit the ER but less likely to report frequent daytime symptoms. These findings indicate that comprehensive strategies to address assessment, monitoring, and treatment are needed to decrease health disparities.

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.

Risk factors and clinical outcomes associated with fixed airflow obstruction in older adults with asthma

BACKGROUND

Asthma in older adults is associated with increased morbidity and mortality compared with asthma in younger patients. Fixed airflow obstruction (FAO) is associated with decreased survival in younger patients, but its significance remains unclear in older adults with asthma.

OBJECTIVE

To identify risk factors and outcomes related to FAO in older adults with asthma.

METHODS

Subjects older than 55 years with a physician diagnosis of persistent asthma were evaluated. Collected data included participant demographic information, medications, asthma exacerbations, Asthma Control Test (ACT) score, Asthma Quality of Life (AQLQ) score, comorbidities, spirometry, atopic status, and fractional exhaled nitric oxide. Clinical characteristics and outcomes associated with FAO (defined as post-bronchodilator ratio of forced expiratory volume in 1 second to forced vital capacity ≤70%) were assessed.

RESULTS

A total of 186 participants were analyzed (48 men and 138 women, mean age 66 years). FAO was demonstrated in 30% of participants. Using regression analysis, predictors of FAO included advanced age, African American race, male sex, and longer duration of asthma. In outcomes analysis, FAO was associated with worsened ACT and AQLQ scores; however, after controlling for confounding factors, logistic regression showed no association. No significant association was found between FAO and exacerbations, fractional exhaled nitric oxide, atopy, rhinitis, education level, depression, smoking, or body mass index.

CONCLUSION

Risk factors associated with FAO in older adults with asthma include advanced age, African American race, increased asthma duration, and male sex. Unlike younger patients, FAO is not independently associated with worsened asthma control, quality of life, or exacerbations in older patients with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01979055.

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.

Distinct Asthma Phenotypes Among Older Adults with Asthma

BACKGROUND

Older adults have high rates of asthma morbidity and mortality. Asthma is now recognized as a heterogeneous disease, yet the distinct phenotypes among older adults are unknown.

OBJECTIVE

The objective of this study was to identify asthma phenotypes in a diverse population of elderly patients with asthma.

METHODS

Using cluster analysis, 180 older adults with persistent asthma were analyzed. Subjects completed detailed questionnaires, skin prick testing, and spirometry with reversibility. Twenty-four core variables were analyzed.

RESULTS

Four groups were identified. Subjects in cluster 1 (n = 69) typically had asthma diagnosed after the age of 40 and the shortest duration of asthma. Cluster 2 (n = 40) had the mildest asthma defined by spirometry, Asthma Control test (ACT), and Asthma Quality of Life Questionnaire (AQLQ). They also had the lowest body mass index (BMI), lowest depression score, and least number of comorbidities. Cluster 3 (n = 46) had the longest duration of asthma (56 years) and the highest atopic skin test sensitization (74%). Cluster 4 (n = 25) had the most severe asthma, with extremely low FEV1% predicted (37.8%), lowest ACT, and lowest AQLQ scores. They were more likely to be black and had the highest comorbidities. Using BMI, posttreatment FEV1% predicted, and duration of asthma, 95.6% of subjects were able to be correctly classified.

CONCLUSIONS

In older adults with asthma, distinct phenotypes vary on key features that are more pronounced among the elderly, including comorbidities, fixed airway obstruction, and duration of asthma ≥40 years. Further work is required to determine the clinical and therapeutic implications for different asthma phenotypes in older adults.

An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly

Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.

Aging exacerbates acute lung injury-induced changes of the air-blood barrier, lung function, and inflammation in the mouse

Acute lung injury (ALI) is characterized by hypoxemia, enhanced permeability of the air-blood barrier, and pulmonary edema. Particularly in the elderly, ALI is associated with increased morbidity and mortality. The reasons for this, however, are poorly understood. We hypothesized that age-related changes in pulmonary structure, function, and inflammation lead to a worse prognosis in ALI. ALI was induced in young (10 wk old) and old (18 mo old) male C57BL/6 mice by intranasal application of 2.5 mg lipopolysaccharide (LPS)/kg body wt or saline (control mice). After 24 h, lung function was assessed, and lungs were either processed for stereological or inflammatory analysis, such as bronchoalveolar lavage fluid (BALF) cytometry and qPCR. Both young and old mice developed severe signs of ALI, including alveolar and septal edema and enhanced inflammatory BALF cells. However, the pathology of ALI was more pronounced in old compared with young mice with nearly sixfold higher BALF protein concentration, twice the number of neutrophils, and significantly higher expression of neutrophil chemokine Cxcl1, adhesion molecule Icam-1, and metalloprotease-9, whereas the expression of tight junction protein occludin significantly decreased. The old LPS mice had thicker alveolar septa attributable to higher volumes of interstitial cells and extracellular matrix. Tissue resistance and elastance reflected observed changes at the ultrastructural level in the lung parenchyma in ALI of young and old mice. In summary, the pathology of ALI with advanced age in mice is characterized by a greater neutrophilic inflammation, leakier air-blood barrier, and altered lung function, which is in line with findings in elderly patients.

