Joyce Hogebrug Specializing in clinical geriatrics Quality of Life and Asthma Control in Elderly Asthmatics: a seven year follow-up – Results from the PRAXIS study Bjorn Stallberg1, Joyce Hogebrug2, Christer Janson3, Mary Kämpe3, Scott Montgomery4, Tjard Schermer2, Josefin Sundh4, Karin Lisspers3 1Uppsala University, 2Radboud University Medical Centre, the Netherlands, 3Uppsala University, Sweden, 4Örebro University, Örebro, Sweden 26/05/2016

Declaration of interest Bjorn Stallberg has received honoraria for educational activities/lectures/ advisory boards from AstraZeneca/Boehringer Ingelheim(BI)/GlaxoSmithKline/ Novartis/MEDA/TEVA. Christer Janson has received honoraria for educational activities/lectures/advisory boards from AstraZeneca/BI/Chiesi/ Novartis/TEVA. Karin Lisspers has received honoraria for educational activities/ lectures/advisory boards from AstraZeneca/GlaxoSmithKline/ Novartis/MEDA/Takeda. Joyce Hogebrug, Mary Kämpe, Scott Montgomery, Tjard Schermer, Josefin Sundh had no conflict of interests related with the present study. 26/05/2016

What did I do? ≥60y Add: why this study? And the aim Why: First long-term (7 years) follow-up study on QoL & asthma control in elderly asthmatics. To optimise asthma management in clinical practice Main aim: compare course of QoL and asthma control between 2005 and 2012 in older adults (aged ≥60 years) Second aim: compare these outcomes with younger adults 26/05/2016

Methods Physician’s diagnosis of asthma 2005 56 PHCC's 14 hospitals Excluded PHCC's <3000 inhabitants 3 PHCC's declined 22 per PHCC 35 per hospital Postal survey to: 1226 from PHCC's 499 from hospitals Response rate 71% 1210 patients 54 deceased 5 lost to follow-up 2012 1151 patients Response rate 65% 747 patients Physician’s diagnosis of asthma Attended centre/hospital in the last 4 years Age 18-75 (in 2005) Of 747: 496 younger (≤ 59) 251 older (≥ 60). Non-responders  no differences 2005: 98% records 2000-2003

Methods MiniAQLQ Asthma control according to GINA Symptoms Activity limitations Emotional function Environmental stimuli 15x MiniAQLQ Asthma control according to GINA Best Worst Controlled vs Uncontrolled MiniAQLQ: 15 questions, 4 domains: Symptoms (5Q), Activity limitations (4Q), Emotional function (3Q), Environmental stimuli (3Q) 7 point interval scale Severe impairment (1)  no impairment (7) Difference ≥0,5 = clinically relevant1 Asthma Control according to GINA: Use of < 3 doses of short-acting β2-agonists per week (last week) No night awakenings (last week) No emergency visits to primary care or hospital (last 6 months) No courses of oral steroids (last 6 months) <3 doses Of ß2 26/05/2016

Methods Statistics (SPSS): 2005 versus 2012; 7 years follow-up Young (18-59y) versus old (≥60y) (both in 2005) Multiple logistic regression: to evaluate baseline predictors for decreased QoL and uncontrolled asthma in 2012. Possible predictors: Age Sex BMI Level of care Educational level Smoking status Treatment level Heart disease Depression Allergic symptoms MiniAQLQ score 2005 Asthma control 2005 2005 versus 2012: paired-samples t-test or McNemar’s test. Young versus old: independent-samples t-test or Chi2 test. 26/05/2016

Results – Quality of Life 26/05/2016

Results – Asthma Control 2005 vs 2012 Old: p = 0.002 Young: p = 0.003 26/05/2016

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Results – predictors Ageing was not a predictor for either one. Decreased Quality of Life 2012 Uncontrolled Asthma 2012 Quality of Life in 2005 Uncontrolled Asthma in 2005 Lower educational level Having allergic symptoms Being in a higher treatment level Having a depression Ageing was not a predictor for either one. 26/05/2016

