Three important reasons asthma is undertreated in older people and what you can do
If you have asthma and you're over age 65, you're much less likely than a person in his or her 30s, 40s, 50s or even early 60s to receive a prescription for a controller medication—an inhaled corticosteroid or a long-acting bronchodilator.
This occurs despite guidelines from the National Asthma Education and Prevention Program recommending one for all adults with persistent asthma. The reasons for this discrepancy are many, ranging from misdiagnosis of asthma in older people and doctors' concerns about asthma medications in seniors, to the tendency of the elderly to underreport worsening asthma symptoms.
But if you're older and have asthma, there's no need to suffer in silence. With proper diagnosis and an appropriate treatment plan, your asthma can be managed successfully at any age.
1. Missed Diagnosis
Asthma may not be the first thing that comes to mind when you start to experience breathing problems. One reason is that asthma is often thought of as a childhood condition. But the Centers for Disease Control and Prevention (CDC) estimates that each year, more than one million people over age 65 have an asthma attack.
Another reason the diagnosis might not be considered is that a cough is often the only symptom in older people. Without the other classic signs of asthma—wheezing, chest tightness, and shortness of breath—the doctor may suspect another condition such as gastroesophageal reflux disease (GERD).
Even when the classic asthma symptoms are present, it may be difficult to distinguish asthma from chronic obstructive pulmonary disease (COPD) in an older person. That's because a diagnosis of asthma is based, in part, on results from pulmonary function tests to check for obstruction of airflow in the lungs and whether that obstruction can be reversed with a short-acting bronchodilator.
Typically, if the obstruction is due to asthma, use of a bronchodilator will at least partially reverse the obstruction. However, asthma in an older person may not be as readily reversible with a bronchodilator, because the lungs become less elastic with age. Thus, a longer, two- to three-week trial of an oral corticosteroid may be necessary. If lung function improves while on the oral corticosteroid, airway obstruction may be due to asthma rather than COPD.
What you can do? If you have a cough that won't go away—or any of the other classic signs of asthma—discuss it with your doctor. If your primary care doctor is unsure of the diagnosis, you may need a referral to a pulmonologist. These lung specialists have extensive knowledge diagnosing and treating lung diseases in people of all ages.
2. Medication Issues
Doctors are sometimes reluctant to prescribe asthma medications out of concern that they may cause serious side effects, aggravate other medical problems, or interact adversely with other medications. While these are valid concerns, your doctor can make some adjustments to your treatment plan to accommodate for them.
Asthma medications of concern to older patients include: Beta2 agonists. Drugs in this class include albuterol (Proventil HFA, Ventolin HFA), levalbuterol (Xopenex HFA), formoterol (Foradil) and salmeterol (Serevent). These medications can increase your heartbeat. They shouldn't be used by people with a rapid heartbeat or some forms of irregular heart rhythm. Beta2 agonists can also aggravate coronary heart disease and diabetes.
If you're being treated for high blood pressure or heart failure with a non-potassium-sparing diuretic, such as hydrochlorothiazide (Microzide) or furosemide (Lasix), use of a beta2 agonist can lead to excessive potassium loss. Left untreated, this depletion increases the risk of heart rhythm disturbances that can lead to cardiac arrest (sudden cessation of the heartbeat).
Corticosteroids. Side effects associated with inhaled corticosteroids like budesonide (Pulmicort Flexhaler) and fluticasone (Flovent HFA) are typically mild. However, at high doses (more than 1,500 mcg per day) and with prolonged use (more than three months), inhaled corticosteroids can lead to the same serious side effects associated with the long-term use of oral corticosteroids.
These side effects include osteoporosis and fractures, worsening of heart failure, elevated blood sugar levels (a concern for people with diabetes), dangerously low potassium levels (particularly if you're also using a non-potassium-sparing diuretic), and cataracts and glaucoma. Oral corticosteroids can also cause muscle weakness and thinning of the skin.
Methylxanthine derivatives. The asthma medication theophylline (Theocron and other brands) belongs to a class of drugs known as methylxanthine derivatives. High blood levels of the drug can produce a variety of adverse effects, including persistent vomiting, heart rhythm disturbances, and seizures.
Because theophylline is slow to clear from the bloodstream in the elderly, it is crucial that your doctor monitor the level of the drug in your system to reduce the risk of these effects.
What can you do? If you're seeing a lung specialist, tell him or her about any other medical conditions you're being treated for and any other medications—prescription or over the counter—you are using. That way your doctor can determine which asthma medications are least likely to aggravate your other medical conditions or interact with the other drugs you're taking.
Conversely, remind your other doctors about your asthma every time you are given a new prescription. Ask whether the drug will interact with any of your asthma medications. If you're buying an over-the-counter medication or supplement, ask the pharmacist about potential interactions.
Also, see an eye doctor regularly to monitor your eyes for the development of glaucoma and cataracts, particularly if you're using oral or inhaled corticosteroids. Your doctor may also recommend regular measurements of your bone mineral density to check for osteoporosis if you are an oral or inhaled corticosteroid user.
3. Poor Communication
Older people are often reluctant to bring up issues with their doctors, particularly if a treatment has already been prescribed. But if your medication isn't working, don't be shy about telling your doctor. Equally important, don't ignore your troubles in hopes that they will go away or assume that worsening breathing problems are a normal part of growing older.
As mentioned previously, make sure your doctor knows about all the medications you're taking because some of them could be exacerbating your asthma. Here are a few to watch out for:
ACE inhibitors. This class of drugs, which include lisinopril (Prinivil, Zestril) and enalapril (Vasotec), is used to treat hypertension and heart disease but can cause a serious cough in some people. This cough can trigger increased wheezing or acid reflux, which in turn can further increase coughing and worsen asthma.
Beta-blockers. These drugs are taken orally to treat high blood pressure, heart disease and migraines or as eyedrops to treat glaucoma. There are two types of beta-blockers: "nonspecific" (affecting blood vessels and lung tissue) or "specific" (affecting blood vessels much more than lung tissue). Nonspecific betablockers, such as propanolol (Inderal LA, Innopran XL), carvedilol (Coreg), and timolol (Betimol, Istalol, Timoptic), are more likely to cause breathing problems for a person with asthma than specific beta-blockers like metoprolol (Lopressor, Toprol XL) and atenolol (Tenormin).
Nonsteroidal anti-inflammatory drugs (NSAIDs). Common pain relievers including aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn) may trigger breathing problems. If you have asthma and are sensitive to aspirin or other NSAIDs, you should avoid these medications. Acetaminophen (Tylenol) usually does not cause breathing problems.
Sleeping pills and tranquilizers. Sleeping pills, tranquilizers and other sedative drugs make you breathe more slowly and less deeply, which can be dangerous in some circumstances if you have lung problems such as asthma.
What can you do? Let your doctor know if you experience any changes in your asthma symptoms. An objective way to document this is to keep track of your daily breathing patterns with a peak flow meter. Then bring the results to your appointment and discuss them with your doctor.
It's also helpful to keep an up-to-date list of all the medications and the dosages you're taking in your wallet or purse so that you don't have to rely on your memory. This list can help the doctor identify potential medication-induced breathing problems.