Asthma Management Handbook

Managing asthma in older adults

Recommendations

When considering management options, take into account the individual’s risk factors, comorbidity and self-management skills as well as assessing asthma control and lung function.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Before prescribing any asthma treatment, consider potential drug-to-drug interactions with the person’s other medicines or potential effects on other conditions.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

When starting a medicine or changing the regimen, conduct a treatment trial (e.g. 6–8 weeks) before prescribing long term.

When trialling any change, follow the steps for conducting a treatment trial.

Table. Steps for conducting a treatment trial

  1. Document baseline lung function.
  2. Document baseline asthma control using a validated standardised tool such as the Asthma Score.
  3. Discuss treatment goals and potential adverse effects with the person.
  4. Run treatment trial for agreed period (e.g. 4–8 weeks, depending on the treatment and clinical circumstances, including urgency).
  5. At an agreed interval, measure asthma control and lung function again and document any adverse effects.
  6. If asthma control has not improved despite correct inhaler technique and good adherence, resume previous treatment and consider referral for specialist consultation.

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Advise and support older patients to quit smoking; explain that quitting has health benefits at any age and discuss all quitting options, considering any potential drug-to-drug interactions.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Zwar et al. 20111

Where possible, prescribe inhalers in preference to nebulisers and ensure the type of inhaler is appropriate for the individual.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Avoid prescribing different types of inhaler devices, if possible. Minimise the number of inhaler devices and simplify the treatment regimen as much as possible.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Carefully train patients to use their inhaler correctly. Check inhaler technique at each visit by asking patients to show you how they use their inhaler. Repeat instructions regularly. Make sure your own knowledge of correct inhaler technique is up to date so you can give a physical demonstration and coach patients.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Provide self-management education, including a written asthma action plan. Consider whether the person needs:

  • a large-print written asthma action plan
  • a pictorial action plan with minimal writing
  • an integrated written self-management plan that includes instructions for managing comorbid conditions.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Prescribing for older adults

Treatment-related adverse effects

Particular care may be needed when prescribing some medicines for older people.

Adverse effects of corticosteroids and beta2-agonists are more common in patients aged 65 years and over than in younger adults, based on epidemiological evidence.2, 3 Older people experience more adverse drug effects because of pharmacodynamic and pharmacokinetic changes and particularly drug–drug and drug–disease interactions.4

Theophylline is metabolised mainly by the liver and commonly interacts with other medicines. Its concentration in plasma should be monitored closely in older people.4

Oral corticosteroids are effective in regaining asthma control after a flare-up. However, long-term or frequent use increases the risk of cataracts and osteoporosis in older patients5 and may affect control of blood pressure, body weight and diabetes. Impaired glucose tolerance is common among older people, so consider monitoring blood glucose (e.g. morning and evening samples).

To minimise the risk of cataracts and osteoporosis, the use of oral corticosteroids should be minimised, and inhaled corticosteroids should be prescribed at the lowest dose needed to maintain good asthma control.5

Table. Treatment-related adverse effects reported in older people with asthma

Class of medicine

Potential adverse effects

Clinical action

Beta2 agonists

Inotropic and chronotropic effects may worsen heart disease (e.g. arrhythmias, cardiomyopathy, myocardial ischaemia) or cause electrolyte disturbances.

Minimise need for short-acting beta2 agonists by maintaining good asthma control with preventer treatment as indicated.

Inhaled corticosteroids

Long-term high doses may slightly increase risk of bone fractures.

Overall, treatment does not appear to increase bone fracture risk in patients with COPD or asthma aged 40 years or over (meta-analysis of randomised controlled clinical trials).

Prescribe minimal dose needed to maintain good asthma control.

Back-titrate dose in patients who have maintained good control for several months.

