of patients who receive these drugs develop a persistent cough. This cough may be confused with asthma in some people and can trigger increased wheezing in others (American Academy of Allergy, Asthma, and Immunology, 2020; Weinberger, 2020).
Healthcare Professional Consideration: A thorough medication review is imperative when assessing the person with asthma. The healthcare provider must be cognizant of the potential interactions of commonly prescribed medications with medications used for asthma treatment. Use of electronic health records and medication reconciliation can facilitate this process. Electronic health records can prevent adverse medication events and improve patient outcomes through maintenance of current and active medication lists and medication allergy lists. These platforms can automatically check for problems whenever a new medication is prescribed, providing alerts for potential drug/drug and drug/allergy interactions. This will assist in reducing adverse events and improve patient outcomes (HealthIT.gov, 2019).
ASTHMA AND THE OLDER ADULT
Asthma prevalence in the older adult is similar to that of the total population. Unfortunately, the mortality rate from asthma for this age groups is vastly greater than all other age groups. In 2019, the mortality rate for those 65 years and older was 27.1%, compared to 10.7% for the total population of people with asthma and 11.5% for those 35 to 64 years of age (CDC, 2021g). Asthma in older adults is frequently underdiagnosed, thus explaining these high rates (Nanda et al., 2020). Several age-related changes in the older adult impact asthma. There is greater chest wall rigidity and reduced respiratory muscle strength. Maximum inspiratory and expiratory pressures are reduced because of diaphragmatic weakness and age- related skeletal muscle weakness. Lungs reveal age-related peripheral airway narrowing with reduced airway surface-to- volume ratio. Because of these changes, older patients, even those without lung disease, are more likely to have increased residual volume and reductions in FEV1, FVC, and FEV1/FVC ratio with a minimal change in TLC. The age-related decline in FEV1 is accelerated in patients with asthma. This highlights the need to use age-adjusted values when interpreting spirometry results in older patients to avoid overdiagnosis of asthma (Dunn et al., 2018). Increasing age also presents with alterations in both the innate and adaptive immune responses. These age-associated changes include a diminished response after a pathogenic exposure, resulting in increased low-grade systemic inflammation. This makes the elderly more susceptible to airway infections, which may exacerbate underlying asthma, or potentially play a role in the inception of late-onset asthma. There is also a reduced ability to produce specific and long-lasting antibodies to antigens, including vaccines and infections (Dunn et al., 2018). Therefore, the older adult with asthma is at higher risk for complications from vaccine-preventable diseases, even if their asthma is well controlled. Increased risk to the older patient may include the correlation between respiratory infections and asthma exacerbations, impairment of the airway lining, increased mucus production, and alterations in immune responses. The immune system may be suppressed if oral steroids are needed to gain asthma control (National Foundation for Infectious Diseases, 2014). A detailed history and physical examination are essential to establish an asthma diagnosis and exclude alternative conditions. Although asthma symptoms are no different in older persons than in younger persons, older individuals are less likely to report dyspnea related to airflow limitation. This may be the result of adaptation to the long-term presence of symptoms or lower health expectations, increasing the likelihood that symptoms are not identified as a concern or are minimized in severity (Vaz Fragoso & Nyenhuis, 2021). For the older adult, other symptoms might be indicative of asthma, so it is imperative to look beyond the usual. Pertinent symptoms that warrant attention for an asthma diagnosis include nasal congestion, rhinorrhea, sneezing, and ocular itching. Chronic cough in nonsmoking older persons should also warrant further investigation (Vaz Fragoso & Nyenhuis, 2021). Treatment needs to include pharmacological as well as nonpharmacologic management. Older adults are more
vulnerable to polypharmacy and medication adverse events, and this should be considered when selecting the appropriate asthma treatment (Nanda et al., 2020). Asthma education should include information about asthma and its mechanism of action, the appropriate role and use of asthma medications, and measures to treat and prevent symptoms. A written asthma action plan is important to achieve optimal care (Vaz Fragoso & Nyenhuis, 2021). Correct inhaler technique using the teach-back methods should be assessed to assure optimal efficacy of inhaled medications for asthma. Some older patients have difficulty learning correct inhaler technique because of cognitive impairment and difficulty performing multistep tasks or being unable to coordinate actuating the inhaler and breathing in the medication. Use of a metered dose inhaler device with a valved holding chamber (a type of spacer that includes a one-way valve at the mouthpiece, which holds the medicine, allowing more time to take a slow, deep breath), a breath-actuated dry powder inhaler, or a nebulizer may improve medication delivery when the older person’s inhaler technique is suboptimal (Vaz Fragoso & Nyenhuis, 2021). The AAFA(2017) recommends the influenza, pneumococcal, shingles, and pertussis vaccines. Those adults with asthma who were vaccinated with the influenza vaccine were found to have fewer negative outcomes and lower mortality (Suárez-Varela et al., 2018). Pneumococcal disease can cause pneumonia, meningitis, sepsis, and ear infections, with high mortality rates for those 65 years or older. People with asthma might be at an increased risk for shingles, even if they have previously had shingles. Pertussis immunity can wane over time, and boosters in the form of Tdap (tetanus, diphtheria, acellular pertussis combination) is recommended (AAFA; 2017). Healthcare Professional Consideration: The presence of comorbid conditions complicates the management of asthma for all age groups. Especially problematic is the lack of clinical trials in asthma patients who are elderly or who have serious comorbid conditions, resulting in a lack of strong evidence to guide asthma treatments for these individuals. Many comorbid conditions may impact asthma directly and some may require medications that can worsen asthma. In addition, other common age-related problems such as osteoarthritis, cognitive impairment, poor eyesight, hearing loss, or poor coordination can hamper a patient’s ability to use their inhaler device correctly (Kaplan et al. 2020).
Book Code: ANCCUS2423
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