Complexities of diagnosis and treatment of allergic respiratory disease in the elderly

Bronchial epithelial cells of young and old mice directly regulate the differentiation of Th2 and Th17

To determine whether or not house dust mite (HDM) and HDM+lipopolysaccharide (LPS) exposure causes a difference in T-cell subsets from young and old mice. The bronchial epithelial cells (BECs) from young and old mice were divided into three groups (PBS (control), HDM, and HDM+LPS). CD4⁺ naive T cells from the spleen and lymph nodes were collected after 24 h of co-culture with BECs. The number of Th2 and Th17 cells was elevated in the HDM and HDM+LPS groups compared with the control group; these responses were exacerbated when exposed to HDM+LPS. The number of HDM- and HDM+LPS-specific Th2/Th17 cells in young mice was higher than old mice; however, the Th2:Th17 cell ratio was greater in young mice, whereas the Th17:Th2 cell ratio was greater in old mice. The expression of GATA-3 and RORc was increased in the HDM+LPS and HDM groups compared with the PBS group and exhibited most in HDM+LPS group. The expression of HDM+LPS-specific GATA-3 in young mice was higher, while the expression of HDM+LPS-specific RORc in old mice was higher. Murine BECs directly regulated CD4⁺ naive T-cell differentiation under allergen exposure.

Co-existence and seasonal variation in rhinitis and asthma symptoms in patients with asthma

BACKGROUND

Asthma and rhinitis are common diseases that often occur concomitantly. However, in patients with asthma, the concurrent assessment of seasonal variation in rhinitis and asthma symptoms has not been comprehensively addressed. We prospectively evaluated seasonal changes in rhinitis and asthma symptoms over one year.

METHODS

Fifty-six patients with asthma were enrolled. Asthma and rhinitis symptoms were assessed by using the State of the Impact of Allergic Rhinitis on Asthma Control (SACRA) questionnaire, developed and validated in Japan by the committee　of Global Initiative for Asthma and the committee of Allergic Rhinitis for asthma and its impact on Asthma.

RESULTS

Fifty-three patients completed the study. Forty-five patients (85%) had nasal symptoms during at least one or more seasons and 15 patients (28%) had perennial rhinitis. The association between asthma symptoms and rhinitis symptoms, assessed by a visual analogue scale (VAS), was significant during each season; seasonal variations of symptoms were synchronous. Uncontrolled asthma was more prevalent in patients with moderate-to-severe rhinitis compared to those with mild rhinitis. The VAS score of asthma symptoms in patients with asthma and perennial rhinitis was significantly higher than that in patients with non-perennial rhinitis or without rhinitis, across every season, except for spring. Correlations were more significantn patients less than 65 years of age than in older patients.

CONCLUSION

Rhinitis is common in patients with asthma. Symptoms of rhinitis and asthma often co-exist, and the association between these symptoms may be stronger n younger patients with asthma than older.

Short-Term Effect of Pollen and Spore Exposure on Allergy Morbidity in the Brussels-Capital Region

Belgium is among the European countries that are the most affected by allergic rhinitis. Pollen grains and fungal spores represent important triggers of symptoms. However, few studies have investigated their real link with disease morbidity over several years. Based on aeroallergen counts and health insurance datasets, the relationship between daily changes in pollen, fungal spore concentrations and daily changes in reimbursable systemic antihistamine sales has been investigated between 2005 and 2011 in the Brussels-Capital Region. A Generalized Linear Model was used and adjusted for air pollution, meteorological conditions, flu, seasonal component and day of the week. We observed an augmentation in drug sales despite no significant increase in allergen levels in the long term. The relative risk of buying allergy medications associated with an interquartile augmentation in pollen distributions increased significantly for Poaceae, Betula, Carpinus, Fraxinus and Quercus. Poaceae affected the widest age group and led to the highest increase of risk which reached 1.13 (95% CI [1.11-1.14]) among the 19- to 39-year-old men. Betula showed the second most consistent relationship across age groups. Clear identification of the provoking agents may improve disease management by customizing prevention programmes. This work also opens several research perspectives related to impact of climate modification or subpopulation sensitivity.

Allergic disorders at a venerable age: a mini-review

This review focuses on 3 allergic disorders of persons coming up against venerable age: asthma, allergic rhinitis, and atopic dermatitis. The prevalence of allergic diseases in the elderly ranges from 5 to 10% and appears to be rising. A gradual decline in immune function, termed immunosenescence, and age-related changes in tissue structure influence the development of these disorders. Common complications are comorbidities, polypharmacy, and adverse effects of drugs. The elderly have difficulty mounting protective immune responses against newly encountered antigens. The integrity of epithelial barriers is compromised, leading to a chronic, subclinical inflammatory state and an enhanced Th2 (allergic) immune response. Undiagnosed asthma is frequent in elderly persons (about 8%) and still more commonplace in those with respiratory symptoms. Poorly controlled asthma in the elderly undermines their functional status and leads to a loss of autonomy and social isolation that may delay seeking medical services. Aggravation of allergic rhinitis coincides with exacerbation of asthma, whereas treatment of nasal inflammation improves control of the asthma. Atopic dermatitis is a chronically relapsing inflammatory skin disease often associated with respiratory allergy.