Combination inhaled corticosteroid/long-acting beta2 agonist

Overall, treatment does not appear to increase risk (composite measure including asthma-related hospitalisations, deaths, and intubations) among patients aged ≥ 65 years (meta-analysis of controlled clinical trials comparing long-acting beta2 agonists with no long-acting beta2 agonist treatment).

Prescribe if indicated, as for younger adults.

Theophylline

Metabolised mainly by the liver.

May interact with other medicines.

Monitor plasma concentration if theophylline needed to manage acute asthma.

Avoid regular theophylline treatment.

Sources

Gupta P, O'Mahony MS. Potential adverse effects of bronchodilators in the treatment of airways obstruction in older people: recommendations for prescribing. Drugs Aging 2008; 25: 415-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18447405

Etminan M, Sadatsafavi M, Ganjizadeh Zavareh S et al. Inhaled corticosteroids and the risk of fractures in older adults: a systematic review and meta-analysis. Drug Saf 2008; 31: 409-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18422381

McMahon AW, Levenson MS, McEvoy BW et al. Age and risks of FDA-approved long-acting β2-adrenergic receptor agonists. Pediatrics 2011; 128: e1147-54. Available from: http://pediatrics.aappublications.org/content/128/5/e1147.long

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Efficacy of asthma treatments

Older patients may have reduced response to bronchodilators and inhaled corticosteroids due to age-related changes such as stiffening of the chest wall, reduced respiratory muscle function, and an increase in residual volume from loss of elastic recoil in the lung.2

Effects of other medicines on asthma

Medicines that are commonly prescribed for older adults may worsen asthma control or interact with asthma medicines. Interactions and adverse effects differ between individuals. Predictable bronchoconstriction can occur with:

  • beta-adrenergic blocking agents (beta blockers) used in the management of hypertension, cardiac disorders, migraine and glaucoma
  • cholinergic agents (e.g. carbachol, pilocarpine)
  • cholinesterase inhibitors (e.g. pyridostygmine).
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Comorbidity in older adults

Many older people with asthma also have multiple comorbidities and complex healthcare needs.56 Common conditions in older people that may affect asthma control include:5

  • obesity
  • gastro-oesophageal reflux disease
  • obstructive sleep apnoea syndrome and other sleep disorders
  • osteoporosis (vertebral fractures can impair respiratory capacity)
  • cardiovascular disease (some medicines may worsen asthma).

The presence of diabetes can affect decisions about the use of systemic corticosteroids, while heart disease or anaemia can mimic symptoms.

There is limited clinical trial evidence to guide asthma management in older people with common comorbid conditions, because most asthma treatment trials have excluded people with these conditions.35 Guidelines for one disease condition may have to be modified for older people with multiple chronic diseases to avoid potential adverse effects including drug–drug interactions.5

Common age-related problems such as cognitive impairment, poor eyesight, hearing loss, poor coordination or osteoarthritis can affect a person’s ability to use inhaler devices correctly.

Medicare items for chronic disease management (e.g. GP Management Plans, Team Care Arrangements, Multidisciplinary Care Plans) apply to patients with asthma.

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Smoking and older adults

Older people who smoke may believe that the damage has already been done and therefore there is no benefit in attempting to quit, or believe that smoking is less risky in older people.5

However, older people can successfully quit smoking, and may even be less likely to relapse than younger adults.5

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Choosing inhaler devices for older adults

Problems for older patients using inhalers

Inhaler devices should be used in favour of nebulisers wherever possible, just as for younger adults.5 The use of nebulisers increases the risk of transmitting infections to other patients or to health workers. The use of ipratropium bromide via nebulisers with loose-fitting masks has been associated with pupil dilatation, blurred vision and acute glaucoma.4 In practice, many patients do not maintain their nebuliser adequately (e.g. change bowl as often as recommended).

