Challenges in Managing Asthma in Elderly Population: A Systematic Literature Review

This systematic literature review aims to identify the challenges in managing asthma in elderly population and the interventions that can be applicable for elderly people. The review was carried out in a meticulous and planned manner using appropriate databases and search terms.

Running head: NURSING
Master project in nursing
Name of student:
Name of university:
Author note:

1
NURSING
Abstract
Asthma is a long-term health condition as a result of which patients suffer from varied
respiratory problems. The condition has a significant impact on elderly population, who
demonstrate equal chances of suffering from the condition. It has been reported that elderly
asthma patients are at increased risk of facing asthma-related morbidity and the rate of mortality
is also high. The reasons behind this are related to pathophysiology of aging. Studies have
reported that in older patients, under-diagnosis of asthma is common and under-treatment might
therefore occur. Further, management of elderly asthma patients has also been noted to be
challenging across care settings. The research problem that has been considered for the
present systematic literature review is poor management of asthma among elderly population
and the implications for practice. The research question selected is ‘‘How proper management
of asthma can be done in elderly population for reducing the symptoms of this condition?” By
conducting the present systematic review the purpose was to develop a clear understanding of
the interventions that can be applicable for elderly people and the factors increasing challenges
for elderly people. The review was carried out in a meticulous and planned manner using
appropriate databases and search terms. The results of the review, key implications for practice,
recommendations, and conclusion are presented in this paper.

2
NURSING
Contents
Introduction.................................................................................................................................. 3
Aims......................................................................................................................................... 4
Objective.................................................................................................................................. 4
Methodology................................................................................................................................ 5
Criteria for including the studies...............................................................................................5
Identification of studies............................................................................................................ 6
Study selection........................................................................................................................ 6
Data extraction......................................................................................................................... 7
Quality Assessment................................................................................................................. 7
Data Analysis........................................................................................................................... 8
Results......................................................................................................................................... 9
Summary table....................................................................................................................... 16
Discussion................................................................................................................................. 22
Implications for clinical practice and recommendations.............................................................25
Conclusion................................................................................................................................. 26
References................................................................................................................................ 28

3
NURSING
Introduction
Asthma is a long-term inflammatory condition associated with narrowing of the airways
and high production of mucus. People affected by asthma experience symptoms of shortness of
breath, wheeziness and breathing difficulty (Ozturk & Iliaz, 2016). According to the World Health
Organization report released in 2016, 3, 83, 000 deaths have occurred due to asthma in 2015
(World Health Organization, 2017). It has become a public health concern for high-income
countries as well as low and middle income countries. Asthma related death is highest in low
and middle income countries. Though it is recognized as the disease of the younger adults
however, mortality rate of asthma is mostly seen in people above 55 years (Gillman & Douglass,
2012). Asthma is common in older adults above 65 years of age and the risk factor is similar to
those found in young age group. The diagnosis of asthma significantly reduces psychological
and physical quality of life of elderly people. It has been noted that the burden of the disease is
also found to increase with age and people between 75-79 years of age experience greatest
burden of the disease (globalasthmareport.org, 2014). Paying attention to optimal management
of asthma in elderly population gains much attention because of disproportionate burden of
asthma in elderly and the presence of multi-faced risk factors unique to older age group.
With the increase in ageing population, paying attention to diseases most commonly
found in older people is important to reduce the burden on the health care system. Elderly
people are vulnerable to asthma because of pulmonary changes due to ageing, challenges in
diagnosis of asthma in elderly people and adverse effect of medications due to presence of
other co-morbidities at old age. All these factors further increased challenges for health care
professionals while managing asthma symptoms in elderly people. Review of research literature
suggests under-diagnosis as one of the treatment challenges in asthmatic older population.
Pandya et al. (2016) reported that diagnosis is difficult because many cardiovascular diseases
mimic asthma related symptoms which is more commonly found in elderly population compared
to young population. Chronic airflow obstruction and asthma symptom in elderly is also
misdiagnosed as chronic bronchitis. Inconsistent results in spirometry also increase the
challenges for elderly population (Gillman & Douglass, 2012). However, the gaps found in the
result was that it was not a population based study and conducting research in a single hospital
gave limited information regarding challenges in diagnosing asthma. Diagnosis of asthma in
elderly not only increases events of misdiagnosis but also challenges in management of the
condition. Benfante and Scichilone (2016) investigated about management challenges in elderly

4
NURSING
people with asthma and it showed that very few studies have evaluated the effect of multiple co-
morbidities on controlling asthma symptoms in elderly. Hence, many gaps remain in literature
regarding asthma management in elderly.
As gaps in research data exist regarding appropriate intervention to overcome
challenges in asthma management, conducting a systematic review on identifying the
challenges in the management of asthma in the elderly population has been felt crucial.
Systematic review and analysis of research articles reporting about interventions for elderly
asthma management and the associated challenges may help to gain understanding regarding
barrier to optimal recovery of elderly people. The main research problem identified from the
above discussion is the prevalence of asthma in elderly population and increase in health
burden due to poor management of asthma in health care setting. The research question that
can provide guidance in conducting the systematic review is as follows:
‘How proper management of asthma can be done in elderly population for reducing the
symptoms of this condition?
Aims
By conducting systematic review on challenges in the management of asthma in elderly
population, the purpose is to develop understanding regarding range of interventions for elderly
people and the factors increasing challenges for elderly people.
Objective
The main objectives of the systematic review are as follows:
 To gain insight about challenges faced in management of asthma in elderly population
 To link comorbidities in elderly patient with management of asthma symptoms
 To understand the effect of asthma interventions for elderly To evaluate intervention implemented for asthma management in elderly population
group

5
NURSING
Methodology
For the purpose of alignment of research outcomes at the end of the research with the
outlined research objectives outlined at the initial stage of the research, it was advantageous to
carry out a systematic literature review. According to LoBiondo-Wood and Haber (2014)
systematic literature reviews are comprehensive yet informative literature reviews that are
aimed at identification and subsequent synthesis of existing studies. Summarization of the main
findings of existing studies is the main purpose of such studies. In the present case, a
systematic literature review aimed at carrying out a planned research and consolidating the
relevant and valuable research findings on the topic of management of asthma in elderly
patients so that the concerned stakeholders can be informed about practice changes in
healthcare settings in relation to asthma management. In systematic literature review, the
integrative assessment relevant data was sorted from a vast pool of information so that
appropriate conclusions can be drawn from it. As mentioned by Alligood (2017) a systematic
literature review is to be considered as a protocol driven and comprehensive review that
focuses on a particular question. A polished methodology is to be followed for enabling best
outcomes of the review.
Criteria for including the studies
Inclusion and exclusion criteria considered in a systematic literature review are
responsible for setting the boundaries of the study. The two sets of criteria are to be articulated
after the research question is set, and prior to commencement of the research and the search
for the articles is conducted. Varied factors can be determined as the inclusion or exclusion
criteria ((LoBiondo-Wood & Haber, 2014).). As per the researchers, inclusion criteria are the set
of characteristics that the selected studies must be possessing and the exclusion criteria are the
set of characteristics that out rightly disqualify the articles from being included in the review. For
the present review, the inclusion and exclusion criteria were pre-set. Inclusion criteria included
Peer-reviewed journal research articles retrieved from different sources. Further, only those
articles that had full-article access were selected for the study. Other inclusion criteria were year
of publication after the year 2009, and those published in English language. Lastly, article with
human participants were significant for the present review. Articles from only last ten years were
selected for synthesizing key inferences from updated and recent studies against evolving