Prevalence and impact of rhinitis in asthma. SACRA, a cross-sectional nation-wide study in Japan

BACKGROUND

Asthma and rhinitis are common co-morbidities everywhere in the world but nation-wide studies assessing rhinitis in asthmatics using questionnaires based on guidelines are not available.

OBJECTIVE

To assess the prevalence, classification, and severity of rhinitis using the Allergic Rhinitis and its Impact on Asthma (ARIA) criteria in Japanese patients with diagnosed and treated asthma.

METHODS

The study was performed from March to August 2009. Patients in physicians' waiting rooms, or physicians themselves, filled out questionnaires on rhinitis and asthma based on ARIA and Global Initiative for Asthma (GINA) diagnostic guides. The patients answered questions on the severity of the diseases and a Visual Analog Scale. Their physicians made the diagnosis of rhinitis.

RESULTS

In this study, 1910 physicians enrolled 29,518 asthmatics; 15,051 (51.0%) questionnaires were administered by physician, and 26,680 (90.4%) patients were evaluable. Self- and physician-administered questionnaires gave similar results. Rhinitis was diagnosed in 68.5% of patients with self-administered questionnaires and 66.2% with physician-administered questionnaires. In this study, 994 (7.6%) patients with self-administered and 561 (5.2%) patients with physician-administered questionnaires indicated rhinitis symptoms on the questionnaires without a physician's diagnosis of rhinitis. Most patients with the physician's diagnosis of rhinitis had moderate/severe rhinitis. Asthma control was significantly impaired in patients with a physician's diagnosis of rhinitis for all GINA clinical criteria except exacerbations. There were significantly more patients with uncontrolled asthma as defined by GINA in those with a physician's diagnosis of rhinitis (25.4% and 29.7%) by comparison with those without rhinitis (18.0% and 22.8%).

CONCLUSION

Rhinitis is common in asthma and impairs asthma control.

Muscle strength and sedative load in community-dwelling people aged 75 years and older: a population-based study

BACKGROUND

Use of psychotropic and sedative drugs has been associated with impaired muscle strength. Muscle weakness predicts important outcomes for older people including functional disability and mortality. The objective of this study was to investigate if the use of drugs with sedative properties is associated with poorer muscle strength.

METHODS

Seven-hundred community-dwelling participants, aged 75 years and older, enrolled in the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study in 2004 were included in the present analyses. Data on demographics, diagnostics, and drug use were collected during standardized interviews, conducted by trained nurses and verified through medical records. Physiotherapists conducted objective tests of handgrip strength, knee extension strength, and the five repeated chair stands test. Sedative load was calculated using a previously published model for each participant.

RESULTS

Twenty-one percent of the participants (n = 147) had a sedative load of 1-2 and 8% (n = 58) had a sedative load 3 or more. After adjusting for covariates, participants with sedative load more than 0 had poorer performance on grip strength (p = .009), knee extension strength (p = .02), and five chair stands (p = .003) than nonusers of drugs with sedative properties. Increasing sedative load was associated with poorer grip strength.

CONCLUSIONS

Use of drugs with sedative properties was associated with impaired muscle strength. Although we adjusted for diagnoses affecting physical function, the possibility of confounding by indication cannot be entirely excluded. Given that muscle strength is predictive of functional disability and mortality, further attention should be directed toward conducting regular reviews of drug therapy and reducing use of sedative drugs.

Effect of age on asthma control: results from the National Asthma Survey

BACKGROUND

two million US citizens older than 65 years have asthma, but little is known about asthma control in this population.

OBJECTIVE

to compared short- and long-term asthma control in elderly (≥ 65 years old) and young adult (18-64 years old) populations from the National Asthma Survey.

METHODS

data from the National Asthma Survey (sponsored by the Centers for Disease Control and Prevention) were analyzed. Demographic variables, health insurance status, smoking status, indoor allergen exposure, and asthma education were compared between the young adult and elderly populations. Asthma control was examined based on short-term measures (recent oral corticosteroid bursts or symptoms) and long-term measures (asthma attacks, urgent care visits, hospitalizations, and activity limitation in the previous year).

RESULTS

a total of 2,557 young and 398 elderly asthmatic patients were included. Elderly patients had a lower income, were less educated, were more obese, were more insured, had less indoor exposure, and were more likely to be former smokers. They were less educated about asthma attack interventions and asthma action plans (P < .05 for both). On multivariate analysis, elderly patients had worse control of asthma based on short-term measures (daytime symptoms in the previous month [odds ratio (OR), 1.73; 95% confidence interval (CI), 1.25-2.35] and any short-term measure [OR, 1.48; 95% CI, 1.11-1.97]) and long-term measures (activity limitation in the previous year [OR, 1.50; 95% CI, 1.12-2.01]).