Incorrect inhaler technique is common among older people with asthma or COPD, whether using a pressurised metered-dose inhaler or a dry-powder inhaler, particularly with those with more severe airflow limitation.75, 89, 10, 11,12

Common problems for older people include:8111314, 1516

  • inadequate inspiratory flow (particularly among those with COPD), which limits ability to use dry-powder inhalers or pressurised metered-dose inhalers properly
  • difficulty connecting a pressurised metered-dose inhaler to a spacer
  • inability to coordinate breathing in with actuating a pressurised metered-dose inhaler
  • inability to actuate a pressurised metered-dose inhaler due to osteoarthritis or weakness of the hands
  • inability to achieve a firm seal around the mouthpiece when using inhalers alone or with a spacer (particularly for patients with cognitive impairment, facial weakness, or who are missing teeth).

Tips for correct use of inhalers

Patients with osteoarthritis may find it easier to use an aid (e.g. Haleraid hand-grip device) to help them actuate their inhaler, or use a breath-actuated inhaler. Mechanical difficulties can usually be overcome by checking each individual’s technique and helping the person identify which inhaler they can use best among those available for the required medicine.

For some patients, a breath-actuated pressurised metered-dose inhaler (e.g. Autohaler) or breath-actuated dry-powder inhaler (e.g. Turbuhaler or Accuhaler) may be easier to use than pressurised metered-dose inhalers.1415 However, some patients (e.g. those with severe COPD) may be unable to achieve a high enough inspiratory rate to actuate dry-powder inhalers (e.g. Accuhaler or Turbuhaler).15 With a breath-actuated inhaler, adequate lung doses of inhaled corticosteroids may be achieved despite poor technique.17

Older people with asthma can acquire and retain appropriate technique after specific instruction, but this instruction needs to be repeated regularly to reinforce correct inhaler technique,5 just as for young people. People with cognitive impairment are likely to have problems retaining skills after instruction in the use of an inhaler.18

About half of all older people with asthma or COPD are prescribed more than one inhaler device.19 As the number of prescribed devices increase, the frequency of error also increases.20

Table. Considerations when choosing inhaler devices for older patients

Problem

Solution

Reduced maximal inspiratory flow

Consider pMDI alone or with spacer

Avoid dry-powder inhalers

Reduced manual dexterity (e.g. due to osteoarthritis)

Consider a Haleraid with a pMDI, where relevant (salbutamol, fluticasone, fluticasone/salmeterol)

Consider pMDI with small-volume spacer or breath-actuated dry-powder inhaler

Inability to coordinate actuation and inhalation

Consider pMDI with spacer, breath-actuated pMDI or breath-actuated dry-powder inhaler

Avoid pMDI without spacer

Inability to form effective seal with lips around mouthpiece

Use spacer plus face mask

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Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.2122

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,23, 24, 25, 26, 27 even among regular users.28 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.29

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.23, 30, 28, 31, 32 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.28

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.33, 34

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:29

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:29

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.29 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.35, 23, 36, 37 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.36 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).21, 34

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.33, 23, 24 

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Self-management education for older adults

Inability to perceive airflow limitation or the severity of asthma symptoms, poor medication adherence, physical disability, cognitive dysfunction, and a passive self-management approach contribute to poorer asthma outcomes among elderly people with asthma.38 Older people commonly attribute asthma symptoms to normal ageing and do not recognise the risk of asthma.39

Written asthma action plans for older people should be clear and easy to read. Some asthma educators use pictorial plans that feature images of the person’s inhalers. Monitoring of peak expiratory flow at home (using a peak-flow meter) probably has no advantage over symptom monitoring in adults aged 50 years and over with moderate-to-severe asthma.40

Older people with multiple comorbid conditions are likely to be receiving advice from various health professionals. It may be necessary to integrate a person’s written asthma action plan with their written advice for self-management of other conditions.

