|Year : 2016 | Volume
| Issue : 1 | Page : 27-31
Under-diagnosis of asthma in elderly
Rahul Pandya1, Arti Shah2, Stani Francis2, Kusum Shah2, Parth Shah2, Ajay George2
1 Department of Respiratory Medicine, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth University, Vadodara, Gujarat, India
2 SBKS Medical Institute and Research Centre, Vadodara, Gujarat, India
|Date of Web Publication||2-Aug-2016|
Department of Respiratory Medicine, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth University, Piparia, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: The concept of asthma affecting the old age people has been universally denied in past. Therefore, rather than suspecting asthma in old age patients, it often gets misdiagnosed as chronic obstructive pulmonary disease (COPD), leading to sub-optimal management of disease. Considering the fact that only one in five life-long smokers ever develop COPD, we must not blindly diagnose it in elderly smokers without going through clinical evaluation. Spirometry can be helpful in differentiating asthma; however, demonstration of small degree of reversibility to bronchodilators alone does not distinguish asthma. Comorbidities in old age or the drugs taken to treat them may exacerbate asthma. Conversely, bronchodilators and corticosteroids used to treat asthma often worsen these co-morbid conditions, such as osteoporosis, diabetes mellitus, and cardiac arrhythmias - making our regimens even narrower. Objectives: To highlight the misdiagnosis of asthma in old age. Materials and Methods: A prospective study was done involving 350 clinically diagnosed obstructive airway diseases (OADs) patients at SBKS Medical Institute and Research Center and their evaluation was done. Results: Out of 350 patients clinically appearing as OAD, 292 had obstructive pattern in pulmonary function tests; from which 100 were found to be asthmatic and 192 were of COPD. Out of these 100 diagnosed asthma patients, 16 were of age more than 60 years, from which five were previously treated as COPD. Conclusion: There is considerable prevalence of asthma in old age too, which, if misdiagnosed, can lead to sub-optimal treatment of the asthma.
Keywords: Adult-onset, asthma, chronic obstructive pulmonary disease, elderly, management, misdiagnosis, senile
|How to cite this article:|
Pandya R, Shah A, Francis S, Shah K, Shah P, George A. Under-diagnosis of asthma in elderly. Indian J Allergy Asthma Immunol 2016;30:27-31
|How to cite this URL:|
Pandya R, Shah A, Francis S, Shah K, Shah P, George A. Under-diagnosis of asthma in elderly. Indian J Allergy Asthma Immunol [serial online] 2016 [cited 2019 Jul 17];30:27-31. Available from: http://www.ijaai.in/text.asp?2016/30/1/27/187565
| Introduction|| |
Asthma is defined as a heterogeneous disease characterized by chronic airway inflammation, symptoms of wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation.  Asthma has multi-factorial etiology. Martinez found that asthma occurs due to the cumulative effect of genes, environment, and developmental factors.  He also showed that unlike many genetic diseases, where single gene is responsible for the disease, there is no single such gene that can be held accountable for the development of asthma. If one identical twin is affected, probability of other having asthma is approximately 25%.  So far, over 100 different genes have been found to have association with asthma. 
Many environmental factors have been associated with asthma development and exacerbation, including air pollution, allergens, dust mites, indoor pollution, and airborne infections. ,
Diagnosis of asthma is based on the history of variable respiratory symptoms, variable airflow limitation confirmed by pulmonary function test (PFT), diurnal PFT, and peak expiratory flow rate variability, significant postbronchodilator reversibility as well as positive bronchial challenge. 
Asthma, in general, is considered as a disease of young adults and when in old age, obstructive disease appear, it more often gets misdiagnosed as chronic obstructive pulmonary disease (COPD), especially with positive history of smoking. 
Though asthma is characterized by reversible airway obstruction, in elderly asthmatics, incomplete reversibility becomes increasingly common, especially when asthma has been severe or persistent,  making the diagnosis even more difficult. The asthma diagnosis is often supported by elevated immunoglobulin E (IgE) levels or positive skin test reactivity. The question arises whether these tests are equally sensitive in elderly as they are in young adults; because both skin test reactivity and IgE levels are known to decrease with age.  After middle age, there will be gradual and progressive decline in lung function,  which often makes patients as well as doctors to overlook asthma as a reason behind the decline in lung function. Senile illnesses such as congestive cardiac failure or chronic bronchitis might produce respiratory symptoms and the symptoms of asthma can be missed among symptoms of comorbidities. Thus, asthma in older age often remains under-perceived, under-diagnosed as well as under-treated. 
