Depressive symptoms, low adherence, and poor asthma outcomes in the elderly

Factors Affecting Usage of a Digital Asthma Monitoring Application by Old-Age Asthmatics Living in Inner Central Portugal

Purpose

To analyse factors affecting the ability to use the digital asthma monitoring application Mask-Air® in old-age individuals living in inland Portugal.

Patients and Methods

In this observational study, patients with medically confirmed asthma who agreed to participate were interviewed and subdivided into Non-users Group: those who could not use the application and Users Group: those who could. Sociodemographic and psychological data, comorbidities, and asthma status were compared between groups. Assessment of reasons for refusal was based on a 6-item questionnaire.

Results

Among the 72 sequentially recruited patients (mean age±SD 73.26±5.43 yrs; 61 women; 11 men), 44 (61.1%; mean age±SD 74.64±5.68 yrs; 38 women; 6 men)) were included in Non-users Group and 28 (38.9%; mean age±SD 71.11±4.26 yrs; 23 women; 5 men) in Users Group. Non-users Group patients were significantly older, had lower socioeconomic level, and more frequently had severe asthma (25% vs 3.6%; Odds ratio=0.08 (95% CI=0.01-0.81; p=0.033)) and diabetes (32.6% vs 7.4%; Odds ratio=0.17 (95% CI=0.03-0.80; p=0.025)) than Users Group. The main reasons for not using the App were "Lack of required hardware" (n=35) and "Digital illiteracy" (n=26), but lack of interest to use the App among those who had conditions to use it was uncommon.

Conclusion

Most old-age asthmatics living in Beira Interior either lack a smartphone or digital skills, which are significant obstacles to implementing app-based monitoring studies.

Asthma medication adherence, control, and psychological symptoms: a cross-sectional study

BACKGROUND

Nonadherence to therapies and psychological disorders are associated with poor asthma control. This study aims to assess the prevalence of anxiety and depressive symptoms, asthma control, and adherence to inhalers and to investigate whether there is an association of anxiety and depressive symptoms with adherence to inhalers and asthma control.

METHODS

We measured anxiety and depressive symptoms using the Hospital Anxiety and Depression Scale in patients with asthma. Asthma Control Test and the 10-Item Test of Adherence to Inhalers Scale were used to assess levels of asthma control adherence to inhalers, respectively. Univariate and multivariate regression models assessed the associations of anxiety and depressive symptoms with adherence to inhalers and asthma control.

RESULTS

A total of 287 patients completed the study, of whom 72% were female. The mean ± SD age and body mass index of our study population were 44 ± 13 years and 29 ± 7.2 kg/m2, respectively. Poor adherence to inhaler use was highly prevalent (49.8%; 95% CI: 43.8 to 55.7). The prevalence of anxiety, depression and poor asthma control was 27.2% (95% CI: 22.1 to 32.7), 20.9% (95% CI: 16.3 to 26.1), and 22.7% (95% CI: 17.9 to 27.9), respectively. We found a negative relationship between asthma control and anxiety, and depressive symptoms (adjusted β: -0.25; 95% CI: -0.36 to -0.14; p < 0.001 and adjusted β: -0.29; 95% CI: -0.40 to -0.18; p < 0.001, respectively). A negative relationship was also observed between adherence to inhalers and anxiety and depressive symptoms (adjusted β: -0.34; 95% CI: -0.46 to -0.22; p < 0.001 and adjusted β: -0.36; 95% CI: - 0.48 to - 0.24; p < 0.001, respectively).

CONCLUSIONS

The high prevalence of uncontrolled asthma symptoms and poor adherence to inhalers and their impact on anxiety and depression levels among patients with asthma point to the need for early screening for psychological symptoms and recognition of nonadherence as part of asthma assessment and management plan in primary care in Saudi Arabia to avoid further worsening of asthma symptoms. Further studies are needed to explore the effectiveness of specific psychoeducational interventions and investigate the long-term impact of early psychological symptom detection on asthma outcomes.

The efficacy of citalopram or escitalopram in patients with asthma and major depressive disorder

BACKGROUND

Major depressive disorder is common in people with asthma. Yet, few studies have evaluated depression treatment in those with asthma.

OBJECTIVE

To explore the relationship between antidepressant use, depressive symptoms, and asthma control, pooled data from 3 randomized trials of either citalopram or escitalopram were assessed.

METHODS

Linear fixed effects and binary logistic regression analyses were conducted with between-subject covariates including treatment group, (original) study, and demographics. The within-subject effect of visit, and a treatment group-visit (between-within) interaction effect, were also evaluated. Analyses were repeated in a high asthma exacerbation subgroup having at least 3 oral corticosteroid bursts in the previous 12 months. Outcomes included the Hamilton rating scale for depression (HAM-D17), the 7-item asthma control questionnaire (ACQ), and oral corticosteroid use (yes or no).

RESULTS

In the pooled sample (n = 255), the antidepressant treatment group exhibited lower HAM-D17 overall (P ≤ .001) and a lower likelihood for oral corticosteroid use (P ≤ .001) relative to the placebo group. In the high-exacerbation subgroup (n = 96), treatment group participants had lower overall asthma control questionnaire (P = .004) and HAM-D17 scores (P ≤ .001), and a lower likelihood of oral corticosteroid use (P = .003), relative to placebo participants. All treatment group interaction effects were not significant.

CONCLUSION

Citalopram or escitalopram exhibited efficacy in reducing depressive symptoms and the need for rescue oral corticosteroids in patients with asthma and major depressive disorder. Future work should determine whether selective serotonin reuptake inhibitors are effective at improving asthma outcomes in those with asthma who are not depressed.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00621946 and NCT01324700 (one study was conducted before ClinicalTrials.gov requirements).

The association of depressive symptoms and medication adherence in asthma patients: The mediation effect of medication beliefs

BACKGROUND

The significant role of depression in influencing medication beliefs, which are pivotal cognitive factors that strongly influence medication adherence, has been established. Poor adherence to asthma-controlled medication poses an significant barrier to achieving optimal asthma management.

OBJECTIVE

To explore the potential mediating effects of medication beliefs on the relationship between depressive symptoms and medication adherence in patients with asthma.

METHODS

Demographic and clinical characteristics, depressive symptoms, medication adherence, and medication beliefs were collected using questionnaires. Structural equation modeling, was utilized to model medication beliefs as mediators in the relationship between depressive symptoms and medication adherence. Bootstrapping was performed to analyze the mediation- and contrast-specific indirect effects of the two medication beliefs.

RESULTS

Among the patients who participated in the study, 29.6 % with depressive symptoms were more prone to poor adherence and exhibited skepticism toward asthma medications. Depression had a direct effect (direct effect = -0.275, 95%CI: -0.369 to -0.190) and an indirect effect on adherence mediated by medication beliefs (indirect effect = -0.168, 95%CI: -0.224 to -0.121). The specific mediation effect of concern belief was stronger than that of necessity belief (difference = -0.076, 95%CI: -0.132 to -0.029).

CONCLUSION

Depressive symptoms have a direct impact on medication adherence as well as an indirect effect mediated by beliefs about medication, particularly concerns belief.

Asthma control and associated risk factors among adults with current asthma: Findings from 2019 behavioral risk factor surveillance system asthma call-back survey

BACKGROUND

Despite the availability of effective treatments, many adults with asthma have uncontrolled asthma. Uncontrolled asthma can lead to severe exacerbations. This study aimed to determine the prevalence and predictors of uncontrolled asthma among adults (≥18 years) with current asthma in the United States.