Effect of aging on sputum inflammation and asthma control

BACKGROUND

Aged asthmatic patients experience increased morbidity and mortality. Knowledge of the aging effect on airway inflammation and asthma control is limited.

OBJECTIVE

We sought to compare airway inflammation and its relationship to asthma control in aged versus younger patients and determine whether differences are asthma specific or caused by "inflamm-aging."

METHODS

We performed a prospective study of aged (>60 years) and younger (21-40 years) inner-city patients with asthma. After a run-in period to control for inhaled corticosteroid use, induced sputum was collected. Age-matched nonasthmatic control subjects were included to measure age-related inflammatory changes.

RESULTS

Aged (mean age, 67.9 ± 5.1 years; n = 35) compared with younger (mean age, 30.8 ± 5.9 years; n = 37) asthmatic patients had significantly worse asthma control and lower FEV₁. Aged asthmatic patients had higher sputum neutrophil (30.5 × 10⁴/mL and 23.1%) and eosinophil (7.0 × 10⁴/mL and 3.8%) numbers and percentages compared with younger patients (neutrophils, 13.0 × 10⁴/mL [P < .01] and 6.9% [P < .01]; eosinophils, 2.0 × 10⁴/mL [P < .01] and 1.2% [P < .01]). Aged asthmatic patients had higher sputum IL-6 (P < .01) and IL-8 (P = .01) levels. No significant inflammatory differences between aged and younger control subjects were observed. In aged asthmatic patients increased sputum IL-6 and macrophage inflammatory protein 3α/CCL20 levels were significantly associated with decreased asthma control and increased sputum neutrophil numbers and IL-1β, IL-6, and macrophage inflammatory protein 3α/CCL20 levels were associated with hospitalization.

CONCLUSIONS

The inflammatory patterns of aged versus younger asthmatic patients are associated with increased sputum neutrophil and eosinophil values and cytokine levels related to neutrophil recruitment. Differences in airway inflammation can contribute to diminished asthma control in the aged. Further understanding of asthma pathophysiology in aged patients is needed to improve management of this vulnerable population.

Asthma in the older adult: presentation, considerations and clinical management

Asthma affects older adults to the same extent as children and adolescents. However, one is led to imagine that asthma prevalence decreases with aging and becomes a rare entity in the elderly. From a clinical perspective, this misconception has nontrivial consequences in that the recognition of the disease is delayed and the treatment postponed. The overall management of asthma in the elderly population is also complicated by specific features that the disease develops in the most advanced ages, and by the difficulties that the physician encounters when approaching the older asthmatic subjects. The current review article aims at describing the specific clinical presentations of asthma in the elderly and highlights the gaps and pitfalls in the diagnostic and therapeutic approaches. Relevant issues with regard to the clinical management of asthma in the elderly are also discussed.

Age is not associated with hospital admission or uncontrolled symptoms of asthma if proper treatment is offered

BACKGROUND

Aging modifies immune response and respiratory physiology. Few studies evaluate the effect of age on asthma. The aim of our study was to evaluate whether age is associated with uncontrolled symptoms and hospital admissions due to asthma in a setting where patients were receiving proper treatment.

METHODS

We enrolled 401 patients with uncontrolled asthma who were inhaled corticosteroid-naive. The follow-up period was 1 year. They received medications for asthma, performed spirometry, a symptoms questionnaire, and all emergency room visits and hospital admissions due to asthma were reported. The primary end point was hospital admission during the follow-up period.

RESULTS

Baseline data demonstrated that subjects >55 years of age had a later onset of asthma and a longer duration of symptoms. Adjusted logistic regression models demonstrated that older age at enrollment did not predict asthma control in the follow-up: hospital admission due to asthma [odds ratio (OR) 1.7 and 95% confidence interval (CI) 0.6-4.7], symptoms score (OR 0.6 and 95% CI 0.3-1.1) and emergency room visits due to asthma (OR 0.9 and 95% CI 0.6-1.3). Older age was associated with worse lung function (OR 1.8 and 95% CI 1.1-3.3).

CONCLUSION

This study allows us to conclude that older age is associated with a later onset of asthma and a longer duration of symptoms. Age does not predict hospital admissions or poor control of asthma symptoms if proper treatment is offered. It does, however, predict worse lung function.