Asthma in old age can be classified in two categories: First category includes the old patients whose asthma symptoms has developed in childhood but increased in the old age; second category, which is less common, includes patients who have developed new symptoms of asthma as older adults. Thorough evaluation of past history becomes important as older adults presenting with asthma might have long symptom-free period after the childhood symptoms. Burrows et al. found that in old adults, symptoms presenting asthma might have been for years without notice.  Adult-onset asthma is often nonatopic, mostly allergen-induced, more severe, and associated with faster decline in lung function.  Symptoms of asthma in elderly are more persistent and comparatively difficult to manage.
Recent research on adult-onset asthma have classified few phenotypes of it; such as smoking related asthma, adult-onset mild asthma, adult-onset obese female predominant asthma, adult-onset nonatopic, inflammation-predominant phenotype with fixed airflow limitation.
Thus this study was undertaken to determine prevalence of asthma in elderly patients as well as to understand how asthma in elderly differs from asthma in young adults.
| Materials and methods|| |
This is a cross-sectional study. Appropriate consent to carry out this study was taken from the Institutional Ethical Committee before the enrolment of patients. Patients coming to SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth University, having the symptoms of obstructive airway disease (OAD) were taken for further clinical examination and investigations. Patients who found to have asthma as per the Global Initiative for Asthma guidelines  were separated from other OAD patients. We have included patients between the age of 15-80 years with informed and written consent.
Patients with ischemic heart diseases, acute left ventricular failure, congestive cardiac failure, bronchitis, and other conditions mimicking asthma were excluded from study.
All included patients had undergone detailed history taking and clinical examination including complaints of wheeze, shortness of breath, cough, as well as diurnal or seasonal variation, exposure to allergens, etc., Detailed family history was asked from each patient, followed by thorough clinical examination. Patients were investigated with complete blood counts, chest X-ray posteroanterior view, and electrocardiography as per the requirements. All patients were asked for PFT. During the PFT, postbronchodilator test was done by giving nebulization of 2.5 mg salbutamol solution and repeating the PFT testing after 20 min. For diagnosis of asthma, there should be an obstructive pattern in PFT curve with forced expiratory volume in 1 s (FEV 1 ) <80% and increase in postbronchodilator reversibility of FEV 1 >12% and >200 ml. Increase of >15% and >400 ml postbronchodilator is considered as confirmative result for diagnosis of asthma.
Proper systemic evaluation was done in these patients to rule out if any concomitant disorders of cardiovascular system or other system that can appear as asthma.
At the end of this study, the collected data was analyzed by the appropriate statistical methods whenever required such as percentage, mean, median, mode, standard deviation, confidence interval, correlation, and sensitivity.
| Results|| |
From 350 clinically diagnosed OAD patients included in the study, 292 were found to be OAD on the basis of PFT. From these 292 patients, 100 were diagnosed as asthmatics, whereas 192 were diagnosed of COPD. Our prime focus was on asthmatic group and how their disease was misdiagnosed as COPD.
One hundred diagnosed asthmatics were further divided in groups according to their age as shown in [Table 1] and [Figure 1]. Age groups were <20 years (five patients), 20-29 years (15 patients), 30-39 years (34 patients), 40-49 years (16 patients), 50-59 years (14 patients), and >60 years (16 patients). Thus, in our study, prevalence of asthma in old age was found to be 16%.
Out of these 16 diagnosed cases of elderly asthmatics, nine were males and seven were females. [Figure 2] shows the sex distribution of elderly asthma patients.
Most frequent complaints with which patients presented included cough with expectoration, chest pain, and breathlessness. Almost all patients had increase in symptoms when exposed to cold climate. After detailed history, 4 out of 16 old age asthma patients gave positive history of childhood wheezing and asthma-like symptoms but had almost symptom-free period after that. Out of 16 old age asthmatics, 5 patients were previously treated on the line of COPD. One patient gave the positive history of migration. Out of 16, 9 patients had been taking inhaler devices since last few months. Two patients had been previously diagnosed with allergic rhinitis, for which they were taking treatment. When asked about exposure, four patients had moldy odor present at home while one patient had exposure to cattle. Frequency of asthma attacks ranged from 6-8 times per month to 0-1 times per month. Mean body mass index was 23.0625 kg/m 2 .