METHODS

We analyzed the 2019 Behavior Risk Factor Surveillance System Asthma Call-Back Survey data from 27 states. Asthma control status was classified as "well-controlled" or "uncontrolled" according to the National Asthma Education and Prevention guidelines. The study population consisted of 7937 adults (weighted n = 13,793,220) with current asthma. We used multivariable logistic regression models to identify predictors of uncontrolled asthma.

RESULTS

Overall, 62 % of adults with asthma reported having uncontrolled asthma, and 26 % had emergency or urgent care visits or hospitalizations in the past year. Potentially modifiable risk factors associated with uncontrolled asthma included cost barriers to asthma-related healthcare (OR = 2.94; 95%CI 1.96-4.40), complementary and alternative medicine use (OR = 1.84; 95%CI 1.45-2.32), current smoking (OR = 2.25; 95%CI 1.48-3.44), obesity (OR = 1.39; 95%CI 1.02-1.89), COPD (OR = 1.98; 95%CI 1.43-2.74), depression (OR = 1.47; 95%CI 1.16-1.88), fair/poor general health (OR = 1.54; 95%CI 1.14-2.07), household income <$15,000 (OR = 2.59; 95%CI 1.42-4.71), and less than high school education (OR = 2.59; 95%CI 1.42-4.71). Non-modifiable risk factor was Hispanic ethnicity (OR = 1.73; 95%CI 1.09-2.73).

CONCLUSION

Our findings suggest that uncontrolled asthma is common among adults and can be impacted by several factors. Effective asthma control programs are needed to improve asthma management and reduce unnecessary healthcare utilization.

Assessment of the Current Practice of Managing Depression in Patients with Asthma in Saudi Arabia: Physicians' Views

Objective

Depression is a common comorbidity in patients with asthma with a significant impact on clinical management. However, little information is available about physicians' perceptions and current practices in identifying and managing depression in individuals with asthma in Saudi Arabia. Thus, this study aims to assess physicians' views and current practices of identifying and managing depression in patients with asthma in Saudi Arabia.

Methods

A cross-sectional study was employed. Between September 2022 and February 2023, an online survey was distributed to physicians (general practitioners and family, internal and pulmonary medicine specialists) in Saudi Arabia. Descriptive statistics were performed to analyze the collected responses.

Results

Out of 1800 invited participants, a total of 1162 physicians completed the online survey. Nearly 40% of the respondents received adequate training for managing depression. More than 60% of physicians reported that depression interferes with self-management and worsens asthma symptoms, while 50% viewed the importance of regular screening for depression. Less than 40% (n=443) aim to identify depression during patients' visits. Of those, only 20% always screen for depression in asthma patients. Physicians show a low level of confidence when asking patients about their feelings (30%), being able to recognize depression (23%), and knowing if patients have depression (23%). The most common barriers linked to recognizing depression are high workload (50%), lack of time to screen for depression (46%), limited knowledge about depression (42%), and poor training (41%).

Conclusion

The rate of recognizing and confidently managing depression in asthmatic patients is significantly low. This is attributed to high workload, poor training, and limited knowledge about depression. There is a need to support psychiatric training and implement a systematic approach to depression detection in clinical settings.

Incident and recurrent depression among older adults with asthma during the COVID-19 pandemic: Findings from the Canadian Longitudinal Study on Aging

OBJECTIVES

(1) In a subsample of older adults with asthma without a history of depression, to determine the factors associated with developing depression during the COVID-19 pandemic; (2) in a subsample of older adults with asthma with a history of depression, to identify factors associated with recurrent depression during the pandemic.

METHODS

Data came from four waves (Baseline [2011-2015], Follow-up 1 [2015-2018]; COVID Spring 2020, COVID Autumn 2020) of the Canadian Longitudinal Study on Aging's comprehensive cohort (n = 2,047 with asthma). The outcome of interest was a positive screen for depression based on the CES-D-10 during the autumn of 2020. Bivariate and multivariate logistic regression analyses were conducted.

RESULTS

Among older adults with asthma without a history of depression (n = 1,247), approximately 1 in 7 (13.5%) developed depression for the first time during the COVID-19 pandemic. Among those with a history of depression (n = 770), approximately 1 in 2 (48.6%) experienced a recurrence of depression. The risk of incident depression and recurrent depression was higher among those who were lonely, those experiencing family conflict during the pandemic, and those who had difficulty accessing healthcare resources during the pandemic. The risk of incident depression only was higher among those who had difficulty accessing resources and/or loss of income during the pandemic. The risk of recurrent depression only was higher among those with functional limitations.

CONCLUSIONS

There is a need for targeted interventions to support the mental health of older adults with asthma who have the above identified vulnerabilities during the pandemic.

Diagnostic and therapeutic approaches for elderly asthma patients: the importance of multidisciplinary and multidimensional management

INTRODUCTION

Asthma is commonly considered a disease of younger ages; however, it is not infrequent to pose a diagnosis of the disease in older individuals. Although current recommendations do not distinguish between young and old asthmatics in terms of diagnostic and therapeutic approaches, asthma in the elderly may present with peculiar features that contribute to complicate its management.

AREAS COVERED

The current review focuses on the challenges that arise when approaching an older individual with suspected asthma. Age-associated changes of the lung may complicate the diagnostic approach. Measurement of the forced expiratory volume in the first 6 s (FEV6) in an easier and faster alternative to FVC estimation, and residual volume should always be assessed. Older individuals are often affected by concomitant diseases, both age- and drug-related, that need to be considered when approaching elderly asthmatics, since they can affect the efficacy of the treatment as well as the control of the disease.

EXPERT OPINION

The potential drug to drug interaction should be routinely investigated, and documented in medical records. The effect of aging on the response to pharmacological therapy in older asthmatics should be explored. Therefore, the need of a multidisciplinary and multidimensional approach to the elderly asthmatics is strongly encouraged.

Health Behavior Theory and Hypertension Management: Comparisons Among Black, White, and American Indian and Alaska Native Patients

In the United States, hypertension is more common among individuals from racial and ethnic minority groups. Hypertension control rates are also lower for minority group members compared with White Americans. However, little research has employed well-established theoretical perspectives on health behavior, such as the Theory of Planned Behavior (TPB) and the Model of Goal-Directed Behavior (MGB), to better understand racial differences in rates of hypertension control. The present study examines the psychological processes involved in efforts to control blood pressure, through the lens of the TPB augmented by the MGB, in hypertensive patients of three racial groups: American Indian/Alaska Native, Black/African American, and White. Participants completed measures of past efforts to control blood pressure, attitudes, norms, perceived behavioral control, intentions, and anticipated emotions. Analyses employed confirmatory factor analysis and cross-groups path analysis. Measurement of the theoretical constructs and core putative mediators of blood pressure control intentions were largely similar across racial groups. With regard to the patterns of relationships among the constructs, differences among the groups were most apparent in pathways from past efforts to both cognitive and affective theoretical antecedents of intentions. These findings contribute to the sparse literature on factors involved in racial differences in hypertension control rates and may inform future interventions aimed at increasing hypertension control behaviors. Trial Registration ClinicalTrials.gov, NCT03028597, registered 23 January 2017, https://clinicaltrials.gov/ct2/show/NCT03028597; ClinicalTrials.gov, NCT04414982, registered 4 June 2020 (retrospectively registered), https://www.clinicaltrials.gov/ct2/show/NCT04414982.

