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A guide to the management of asthma in elderly patients

Dave Burns
RGN DPSN RNT MSc
Senior Lecturer
Edge Hill University;
National Training Manager, Respiratory Education UK

In this article, Dave Burns looks at the prevalence of asthma in older people, with a focus on making the correct diagnosis, treatment, and ensuring good inhaler technique

Asthma is one of the most common chronic conditions in the UK. While seen as a disease of younger people, substantial numbers of adults, including elderly adults, are also affected. Elderly asthma sufferers tend to have intrinsic asthma, where obvious external causes and triggers of the condition are not apparent. Like other age groups, elderly asthma patients tend to have suboptimal control. Confirming that the patient actually does have asthma is important. Following on from this, ensuring good inhaler technique and adequate adherence are essential to maintain good control and prevent consequences of poor control.

Asthma is a common chronic inflammatory condition affecting the lower airways. Oedema of the airway wall, excessive secretion of mucous and airway smooth muscle contraction all produce (in variable degrees) the classic symptoms of breathlessness, cough, chest tightness and wheezing. The condition can be highly variable both between and within individuals, with sufferers at one end of the spectrum experiencing only intermittent symptoms, while a small proportion (

Is it really asthma?
This may seem an odd question, but the most common alternative diagnosis in adults is chronic obstructive pulmonary disease (COPD). This can also cause similar symptoms to those seen in asthma, but usually develops in middle age, whereas asthma can frequently manifest in childhood.

The most common cause of COPD is cigarette smoking. While a typical COPD patient (significant smoking history, gradual onset of symptoms over time which have been getting worse, with little if any variation) differs significantly form a typical asthma patient, there can be overlap between the two conditions, with some asthma patients having some evidence of permanent airflow obstruction and some COPD patients having significant degrees of reversibility. With appropriate questioning and lung-function testing, however, it should be possible to diagnose the majority of patients correctly. This point is particularly important in the elderly, where it is not unknown for patients to receive a wrong diagnosis and, consequently, inappropriate treatment for many years.

Specific issues in the elderly
While asthma is seen primarily as a disease of younger people, it can affect adults and the elderly as well. Of interest in terms of older people is that they tend to suffer from what has been termed "intrinsic asthma", meaning they have no obvious triggers or allergies that exacerbate the condition. This can happen for no obvious reason, and these exacerbations can, like in some allergic (or "extrinsic") asthma sufferers, occur quite suddenly. A further issue to consider in the elderly is the death rate from asthma, which is substantially higher compared to children, young adults and even middle-aged adults.1

Treatment
Guidelines on asthma treatment in the UK are published by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN).2 These advocate a five-step approach to the pharmacological management of asthma (see Table 1). Many of the preparations referred to are available in inhaled form. Inhaled therapy seems to have a number of advantages. Inhaled drugs can be delivered straight to the target organ, meaning lower doses can be used, which reduces the risk of unwanted effects. For one class of drug, the reliever (eg, Salbutamol) the effect is much more rapid compared to taking a drug orally.

[[Tab 1 asth old]]

Inhaler devices
A number of devices are available. These include:

  • The pressurised metered dose inhaler (pMDI).
  • The breath activated device (BAD).
  • The dry powder inhaler (DPI).

In addition, a variety of holding chambers (sometimes called spacers) are also available, along with nebulisers, and the latter will not be discussed here.

Inhaled therapy is not without its problems. Several studies have shown that significant numbers of patients who are prescribed inhalers are unable to use them properly.3 What has been recognised is that there is no single device that is perfect for all patients and that, while patients of all ages may have problems with a range of devices, those at the extremes of age have particular difficulties. We will consider issues the elderly may have with each type of device.

The pMDI is the most commonly prescribed device, probably due to its low price. However, it is also notoriously difficult to use, with one review finding that, in total, only approximately 25% of patients using this device do so appropriately.4 One common error is a failure to coordinate the activation of the device with the commencement of inspiration.5 This is essential to maximise deposition of the drug in the airway. Elderly people may have trouble with this vital phase, which, in part, may be linked to a lack of hand strength, particularly in the thumb used to depress the canister.

Having said this, Ho et al found that large numbers of elderly patients were able to use a pMDI adequately, although individuals with cognitive impairment were excluded from the study.6 So if the pMDI is the most commonly prescribed device, what can we do if a patient cannot use it? The logical approach would be:

  • Re-educate them in the correct technique.
  • If problems still persist with coordination consider a spacer device (consider this anyway for all patients, as evidence suggests that where a patient is unable to demonstrate an adequate pMDI technique, a spacer helps in the acquisition and retention of adequate technique. Conventional wisdom states this will also increase drug deposition in the lung).7
  • If the problem is in pressing the canister to activate the device, consider a haleraid. These fold over the pMDI and when compressed using the whole hand (which has more strength than the thumb alone) activate the device, and are available through Allen and Hanbury's.