6
NURSING
healthcare services in relation to asthma (Alligood, 2017). Exclusion criteria therefore were non-
full text articles, those not published in English language and before 2009, and absence of
human participants in research. Articles from across the globe were considered for increasing
the generalizability of the study findings.
Identification of studies
Databases- Electronic databases are powerful and reliable tools used by researchers
across the globe for engaging in secondary research, including systematic literature review.
Appropriate electronic databases are to be identified and used for making the systematic search
successful (LoBiondo-Wood & Haber, 2014). A number of electronic databases are present that
are beneficial in health science research. For the present review, the databases that were used
are Medline, CINAHL, PubMed and EMBASE. It has been noted that the above mentioned
databases are the ones that are commonly used for accessing a diverse range of research
articles. It is easy to access full-text articles from these databases wherein access to different
journals is possible, and since peer reviewed articles is found, the same are reliable and
authentic. Updated articles make the databases beneficial as recent information can be
retrieved.
Search terms-Search terms are a crucial elementin systematic literature review. These
are the terms, words or short phrases used for searching the relevant articles in an electronic
database. The terms mainly relate to the research objectives. The use of appropriate terms
makes the research process faster and convenient (Peters et al., 2015). For the present review,
the search terms used were asthma, elderly, elder, older, management, treatment, challenge,
and difficulty.
Boolean operation-Usage of appropriate search terms is not alone sufficient for making
the search an easy process. Application of Boolean operations comes into forefront in this
regard. These operations are logical terms that researchers use together with the identified
search terms for making the process of research more refined. An authentic and smooth search
is therefore enabled. The utility is that inappropriate search hits can be suitably eliminated,
making the end result more productive (LoBiondo-Wood & Haber, 2014). Boolean operations
that were considered for use in the present review were AND and OR, as per the requirement of
the respective database.

7
NURSING
Study selection
A meticulous search is necessary for appropriate study results. To ensure that the
inference drawn from the research aligns with the research objectives, the researchers are to
select the articles through proper screening (Parahoo, 2014). In case of systematic literature
review, intensive activities are required from the researcher’s end as they are to evaluate a
large pool of studies for identifying only those that are meeting the eligibility criteria
appropriately. A bird’s eye view is needed for producing a full review, as readers gain in depth
knowledge of the articles presented. An investment in valuable resources was entailed in the
present review to highlight the challenges in managing asthma in elderly patients. Each of the
databases was searched one at a time for the related articles. Total number of articles retrieved
was 106. 35 articles were selected for the second round of screening. The title of the articles
and the abstracts were scrutinized for understanding their validity. 28 articles subsequently
screened in the next step. The suitability of the articles was adjudged after reading the full
articles. 13 articles were finally included in the systematic literature review.
Data extraction
The next step after retrieving articles is to read the full text of the articles to be included
in the review so that pertinent data can be extracted. Extraction of data in a systematic literature
review has to be precise for augmenting the research outcome. This also helps in reducing the
amount of time taken for completing the review. Systematic literature reviews helps in the
identification, synthesis and interpretation of published pool of evidence on the concerned topic
for improving decision making process for stakeholders such as policy makers and clinicians
(Jonnalagadda et al., 2015). For the present research on challenges of managing asthma
patients in elderly, the key insights from the articles were drawn in. In the present review, a
summary table was used for summarizing the key information from the eligible studies. The
information that was focused on in the summary table was author details, country and year of
publication, study aim, study setting, research sample, study design, results. The table provides
an all-inclusive overview of the papers and the main findings of the paper. An idea can be made
out of the summary table about the direction in which the results of the review is heading.
Quality Assessment
Quality assessment of the quantitative articles was done with the help of the PRISMA
checklist. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) is
an evidence based set of items that are referred to for reporting on reviews. The checklist offers

8
NURSING
precise outline about what is to be included in the systematic literature review. It covers varied
aspects ranging from the methodology to the results. It is reported that it acts as an excellent
template for reporting on the systematic review.
Data Analysis
The content of the research articles selected for the review are to be analyzed in an
appropriate manner and presented in a clear form. Systematic literature review aim at assessing
the quality of the study and the efforts given into research. In the present review it was found
considerable to carry out thematic analysis in place of meta-analysis. Meta-analysis is carried
out when the aim of the research is identification of consistency is research studies and a
certain treatment effect (Parahoo, 2014). In the preset case, the aim of the review was not to
highlight any treatment or management effect on asthma. Thematic method was adopted for
analyzing articles and categorizing them under different refrains. The focus was no pinpointing
and recording patterns within data. As opined by LoBiondo-Wood and Haber (2014) thematic
analysis is known to be an operative and efficient approach for linking selected studies with the
research objective, thereby enabling drawing of conclusion. The categorization into different
themes has been found to help researchers to process text after refining key findings. Each
theme is a representation of the pattered meaning or response from the generated data in
regards to the research question.

9
NURSING
PRISMA Flow chart

10
NURSING
Results
Challenges in the use of inhalation therapy in elderly population
Inhalation therapy is one of the interventions used for treatment of people with asthma.
The utility of inhalation therapy is that the same holds the potential to assist the delivery of
medication to the right site for action. The effectiveness of the therapy is dependent on choice of
device and correct use of inhalation technique. It has a major contribution in controlling asthma
and preventing affected people from future exacerbation (Scichilone, 2015). The review of
research literature gave idea about unique challenges in providing instructions on inhaler use in
elderly patients with asthma.
The article by Turan, Turan and Mirici (2017) also focussed on the problem associated
with treatment of elderly patients with asthma and the main aim was to identify the factors that
affect the success of using inhalers and the factors affecting treatment adherence rate. COPD
or asthma patients above 65 years old were the main research participants. Assessment of
cognitive impairment in participants was done by the Mini Mental state test and treatment
adherence was measured by Morisky Medication Adherence Scale. Usage of inhaler and skills
in using inhaler device technique was collected and a questionnaire was used. The analysis of
research findings revealed that the breath out before and after inhalation as the most common
mistake done by elderly patients. Various other forms of mistakes related to inhaler use was
found. Association between cognitive impairment and lower inhalation device use was also
found. The findings gives the implication that cognitive dysfunction in elderly people can be a
major barrier to effective use of inhalation device technique. The study has small sample size
limitation; the findings can gives implication to health care professionals to learn ways to teacher
inhalation technique to elderly patients with cognitive impairment. The findings obtained by is is
supported by Elliott et al. (2015) as the author explains that cognitive impairment in elderly
people impairs functional status of elderly people such as self-administration of medication.
Hence, identify impaired capacity to manage medication is essential to prevent risk of
medication errors and hospitalization in elderly patients.
Impact of comorbidity on treatment challenges in elderly population with asthma
Asthma is a common illness in people above 65 years of age however challenges in
treatment and management process increase because of the presence of complex co-