Comorbidities and depressive symptoms among older adults with asthma

OBJECTIVE

Depression is associated with poor outcomes among older adults with asthma, and the presence of multiple comorbidities may magnify this relationship. We sought to determine the association of comorbidities with depressive symptoms among older adults with asthma.

METHODS

Secondary analysis of data from a randomized controlled trial of older adults with poorly controlled asthma and comorbidities. Comorbidities were measured in two ways: (1) as a count of all the patient's chronic diseases, and (2) as a count of chronic illnesses with self-management intensive needs (diabetes, hypertension, congestive heart failure). Depressive symptoms were measured using the PROMIS SF8a scale. Multiple regression analyses tested the relationship between comorbidities and depressive symptoms, adjusting for sociodemographic factors.

RESULTS

Overall, 25% of participants had moderate-severe levels of depressive symptoms, 87% had ≥ two comorbidities, and 41% had ≥ one comorbidity with self-management intensive needs. The count of all comorbidities was significantly associated with depressive symptoms (F (8, 330) = 7.7, p < 0.0001, R2 = 0.158) in adjusted models, whereas the count of self-management intensive conditions was not significantly associated with depressive symptoms in adjusted analyses.

CONCLUSIONS

In older adults with asthma and multiple comorbidities, depressive symptoms increased with the overall count of comorbidities but not with the count of comorbidities with self-management intensive needs. Given the impact of depression on asthma outcomes for older adults, the mechanisms by which comorbid illness contributes to depressive symptoms in older asthmatics warrants further evaluation.

The Management of Extrapulmonary Comorbidities and Treatable Traits; Obesity, Physical Inactivity, Anxiety, and Depression, in Adults With Asthma

Asthma is a complex and heterogenous disease characterized by variability in disease expression and severity. Multiple extrapulmonary comorbidities and treatable traits are common in people with asthma, and there is an increasing appreciation of how these may complicate asthma management. This review will discuss the prevalence and impact of extrapulmonary comorbidities/risk factors or "traits," which have been found to co-exist in asthma (obesity, symptoms of depression and/or anxiety and physical inactivity), the impact these traits have on future outcomes (including exacerbation risk and quality of life) and asthma management, and how we should target treatment in asthma when these extrapulmonary traits are present.

Cognition, symptom perception, and medication non-adherence in older adults with asthma

BACKGROUND

Cognitive impairment (CI) is highly prevalent in elderly asthmatics and is associated with worse asthma self-management (SM) and outcomes. CI may also explain why older adults may under-perceive asthma symptoms. We hypothesized that CI would be associated with low medication adherence and asthma symptom under-perception (ASP). We also hypothesized that ASP would mediate the relationship between CI and medication adherence.

METHODS

Participants of this longitudinal cohort study were asthmatics (N = 334) ≥60 years (51% Hispanic, 25% Black). Cognitive measures assessed general cognition, attention, processing speed, executive functioning, memory, and language. Measures of SM were self-reported and electronically measured adherence to controller medications. ASP was assessed for 6 weeks by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter, followed by PEF blows. Participants were blinded to actual PEF values. Percentage of time that participants were in the over-perception zone was calculated as an average.

RESULTS

In regression analyses, those with impairments in memory and general cognition had lower odds ratios (OR) for self-reported non-adherence (OR: 0.96, 95% CI 0.93 - 0.98 & OR: 0.90, 95% CI 0.83 - 0.96, respectively). CI was not associated with electronically measured non-adherence or ASP. In structural equation modeling, while CI was associated with adherence (β = 0.04, SE = 0.021, p = 0.04), ASP did not mediate this relationship.

CONCLUSIONS

While results confirmed the importance of cognition in asthma SM, these findings were not linked to ASP. Future analyses are needed to understand the role of confounding factors.

The Relationship Between Post-Traumatic Stress Disorder and Self-Management Behaviors in World Trade Center Workers with Asthma

BACKGROUND

Comorbid posttraumatic stress disorder (PTSD) is highly prevalent and associated with increased morbidity among World Trade Center (WTC) rescue and recovery workers with asthma. However, the potential behavioral pathways underlying this relationship remain unclear.

OBJECTIVE

To evaluate whether PTSD is associated with lower adherence to asthma self-management behaviors among WTC workers with asthma.

METHODS

We used data from a prospective cohort of WTC workers with a physician diagnosis of asthma who were prescribed controller medications. Presence of comorbid PTSD was determined based on structured clinical interviews. Asthma self-management behaviors included medication adherence, inhaler technique, use of action plans, and trigger avoidance. We conducted unadjusted and multiple regression analyses to evaluate the association of PTSD with asthma self-management.

RESULTS

Overall, 30% of 276 WTC workers with asthma had comorbid PTSD. Posttraumatic stress disorder was associated with worse asthma control and poorer quality of life. However, PTSD was not significantly associated with medication adherence (odds ratio [OR] -0.15; 95% confidence interval [CI] -0.5 to 0.2), inhaler technique (OR -0.12; 95% CI -0.7 to 0.5), use of action plans (OR 0.8; 95% CI 0.4 to 1.8), or trigger avoidance (OR 0.9; 95% CI 0.4 to 1.8).

CONCLUSIONS

We did not find significant differences in key asthma self-management behaviors between WTC workers with and without PTSD. These results suggest that other mechanisms, such as differences in symptom perception or inflammatory pathways, may explain the association between PTSD and increased asthma morbidity.

Depressive Symptoms and Overperception of Airflow Obstruction in Older Adults With Asthma

OBJECTIVE

Older adults are at increased risk for depression and poor asthma outcomes. We examined whether depressive symptoms are associated with overperception of airflow obstruction and a pattern of worse asthma control, but not pulmonary function.

METHODS

We recruited a cohort of adults with asthma 60 years and older in East Harlem and the Bronx, New York. Baseline measures included the Geriatric Depression Scale, Asthma Control Questionnaire, and Mini Asthma Quality of Life Questionnaire. Spirometry was conducted at baseline to assess pulmonary function. Perception of airflow obstruction was assessed for 6 weeks following baseline by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter followed by PEF blows. Participants were blinded to actual PEF values. The percentage of time that participants were in the overperception zone was calculated as an average.

RESULTS

Among the 334 participants (51% Hispanic, 25% Black), depressive symptoms were associated with overperception of airflow obstruction (β = 0.14, p = .029), worse self-reported asthma control (β = 0.17, p = .003), and lower asthma-related quality of life (β = -0.33, p < .001), but not with lung function (β = -0.01, p = .82). Overperception was also associated with worse self-reported asthma control (β = 0.14, p = .021), but not lung function (β = -0.05, p = .41).

CONCLUSIONS

Depressive symptoms were associated with greater perceived impairment from asthma, but not pulmonary function. Overperception of asthma symptoms may play a key role in the relationship between depression and asthma outcomes in older adults.

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.

Comorbid posttraumatic stress disorder and major depressive disorder are associated with asthma morbidity among World Trade Center workers

BACKGROUND

World Trade Center (WTC) rescue and recovery workers have a high burden of asthma, comorbid posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). PTSD is associated with worse asthma outcomes.

OBJECTIVE

In this study, we evaluated whether the relationship between PTSD and asthma morbidity is modified by the presence of MDD.

METHODS

We used data from a cohort of WTC workers with asthma. Asthma control (asthma control questionnaire), resource utilization, and quality of life (asthma quality of life questionnaire) were evaluated. We used regression analyses to evaluate the adjusted association of PTSD and MDD with asthma control, resource utilization, and quality of life.

