From the Guidelines
Asthma can indeed be diagnosed newly in a 65-year-old man, and it is essential to consider this possibility due to the potential for late-onset asthma and the complexity of differential diagnoses in older adults. While asthma often begins in childhood, it can develop at any age, including in older adults, as noted in the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1. Late-onset asthma (appearing after age 40) is actually quite common and may present differently than childhood asthma, with symptoms like wheezing, chest tightness, shortness of breath, and coughing that might be mistaken for other conditions such as chronic obstructive pulmonary disease (COPD) or heart failure.
Key Considerations for Diagnosis
- The diagnosis of asthma in older adults should involve a thorough assessment, including pulmonary function tests, particularly spirometry with bronchodilator reversibility testing, which shows improvement in airflow after using a bronchodilator medication.
- A short course of oral systemic corticosteroids may be considered to establish reversibility and the extent of possible benefit from asthma treatment, as suggested by the EPR-3 guidelines 1.
- It is crucial to adjust medications as necessary to address coexisting medical conditions, considering the potential for drug interactions and side effects, especially with nonsteroidal anti-inflammatory drugs, β-blockers, and theophylline.
Treatment Approach
- Treatment generally follows a stepwise approach, starting with short-acting beta-agonists for rescue use.
- Inhaled corticosteroids may be added for daily control, with careful monitoring for side effects and potential drug interactions.
- Proper inhaler technique is especially important to ensure effective medication delivery, and patients should be reviewed for their technique and adherence in using medications, making necessary adjustments for physical or cognitive impairments.
From the Research
Asthma Diagnosis in Older Adults
- Asthma can be diagnosed in adults over 65 years old, and it is a relatively common and important health problem in this age group 2, 3, 4.
- The symptoms of asthma in older adults may differ from those in younger populations and can include fatigue, making diagnosis more challenging 2.
- Comorbidities, menopause, caregiver roles, and depression can complicate asthma management in older adults, and pharmacologic therapies may have greater side effects 2.
- Spirometry, peak flow measurements, and asthma education are often underused in older adults, which can contribute to delays in diagnosis and worse outcomes 2.
Diagnosis and Management
- Asthma diagnosis in older adults can be made using spirometry with bronchodilator response or methacholine challenge testing, but these tests may have limitations 5.
- A negative bronchodilator response test does not exclude asthma, and methacholine challenge testing can be positive in some cases 5.
- Controller medication tapering and temporal variability can affect methacholine challenge test results, and repeat testing may be warranted in patients with a high clinical suspicion of asthma 5.
- Pulmonologists may diagnose asthma clinically despite negative test results, highlighting the importance of clinical judgment in diagnosis 5.
Prevalence and Morbidity
- The prevalence of current asthma in individuals over 65 years old is high, affecting at least 2 million US citizens, and is expected to increase as the population ages 3, 4.
- Asthma morbidity and mortality rates are highest in older adults, with approximately 50% of deaths from asthma occurring in this age group 2, 4.
- Asthma in older adults is often underdiagnosed and undertreated, and present paradigms for diagnosis may require modification 4.