11
NURSING
morbidities in patient. This is the reason for frequent hospitalizations, poor adherence to
treatment, high mortality rate and poor quality of life (Song & Cho, 2015).
Wardzyńska, Kubsik & Kowalski (2015) highlighted about the issue of comorbidties and
its link with control of asthma and asthma management. Elderly people aged above 65 years
and younger asthmatic patient were selected and participants were evaluated based on
questionnaire, spirometry and prick testing. The questionnaires covered topics like smoking,
respiratory symptoms, use of health services and history of concomitant chronic disease. On
comparison of data obtained from young and old participant group, it was found that elderly
patient had low forced expiratory volume and high number of co-morbidities compared to
younger asthmatics. Older patients were found to use non-asthma drugs in large numbers.
However, one significant outcome is that the study revealed no association between co-
morbidities and asthma control. This is a contradictory finding and this could have occurred
because diagnosis of co-morbidities was done based on answers in the questionnaire. Despite
this limitation, the study showed effect of concomitant medication on asthma control. Milanese
et al. (2014) also supports the argument as the author explained that co-morbidities is one of
the hallmarks of elderly patient this may account for poor outcome in elderly patients compared
to younger patients.
While reviewing impact of co-morbidities on asthma management in elderly population,
coexistence of COPD has also been found as a treatment challenge. This is because COPD
deteriorates symptom of asthma as proved by the study by Milanese et al. (2014). The main
purpose of the study by Milanese et al. (2014) was to carry out an exploration of the level of
asthma control in elderly patients along with identifying barriers to asthma control. The multi-
centre observational study was done with patients above 64 years old and information related to
age, smoking status, age of asthma onset and chronic bronchitis was recorder by research
participants. The level of co-morbidities in participants was analyzed by the use of concomitant
drug prescription for other diseases. Airborne allergen and spirometry test was also performed.
29% of asthma patients were found to be suffering from COPD and those patients had high rate
of dypnea and asthma control test score. Hence, patients with COPD were found to have worse
asthma control and a high exacerbation rate. This established links between presence of COPD
and treatment challenges due to COPD exacerbation. Despite this finding, transferability of the
research is low as certain test were done in subjects only with smoking habits and airway
obstructions. The study gives the implication to pay special attention to elderly asthma patients
with COPD as comorbidity as this leads to worst outcome and clinical deterioration in patient.

12
NURSING
Ross et al., (2013) stated that older adults suffering from asthma often experience poor
quality of life, asthma control, and require increased health care utilization. However, thee
factors that lead to such state remain unknown. The researchers carried out a study for
identifying physiologic, psychological or demographic characteristics related to quality of life of
asthma patients. A cross-sectional study design was considered for people aged more than 65
years. The individuals had a history of asthma. Psychological, physiological and demographic
characteristics were identified. Correlation was obtained for the mentioned factors, and the mini
Asthma Quality of Life Questionnaire, Asthma Control Questionnaire and health care utilization
were under scrutiny. 70 participants enrolled in the study who had the mean age of 73.3 years.
It was indicated that higher depression screening scores and self-reported depression had
strong association with poor quality of life. Overall poor functional status also led to poor level of
motivation among patients to bring improvement in their condition. Subjects who reported to be
living alone were found to be having unscheduled visits to a physician's office (P = .06). It was
therefore concluded that comorbid depression led to poor management of asthma in elderly
population and control over life. Screening for depression might lead to better healthcare
outcomes.
Challenges in medication management and adherence in elderly population with asthma
From the review of research literature, another common themes identified related to
treatment challenges include poor adherence to asthma medications in elderly patients. Various
factors were identified to be contributing to poor adherence and treatment challenges in geriatric
asthma management. For example, health literacy, cognitive skills and other factors were
identified as factors that influence medication adherence rare in older adults with asthma.
Soones et al., (2016) pointed out that limitations in health literacy are significantly
associated with lower level of adherence to controller medications of asthma in older adults.
There are multi-varied factors that lead to inappropriate and inadequate use of asthma controller
medications. The barriers range from those related to costly regimens, complex regimens,
provider-patient level challenges, and perception regarding the time taken for completion of
patient counseling. The researchers aimed at describing the causal pathway that links health
literacy and adherence to medication through modeling of asthma illness and medication
beliefs. Recruited of elder asthma patient was done above the age of 60 years from different
community practices and hospitals in New York and Chicago. Measurement of health literacy
was done along with medication adherence with the help of Short Test of Functional Health

13
NURSING
Literacy with the help of Short Test of Functional Health Literacy in Adults and the Medication
Adherence Rating Scale. Validated instruments were used for assessment of asthma and
medication beliefs. Cognition assessment was undertaken with the help of a cognitive battery.
The results indicated that there was a direct relation between health literacy and adherence to
medication (beta = 0.089; P < .001). It was further indicated that 36% of individuals with lower
level of health literacy had more chances of developing misconceptions about asthma
medications (P < .001) and asthma (P < .001). Illness beliefs did not demonstrate a meditational
role between adherence and health literacy (beta= 0.007; P =.143). It was therefore inferred that
improved asthma controller medication adherence can be achieved through adequate focus
given on to communication strategies as deemed fit for cognitive impairments and lower level of
health literacy.
Asthma in elderly population is often linked with under-diagnosis and uncontrolled
disease lead to poor quality of life, if not morality. Previous research indicates that in elderly
patients functional and mental states, and depressive symptoms are influential in due course of
adherence to therapy of asthma. In this regard it is to be mentioned that the contribution of
medical staff as well as physician is primitive. Insufficient role delegation in terms of treatment
monitoring leads to poor adherence to treatment (Bozek & Jarzab, 2010).The scholars
estimated extent of anti-asthmatic therapy adherence prior to and after one year of treatment
monitoring through an assessment carried out with anti-asthmatic drugs. Patients above the age
of 65 years were recruited for the study, and retrospective analysis was done for evaluation of
adherence with the help of the Modified Morisky (MM) scale and a visual analog scale (VAS).
As a latter element of the study, monitoring of asthma was undertaken for one year on the basis
of drug usage. The researchers considered assessment through VAS, MM scale and
assessment of functional status, depressive symptoms and cognition prior to the observation
and after completion of the observation. The results indicated that out of the 117 total numbers
of participants, only 21% and 9% had adherence to therapy as per the VAS and MM scale
respectively. Monitoring of adherence led to an increase in compliance, from 3.08 ± 0.97 to 3.85
± 1.01 as assessed by the MM scale, and from 44% ± 7.8% to 90% ± 5.9% as assessed by
VAS. Further it was assessed found that a statistical correlation was evident between
adherence, cognition and depression symptoms, as compared to functional status. It was
therefore concluded from the study that poor compliance with anti-asthmatic treatment can be
due to poor degree of monitoring, and use of drug packages with cognitive status and
depression symptoms estimation would be beneficial for ensuring patient outcomes.

14
NURSING
The significance of the study by O'Conor et al. (2015) is that it aimed to investigate the
extent to which asthma patient’s cognitive skills can be related to health literacy. The
significance of this study is that it recognizes the fact that component of health literacy can limit
the effectiveness of interventions and asthma management strategies and cognitive ability can
be a significant factor that mediates the relationship between health literacy and health
outcomes (Baker et al., 2008). O'Conor et al. (2015) conducted the study with patients aged 60
years at eight outpatient clinics and the main outcome of interest for the study included
medication adherence, inhaler technique, health literacy and cognitive ability. Standard tools
were used to measure each outcome variables. The statistical analysis of study findings
revealed that very few participants (only 38.2%) adhere to asthma medication. The likelihood of
adhering to medication differed based on level of health literacy and the indication was that
because people with limited health literacy were less likely to comply with asthma medications.
This provides the evidence that adequate health literacy acts as a significant predictor of
medication adherence rate. Another important finding was that cognitive functions were
independent predictor of medication behaviour. This finding is consistent with research
hypothesis and other research evidence too. Wilson and Wolf (2009) justified that fluid abilities
of people decline with age and because of cognitive decline, they require careful management
process. The strength of the study is that it gives the implication to implement self-care
behaviour interventions so that cognitive burden related to asthma and medication management
can be reduced. However, the findings cannot be generalized because the findings focus only
on asthma medication behaviour, but elderly people struggle in managing multiple medication
routine for multiple co-morbidities (Wallace et al. 2015).
Challenges due to under diagnosis of asthma in elderly population
Asthma in the elderly population is associated with higher mortality and morbidity. Skloot
et al. (2016) identified that the poor outcomes of asthma in elderly population are a result of, to
some extent, under-diagnosis followed by under-treatment. There are a number of factors in
relation to aging that influences to a great extent asthma presentation in elderly population,
thereby influencing management. The researchers carried out a study with noted researchers
and clinicians from different clinical backgrounds such as allergy, immunology, pulmonary
medicine and geriatrics, who had interest in the field of Asthma in elderly (AIE). An official
American Thoracic Society Workshop was conducted. Participants were required to present the
current knowledge present relevant to AIE. Each presentation by the participants was followed
by discussions. Transcripts were prepared on the basis of information collected. The study