Whichever solution is attempted, it is (as with all patients) essential to review the patient at some date in the near future to ensure correct technique is present.

What if the patient still cannot use a pMDI (for whatever reason)?
If the problem is still around coordination and/or the patient refuses to use a spacer, the next step is to consider a breath-actuated device. Essentially, these are still pressurised containers containing the drug, but are activated when the patient closes their mouth around the mouthpiece and inhales. This obviously removes the need for the precise coordination of activation and inspiration. However, the patient still needs to be advised that inspiration should be gentle and prolonged.

BADs seem to be a convenient solution, and indeed can be, although they are not without their problems. Some patients resent being switched to a different device and learn to remove the top of the canister holder. This enables them to activate the canister manually, using the BAD as a pMDI - but of course they were switched to a BAD because they couldn't use a pMDI in the first place! Patients who do this will probably have no better level of control than previously. If, despite the clinician's best attempts to educate a patient about the use of a BAD, they remain poorly controlled, the third option (a DPI) may be attempted.

DPIs, like BADs, remove entirely the need for coordination of activation/inspiration, but they do present a different type of problem. Whereas in the pMDI/BAD the drug is emitted under the force of a propellant, drug emission in a DPI is entirely dependent upon an adequate inspiratory flow on the part of the patient. This inspiratory flow is necessary to suck the drug out of the device, and to do so at a flow rate that also helps break the drug up into smaller molecules, facilitating lung deposition. While these inspiratory flows can be easily achievable for many patients, some may not have adequate flow. Checking inspiratory flow would seem advisable, and this can be done in a number of ways:

  • Use an "in-check dial". This device (which is basically the opposite of a peak flow meter) can be calibrated to mimic the internal resistance of a number of common inhaler devices. The patient's inspiratory flow can then be measured against scales on the side of the dial to determine whether they have sufficient inspiratory flow for a particular device.
  • Use a training inhaler for the device(s) you think might be appropriate; an example is the training whistle for the turbuhaler. This works on the principle of emitting a sound when the correct inspiratory flow has been reached, and so guides the patient towards the correct flow rate. It is worth contacting local pharmaceutical representatives for information regarding availability of products such as these.

If the options above are not available, it may be worth trialling the device for a month after showing the patient how to use it, and then reviewing the results. Patients whose level of control improves will probably have adequate technique; bear in mind that those who do not improve should have their general level of adherence checked, although evidence suggests that as a group elderly asthma patients tend to be more adherent compared to younger ones.8

Why is this so important?
A number of studies have shown that while complete or very good asthma control is a realistic target in most patients, only around 50% manage this at best. Given the importance of delivering the drug into the airways (and particularly corticosteroids to suppress the inflammation), good inhaler technique is absolutely vital. Even with the best molecule, the best device and the best technique possible, at most, 50% of an emitted dose will reach the airways. Certainly, poor inhaler technique in the case of the pMDI is associated with poor asthma control, which may contribute to the increased morbidity and even mortality in elderly patients referred
to above.9

Conclusion
Asthma is more prevalent in the elderly than we might think. A common incorrect diagnosis is COPD, although the two conditions, while sharing a number of features, also possess marked differences.

Asthma management in the elderly is no different to that of any other age group. However, ensuring the patient really does have asthma is essential. Assuming this is the case, particular attention needs to be paid to the selection of device though which to deliver their treatment. Poor inhaler technique contributes to poor control, and this may increase the risk of death in an age group where the death rate is considerably higher compared to younger age groups.

References
1. National Asthma Campaign. Out in the open: a true picture of asthma in the UK today. Asthma J 2001;6(3):6.
2. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Available from: www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guideli...
3. Crompton GK, Barnes PJ, Broeders M et al. The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team. Respir Med 2006;100:1479-94.
4. Luskin AT, Bukstein D, Ben-Joseph R. The relationship between prescribed and delivered doses of inhaled corticosteroids in adult asthmatics. J Asthma 2001;38(8):645-55.
5. Blackler P, Sinclair D. Audit of inhaled asthma therapy. Nurs Stand 1993;7(33):28-30.
6. Ho SF, O'Mahony MS, Steward JA, Breay P, Burr ML. Inhaler technique in older people in the community. Age Ageing 2004;33:185-8.
7. Johnson DH, Robart P. Inhaler technique of outpatients in the home. Respir Care 2000;45(10):
1182-7.
8. Haughney J, Barnes G, Partridge M, Cleland J. The Living and Breathing Study: a study of patients' views of asthma and its treatment. Prim Care Respir J 2004;13:28-35.
9. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19:246-51.