RESULTS

Of the study cohort of 293 WTC workers with asthma, 19% had PTSD alone, 2% had MDD alone, and 12% had PTSD and MDD. Adjusted mean differences (95% confidence interval) in asthma control questionnaire scores were 1.32 (0.85-1.80) for WTC workers with PTSD and MDD, 0.44 (0.03-0.84) for those with PTSD alone, and 0.50 (-0.38 to 1.38) for workers with MDD alone compared with those without MDD or PTSD. WTC workers with PTSD and MDD, PTSD alone, and MDD alone had mean (95% confidence interval) adjusted differences in asthma quality of life questionnaire scores of -1.67 (-2.22 to -1.12), -0.56 (-2.23 to -1.12), and -1.21 (-2.23 to -0.18), respectively, compared with workers without MDD or PTSD. Similar patterns were observed for acute resource utilization.

CONCLUSION

PTSD and MDD seem to have a synergistic effect that worsens asthma control and quality of life. Efforts to improve asthma outcomes in this population should address the negative impacts of these common mental health conditions.

Elevated Circulating Th2 Cells in Women With Asthma and Psychological Morbidity: A New Asthma Endotype?

PURPOSE

Psychological stress shifts the immune system toward the production of T-helper (Th)-2-mediated cytokines and eosinophilia, increases the risks for both asthma and depression, and can precipitate asthma exacerbations. Th2-mediated inflammation is a characteristic of allergic asthma. We have shown that the levels of CD4⁺ Th2 cells in the peripheral blood of patients with asthma are associated with severity and/or control of the disease. To improve our understanding of the interactions between stress and asthma symptoms, we evaluated the effects of psychological comorbidity on Th2-mediated inflammation in patients with asthma.

METHODS

Sixty-six asthmatic patients were recruited from the University of Alberta Asthma Clinic after they gave informed consent. Stress-related effects on asthma and psychological morbidity were assessed using the Asthma Control Questionnaire, completed by the patients at recruitment. Venous blood was collected at recruitment and Th2-mediated immunity evaluated by flow cytometry, quantitative real-time reverse-transcription polymerase chain reaction and enzyme-linked immunosorbent assay.

FINDINGS

Patients with stress-triggered asthma (n = 12) had higher percentage of CD4⁺ T cells (P = 0.006) and Th2 cells (CD4⁺CRTh2⁺ T cells; P = 0.002) in peripheral blood compared to patients with asthma who did not experience stress-related worsening of disease (n = 54). The same was true when we analyzed patients with any form of psychological comorbidity (n = 19) compared to those without psychological comorbidities (n = 47). These differences were evident among women, but not among men. Women with psychological comorbidity also required higher doses of inhaled and oral corticosteroids compared to those without psychological comorbidity.

IMPLICATIONS

Asthma involving psychological morbidity associates with an elevated level of circulating Th2 cells and increased corticosteroid usage, and may be more prevalent in women. Larger-scale prospective studies are required for assessing whether these women constitute a new endotype of Th2-high asthma responsive to treatments aimed to improve psychological comorbidities.

Chronic cough, not asthma, is associated with depression in the elderly: a community-based population analysis in South Korea

BACKGROUND/AIMS

Depression and allergic diseases, including asthma, are frequently reported as comorbid conditions. However, their associations have been rarely examined in community-based elderly populations.

METHODS

The analyses were performed using the baseline data set of the Korean Longitudinal Study of Health and Aging, which consists of 1,000 elderly participants (aged > 65 years) randomly recruited from an urban community. Depression was assessed using the Geriatric Depression Scale, Center for Epidemiologic Studies Depression Scale, and Hamilton Rating Scale for Depression. Major and minor depressive disorders were diagnosed by psychiatrists. Allergic conditions were assessed using structured questionnaires, lung function, and skin prick test. Quality of life and comorbidities were assessed using structured questionnaires.

RESULTS

Prevalence of asthma and major depressive disorder were 5.4% and 5.3%, respectively. The rate of depression was not significantly different between the non-asthmatic and asthmatic groups. No correlation was observed between the scores obtained using the depression scales and self-reported asthma. However, chronic, frequent, and nocturnal cough were significantly associated with depression and scores obtained using the depression scales, which remained significant in multivariate logistic regression analyses (chronic cough: odds ratio [OR], 3.23; 95% confidence interval [CI], 2.57 to 12.74; p = 0.04). Rhinitis was independently associated with high Mini-Mental State Examination scores (OR, 1.11; 95% CI, 1.05 to 1.17; p < 0.001) and low 36-item short-form (OR, 0.96; 95% CI, 0.80 to 0.98; p = 0.002).

CONCLUSION

Depression may not be significantly associated with asthma and allergic diseases in elderly populations, but cough is a significant factor affecting depression.

A systematic review of psychological, physical health factors, and quality of life in adult asthma

Asthma is a common non-communicable disease, often characterized by activity limitation, negative effects on social life and relationships, problems with finding and keeping employment, and poor quality of life. The objective of the present study was to conduct a systematic review of the literature investigating the potential factors impacting quality of life (QoL) in asthma. Electronic searches were carried out on: MEDLINE, EMBASE, PsycINFO, the Cochrane Library, and Web of Science (initial search April 2017 and updated in January 2019). All primary research studies including asthma, psychological or physical health factors, and quality of life were included. Narrative synthesis was used to develop themes among findings in included studies in an attempt to identify variables impacting QoL in asthma. The search retrieved 43 eligible studies that were grouped in three themes: psychological factors (including anxiety and depression, other mental health conditions, illness representations, and emotion regulation), physical health factors (including BMI and chronic physical conditions), and multifactorial aspects, including the interplay of health and psychological factors and asthma. These were found to have a substantial impact on QoL in asthma, both directly and indirectly, by affecting self-management, activity levels and other outcomes. Findings suggest a complex and negative effect of health and psychological factors on QoL in asthma. The experience of living with asthma is multifaceted, and future research and intervention development studies should take this into account, as well as the variety of variables interacting and affecting the person.

Effect of a Self-management Support Intervention on Asthma Outcomes in Older Adults: The SAMBA Study Randomized Clinical Trial

IMPORTANCE

Older adults with asthma have worse control and outcomes than younger adults. Interventions to address suboptimal self-management among older adults with asthma are typically not tailored to the specific needs of the patient.

OBJECTIVE

To test the effect of a comprehensive, patient-tailored asthma self-management support intervention for older adults on clinical and self-management outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Three-arm randomized clinical trial conducted between February 2014 and December 2017 at primary care practices and personal residences in New York City. Adults 60 years and older with persistent, uncontrolled asthma were identified from electronic medical records at an academic medical center and a federally qualified health center. Of 1349 patients assessed for eligibility, 406 met eligibility criteria, consented to participate, and were randomized to 1 of 3 groups: home-based intervention, clinic-based intervention, or control (usual care). A total of 391 patients received the allocated treatment.

INTERVENTIONS

Screening for psychosocial, physical, cognitive, and environmental barriers to asthma control and self-management with actions to address identified barriers. The intervention was delivered in the home or primary care practices by asthma care coaches.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the Asthma Control Test, Mini Asthma Quality of Life Questionnaire, Medication Adherence Rating Scale, metered dose inhaler technique, and emergency department visits for asthma care. Primary analyses compared intervention (home or clinic based) with usual care.