15
NURSING
concluded that confounding influences such as impaired motor skills, impaired cognitive skills,
medication adverse effects due to age, psychosocial effects of aging guide treatment of asthma
in the elderly. Further studies are necessary for understanding how patient specific asthma
management can be promoted in clinical settings.
Pandya et al. (2016) identified that asthma affects older people in a universal manner.
Instead of suspecting the condition in elder population, misdiagnosis is common as chronic
obstructive pulmonary disease (COPD). Due to this, suboptimal treatment is evident. The
researchers aimed at highlighting the extent of misdiagnosis of elderly asthma. A prospective
study was carried out that involved 350 patients with clinically diagnosis of obstructive airway
diseases (OADs). Out of the total number of patients, 292 individuals were found to be suffering
from obstructive pattern in pulmonary function test. Out of these individuals, 100 had been
diagnosed with asthma while 192 were suffering from COPD. Out of the 100 patients, 16
individuals were of more than 60 years and 5 individuals of them were previously given
treatment for COPD. It was concluded that if misdiagnosis occurs, proper management of
asthma in elderly is related to key challenges.
Other challenges in clinical management of asthma and education impartment in elderly
population
According to McDonald et al., (2011) COPD and asthma in elderly population are known
to be complex conditions that have a distinct relationship with multiple clinical concerns. Asthma
frequently has a coexistence with COPD, and research indicates that in elder population asthma
is associated with comorbidities. The clinical problems that arise in elderly asthma patients
relate to symptoms of pathophysiological changes, lifestyle, self-management skills and
individual problems as brought into the limelight by the patient himself. The problems might not
be elicited by the clinician unless adequate probing is done. The research carried out by the
McDonald et al., (2011) aimed at assessing patient’sand physician’s perceived importance of
understanding clinical problems and describing the extent of concordance between physicians
and patients with regards to the problems. 52 participants aged above 55 years were selected
for the problem prioritization study. A multidimensional assessment was carried out for
characterizing the prevalence of clinical problems. The objective was to achieve rating for
problem importance. The results indicated that the higher rated problems were activity limitation,
dyspnoea, airway inflammation. Further, these areas demonstrated satisfactory patient-
physician concordance. The result further indicated that poor concordance was evident in

16
NURSING
relation to airflow obstruction, and inhaler technique adequacy. Though good agreement was
found in relation to written action plans, the importance to physicians and patients was limited. It
was therefore concluded from the paper that patients and physicians agree on limited aspects of
asthma care in elderly patients. It can be inferred that the problems faced by elderly asthma
patients are not adequately elicited and thus not addressed for ensuring better health outcomes.
Goeman et al., (2011) identified that asthma burden in expected to increase
considerably in the coming few decades. The researchers considered undertaking a cross-
sectional survey for identifying concerns of elderly asthma patients and the perceived symptom
of asthma. 199 individuals above the age of 55 years and suffering from asthma were included
in the study conducted in Australia. 120 individuals reported that they could well control their
conditions while 78% individuals claimed that they adhered to asthma treatment. in spite of this,
105 individuals said that they experienced moderate to severe symptoms, Further, it was
indicated that exacerbations were common in around one-third of the population would required
emergency care in the past one year. Though 80% of the respondents said that they could
manage their condition properly, only 10% reported that they could visit an emergency
department when they had severe aggravation of symptoms. Those with age above 65 years
had the preference for less autonomy in decision making. It was therefore concluded that
asthma educators are supposed to identify the individual needs of the elderly asthma patients
for tailoring the delivery of comprehensive asthma care.
Asthma education delivered to a wide population of patients had been found to be
promising. Asthma is considered as a major public health concern that affects individuals across
the age spectrum. Research indicates that elderly asthma leads to almost half of the total
number of deaths due to asthma on an annual basis. Further, asthma in elderly leads to
significant hospitalizations. Baptist et al., (2011) highlighted that though the burden of medical
costs and healthcare resource utilization for elderly asthma is high, little research has been
done to understand the methods by which quality of life of elderly asthma patients can be
improved. Patient education acts as a vital component for asthma management. Limited
research has been done to understand the challenges faced in educating elderly asthma
patients so that they can combat the symptoms experienced. The researchers brought into
notice that previous trials to understand effectiveness of asthma education did not consider
patient population above the age of 65 years. The researchers therefore conducted a study to
carry out an evaluation of the effectiveness of asthma education of long terms and short term
indicators of asthma management in the population above 65 years. The research considered

17
NURSING
using the Four-State National Asthma Survey (NAS) data. Asthma control was evaluated and
compared between population of elder adults above the age of 65 years who received
education and those who did not use. Elderly asthma patients were taught to use asthma action
plan (AAP) and peak flow meter (PEM). Comparison was done among older patients who took
part in asthma course and those who did not. The short term outcomes measured were
(symptoms within last 1 week, day and night symptoms in last 30 days, and the use of steroid in
last 3 months), while the long term outcomes studied were asthma attack, emergency
department visit, hospitalizations, and activity limitations in the prior year. No differences were
found in the short- and long-term asthma outcomes between older adults receiving and not
receiving education. It was therefore concluded that instructions on asthma plan, asthma
education course and instruction of using of PFM were not effective in changing asthma
outcomes in elderly population. The inference drawn was that education programs are to be
tailored specifically for older population for making the same effective.
Summary table
Author Country
and year
of
publicatio
n
Study aim Study
setting
Research
sample
Study design Results
Bozek &
Jarbaz
Poland,
2010
Assessme
nt of
adherence
to
antiasthma
tic therapy
among
elderly
asthmatic
spatient
Hospital
setting
One
hundred
and
seventee
n
participan
ts from
outpatient
allergolog
ical and
geriatric
clinics, 63
women
and 54
Retrospective
study design
Low
adherence
to anti-
asthmatic
treatment is
common in
elderly
people as a
result of
poor
monitoring
course

18
NURSING
men,
age 65
and older
(mean
age: 72 ±
3.9,
range:
65–102),
McDonald
et al.
Australia,
2011
Assessme
nt of
patients’
and
physicians’
perceived
importance
of clinical
problems
in asthma
Respirato
ry
ambulato
ry care
clinics at
the John
Hunter
Hospital,
Newcastl
e, NSW,
Australia
100
participan
ts aged
55 years
and
above
Multidimension
al assessment
Higher rated
patient
problems
are airway
inflammatio
n, activity
limitation
and
dyspnoea
Soones et
al.
USA,
2016
Description
of describe
the causal
pathway
linking
health
literacy to
medication
adherence
by
modeling
asthma
illness and
medication
beliefs as
Communi
ty and
hospital
practices
Adult
asthma
patients
60 years
and
above
age
Structural
equation
modeling
Lower level
of health
literacy
increase the
chances of
non
adherence
to asthma
medication

