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Challenges surround asthma diagnosis, management in older, obese adults

SAN DIEGO — The diagnosis and management of asthma in obese or adults aged older than 65 years is often complicated by age-related changes in physiology and psychosocial functioning, as well as comorbid medical conditions, according to researchers here.

“Older patients with asthma are frequently poor perceivers of lung impairment, with less active lifestyles that can lead to an under recognition of symptoms,” Tolly E. Epstein, MD, MS, FACAAI, FACP, of University of Cincinnati and Allergy Partners of Central Indiana, said during a presentation at the American Academy of Allergy, Asthma & Immunology annual meeting.

Age-related challenges

Epstein quoted previous studies indicating that the number of patients aged older than 65 years who will develop asthma in the next 25 years is expected to double to 6.2 million in the United States alone.

“We know that morbidity and mortality from asthma are much higher in older adults and that asthma-related quality of life and medication use is higher in this population,” Epstein said. “In addition, several studies found that the asthma diagnosis may be missed in up to 50% of asthmatics over 65 years. This is because of the large differential diagnosis of diseases that present with respiratory illnesses in this age group, such as COPD, cardiac disease, pulmonary embolism, etc. and the misconception that asthma only begins in childhood to young adulthood.”

However, Epstein said that the reality of asthma incidence remains at 1:1,000 throughout the adult life, and 40% to 50% of patients with asthma develop it after age 40 years.

“In addition, some studies have shown as many as 10% of patients may report symptom onset after age 65 years,” she said.

Often times, older patients with asthma have a poor perception of lung impairment, in addition to less active lifestyles which can lead to an under recognition of symptoms. Moreover, patients often experience cognitive impairment and depression that can confound diagnosis, Epstein said.

The obese asthma phenotype

There are two epidemics in the United States, according to the subsequent presentation by Juan C. Celedón, MD, DrPH, FAAAAI, of the Children’s Hospital of Pittsburgh.

 

Juan C. Celedón

“One is overweight and obesity and the other is asthma,” Celedón said. “There is probably, with the exception of tobacco smoke, no association that is as consistently observed in children or adults as that between obesity and asthma.”

Celedón said severe exacerbations are therapeutic challenges in the obese asthmatic.

“In obese children without pre-existing disease, obesity is likely associated with asthma through non-allergic mechanisms. In obese children who already have disease, allergic inflammation makes their asthma worse. You can safely infer from this talk that not all obese asthma is the same. One of the major areas of emphasis is to identify these obese asthma phenotypes, which would have profound implications in diagnosis and treatment,” Celedón said.

Potential solutions

According to Epstein, objective testing is needed to differentiate asthma from other prevalent conditions.

In addition, communication and shared goals between patients and health care providers are critical in this age group, she said.

“Medication choices should be formed by accepted asthma guidelines with considered factors that may impact adherence and efficacy. Age-related and efficacy do occur with some treatment. There are increased rates of side effects in this population. Factors such as the delivery method of a medication that may impact adherence should be taken into account, and the cost of medications is a huge issue in this population,” Epstein said.

Of course, controlling exposures to triggers are needed, she added.

Regarding obesity in asthma, Celedón recommended weight management.

“Weight management should be the number one, two and three priority in the management of the obese asthmatic whether it’s a child or adult. Yes, it is hard; so is smoking cessation. But we must try,” Celedón said. – by Samantha Costa

For more information:

• Epstein T. #1802: Pitfalls in the diagnosis and management of asthma in older adults: an evidence-based update.
• Celedon JC. #1802: New insights into the obese asthma phenotype: diagnostic and therapeutic challenges in obese asthmatics. Both presented at the American Academy of Allergy, Asthma & Immunology annual meeting; Feb. 28-March 4, 2014; San Diego.

Disclosure: The researchers report no relevant financial disclosures.