RESULTS

Of the 391 patients who received treatment, 58 (15.1%) were men, and the mean (SD) age was 67.8 (7.4) years. After accounting for baseline scores, scores on the asthma control test were better in the intervention groups vs the control group (difference-in-differences at 3 months, 1.2; 95% CI, 0.2-2.2; P = .02; 6 months, 1.0; 95% CI, 0.0-2.1; P = .049; 12 months, 0.6; 95% CI, -0.5 to 1.8; P = .28; and overall, χ2 = 13.4, with 4 degrees of freedom; P = .01). Emergency department visits were lower at 12 months for the intervention groups vs the control group (16 [6.2%] vs 17 [12.7%]; P = .03; adjusted odds ratio, 0.8; 95% CI, 0.6-0.99; P = .03). Statistically significant improvements were observed for the intervention vs control patients in quality of life (overall effect: χ2 = 10.5, with 4 degrees of freedom; P = .01), medication adherence (overall effect: χ2 = 9.5, with 4 degrees of freedom; P = .049), and inhaler technique (metered-dose inhaler technique, correctly completed steps at 12 months, median [range]: 75% [0%-100%] vs 58% [0%-100%]). No significant differences in outcomes were observed between patients receiving the intervention in home vs practice settings.

CONCLUSIONS AND RELEVANCE

An intervention directed by patients' needs and barriers improved asthma outcomes and self-management behaviors among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02316223.

Omalizumab Treatment Patterns Among Patients with Asthma in the US Medicare Population

BACKGROUND

Asthma in older adults is associated with high rates of morbidity and mortality; similarly, asthma can be severe enough among younger adults to warrant disability benefits. Reasons for poor outcomes in both groups of patients may include discontinuation and lack of adherence to controller therapies.

OBJECTIVE

To examine characteristics and treatment patterns of US Medicare patients initiating omalizumab for asthma, and factors associated with its discontinuation and adherence.

METHODS

A retrospective claims database analysis of Medicare beneficiaries with asthma initiating omalizumab treatment was carried out. The primary outcomes were omalizumab discontinuation (gap in use ≥90 days) and adherence (proportion of days covered ≥0.8) over a 12-month follow-up. Multivariable regressions were used to examine factors associated with omalizumab discontinuation and adherence.

RESULTS

Of the 3058 Medicare patients initiating omalizumab for asthma (mean age, 62.7 years), 36.9% discontinued omalizumab and 60.6% were adherent. Discontinuation rates were 32.7% and 42.8%, and adherence rates were 65.4% and 53.9%, for disabled and older Medicare patients, respectively. Patients aged 65 to 69 years and 70 to 74 years had significantly lower odds of discontinuation (odds ratios [95% CI], 0.66 [0.46-0.93] and 0.62 [0.43-0.89], respectively) and higher odds of adherence than did patients aged 80 years or older. Compared with patients receiving low-income subsidy, patients not receiving low-income subsidy had lower odds of discontinuation (0.66 [0.52-0.83]) and higher odds of adherence (1.52 [1.20-1.93]). Greater numbers of preindex evaluation and management physician visits and comorbid rhinitis were associated with lower odds of discontinuation and higher odds of adherence.

CONCLUSIONS

More than 60% of Medicare patients with asthma continued and were adherent to omalizumab over a 12-month follow-up. Patient age, low-income subsidy status, and the numbers of evaluation and management physician visits were among factors associated with treatment adherence and discontinuation.

[Role of non pharmacological Interventions for asthma]

Smoking cessation remains a major issue for asthmatic smokers. Respiratory rehabilitation and respiratory physiotherapy have shown a benefit in controlling symptoms, preventing exacerbations and improving the quality of life. The control of the environment is crucial and must be approached in a global way. Management of obesity and psychological disorders should be systematically proposed. Allergen immunotherapy may be discussed in allergic persistent asthma to house dust mites. Certain dietary interventions or alternative medicines have not proved their worth.

Epidemiology of Depression and Associated Factors among Asthma Patients in Addis Ababa, Ethiopia

BACKGROUND

Depression in asthma patients can cause worsening of respiratory symptoms. Addressing mental illness in those with asthma improves asthma outcomes. This study aimed to assess the epidemiology of depression and associated factors among asthma patients attending government hospitals in Ethiopia.

METHODS

Institutional based cross-sectional study was conducted on patients with asthma at three governmental hospitals of Addis Ababa from June to July 2017. Patient health questionnaire (PHQ-9) depression scale was used to assess prevalence of depression among asthmatic patients. The data were entered and analyzed using SPSS version 20 statistical software. Binary logistic regression analysis was conducted to identify associated factors for depression. To indicate the strength of association, odds ratios (OR) and 95% confidence intervals (95% CI) were used.

RESULT

A total of 405 participants were enrolled in the study giving an overall response rate of 96%. The respondents had mean age of 54.46 and standard deviation (SD) of 10.01 years. About 273 (67.4%) were females. The prevalence of depression among asthma patients was 85 (21%). The odds of developing depression among single asthma patients were increased by 1.63 with 95% CI [1. 8, 3.493]. Depression among asthma patients who had comorbid cardiac illness was 6.2 times higher than those who do not have at CI [1.145, 24.109]. The prevalence of depression among uncontrolled asthma patients was 8 times higher than those with well-controlled asthma at CI [1.114, 19.025].

CONCLUSION

One-fifth of asthmatic patients were experiencing depression. Uncontrolled asthma, comorbid cardiac illness, and single patients were important predictors of depression among asthmatic patients. Proper control of asthmatic attack and cardiac illnesses is very important to reduce the burden of depression.

A Cluster Analysis of Bronchial Asthma Patients with Depressive Symptoms

Objective Whether or not depression affects the control or severity of asthma is unclear. We performed a cluster analysis of asthma patients with depressive symptoms to clarify their characteristics. Methods Multiple medical institutions in Niigata Prefecture, Japan, were surveyed in 2014. We recorded the age, disease duration, body mass index (BMI), medications, and surveyed asthma control status and severity, as well as depressive symptoms and adherence to treatment using questionnaires. A hierarchical cluster analysis was performed on the group of patients assessed as having depression. Results Of 2,273 patients, 128 were assessed as being positive for depressive symptoms [DS(+)]. Thirty-three were excluded because of missing data, and the remaining 95 DS[+] patients were classified into 3 clusters (A, B, and C). The patients in cluster A (n=19) were elderly, had severe, poorly controlled asthma, and demonstrated possible adherence barriers; those in cluster B (n=26) were elderly with a low BMI and had no significant adherence barriers but had severe, poorly controlled asthma; and those in cluster C (n=50) were younger, with a high BMI, no significant adherence barriers, well-controlled asthma, and few were severely affected. The scores for depressive symptoms were not significantly different between clusters. Conclusion About half of the patients in the DS[+] group had severe, poorly controlled asthma, and these clusters were able to be distinguished by their Adherence Starts with Knowledge (ASK)-12 score, which reflects adherence barriers. The control status and severity of asthma may also be related to the age, disease duration, and BMI in the DS[+] group.

Is aging a "comorbidity" of asthma?

The aging population is growing at an unparalleled rate. Asthma is common in the elderly (age over 65 years) and can be more severe with little chance for remission. Asthma in older individuals is often under-diagnosed, misdiagnosed and frequently under-treated. Concomitant medical and psychosocial conditions are more prevalent in the elderly and can obfuscate the presentation of asthma and make it more difficult to assess and manage. While these comorbidities are important in understanding elderly asthma, aging itself can be considered a "comorbidity" since it impacts structural and functional changes in the lung. Structural changes of the aging lung may worsen physiologic function in asthma. The immune system also changes with age, with increased vulnerability to pathogens and differences in airway inflammation, leading to variability in how asthma manifests and responds to treatment. The fact that aging can influence the severity and presentation of asthma along with its diagnosis and management is important for the treating physician to understand. This article will discuss the multitude of factors that justify considering aging as a comorbidity of asthma.

Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation

The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.

Barriers to medication adherence in asthma: The importance of culture and context

OBJECTIVE

Significant disparities exist in asthma outcomes. Racial and ethnic minorities have lower controller medication adherence, which may contribute to differences in asthma morbidity between minority and non-minority groups. The objective of this review is to identify individual, patient-provider communication, and systems issues that contribute to this pattern of medication underuse and to discuss potential strategies for intervention.

DATA SOURCES

Data were gathered from numerous sources, including reports of pharmacy and medical records, observational studies, and trials.

STUDY SELECTIONS

Studies analyzed factors contributing to patterns of asthma medication adherence that differ by race and ethnicity.

RESULTS

There is clear evidence of underuse of asthma controller medications among racial and ethnic minorities in prescription receipt, prescription initiation, and medication use once obtained. Individual factors such as medication beliefs and depressive symptoms play a role. Provider communication is also relevant, including limited discussion of complementary and alternative medicine use, difficulties communicating with patients and caregivers with limited English proficiency, and implicit biases regarding cultural differences. Systems issues (eg, insurance status, cost) and social context factors (eg, exposure to violence) also present challenges. Culturally informed strategies that capitalize on patient strengths and training providers in culturally informed communication strategies hold promise as intervention approaches.

CONCLUSION

Disparities in controller medication use are pervasive. Identifying the sources of these disparities is a critical step toward generating intervention approaches to enhance disease management among the groups that bear the greatest asthma burden.

Cultural Issues in Medication Adherence: Disparities and Directions

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient's family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

Cultural Issues in Medication Adherence: Disparities and Directions

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient's family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

Multifaceted interventions to reduce acute exacerbations in elderly asthmatics

Background

Although many risk factors are known to be associated with poor asthma outcomes in the elderly, the literature on the effect of risk factor control on asthma outcomes in the elderly is very sparse.

Objective

To evaluate the role of multifaceted interventions in reducing acute exacerbations in elderly asthmatics.

Methods

A total of 100 subjects were randomly selected from our prospective cohort of elderly asthmatics aged 65 years or older and were provided multifaceted intervention for 1 year. Our multifaceted interventions included repeated education on asthma and inhaler technique for patients and their caregivers, provision of an action plan to cope with acute exacerbations, short message service to prevent follow-up losses, and oral replacement of magnesium. The primary outcome was an acute asthma exacerbation rate compared to the previous year.

Results

Ninety-two subjects completed this study, although only 58 subjects continued to take magnesium. Compared to the previous year, the acute asthma exacerbation rate showed a significant reduction from 67% to 50% (p = 0001) and significant improvement was observed in forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC) (p = 0.04, p = 0.036 for each). Interestingly, a subgroup analysis revealed that predicted value of FEV₁ increased significantly in subjects who continued to take magnesium from 79.6% to 87.1% (p = 0.008).

Conclusion

To reduce acute exacerbations in elderly asthmatics, a multifaceted approach in increase medical awareness, proficiency and adherence to inhaler, assistance of caregivers and correction of micronutrients deficiency is likely to be effective. In addition, a continuous oral replacement of magnesium may increase FEV₁ in elderly asthmatics.

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.

Leukotriene Receptor Antagonists for the Treatment of Asthma in Elderly Patients

Elderly asthma (EA) is regarded as a distinct phenotype of asthma and is associated with age-related changes in airway structure and alterations in lung function and immune responses. EA is difficult to diagnose because of aging and co-morbidities, and overlaps with fixed airway obstructive disease. Novel modalities to differentiate between EA and chronic obstructive pulmonary disease (COPD) are necessary. A multifaceted approach, including clinical history, smoking habits, atopy, and measurement of lung function, is mandatory to differentiate asthma from COPD. There are a variety of co-morbidities with EA, of which COPD, upper airway diseases, depression, obesity, and hypertension are the most common, and these co-morbidities can affect the control status of EA. However, leukotriene receptor antagonists (LTRAs) can facilitate the management of EA, and thus addition of an LTRA to inhaled corticosteroid (ICS) monotherapy or ICS plus long-acting β₂-agonist therapy improves symptoms in EA patients. LTRA treatment is safe and beneficial in patients who are unable to use inhalation devices properly or who have co-morbid diseases. Therefore, clinical studies targeting a specific population of EA patients are warranted to help achieve a better therapeutic strategy in EA patients.

Predictors of asthma control in elderly patients

PURPOSE OF REVIEW

We are in the era of rapid aging of the global population. Elderly asthmatic patients have an increased frequency of hospitalization and a high mortality rate. In this review, we focus on comorbidities and treatment issues in terms of the predictors of asthma control in the elderly.

RECENT FINDINGS

Some frequent comorbidities, such as chronic obstructive pulmonary disease, chronic sinusitis, obesity, and depression, are associated with uncontrolled asthma in elderly asthmatic patients. Smoking status in elderly asthmatic patients was associated with more frequent exacerbations. Management of comorbidities should be taken into account when we treat elderly asthmatic patients. Low treatment adherence, which is common in elderly asthmatic patients, predicts poor asthma control status. A poor knowledge about asthma, cognitive function impairment, and inappropriate inhaler technique result in low treatment adherence. Polypharmacy is associated with low treatment adherence, adverse drug reactions, and drug-drug interactions, and it is supposed to be a predictor of asthma control.

SUMMARY

Multifactorial assessments, including comorbidities, treatment adherence, and polypharmacy, are important for better asthma control in elderly asthmatic patients. Further studies on the strategy for the management of elderly asthmatic patients in a real-world setting are warranted.

Comorbidities of Lung Disease in the Elderly

Comorbidities are common in elderly individuals with chronic respiratory diseases. They can affect disease manifestations and severity and can even impact management. Comorbidities can affect the treatment of the lung disease, particularly because of the interaction with the respiratory drugs. Thus, a multidimensional approach with multidisciplinary intervention is suggested for elderly respiratory patients, switching from a disease-oriented scheme to a dysfunction-oriented approach. Unfortunately, older individuals are often excluded from clinical trials because of advanced age and comorbidities. This article reviews the role of comorbidities in the management of respiratory diseases in the elderly.

Multidisciplinary Consensus on the Nonadherence to Clinical Management of Inhaled Therapy in Spanish asthma patients

PURPOSE

Rates of nonadherence to asthma treatment in Spain are between 24% and 76%, which results in poor disease control and increased health care costs. The main objective of this multidisciplinary consensus was to investigate the opinions of health professionals and patients regarding adherence to inhaled therapy in Spain. The results will help to identify the causes of nonadherence and to establish strategies to detect and correct the problem.

METHODS

This research was conducted by using a modified Delphi method organized into 2 rounds and involving a panel of 64 physicians, 16 nurses, and 10 community pharmacists. In addition, 70 patients with asthma completed a simplified 1-round survey, based on the Delphi questionnaire. The items proposed to reach a consensus included topics such as impact and causes of nonadherence, as well as strategies to improve adherence to treatment.

FINDINGS

Expert panelists reached a consensus on ~80% of the items proposed. They agreed that the lack of control in asthma has an important economic impact. The causes of nonadherence with more agreement were the patients' beliefs about treatment and the complexity of the inhalation devices. Panelists agreed that the most important strategies to improve adherence were modification of patients' beliefs, training of professionals in the management of adherence, and personalization of interventions. Most patients only agreed with items that referred to strategies to improve adherence.