19
NURSING
mediators
Ross et al. USA,
2013
To identify
demograph
ic,
psychologi
cal or
physiologic
characteris
tics
associated
with
asthma
quality of
life, control
and health
care
utilization
in older
adults
Data
taken
from the
university
of
Michigan
asthma
registry
Elderly
asthma
patients
with
mean age
of 73.3
years
Cross sectional
study
Comorbid
depression
leads to
poor
managemen
t of asthma
in elderly
patients
Skloot et al. USA,
2016
To assess
the
challenges
faced in
managing
asthma in
elderly
American
Thoracic
Society
Experts
and
clinicians
Workshop with
focus group
discussions
Confoundin
g influences,
such as
comorbiditie
s impaired
cognition
and motor
skills,
psychosocia

20
NURSING
l effects of
aging, and
age-related
adverse
effects of
medications,
have an
impact on
treatment of
asthma in
the elderly
Pandya et
al.
India
2016
To
understand
the
mismanag
ement of
asthma in
elderly
population
Patients
at SBKS
Medical
Institute
and
Research
Center
350
clinically
diagnose
d with
obstructiv
e airway
diseases
(OADs)
Prospective
study
Misdiagnosi
s of asthma
leads to
suboptimal
treatment in
elderly
Wardzynsk
a et al.
Japan,
2015
To carry
out an
assessmen
t of the
impact of
comorbiditi
es on
asthma
severity
and
manageme
nt in older
adults
Patients
selected
through
database
93 elderly
asthma
patients
aged 65
years and
above
Evaluation
through
questionnaire
Higher
prevalence
of
comorbiditie
s have no
significant
relation with
asthma
control
O’conor et
al.
USA,
2015
To
investigate
8
outpatien
Patients
aged 60
In person
interview
Limited
literacy

21
NURSING
the extent
to which
cognitive
skills is
related to
health
literacy and
medication
adherence
in asthma
t clinics years and
above
leads to
poor
medication
adherence
Turan et al. Turkey,
2015
To assess
the
parameters
affecting
inhaler
using
success
and
treatment
adherence.
Hospital
setting
Asthma
outpatient
s over
age of 65
Assessment
scale and
questionnaire
Cognitive
dysfunction,
Cognitive
dysfunction,
socio-
economical
status,
pulmonary
symptoms,
smoking,
have effects
on the
adherence
to inhalation
therapy
Buranello
et al.
Brazil,
2016
To
evaluate
knowledge
possession
among
older
asthma
patients
Medical
clinic
departme
nt of
private
hospital
52 elderly
asthma
patients
with
mean age
75 years
Observational,
descriptive
cross-sectional
study
Low level of
standardize
d
information,
prescription
s and
monitoring
leads to
poor

22
NURSING
outcome of
oxygen
inhalation
therapy
Milanese et
al.
Italy
2014
To explore
extent of
asthma
control in
elderly
subjects
Hospital
setting
350
patients
aged 64
years and
above
Observational
study
Coexistence
of COPD
negatively
influences
asthma
control
Baptist et
al.
USA,
2011
To assess
the
effectivene
ss of
asthma
education
in
improving
asthma
condition in
elderly
Survey
conducte
d by
National
Center
for
Environm
ental
Health
Older
adults
above
age of 65
years
Cross sectional
study
Engagemen
t in asthma
education
course,
instruction
on
action plans,
and
instruction
on PFM use
are not
effective in
controlling
poor asthma
outcomes in
elderly
patients
Goeman et
al.
Australia,
2011
To identify
the unmet
needs of
older
people with
asthma
Communi
ty
pharmaci
es in
Victoria,
Australia
120
asthma
patients
aged
above 55
years
Cross sectional
survey
Asthma
educators
are to
provide
tailored
education
program

23
NURSING
after
identification
of individual
needs of
patients

24
NURSING
Discussion
Asthma is a form of respiratory disease due to which patients suffer variable respiratory
symptoms along with obstruction of the airway in relation with airway hyper-responsiveness
(AHR). The feature mentioned are cause due to an inflammatory process that is marked by
progressive bronchial remodeling (Iwanaga et al., 2017). The prevalence of asthma among the
elderly population is reported to be equal or in some cases even higher than the general
population suffering from asthma. It has been estimated that around 7-15% of people living in
Australia aged above 65 years suffer from asthma. This implies that near about one out of
seven people in the country are asthmatic. This statistics includes individuals who are
diagnosed with asthma in the later stages of life, and those who are diagnosed with the
condition in early stages (Braman, 2017). Asthma in older population of Australia is found to be
distinct in a number of ways. The disease is known to be highly persistent and severe in elders,
making the management of the same highly challenging. As per the data of 2006, around 92%
of asthma deaths in the country were among those aged 45 years and above. It has been
reported that asthma is more prevalent among females as comparison to males (10.8%
compared to 7.4%) (Inoue et al., 2014).
Management of asthma in elderly has been pointed out to be highly challenging due to
different causes. The present review aimed at understanding the challenges faced by
healthcare professionals to address asthma presentations in the elderly population. It had the
objective of identifying the underlying factors related to poor management of asthma in the
elderly population. The focus was to highlight the different aspects that hinder optimal care
delivery to the patient population and the factors that diminish the effectiveness of self-
management. By undertaking the systematic review on challenges in the management of
asthma in elderly population, the purpose was to develop a thorough understanding of different
interventions that can be applied to elderly asthma population for addressing their concerns and
enabling better patient outcomes. The objectives of the review were multifold. The focus was on
gaining insight into main challenges faced by healthcare professionals and the effect of asthma
interventions on the elderly. Several issues particular to asthma management in elder people
and their subsequent clinical implications have come into limelight through the present
systematic review.

25
NURSING
The review indicates that severity of asthma in the elderly population is significant and
disrupts the course of care given. The severity of the condition leads to comorbid conditions in
the chosen population, which in turn results in complications of management of the condition.
Comorbidities hold the potential to affect the metabolism and excretion of respiratory drugs, and
can negatively impact adherence to and persistence with chronic treatment. The impact of
comorbidities on asthma management is of high significance and the common comorbidities
that influence effective outcomes of treatment are coexistence of COPD, impaired cognition and
motor skills, and psychosocial effects of aging. As opined by Ban et al., (2016) comorbidities
such as COPD, cognition and motor skills, psychosocial impact of aging are common in elderly
asthma patients and can effectively lead to alteration in the natural history of asthma, further
complicating the management process and increasing the risk of suffering adverse drug
reactions. Yanez et al., (2014) had further commented that patients suffering from multiple
comorbidities also are subjected to complicated medication regimen adherence, leading to risks
of treatment failure. There has been a lack of studies that focused on recruiting older patients in
drug efficacy trials. In this regard Lombardi et al., (2016) had stated that overlapping symptoms
of different lung diseases and other chronic diseases further lead to a confusion regarding the
discourse of asthma self-management. For instance, considerable overlap of asthma and
COPD in elder population is distinct. A key concern that has come into limelight through the
systematic review is misdiagnosis and under-diagnosis of asthma in the elderly population.
Diagnosis of asthma in the elderly population is usually based on the variable airflow limitation,
variable respiratory symptoms, diurnal PFT, and peak expiratory flow rate variability. These
might be difficult to be diagnosed in elderly population. Speaking on a general basis, asthma
might be misdiagnosed in the elderly population for those with a history of smoking. It has been
noted that asthma is characterized by reversible airway obstruction. In case of the elderly
population, it is common to find incomplete reversibility, since asthma is persistent or severe in
aged population. The diagnosis is therefore more difficult in the elderly population (Battaglia et
al., 2016).
Further, it had been highlighted from the present systematic literature review that age
related adverse effects of medications of asthma also pose problems for patient condition
management. The primary method of asthma treatment might be similar across age groups as
the goal of therapy is same for both elderly and young population. However, the drugs might be
under-used in case of elderly patients due to the adverse effects brought about by the same
(Adams & Urban,, 2015). In a study of Ray et al., (2016) it has been reported that the patho-