[Table 2] shows the PFT values of these 16 patients. Mean forced vital capacity (FCV) value was found to be 52.82 and mean FEV 1 value was 47.55 with lowest value being 23.83 and highest value being 72.45. [Figure 3] shows the distribution of FVC and FEV 1 among old age asthma patients.
|Figure 3: Distribution of forced vital capacity and forced expiratory volume in 1 s in old age asthmatics|
Click here to view
Depending on the severity of disease as per the symptoms and PFT values, patients were treated accordingly with controller or relievers in the form of inhaled long acting beta agonist or short acting beta agonist, inhaled corticosteroids or added leukotriene receptor antagonists when previous inhaled agents were not able to control asthma.
| Discussion|| |
Asthma is often seen as a disease of young adults. Since many decades, pediatric onset of the disease is greatly emphasized, while little attention has been paid to asthma in elderly. 
As far back as in 1973, Lee and Stretton published a study of 15 patients in British medical journal, describing asthma onset after the age of 60 and the difficulties in diagnosing asthma in 60+ age group.  Again in 1979, another study done in South Wales by Burr et al. showed statistically significant proportion of asthmatics with age more than 70 years in general population.  In both these studies, two things should be duly noted: One, persistent airway obstruction was a characteristic feature and second, corticosteroids were an essential part of the asthma management.
There is no statistically significant gender difference in old age asthma. Burr et al. found male predominance,  whereas other similar studies done by Braman et al.  and Yunginger et al.  found female predominance.
Asthma in old age is often associated with not just difficult diagnosis but also with difficult management.
Diagnosis will be difficult because cardiovascular diseases that can often mimic asthma will be more associated in old age, as compared to the young age. Furthermore, skin prick testing as well as elevated IgE levels that are often beneficial in diagnosing the asthma will not be sufficiently helpful in old age,  as sensitivity of skin prick test and IgE levels are found to be physiologically decreasing with aging.  Similarly, lung function also gradually decreases naturally without the presence of any disease as the age progresses. Airway obstruction in asthma too, worsens at an excessive rate with increasing age.  In young asthmatics, postbronchodilator values come to near normal, which is not seen in most old age asthmatics. Even in COPD, few patients shows little reversibility in airway obstruction, so some degree of reversibility seen in PFT alone is not helpful in distinguishing asthma from COPD. Thus, in old age, patients with asthma symptoms and chronic airflow obstruction often get misdiagnosed as either COPD or chronic bronchitis,  unless there is asthma exacerbation. Furthermore, as the age progresses, asthma becomes more and more persistent with increasing airway obstruction. 
In management too, aging has its significant impact. Corticosteroids and bronchodilators - the primary drugs to treat asthma may worsen the co-morbid conditions found in old age, such as osteoporosis, diabetes mellitus, and cardiac arrhythmia, making out treatment regimens even narrower when treating asthma in old age. Patients with ongoing treatment of angiotensin converting enzyme inhibitors would require change in treatment line due to thr frequently observed adverse drug reaction of coughing.
A similar study done by Burrows et al. to evaluate the prevalence of old age asthma patient among the population also showed similar results.  A total of 1517 subjects with age more than 60 were included in study. After the exclusion of preexisting respiratory conditions, 1185 patients were enrolled, including 725 (61%) females and 460 (39%) males. From these 1185, forty patients were diagnosed as asthmatics (prevalence 3.37). Out of these 40 old age asthma patients, 14 were male and 26 were female. Though there was not any statistically significant difference due to sex, female predominance was observed, whereas in our study, male predominance was seen. In this study, 35% patients had positive history of childhood respiratory troubles, whereas in our study, 25% patients had positive childhood history. Mean FEV 1 value was 82.5 in this study, compared to 47.55 found in our study. Furthermore, this study also showed asthmatic patients in old age had significantly lower initial lung function compared to nonasthmatic patients; along with persistent and progressive lung function decline observed with aging in old age asthma patients. They have also concluded that single best predictive clinical factor of asthma was breathlessness associated with wheezing.
Another cross-sectional study done by Littlejohns et al.  showed that out of 1444 patients aged 40-70, 9% male (n = 60) and 3% female (n = 20) were diagnosed as asthmatics. Out of these, only half to a third of patients had been diagnosed as asthma previous to study. The prevalence was thus 12%, which is close to the prevalence found in our study (16%).