IMPLICATIONS

Although the problems, impact, causes, and interventions regarding nonadherence to asthma treatment are known, adequate monitoring of adherence to treatment is not performed. A multidisciplinary and personalized approach is necessary to control and improve adherence.

Assessing usability of the "Adherence Starts with Knowledge 20" (ASK-20) questionnaire for Japanese adults with bronchial asthma receiving inhaled corticosteroids long term

BACKGROUND

Maintaining high treatment adherence levels is critical for effective management of chronic diseases. The Adherence Starts with Knowledge 20 (ASK-20) questionnaire is the only linguistically validated patient-reported treatment adherence tool available in Japan. We conducted additional analyses on ASK-20 data from Japanese adults with asthma.

METHODS

This was a prospective, non-interventional, single-visit, multi-centre study in Japanese adults (n = 300) with asthma receiving long-term treatment with inhaled corticosteroids (ICS) or ICS/long-acting beta-agonists. We tested the reliability, validity and the relationship between different adherence conditions and ASK-20 score. At one centre, ICS adherence prescription rate was calculated retrospectively based on 2-year percentage ICS adherence data contained within medical records.

RESULTS

The ASK-20 had good internal consistency reliability (Cronbach's alpha = 0.76; n = 290). Discriminant validity was demonstrated with significant correlations between the percentage ICS adherence rates and both the mean ASK-20 total score and mean total barrier count (TBC) (r = -0.51 and -0.58, p < 0.001; n = 111). The ASK-20 total score discriminated between subjects with good and poor adherence measured by patients' reported questionnaire and between those of high and low percentage ICS adherence rates. All other factors that possibly affect adherence were correlated with the mean ASK-20 total score and mean TBC in addition to the number of medicines taken every day.

CONCLUSIONS

The Japanese ASK-20 is a reliable tool for assessing possible medication adherence barriers and adherence behaviour in Japanese adults with asthma. Furthermore, our results are comparable with those obtained using the ASK-20 in the United States.

The pharmacotherapy preferred by doctors in treatment of patients diagnosed with asthma or chronic obstructive pulmonary disease or allergic rhinitis and concomitant diseases: an epidemiological analysis

INTRODUCTION

The clinical course of asthma and chronic obstructive pulmonary disease (COPD) is influenced by the co-occurrence of other chronic diseases and their pharmacotherapy. There are no data associated with the doctors' pharmacotherapy preferences in treatment of patients with asthma, COPD or allergic rhinitis and concomitant diseases.

AIM

The assessment of doctors' preferences in pharmacotherapy of asthma, COPD or allergic rhinitis in relation to concomitant diseases.

MATERIAL AND METHODS

General practitioners, pulmonologists, allergists, laryngologists and paediatricians (n = 319) participated in a questionnaire survey concerning their preferences in pharmacotherapy of asthma, COPD and allergic rhinitis in relation to concomitant diseases enrolling 11,310 patients with asthma, COPD and allergic rhinitis.

RESULTS

The concomitant diseases were reported in 58.5% of patients with asthma, 80.8% of patients with COPD and 46.4% of patients with allergic rhinitis. Patients with asthma were most frequently treated with inhaled glucocorticosteroids. However, in the subgroups with concomitant diseases, an increased usage of inhaled long-acting β2-mimetics was noted. Regardless of comorbidities, patients with COPD were most frequently treated with inhaled long-acting β2-mimetics whereas patients with allergic rhinitis - with nasal glucocorticosteroids and third-generation antihistamines.

CONCLUSIONS

The co-occurrence of chronic diseases was most frequent among patients diagnosed with COPD. The treatment of asthma, COPD and allergic rhinitis is consistent with international recommendations and the occurrence of concomitant diseases did not significantly influence therapeutic preferences and decisions.

Effects of older age and age of asthma onset on clinical and inflammatory variables in severe refractory asthma

BACKGROUND

Asthma in the elderly as well as asthma of adult-onset has been associated with increased morbidity, but little is known specifically about the effects of age on clinical and inflammatory outcomes in severe refractory asthma. The aims of the study were to examine the effects of age [<65 versus ≥65 years] and age of onset of asthma [childhood-onset, <18 versus adult-onset, ≥18 years] on clinical and inflammatory variables in patients with severe asthma.

METHODS

In 1042 subjects with refractory asthma recruited to the British Thoracic Society Severe Asthma Registry, we compared patient demographics, disease characteristics and biomarkers of inflammation in patients aged <65 years (n = 896) versus ≥65 years (n = 146) and onset at age <18 years (n = 430) versus ≥18 years (n = 526).

RESULTS

Severe asthma patients aged ≥65 years had improved symptom control, better asthma quality of life and in the last year, less emergency visits and rescue oral steroid courses [3 (1-6) versus 5 (2-7), p < 0.001] than severe asthmatics aged <65 years. Blood eosinophils were lower in the elderly group. Patients with severe adult-onset asthma had similar symptom control, lung function and health-care utilization compared to severe childhood-onset asthma. Adult-onset asthmatics had higher blood eosinophils and were less atopic.

CONCLUSIONS

Patients with severe refractory asthma aged ≥65 years exhibit better clinical and health care outcomes and have lower blood eosinophils compared to those aged <65 years. Severe refractory adult-onset asthma is associated with similar levels of asthma control, higher blood eosinophils and less atopy than severe refractory childhood-onset asthma.

Co-morbid psychological dysfunction is associated with a higher risk of asthma exacerbations: a systematic review and meta-analysis

BACKGROUND

The longitudinal associations between psychological dysfunction (PD) and asthma exacerbations (AE) have not been adequately addressed. This study aimed to systematically assess the influence of PD on AE, and to determine whether different PD affects AE differentially.

METHODS

Electronic databases (PubMed, Cochrane library, Web of Science, Embase, and Ovid) were searched for prospective cohort studies on the influence of PD on AE in individuals with asthma. Relative risk (RR) and adjusted RR (RRadj) were pooled across studies. Subgroup analyses assessed the effects of different types of PD and the time-dependent response to the duration of PD exposure.

RESULTS

Ten articles that involved 31,432 adults with asthma with follow-up of 6.0-86.4 months were included. PD significantly increased the risk of AE [RRadj =1.06, 95% confidence interval (95%CI): 1.04-1.09, P<0.001], presenting as hospitalizations (RRadj =1.22, 95% CI: 1.12-1.34, P<0.001), unscheduled doctor visits (RR =4.26, 95% CI: 2.52-7.19), and emergency department (ED) visits (RRadj =1.06, 95% CI: 1.01-1.10, P=0.009) because of asthma. Depression significantly increased the risk of AE (RRadj =1.07, 95% CI: 1.04-1.11, P<0.001), presenting as hospitalizations (RRadj =1.26, 95% CI: 1.07-1.49, P=0.007) and ED visits (RRadj =1.06, 95% CI: 1.02-1.11, P=0.007) because of asthma. Anxiety was only associated with an increased risk of AE in pregnant women (RR =1.05, 95% CI: 1.01-1.08), possibly due to the small amount of data available on anxiety. The influence of PD on AE was only significant when the PD exposure time exceeded one year.

CONCLUSIONS

Co-morbid PD adversely affects AE, and there are differential effects of depression and anxiety. Asthmatic subjects with PD may benefit from more attention when establishing a treatment regimen in clinical practice.