26
NURSING
physiologic mechanism of asthma is different in elder and younger population, influencing
clinical outcomes to a great extent. The symptoms that the elderly population faces are not easy
to be addressed through drug therapy since the patients might be resistant to steroids. Rance
and O’Laughlen (2014) highlighted that a key medication for chronic and acute asthma is beta-
adrenergic agents; however, elderly patients might be not responding adequately to such
bronchodilator due to aging. In such case anti-cholinergic and beta agonist agents might be
used which are not influenced by the patient’s age.
The elderly population also might face concerns about poor inhalation techniques and
insufficient inspiratory flows, as pointed out by the present study. Difficulties in relation to poor
medication have been attributed to inappropriate use of inhaler devices. The choice of inhaler
has been reported to be crucial in treatment outcome achievement. The visual acuity,
neuromotor impairment and dexterity might be affecting the level of understanding of the patient
regarding the use of inhaler (Carnegie & Jones, 2013). Nurses often do not discuss the
required inspiratory flow rate with the patient, leading to difficulties. In absence of inhalation
airflow meter devices, patients cannot assess the needed inspiratory flow rate as per the device
to be used (Boulet, 2016). Further, professionals might not be considerate of the requirement of
a patient to use a spacer and the corresponding mode of delivery. In addition, lack of proper
review by nurses of the devices used contributes to challenges (Guilbert et al., 2017).
It is also know as a result of the systematic review that poor monitoring by care
professionals, communication gap with professionals, and perception of professionals regarding
clinical problems to be less important also add to difficulties in managing asthma in elderly
population. Poor quality physician-patient relationship has a negative impact on treatment
adherence among elderly asthma patient population. Due to unavailability of support from care
professionals, patients are deterred from estimating the vitality of adhering to the self-
management plan or medication regime (Webb, 2011). When the physicians and nurses
adequately recognize the clinical problems faced by the patient, the patient’s confidence to carry
out the self-management behavior is stronger. Riley (2015) in this regard said that higher level
of support from professionals and effective communication are in support of increased self-
efficacy and better quality of life. Based on a review of the factors contributing to challenges in
managing asthma in elderly, the researcher pointed out that one category of factors perceived
to be influential in asthma management is patients’ beliefs and attitudes regarding the treatment
course as a result of education provided by professionals. Patients might not be satisfied with

27
NURSING
the quality of care provided to them from the clinician’s end, contributing to poor adherence to
regimen (Roberts et al., 2016).
The present systematic literature review further points out that non-adherence to
treatment regimen are due to poor socio-economic status, and lower level of literacy. As
mentioned by Gemicioglu et al., (2018) treatment and medication regimen non-adherence might
be intentional or unintentional among elderly asthma patients. Intentional under-use as a result
of cost considerations has been linked with economic vulnerability. Other factors that influence
adherence include dependency development, perception regarding necessity of medication and
their effectiveness (Iwanaga et al., 2017). Concerns regarding certain side effects such as voice
changes, osteoporosis, cataract, glaucoma and infections are reported by elderly asthma
patient. These concerns also contribute to lower level of committeemen regarding adherence of
treatment regimen (Abreu et al., 2018). As found in the research of Boulet (2016) literacy level
of the patients is a crucial factor in adherence to treatment regimen. A rich pool of evidence
suggests that demographic and social factors have a key association with unintentional non-
adherence to regimen. Education level is inked with the ability of the patient to understand the
implications of self-management and the outcomes in the long run. Patients often fail to
perceive the symptom severity that lead to delay in accessing appropriate medical help and
implementing required self-management protocols. In addition, social relationship disruptions
suffered by those with low literacy level also has an impact on management of disease. Those
entailed to care for others, and those who act as primary care giver to other patients within the
social context might often remain silent regarding their needs of asthma management. Access
to pharmacies might also be challenging for those with lower socio-economic background.
The effectiveness of asthma education course and instructions on asthma care plan are
also to be reviewed at the end of the discussion. From the literature review it can be concluded
that patient education needs to be of optimal level and much specific for reaching to the desired
outcomes. Tailored patient education programs are required for reaching out to the target
population. Patient education holds the potential to be a crucial component of asthma
management in the elderly population. Patients can be helped to gain confidence, motivation
and skills for controlling their condition (O'Conor et al., 2015). Therefore much importance is to
be given to this area of asthma management. Asthma education programs have different
components in them, such as information about inhalation techniques, need of follow-up, and
need of proper communication, and criteria for using control measures. When an individualized
approach is demonstrated, elderly patients can be educated in a better way, and empowered to

28
NURSING
take care of the disease. Tailored programs as per the age of the patient, education level, desire
for autonomy and psychological status might be more beneficial for managing asthma in the
elderly population.
Implications for clinical practice and recommendations
The key inference drawn from the above discussion is that better understanding of
asthma in elderly population is recommended for addressing the key challenges faced by
professionals in managing the condition. Healthcare professionals, especially nurses, are to
improve their level of knowledge regarding the development and impact of the condition in the
elderly. The knowledge of nurses might be limited regarding the pathophysiology of aging and
asthma (Song & Cho, 2015). Improvement of asthma management in elderly patients is of much
significance in the present era, owing to the increasing prevalence of elderly asthma cases.
Healthcare organizations and responsible for developing intervention strategies that are directed
at care providers for encouraging them to treat asthma as a condition distinctly presented by
elderly. There is also a need of increasing the adherence level of professionals to the set clinical
guidelines for acknowledgement of barriers to management (Scichilone et al., 2015).
Further, increased awareness and understanding of elderly asthma is required.
Healthcare professionals must be engaging in research to find out the optimal strategies
through which there can be an increase in the community awareness level of elderly asthma.
The elderly often demonstrate underestimation of significance of asthma prevalence. Both non-
government and government public health organizations are in urgent need of evidence-based
guidance for effectively facilitating communication of health messages to asthma patients. The
nature of primitive challenge regarding asthma management is evident when population
considers asthma to be a health condition occurring in childhood and not adulthood.
Professionals are also to research on interventions that can augment acceptance of elderly
asthma among the elderly population (Jones et al., 2011).
Healthcare providers must have a proactive approach in identifying efficient and
effective methods of providing personalized and detailed information to the target population
regarding asthma management so that their needs are met adequately (Newcomb et al., 2010).
Medication management is elementary for successfully managing symptoms of asthma. Elderly
population suffering from asthma, often lack clear idea about self-management aspects. They
however do not seek help in the correct and in adequate manner. Patient receiving information