Limitations of our study
Since it was a hospital-based study, it might not correctly represent the general population per se. More precise prevalence would be evaluated if the study had included more sample size.
| Conclusion|| |
Asthma in elderly is not a rare entity and prevalence of 16% is a sizable proportion of asthmatic population, which cannot be neglected. Since COPD is perceived as a disease of old age and asthma as disease of young adults; there is a laxity among the clinicians to term old age OAD patients as COPD, especially when complete evaluation is not available.
Aging leads to normal physiological as well as abnormal pathological changes that are caused by diseases primary affecting senile population. Differentiating those normal physiological changes from abnormal pathological changes can be difficult. Both physiological and pathological changes associated with aging affects asthma symptoms as well as therapeutic interventions.
Compared to childhood onset asthma, adult-onset asthma is often nonatopic, mostly allergen-induced, more severe and associated with faster decline in lung function. Asthma is a disease which has better prognosis with medicines. Quality of life of asthma patient significantly improves with the treatment. However, if the condition is under-diagnosed, patient can end up with improper management of the disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Martinez FD. Genes, environments, development and asthma: A reappraisal. Eur Respir J 2007;29:179-84.
Elward K, Douglas G. Asthma: Clinician′s desk Reference. London: Manson Pub.; c2010. p. 27-9.
Halapi E, Bjornsdottir US. Overview on the current status of asthma genetics. Clin Respir J 2009;3:2-7.
Kelly FJ, Fussell JC. Air pollution and airway disease. Clin Exp Allergy 2011;41:1059-71.
Ramsey CD, Celedón JC. The hygiene hypothesis and asthma. Curr Opin Pulm Med 2005;11:14-20.
Traver GA, Cline MG, Burrows B. Asthma in the elderly. J Asthma 1993;30:81-91.
Burrows B, Barbee RA, Cline MG, Knudson RJ, Lebowitz MD. Characteristics of asthma among elderly adults in a sample of the general population. Chest 1991;100:935-42.
Sekiya K, Taniguchi M, Fukutomi Y, Watai K, Minami T, Hayashi H, et al.
Age-specific characteristics of inpatients with severe asthma exacerbation. Allergol Int 2013;62:331-6.
Parameswaran K, Hildreth AJ, Chadha D, Keaney NP, Taylor IK, Bansal SK. Asthma in the elderly: Underperceived, underdiagnosed and undertreated; a community survey. Respir Med 1998;92:573-7.
Burrows B, Lebowitz MD, Barbee RA, Cline MG. Findings before diagnoses of asthma among the elderly in a longitudinal study of a general population sample. J Allergy Clin Immunol 1991;88:870-7.
de Nijs SB, Venekamp LN, Bel EH. Adult-onset asthma: Is it really different? Eur Respir Rev 2013;22:44-52.
Seaton A, Weiss EB, Segal MS, Stein M, editors. Bronchial Asthma. 2 nd
ed. Boston: Little Brown and Co.; c1985. p. 854-6.
Lee HY, Stretton TB. Asthma in the elderly. Br Med J 1972;4:93-5.
Burr ML, Charles TJ, Roy K, Seaton A. Asthma in the elderly: An epidemiological survey. Br Med J 1979;1:1041-4.
Braman SS, Kaemmerlen JT, Davis SM. Asthma in the elderly. A comparison between patients with recently acquired and long-standing disease. Am Rev Respir Dis 1991;143:336-40.
Yunginger JW, Reed CE, O′Connell EJ, Melton LJ 3 rd
, O′Fallon WM, Silverstein MD. A community-based study of the epidemiology of asthma. Incidence rates, 1964-1983. Am Rev Respir Dis 1992;146:888-94.
Derrick EH. The significance of the age of onset of asthma. Med J Aust 1971;1:1317-9.
Peat JK, Woolcock AJ, Cullen K. Rate of decline of lung function in subjects with asthma. Eur J Respir Dis 1987;70:171-9.
Banerjee DK, Lee GS, Malik SK, Daly S. Underdiagnosis of asthma in the elderly. Br J Dis Chest 1987;81:23-9.
Finucane KE, Greville HW, Brown PJ. Irreversible airflow obstruction. Evolution in asthma. Med J Aust 1985;142:602-4.
Littlejohns P, Ebrahim S, Anderson R. Prevalence and diagnosis of chronic respiratory symptoms in adults. BMJ 1989;298:1556-60.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]