Assessing the association of obesity and asthma morbidity in older adults

BACKGROUND

Obesity is a robust predictor of poor asthma control in younger adults. Given the high prevalence of asthma and obesity in older Americans, weight reduction could benefit asthma management in this population.

OBJECTIVE

To assess the association between obesity and asthma outcomes among older adults.

METHODS

We recruited from urban primary care clinics a prospective cohort of nonsmoking individuals with asthma who were 60 years or older without a history of other respiratory diseases. At baseline, body mass index (BMI) measurements were classified as normal (BMI, 18-25), overweight (BMI, 25-30), or obese (BMI, >30). Measures of asthma morbidity (Asthma Control Questionnaire [ACQ], and Mini Asthma Quality of Life Questionnaire [Mini-AQLQ]) and asthma-related resource utilization (inpatient or outpatient) were taken at baseline and at 3- and 12-month interviews. We used generalized estimating equation models to assess associations between obesity and asthma outcomes after controlling for potential confounders.

RESULTS

Of the 437 older adults with asthma in the study, 17% had a normal BMI, 32% were overweight, and 51% were obese. Unadjusted analyses revealed that obesity was associated with lower ACQ scores (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.09-1.31) and poorer Mini-AQLQ scores (OR, 1.21; 95% CI, 1.11-1.33). Adjusted analyses revealed no significant association between obesity and ACQ (OR, 1.05; 95% CI, 0.96-1.15) and Mini-AQLQ (OR, 1.08; 95% CI, 0.99-1.19).

CONCLUSION

Our study suggests that obesity is not independently associated with worse asthma outcomes in older adults, reflecting potential differences in the mechanisms that link obesity with asthma control in older vs younger populations.

Challenges in the pharmacological treatment of geriatric asthma

Asthma in older populations is characterized by frequent comorbid conditions, which increase the risk of side effects and of detrimental interactions between respiratory and non-respiratory drugs. These observations lead to the need to manage asthma in older populations by applying a multidimensional assessment and a multidisciplinary treatment; therefore, we favor the use of the 'geriatric' term to define asthma in the elderly. Geriatric asthma is a complex disease, which may not necessarily imply that it is also complicated, although the two conditions may often coexist. On this basis, the switch from an organ-driven management to the holistic approach may be the key factor to attain optimal control of the disease in this age range. The current review discusses the age-related factors affecting asthma treatment in the oldest individuals, such as the comorbid conditions, and age-related changes of metabolism and excretion that can impair the efficacy and safety of drugs.

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.

Management of allergic disease in the elderly: key considerations, recommendations and emerging therapies

The number of people over 65 is increasing around the world. At present, between 5 and 10% of allergic diseases affect the elderly. In particular, rhinitis is increasing worldwide; the presence of high comorbidity makes the therapy of asthma even more complicated. With reference to dermatological allergies, the dryness of the skin favors the onset of allergic contact and atopic dermatitis, while the senescence of mucous membranes and the impaired secretion of polymeric IgA could be linked to food allergy. Overcoming the problem of adverse drug reaction is limited by the diagnostic difficulty in patients taking multiple drugs. In addition, some drugs, such as β-blockers, angiotensin-converting enzyme (ACE)-inhibitors and NSAIDs, are relevant factors of urticaria and anaphylaxis. The aim of this review is to provide updated diagnostic and therapeutic guidelines through a better understanding of the pathophysiologic mechanisms, preventive measures and adherence to therapy.

Predictors of Asthma Control by Stepwise Treatment in Elderly Asthmatic Patients

The geriatric population is increasing, and asthma severity increases with age. We determined the predictors of asthma control, exacerbation, and the factors that affect asthma-specific quality of life (A-QOL) in elderly asthmatic patients. This was a prospective, multicenter, real-life study for 6 months with stepwise pharmacologic treatment based on the Global Initiative for Asthma (GINA) guideline. A total of 296 asthmatic patients aged ≥ 60 yr were recruited from 5 university centers in Korea. The improved-asthma control group was defined as the group of patients who maintained well-controlled or improved disease and the not-improved asthma control group was defined as the remaining patients. Fewer number of medications for comorbidities (2.8 ± 3.3 in the improved vs. 4.5 ± 4.4 in the control) and higher physical functioning (PF) scale (89.8 ± 14.2 in the improved vs. 82.0 ± 16.4 in the control) were significant predictors in the improved-asthma control group (OR = 0.863, P = 0.004 and OR = 1.028, P = 0.018, respectively). An asthma control test (ACT) score of ≤ 19 at baseline was a significant predictor of asthma exacerbation (OR = 3.938, P = 0.048). Asthma duration (F = 5.656, P = 0.018), ACT score (F = 12.237, P = 0.001) at baseline, and the presence of asthma exacerbation (F = 5.565, P = 0.019) were significant determinants of changes in A-QOL. The number of medications for comorbidities and performance status determined by the PF scale may be important parameters for assessing asthma control in elderly asthmatic patients.

Rationale and design of a comparative effectiveness trial of home- and clinic-based self-management support coaching for older adults with asthma

Older adults with asthma face numerous barriers to effective self-management and asthma control, and experience worse outcomes than younger asthmatics. Yet, there have been no controlled trials of interventions specifically designed to improve their care and outcomes. Through a multi-stakeholder collaboration (patients, academia, community-based organizations, a state department of health, and an advocacy organization) we developed a multi-component asthma self-management support intervention to address the myriad psychosocial, functional, health status, and cognitive barriers to effective asthma self-management in adults ages 60 and older. We are recruiting 425 New Yorkers in Manhattan and the Bronx for a pragmatic randomized controlled trial with 3 arms: the intervention delivered in primary care settings or in their home, or usual care. In the intervention, care coaches use a novel screening tool to identify the specific barriers to asthma control and self-management they experience. Once identified, the coach and patient choose from a menu of actions to address it. The intervention emphasizes efficiency, flexibility, shared decision making and goal setting, communication strategies appropriate for individuals with limited cognition and literacy skills, and ongoing reinforcement and support. Additionally, we introduced asthma-specific enhancements to the electronic health records of all participating clinical practices, including an asthma severity assessment, clinical decision support, and a patient-tailored asthma action plan. Patients will be followed for 12months and interviewed at baseline, 3, 6, and 12months and data on emergency department visits and hospitalizations will be obtained through the New York State Statewide Planning and Research Cooperative System.

Choosing wisely: practical considerations on treatment efficacy and safety of asthma in the elderly

The prevalence of asthma in the most advanced ages is similar to that of younger ages. However, the concept that older individuals may suffer from allergic asthma has been largely denied in the past, and a common belief attributes to asthma the definition of "rare" disease. Indeed, asthma in the elderly is often underdiagnosed or diagnosed as COPD, thus leading to undertreatment of improper treatment. This is also due to the heterogeneity of clinical and functional presentations of geriatric asthma, including the partial loss of reversibility and the lower occurrence of the allergic component in this age range. The older asthmatic patients are also characterized the coexistence of comorbid conditions that, in conjunction with age-associated structural and functional changes of the lung, may contribute to complicate the management of asthma. The current review addresses the main issues related to the management of allergic asthma in the geriatric age. In particular, the paper aims at revising current pharmacological and non pharmacological treatments for allergic asthmatics of advanced ages, primarily focusing on their safety and efficacy, although most behaviors are an arbitrary extrapolation of what has been tested in young ages. In fact, age has always represented an exclusion criterion for eligibility to clinical trials. Experimental studies and real life observations specifically testing the efficacy and safety of therapeutic approaches in allergic asthma in the elderly are urgently needed.