29
NURSING
regarding management would likely demonstrate higher self-care behaviors, encompassing
medication regimen adherence, self-confidence and self-monitoring. Education topics might
include topics such as exposure to smoke and irritants, air pollution, exercise and vaccinations
(Tousman et al., 2010). In this regard, it is recommended that older people with asthma are to
be given increased attention and provided with information so that they are in a position to
identify the emergence need of accessing medical help, or use reliever medicines. Tools for
increasing patient confidence and imparting education include personalized action plans,
provision of available health information and patient-held records. The plans have shown to be
designed in such a manner that care givers are encouraged to take up additional accountability
in managing asthma (Goeman et al., 2009).
Tailored self-management protocols are to be developed that can enhance proper
management of asthma. All attempts of improving asthma management in the elderly are to
consider literacy level, cognitive ability and confidence level. Thus, care providers, especially
nurses must utilize optimal resources for influencing the perspectives and attitudes of elderly
patients towards asthma care and management (Gemicioglu et al., 2018).
Conclusion
The present integrated literature review has led to the suitable identification of the
status of present research on asthma management in elderly population. The prevalence of
asthma among the elderly population has been noted to be high across different regions of the
country, including Australia. Asthma is often found to be coexisting with other conditions such as
COPD and cardiac complications. The explanation of poor outcomes of elderly asthma
discourse can be attributed to changes in the asthma phenotype with increasing age. It has
been reported that the severity of asthma increases with age, and women are more likely to
suffer from the condition. Increased airway inflammation, activity limitation and dyspnoea are all
related to asthma suffered by the older individuals. These medical aspects are to be considered
as the prime focus for successful managing the condition among the chosen population.
The present literature review highlights that many challenges emerge in due course
of managing elderly asthma condition. The challenges are highly unique in nature, and are
partially due to under-diagnosis and under-treatment. Comorbidities and physiological changes
are related to the process of management. Along with low level of literacy and psychosocial
effects of aging, comorbidities and physiological changes contribute to major care burden on

30
NURSING
nurses across health care settings. Despite the acknowledgement of the challenges faced by
care providers and patients alike, much is still needed to be done for enabling better outcomes.
Several other issues regarding practice of nurses also come into limelight at this juncture that
are responsible for poor management. In absence of role delegation of professionals,
management is challenging. This is further aggravated if the communication between the patient
and the care provider is not effective. Limited patient education is also a contributory factor.
It can therefore be concluded that management of elderly asthma should be
multifaceted. It is expected that evidence-based strategies when applied in the future would
address multiple, challenges at a single time. Older people are to be made to understand that
seriousness of the condition that they suffer from so that they can seek assistance when in
need. Increased patient education is entailed in this regard. The primary objective of nursing
care for asthma patients is to enhance the quality of life and regain functionality. Nurses
accountable for caring for older patients must therefore demonstrate high level of knowledge
and skills for breaking treatment barriers. They are to put in their best efforts for delivering
pharmacological treatment that are age-appropriate and non-pharmacological treatments
including self-management tools and individualized education. In short, care is to be provided in
a holistic manner. When offered with adequate information and high quality services, older
people would be better assisted in the whole process of obtaining better mental and physical
wellbeing. This would directly lead to less incidents of hospitalization over a considerable period
of time due to fatal asthma cases.
Further, management of asthma in elderly must focus on frequent monitoring of
symptoms as well as adverse medications. More attention to the possible chances of suffering
complications is warranted. A suitable and effective health care model focusing on better quality
service provision clubbed with ongoing research would ensure development of best practices for
further improvement of health outcomes of the target population.

31
NURSING
References
Abreu, L., Arriscado-Nunes, J., Taylor, P., & Silva, S. (2018). The Role of Distributed Health
Literacy in Asthma Integrated Care: A Public Medical Context from Portugal.
International Journal of Integrated Care, 18. http://doi.org/10.5334/ijic.3301
Adams, M. P., & Urban, C. (2015). Pharmacology: Connection to Nursing. Pearson Education.
Alligood, M. R. (2017). Nursing Theorists and Their Work-E-Book. Elsevier Health Sciences.
Retrieved from https://books.google.co.in/books?
hl=en&lr=&id=l7stDwAAQBAJ&oi=fnd&pg=PP1&dq=nursing+research,
+book&ots=yVsH-VPLe8&sig=ieyyoQL7B4t8nAa7B1T09Nttmzk#v=onepage&q=nursing
%20research%2C%20book&f=false
Baker, D. W., Wolf, M. S., Feinglass, J., & Thompson, J. A. (2008). Health literacy, cognitive
abilities, and mortality among elderly persons. Journal of general internal
medicine, 23(6), 723-726. doi: 10.1007/s11606-008-0566-4
Ban, G. Y., Trinh, T. H., Ye, Y. M., & Park, H. S. (2016). Predictors of asthma control in elderly
patients. Current opinion in allergy and clinical immunology, 16(3), 237-243.
https://doi.org/10.1097/ACI.0000000000000273
Baptist, A. P., Talreja, N., & Clark, N. M. (2011). Asthma education for older adults: results from
the National Asthma Survey. Journal of Asthma, 48(2), 133-138. DOI
10.3109/02770903.2010.535880
Battaglia, S., Benfante, A., Spatafora, M., & Scichilone, N. (2016). Asthma in the elderly: a
different disease? Breathe, 12(1), 18–28. http://doi.org/10.1183/20734735.002816
Benfante, A., & Scichilone, N. (2016). The geriatric asthma: pitfalls and challenges. Asthma
Research and Practice, 2, 2. http://doi.org/10.1186/s40733-015-0018-y
Boulet, L. P. (2016). Asthma in the elderly patient. Asthma research and practice, 2(1), 3.
10.1186/s40733-015-0015-1
Bozek, A., & Jarzab, J. (2010). Adherence to asthma therapy in elderly patients. Journal of
Asthma, 47(2), 162-165. https://doi.org/10.3109/02770900903497204
Braman, S. S. (2017). Asthma in the Elderly. Clinics in geriatric medicine, 33(4), 523-537.
https://doi.org/10.1016/j.cger.2017.06.005

32
NURSING
Buranello, M. C., Shimano, S. G. N., & Patrizzi, L. J. (2016). Oxygen inhalation therapy among
elderly patients of a public hospital. Revista Brasileira de Geriatria e Gerontologia, 19(2),
247-256. http://dx.doi.org/10.1590/1809-98232016019.140208
Carnegie, E., & Jones, A. (2013). Improving the management of asthma in older adults. Nursing
Standard (through 2013), 28(13), 50. Retrieved from
https://rcni.com/sites/rcn_nspace/files/ns2013.11.28.13.50.e8075.pdf
Elliott, R. A., Goeman, D., Beanland, C., & Koch, S. (2015). Ability of Older People with
Dementia or Cognitive Impairment to Manage Medicine Regimens: A Narrative
Review. Current Clinical Pharmacology, 10(3), 213–221.
http://doi.org/10.2174/1574884710666150812141525
Elliott, R. A., Lee, C. Y., Beanland, C., Vakil, K., & Goeman, D. (2016). Medicines management,
medication errors and adverse medication events in older people referred to a
community nursing service: a retrospective observational study. Drugs-real world
outcomes, 3(1), 13-24. Retrieved from: https://link.springer.com/article/10.1007/s40801-
016-0065-6.
Gemicioglu, B., Bayram, H., Cimrin, A., Abadoglu, O., Cilli, A., Uzaslan, E., ... & Misirligil, Z.
(2018). Asthma control and adherence in newly diagnosed young and elderly adult
patients with asthma in Turkey. Journal of Asthma, 1-9.
https://doi.org/10.1080/02770903.2018.1471707
Gillman, A., & Douglass, J. A. (2012). Asthma in the elderly. Asia Pacific Allergy, 2(2), 101–108.
http://doi.org/10.5415/apallergy.2012.2.2.101
globalasthmareport.org (2014). The Asthma Global Report 2014. Retrieved from:
http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
Goeman, D. P., Jenkins, C. R., Crane, M. A., Bosnic-Anticevich, S. Z., & Douglass, J. A. (2011).
Unmet needs of older people with asthma: cross-sectional survey. Journal of
Asthma, 48(9), 865-875. DOI: 10.3109/02770903.2011.616253
Goeman, D. P., Sanci, L. A., Scharf, S. L., Bailey, M., O’Hehir, R. E., Jenkins, C. R., &
Douglass, J. A. (2009). Improving general practice consultations for older people with
asthma: a cluster randomised control trial. Med J Aust, 191(2), 113-117. Retrieved from
https://pdfs.semanticscholar.org/a310/0512447bc8c43f7984f641d91fe482c759e0.pdf