The normative value of inflammatory cells in the nasal perfusate of Chinese adults: a pilot study

OBJECTIVE

To establish stable, well-accepted nasal perfusion and a normative value of classifying cells in the nasal perfusate of Chinese adults.

METHODS

A total of 500 healthy adults were divided into two groups of 250 people per group (group A, 16-30 years old and group B, 31-60 years old; male-to-female ratio, 1:1). All volunteers were non-smokers; they were irrigated with saline, and multiple inflammatory cells in the perfusate were analyzed.

RESULTS

Irrigation was successfully performed in 479 cases, a success rate of 95.80%. The types of inflammatory cells showed a skewed distribution. The median number and interquartile range (IQR) of eosinophils were 0 and 0.2, respectively. These values were 0.4 and 2.2, respectively, for neutrophils and 0 and 0, respectively, for both lymphocytes and macrophages. There was no significant difference between males and females (P>0.05). There was a significant difference in the numbers of neutrophils and lymphocytes in the different age groups (P=0.000), but there was no significant difference in the numbers of eosinophils and macrophages (P>0.05). The 95% unilateral upper limited values (UULVs) of eosinophils and neutrophils in the nasal perfusates were 2.99 and 14.94, respectively, for group A and 1.41 and 17.08 for group B. As a result, the total 95% UULVs of eosinophils and neutrophils in the nasal perfusate were 2.00 and 16.80.

CONCLUSIONS

We established stable, well-accepted nasal perfusions and normal values for classifying the cells in the nasal perfusate of Chinese adults; the normative values of the inflammatory cells in nasal perfusate are 2.00 for the 95% UULV of eosinophils and 16.80 for neutrophils. Age might be one of the factors affecting the cells in rhinitis.

Relationship between airway neutrophilia and ageing in asthmatics and non-asthmatics

BACKGROUND AND OBJECTIVE

Increased sputum neutrophilia has been observed in asthma, but also during normal ageing in asthmatics and non-asthmatics. It remains unclear what constitutes 'normal' neutrophil levels in different age groups.

METHODS

We assessed the relationship between age and airway neutrophils of 194 asthmatics and 243 non-asthmatics (age range: 6-80 years). Regression analyses were used to assess this relationship adjusted for confounders including asthma status, atopy, gender, smoking and current use of inhaled corticosteroids (ICS). Age-corrected reference values for different age groups were determined using the 95th percentile of non-asthmatic participants.

RESULTS

Age was positively associated with sputum neutrophils in both asthmatic and non-asthmatic adults (0.46% neutrophil increase/year (95% confidence interval (CI) 0.18, 0.73) and 0.44%/year (0.25, 0.64, respectively), but no association was found in the <20-year age category. Individuals with high sputum neutrophil counts (>95th percentile of non-asthmatic counts for any given age group) were significantly more likely to be asthmatic (odds ratio = 2.5; 95% CI: 1.3, 5.0), with the greatest effect observed in the older age group. Other factors that independently associated with increased sputum neutrophil levels included atopy in non-asthmatic adults, male gender and current use of ICS in asthmatic adults. Age-specific reference values for neutrophil percentage were under 20 years-76%, 20-40 years-62%, 40-60 years-63% and over 60 years-67%.

CONCLUSIONS

Airway neutrophilia is related to age in adults, with a neutrophilic asthma phenotype present in older adults. The use of appropriate age-specific reference values is recommended for future studies aimed at elucidating the role of neutrophils in asthma.

Safety and efficacy of montelukast as adjunctive therapy for treatment of asthma in elderly patients

Asthma is a disease of all ages. This assumption has been challenged in the past, because of several cultural and scientific biases. A large body of evidence has accumulated in recent years to confirm that the prevalence of asthma in the most advanced ages is similar to that in younger ages. Asthma in the elderly may show similar functional and clinical characteristics to that occurring in young adults, although the frequent coexistence of comorbid conditions in older patients, together with age-associated changes in the human lung, may lead to more severe forms of the disease. Management of asthma in the elderly follows specific guidelines that apply to all ages, although most behaviors are pure extrapolation of what has been tested in young ages. In fact, age has always represented an exclusion criterion for eligibility to clinical trials. This review focuses specifically on the safety and efficacy of leukotriene modifiers, which represent a valid option in the treatment of allergic asthma, both as an alternative to first-line drugs and as add-on treatment to inhaled corticosteroids. Available studies specifically addressing the role of montelukast in the elderly are scarce; however, leukotriene modifiers have been demonstrated to be safe in this age group, even though cases of acute hepatitis and occurrence of Churg-Strauss syndrome have been described in elderly patients; whether this is associated with age is to be confirmed. Furthermore, leukotriene modifiers provide additional benefit when added to regular maintenance therapy, not differently from young asthmatics. In elderly patients, the simpler route of administration of leukotriene modifiers, compared with the inhaled agents, could represent a more effective strategy in improving the outcomes of asthma therapy, given that unintentional nonadherence with inhalation therapy represents a complex problem that may lead to significant impairment of asthma symptom control.

