1. Bronchial Asthma in the Elderly Presented by: Dr. Naif Shroof FRCP, FACCP, FACP Prof of medicine Jordan University Hospital

5. Bronchial Asthma Definition Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airways hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible spontaneously or with treatment.

7. COPDAsthmaParameter No or poor response; FEV1 less than 80%, FEV1/FVC ratio less than 70% Increase in post bronchodilator FEV1 of more than 12% or 200 ml Spirometry DecreasedWithin normalDLCO A strong historyMay or may not have history Tobaco smoke history Comparison of diagnostic features of patient with asthma with those with COPD Less AtopyMore AtopyAtopy More reversibility after bronchodilators Marked reversibility Pulmonary Functions

8. Bronchial Asthma in The Elderly Little is known about the natural history of asthma in elderly patients, But there is evidence in literature that the elderly asthmatic patient is underdiagnosed, undertreated, has higher risk of hospitalization, has a lower quality of life, and experiences greater morbidity and mortality.

9. Reasons for under diagnosis of Asthma Dyspnea is caused by aging Reduction in perception of dyspnea Self-limitation of activities Social isolation Depression Misconception that adult-onset asthma is rare Comorbid conditions

10. Physiologic Changes in Elderly Decreased lung elastic recoil Decreased strength of respiratory muscles Decreased chest wall compliance Impaired respiratory reflexes ( B-agonist responsiveness) Reduced mucociliary clearance

11. Factors Thought to Contribute to such Risk Include: Delay in diagnosis and treatment Poor cardiovascular reserve Impaired perception of airway obstruction Blunted hypoxic ventilator drive Psychosocial problems Cognitive problems

12. Diseases that Mimic Asthma Chronic obstructive pulmonary disease Congestive heart failure Bronchiectasis Upper airway obstruction Aspiration or inhaled foreign body Hyperventilation/panic disorder Churg-Strauss syndrome and other vasculitides

13. Spirometry (gold standard): shows reversibility of at least 12% of FEV1 and 200 ml. Symptoms: Atypical presentation is common in elderly; high index of suspecion for diagnosis is needed with isolated dyspnea, cough or wheezes. Making Diagnosis of Making Diagnosis of Bronchial Asthma in The Elderly

14. Other investigations maybe needed Spirometry Arterial Blood Gas Chest X-ray Fractional expiratory Nitirc Oxide ECG H.R.C.T Scan Allergic skin test DLCO (diffusion capacity) Brocho Alveolar Lavage

15. Classification of Asthma Severity by Clinical Features  Intermittent Symptoms less than once a week Brief exacerbations Nocturnal symptoms not more than twice a month FEV1 or PEF > 80% predicted PEF or FEV1 variability < 20%  Mild Persistent Symptoms more than once a week but less than once a day Exacerbations may affect activity and sleep Nocturnal symptoms more than twice a month FEV1 or PEF > 80% predicted PEF or FEV1 variability < 20%–30%

16. Classification of Asthma Severity by Clinical Features…continued  Moderate Persistent Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week FEV1 or PEF 60%–80% predicted PEF or FEV1 variability > 30%  Severe Persistent Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms FEV1 or PEF < 60% predicted PEF or FEV1 variability > 30%

17. Patients older than 65 years Younger patients Feature Broncho- constriction causes less dyspnea Bronchoconstriction causes dyspnea Dyspnea Often minimize symptoms and decrease energy expenditure Likely to seek treatment as symptoms interfere with activities Response to symptoms Higher mortalityLower mortalityMortality rate Features of Asthma in Adults To be continued…

18. Patients older than 65 years Younger patients Feature Features of Asthma in Adults… continued Likely to have multiple comorbid conditions Often healthy aside from asthma Comorbid conditions Higher percentage of patients have fixed broncho- constriction Airway obstruction usually reversible Reversibility of airway obstruction Less common allergic triggers Frequent allergic triggersAllergic triggers

19. The goals for Successful Management of Asthma Achieve and maintain control of symptoms. Prevent asthma exacerbations. Maintain P.F.T.s as close to normal as possible. Maintain normal activity level. Avoid adverse effects from asthma medications. Prevent asthma mortality.

20. Other treatment options Daily controller medications Level of Severity None necessaryIntermittent asthma Sustained-release theophylline LTRAs Sodium cromoglycate Low – dose ICSMild persistent asthma Recommended medications vs. level of severity Sustained-release theophylline LTRAs Sodium cromoglycate Low – to medium dose ICS plus LABA Moderate persistent asthma High-dose ICS plus LABA plus one or more of the following, if need Sustained –release theophylline LTRAs Oral CS Severe persistent asthma

21. Asthma drugs that worsen comorbid conditions  agonist Arrythmias Tremors Hypertension Hypokalemia  Theophylline Gastroesophageal reflux Tremors Insomnia  Corticosteroids Existing osteoporosis

22. Drugs that worsen Asthma  Hypertension blockers and ACE inhibitors  Glaucoma Topical blockers  Arthritis Acetylsalicylic acid (ASA)/Non steroidal anti- inflammatory drugs (NSAIDs)

23. Conclusion Though prevalence of asthma in old and young people is similar; asthma is under- diagnosed and under treated in elderly. The higher incidence of co-morbid conditions makes diagnosis and treatment more difficult. Despite the availability of effective drugs, many of asthmatics, in general, remain uncontrolled.