The best type of self-management education for older people with asthma has not been clearly identified, because the majority of studies have included younger adults. However, individualised education can improve older patients’ ability to manage their asthma:

  • Provision of information in writing (large, easy-to-read lettering with few words) and pictures can improve older people’s lung function, asthma knowledge and skills, and ability and confidence to manage their asthma, compared with individualised education alone.41
  • A combination of regular monitoring of asthma control, small-group education, personalised written asthma action plans, and coaching in correct use of inhalers can improve asthma-related quality of life, lung function and inhaler technique in adults aged 50 years and over with moderate-to-severe asthma.40

Telephone follow-up may help ensure older people have an asthma action plan.42 Few studies have assessed strategies for improving adherence to asthma medicines in older patients.6

When caring for older Aboriginal and Torres Strait Islander people or people from culturally and linguistically diverse communities, health professionals should provide culturally appropriate health care and should work with interpreters as necessary to ensure effective communication.

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Psychosocial factors affecting asthma self-management

Psychosocial factors can affect asthma symptoms and outcomes in children and adults. These can include biological, individual, family and community-level factors, which can have synergistic effects in an individual with asthma.43 Mechanisms may include effects of stress on the immune system43 and effects of life circumstances on patients’ and families’ ability to manage asthma.

Relationships between psychosocial and cultural factors

Important influences on asthma outcomes include the person’s asthma knowledge and beliefs, confidence in ability to self-manage, perceived barriers to healthcare, socioeconomic status, and healthcare system navigation skills, and by the quality of interaction and communication between patient and healthcare provider.44 There is a complex interrelationship between:44

  • patient factors (e.g. health literacy, health beliefs, ethnicity, educational level, social support, cultural beliefs, comorbidities, mental health)
  • healthcare provider factors (e.g. communication skills, teaching abilities, available time, educational resources and skills in working with people from different backgrounds)
  • healthcare system factors (e.g. the complexity of the system, the healthcare delivery model, the degree to which the system is oriented towards chronic disease management or acute care, and the degree to which the system is sensitive to sociocultural needs).

Health literacy

‘Health literacy’ refers to the individual’s capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisions.45 A person’s level of health literacy is influenced by various factors including skills in reading, writing, numeracy, speaking, listening, cultural and conceptual knowledge.44

Inadequate health literacy is recognised as a risk factor for poorer health outcomes and less effective use of health care services.44 Poor health literacy has been associated with poor asthma control,46 poor knowledge of medications,47 and incorrect inhaler technique.47 Aspects of health literacy that have been associated with poorer asthma outcomes in adults include reading skills, listening skills, numeracy skills, and combinations of these.44 Studies assessing the association between parents’ health literacy and children’s asthma have reported inconsistent findings.44 Overall, there is not enough evidence to prove that low health literacy causes poor asthma control or inadequate self-management.44

Australian research suggests that there are probably many Australians with limited health literacy.48 It may be possible to identify some groups of patients more likely to have inadequate health literacy, such as people living in regions with low socioeconomic status, and those with low English literacy (e.g. people with limited education, members of some ethnic minorities, immigrants, and the elderly).44 However, even well-educated patients might have trouble with basic health literacy skills.44

Attempting to assess every patient’s health literacy is impractical and may be embarrassing for the person and time-consuming for the health professional.44 Instead, it may be more effective for health professionals simply to assume that all patients have limited health literacy.44 Accordingly, all self-management skills need to be explained carefully, simply and repeatedly, and all written material should be clear and easy to read. Special consideration is needed for patients from culturally and linguistically diverse communities, including Aboriginal and Torres Strait Islander people.

Psychosocial support and improving health literacy

Psychosocial interventions that include asthma education may improve health-related quality of life for children and adolescents with asthma and their families.49 However, simply providing education might not improve a person’s health literacy, since it also depends on other factors like socioeconomic status, social support, and is influence by the provider and the healthcare system.44

Asthma Australia provides personal support and information for people with asthma and parents of children with asthma through the Asthma Australia Information line by telephone on 1800 Asthma (1800 278 462) or online.

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References

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  32. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
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  35. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
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