Conclusions MiniAQLQ scores did not change in 7 years Older asthmatics have a lower QoL Ageing is no predictor for lower QoL over time Asthma control got better in 7 years No difference between young & old in 2012 Ageing is no predictor for uncontrolled asthma 26/05/2016

Questions? 26/05/2016

Patient characteristics Follow-up 2012: Younger group changed in BMI + smoking status Older group changed in treatment level Both groups: 2/3 female 70% primary care Older group: Lower educational level More former smokers Lower personal best of FEV1% predicted More comorbidities (except depression) Less allergic symptoms Higher treatment level More often late onset asthma 26/05/2016

Patient characteristics   Survey 2005 Survey 2012 Younger (18-59) Older (60-75) Younger Older N (mean, SD or %) p1 p2 Age N (mean, SD) 496 (44.0, 11.5) 251 (66.3, 4.4) 496 (50.3, 11.5) 251 (72.6, 4.4) Sex p = 0.870 Men 197 (39.7) 102 (40.6) Women 299 (60.3) 149 (59.4) BMI p = 0.801 Young p < 0.001 Old p = 0.220 BMI < 18 3 (0.6) 1 (0.4) 4 (0.8) BMI 18-25 187 (38.5) 85 (35.6) 148 (30.8) 88 (37.1) BMI 25-30 192 (39.5) 103 (43.1) 202 (42.1) 90 (38.0) BMI > 30 104 (21.4) 50 (20.9) 126 (26.3) 58 (24.5) Educational level p < 0.001 Low 232 (47.4) 187 (76.6) High 257 (52.6) 57 (23.4) Level of care p = 0.723 Primary Care 346 (69.8) 179 (71.3) Secondary care 150 (30.2) 72 (28.7) Smoking status p = 0.001 Young p = 0.003 Old p = 0.083 Current smoker 81 (16.4) 27 (10.8) 57 (11.7) 17 (6.9) Former smoker 138 (27.9) 102 (40.8) 149 (30.5) 105 (42.5) Never smoker 276 (55.8) 121 (48.4) 283 (57.9) 125 (50.6) Personal best FEV1 % predicted; N (mean, SD) 181 (90.1, 19.8) 90 (84.8, 23.0) p = 0.049 Comorbidity COPD3 14 (2.8) 21 (8.5) Heart disease3 55 (22.2) Hypertension3 56 (11.3) 72 (29.0) Diabetes mellitus3 16 (3.2) 26 (10.5) Depression3 36 (7.3) 16 (6.5) p = 0.788 Allergic symptoms4 396 (79.8) 165 (66.0) Treatment level5 p = 0.004 Young p = 0.070 Old p = 0.004 Step 1 119 (24.0) 36 (14.4) 138 (28.2) 51 (20.8) Step 2 116 (23.4) 55 (22.0) 93 (19.0) 33 (13.5) Step 3 261 (52.6) 159 (63.6) 259 (52.9) 161 (65.7) Age at onset6 ≤ 15 years 187 (38.6) 49 (21.3) ≥ 16 years 297 (61.4) 181 (78.7) 26/05/2016

Results – Treatment level Y: 74.8 Y: 14.3 Treatment levels Only short-acting ß2 agonists (SABA) Inhaled cortico-steroids (ICS) ICS & long-acting ß2 agonists (LABA)/ anti-leukotriene (LTRA) Y: 10.9 Y: 24.3 Y: 22.8 Y: 23.3 Y: 45.6 Y: 52.4 Y: 31.6 Y: 8.9 Y: 9.3 Y: 81.7 26/05/2016

Relating to previously published work - QoL Lower QoL in older: More comorbidities Lower functional status Lower educational level No decrease in QoL over the years: Reduced perception bronchoconstriction Attributing symptoms to other causes than asthma (eg ageing) 26/05/2016

Relating to previously published work – Asthma Control Better asthma control after 7 years: Better management (more awareness among physicians) Higher treatment level Proportion controlled asthma is according to previous research 26/05/2016

Future research Impact of comorbidities in elderly asthmatics Impact of age of onset (different phenotypes) 26/05/2016