Quantitation of leukotriene B(4) in human sputum as a biomarker using UPLC-MS/MS

Leukotriene B4 (LTB4) is a potent mediator of inflammation and has been recognized as an important target for therapeutic intervention for treatment of diseases such as asthma. In the current work, a highly selective and sensitive UPLC-MS/MS assay was developed for quantitation of LTB4 in human sputum as a biomarker for LTB4 biosynthesis inhibition. A fit-for-purpose strategy for method development, assay qualification, and study support was adopted for this biomarker project. A surrogate matrix (protein buffer) was used for preparation of calibration samples and certain levels of quality control (QC) samples to avoid interference from endogenous analyte, while the low QC was prepared in authentic matrix, human sputum. The analytical methodology utilized a liquid-liquid extraction procedure in 96-well plate format. Chromatographic separation was achieved with a reversed-phase ultra high pressure liquid chromatography (UPLC) column using gradient elution, and the run time was 4.5min per sample. The lower limit of quantitation (LLOQ) was 0.2ng/mL, and the calibration curve range was 0.2-20ng/mL. Acceptable accuracy, precision, linearity, specificity, recovery, and matrix effect was obtained. Bench-top stability (6h), freeze-thaw stability (3 cycles at -20°C), and autosampler stability (97h at ambient temperature) all met acceptance criteria. Frozen long-term stability for 166 days at -20°C in sputum did not meet acceptance criteria by showing only ≥75% of nominal concentration and the information was taken into consideration for study support. Two important observations in the current work were: (1) LTB4 was unstable in sputum in the presence of liquification reagent dithiothreitol (DTT). Therefore, a non-DTT treatment method for sputum processing was developed and applied to the bioanalytical assay and clinical study support; and (2) chromatographic separation of LTB4 from its three non-enzymatically derived isomers, i.e. 6-trans-LTB4, 12-epi-LTB4, and 6-trans-12-epi-LTB4, was achieved. This assay was successfully applied to a Phase II clinical study for proof-of-concept of a LTA4 hydrolase inhibitor for treatment of asthma.

Influences of smoking and aging on allergic airway inflammation in asthma

Asthma is a heterogeneous disease with varying phenotypes and numerous risk factors. This condition results from complex interactions between genetic and environmental factors, and active smoking is one of these risk factors. The effects of aging should also be taken into account in these interactions. From an epidemiological standpoint, smokers and/or elderly patients with asthma are not small part in the total population with asthma. Furthermore, both smoking and aging are important risk factors for severe asthma. This review discusses the potential effects of smoking and aging on healthy subjects and patients with asthma, particularly from the perspective of inflammatory changes. First we show evidence that smokers and the elderly have increased neutrophil counts in their airways, which may have impacts on their clinical characteristics of elderly smokers with asthma. Secondly, on the basis of our recent findings on the interactions between smoking and aging in patients with asthma, we propose that IgE/eosinophilic inflammation should not be underestimated in elderly smokers with asthma, particularly those who are atopic. This review may expand our understanding of the effects of smoking and aging on asthma with a new perspective of an old issue.

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.

Age-related changes in immune function: effect on airway inflammation

Immunosenescence is defined as changes in the innate and adaptive immune response associated with increased age. The clinical consequences of immunosenescence include increased susceptibility to infection, malignancy and autoimmunity, decreased response to vaccination, and impaired wound healing. However, there are several immune alterations that might facilitate persistence of asthma into late adulthood or development of asthma after the age of 50 to 60 years. Asthma in older patients is not uncommon, and this is a growing population as the average lifespan increases. Specific innate changes that might affect severity of asthma in older patients or be involved in the development of late-onset asthma include impaired mucociliary clearance and changes in airway neutrophil, eosinophil, and mast cell numbers and function. Additionally, age-related altered antigen presentation and decreased specific antibody responses might increase the risk of respiratory tract infections. Respiratory tract infections exacerbate asthma in older patients and possibly play a role in the pathogenesis of late-onset asthma. Furthermore, cytokine profiles might be modified with aging, with some investigators suggesting a trend toward T(H)2 cytokine expression. This review examines specific innate and adaptive immune responses affected by aging that might affect the inflammatory response in older adults with asthma.