CONCLUSIONS

elderly asthmatic patients have worse short- and long-term asthma control compared with the young adult population. Further studies are needed to elucidate whether these findings are due to pathophysiologic differences and whether tailored education or other novel strategies can provide better asthma control.

Asthma education for older adults: results from the National Asthma Survey

RATIONALE

Although asthma education is effective in younger population, it is unknown whether it is effective in older adults.

METHODS

Using the Four-State National Asthma Survey (NAS) data, asthma control was compared between older adults (≥65 years) who had been taught to use a peak flow meter (PFM) and asthma action plan (AAP) with those who had not. We also compared older adults who had taken an asthma course with those who had not. Both short-term (symptoms within last 1 week, day and night symptoms in last 30 days, and the use of steroid in last 3 months) and long-term (asthma attack, emergency department visit, hospitalizations, and activity limitations in the prior year) outcomes were compared.

RESULTS

Three hundred and ninety-eight older adults with asthma were identified. There were no differences in the short- and long-term asthma outcomes between the older adults who had or had not received instruction on PFM or AAP use. In preliminary analysis, those who took AC were more likely to have at least one poorly controlled long-term outcome measure (81 vs. 65%, p = 0.034). However, this difference did not remain significant in a logistic regression analysis.

CONCLUSIONS

Engagement in asthma education course, instruction on action plans, and instruction on PFM use does not appear to affect asthma outcomes in older adults. Education specifically tailored toward older adults is required for better asthma control.

The traditional Chinese herbal formula ASHMI inhibits allergic lung inflammation in antigen-sensitized and antigen-challenged aged mice

BACKGROUND

Although asthma is typically characterized as a childhood disease, it can develop later in life. Older asthmatic patients may be at increased risk for corticosteroid adverse effects. We developed a novel traditional Chinese medicine to treat asthma called antiasthma simplified herbal medicine intervention (ASHMI). Herbal products may offer safer adjunctive treatment for older asthmatic patients.

OBJECTIVE

To investigate the effects of ASHMI on characteristics of allergic asthma in an aged mouse model of asthma.

METHODS

BALB/c mice (6 weeks old [young] and 6, 12, and 18 months old [aged]) received ASHMI treatment before and during intraperitoneal ovalbumin sensitization and intratracheal challenges. The control groups were untreated, age-matched, ovalbumin-sensitized and ovalbumin-challenged mice (ovalbumin mice) and naive mice. After the final antigen challenge, airway pressure (defined as the time-integrated change in peak airway pressure) after acetylcholine provocation was measured, representing airway hyperresponsiveness, and bronchoalveolar lavage fluid, sera, lung tissues for histologic analysis, messenger RNA, and collagen were collected.

RESULTS

Mean time-integrated change in peak airway pressure values in 6-week-old and 6-, 12-, and 18-month-old ASHMI ovalbumin mice were significantly reduced compared with those of age-matched, nontreated ovalbumin mice. Bronchoalveolar lavage fluid eosinophil numbers were significantly lower in all ASHMI ovalbumin mice. Treatment with ASHMI of young and aged ovalbumin mice resulted in significantly decreased lung inflammation, detected via hematoxylin-eosin staining; airway mucous cell metaplasia, determined by means of periodic acid-Schiff staining; and messenger RNA copy numbers of the mucin gene MUC5AC. Levels of ovalbumin specific IgE and the T(H)2 cytokines interleukin 4 (IL-4), IL-5, and IL-13 in lung and splenocyte cultures were reduced. Interferon gamma secretion was increased. Treatment with ASHMI reduced collagen production.

CONCLUSION

Treatment with ASHMI reduces several features of asthma in aged antigen-sensitized and antigen-challenged mice.

Asthma in the elderly: current knowledge and future directions

PURPOSE OF REVIEW

Asthma is a common disease in the older population that is frequently undiagnosed and undertreated. We will review the current knowledge of asthma in the elderly (AIE) and shed light on the diagnostic and management challenges outlining needs for future research.

RECENT FINDINGS

There has been very little original research in the field of AIE published in the last few years, and current literature focuses primarily on a series of review articles. AIE often presents with multiple comorbidities, which complicates its course and management. There is renewed interest in nonallergic (intrinsic) asthma. T helper cell 1 inflammation triggered by respiratory infection, superantigens, proteases and interleukin 17 are possible mechanisms. An association between systemic inflammation in frailty and asthma may also be important.

SUMMARY

The diagnosis and treatment of AIE requires that the individual patient and his or her specific triggers and the likely pathophysiology be understood. Understanding the mechanisms of inflammation in this population is key to improved therapeutic interventions.