33
NURSING
Guilbert, T. W., Colice, G., Grigg, J., van Aalderen, W., Martin, R. J., Israel, E., ... & Evans, J. M.
(2017). Real-life outcomes for patients with asthma prescribed spacers for use with
either extrafine-or fine-particle inhaled corticosteroids. The Journal of Allergy and Clinical
Immunology: In Practice, 5(4), 1040-1049. https://doi.org/10.1016/j.jaip.2016.11.026
Inoue, H., Niimi, A., Takeda, T., Matsumoto, H., Ito, I., Matsuoka, H., ... & Tajiri, T. (2014).
Pathophysiological characteristics of asthma in the elderly: a comprehensive study.
Annals of Allergy, Asthma & Immunology, 113(5), 527-533.
https://doi.org/10.1016/j.anai.2014.08.002
Iwanaga, T., Sano, H., & Tohda, Y. (2017). The current state and provisions for elderly patients
with asthma. Journal of general and family medicine, 18(3), 102-107.
https://doi.org/10.1002/jgf2.6
Jones, S. C., Iverson, D., Burns, P., Evers, U., Caputi, P., & Morgan, S. (2011). Asthma and
ageing: an end user's perspective‐the perception and problems with the management of
asthma in the elderly. Clinical & Experimental Allergy, 41(4), 471-481. : 10.1111/j.1365-
2222.2011.03718.x
Jonnalagadda, S. R., Goyal, P., & Huffman, M. D. (2015). Automating data extraction in
systematic reviews: a systematic review. Systematic reviews, 4(1), 78,
doi: 10.1186/s13643-015-0066-7
LoBiondo-Wood, G., & Haber, J. (2014). Nursing Research-E-Book: Methods and Critical
Appraisal for Evidence-Based Practice. Elsevier Health Sciences.
Lombardi, C., Raffetti, E., Caminati, M., Liccardi, G., Passalacqua, G., Reccardini, F., ... & ELSA
Study Group. (2016). Phenotyping asthma in the elderly: allergic sensitization profile and
upper airways comorbidity in patients older than 65 years. Annals of Allergy, Asthma &
Immunology, 116(3), 206-211. https://doi.org/10.1016/j.anai.2015.12.005
McDonald, V. M., Higgins, I., Simpson, J. L., & Gibson, P. G. (2011). The importance of clinical
management problems in older people with COPD and asthma: do patients and
physicians agree?. Primary Care Respiratory Journal, 20(4), 389.
https://doi.org/10.4104/pcrj.2011.00025
Milanese, M., Di Marco, F., Corsico, A. G., Rolla, G., Sposato, B., Chieco-Bianchi, F., ... & ELSA
Study Group. (2014). Asthma control in elderly asthmatics. An Italian observational
study. Respiratory medicine, 108(8), 1091-1099.
https://doi.org/10.1016/j.rmed.2014.05.016

34
NURSING
Newcomb, P. A., McGrath, K. W., Covington, J. K., Lazarus, S. C., & Janson, S. L. (2010).
Barriers to patient-clinician collaboration in asthma management: the patient experience.
Journal of Asthma, 47(2), 192-197. 10.3109/02770900903486397
O'Conor, R., Wolf, M.S., Smith, S.G., Martynenko, M., Vicencio, D.P., Sano, M., Wisnivesky,
J.P. and Federman, A.D., 2015. Health literacy, cognitive function, proper use, and
adherence to inhaled asthma controller medications among older adults with
asthma. Chest, 147(5), pp.1307-1315. doi: 10.1378/chest.14-0914
Ozturk, A. B., & Iliaz, S. (2016). Challenges in the management of severe allergic asthma in the
elderly. Journal of asthma and allergy, 9, 55, doi: 10.2147/JAA.S85420
Pandya, R., Shah, A., Francis, S., Shah, K., Shah, P., & George, A. (2016). Under-diagnosis of
asthma in elderly. Indian Journal of Allergy, Asthma and Immunology, 30(1), 27,
Retrieved from: http://www.ijaai.in/article.asp?issn=0972-
6691;year=2016;volume=30;issue=1;spage=27;epage=31;aulast=Pandya
Pandya, R., Shah, A., Francis, S., Shah, K., Shah, P., & George, A. (2016). Under-diagnosis of
asthma in elderly. Indian Journal of Allergy, Asthma and Immunology, 30(1), 27. DOI
10.4103/0972-6691.187565
Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan International
Higher Education. Retrieved from https://books.google.co.in/books?
hl=en&lr=&id=5ti3AwAAQBAJ&oi=fnd&pg=PP1&dq=nursing+research,
+book&ots=RBwB_yLjBV&sig=JWYVGpPGInWzFmuUGAg0u9nIhp0#v=onepage&q=nu
rsing%20research%2C%20book&f=false
Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015).
Guidance for conducting systematic scoping reviews. International journal of evidence-
based healthcare, 13(3), 141-146,DOI: 10.1097/XEB.0000000000000050
Rance, K., & O’Laughlen, M. (2014). Managing asthma in older adults. The Journal for Nurse
Practitioners, 10(1), 1-9. https://doi.org/10.1016/j.nurpra.2013.11.009
Ray, M., Sano, M., Wisnivesky, J. P., Wolf, M. S., & Federman, A. D. (2015). Asthma control
and cognitive function in a cohort of elderly adults. Journal of the American Geriatrics
Society, 63(4), 684-691. https://doi.org/10.1111/jgs.13350 Retrieved from
https://books.google.co.in/books?
hl=en&lr=&id=3tTsAwAAQBAJ&oi=fnd&pg=PP1&dq=nursing+research,

35
NURSING
+book&ots=JFgTDeMiVY&sig=95Z58K_Wvm0Tx23xFHJgwWwury0#v=onepage&q=nur
sing%20research%2C%20book&f=false
Riley, J. B. (2015). Communication in nursing. Elsevier Health Sciences. Retrieved from
https://books.google.co.in/books?
hl=en&lr=&id=SwndCwAAQBAJ&oi=fnd&pg=PP1&dq=Communication+in+Nursing&ots=
YZpk57vlzF&sig=mLVzMVPM-_qv-xfdi4xDfSU9oyM#v=onepage&q=Communication
%20in%20Nursing&f=false
Roberts, C. A., Geryk, L. L., Sage, A. J., Sleath, B. L., Tate, D. F., & Carpenter, D. M. (2016).
Adolescent, caregiver, and friend preferences for integrating social support and
communication features into an asthma self-management app. Journal of Asthma, 53(9),
948-954. https://doi.org/10.3109/02770903.2016.1171339
Ross, J. A., Yang, Y., Song, P. X., Clark, N. M., & Baptist, A. P. (2013). Quality of life, health
care utilization, and control in older adults with asthma. The Journal of Allergy and
Clinical Immunology: In Practice, 1(2), 157-162. DOI
https://doi.org/10.1016/j.jaip.2012.12.003
Scichilone, N. (2015). Asthma Control: The Right Inhaler for the Right Patient. Advances in
Therapy, 32(4), 285–292. http://doi.org/10.1007/s12325-015-0201-9
Scichilone, N., Ventura, M. T., Bonini, M., Braido, F., Bucca, C., Caminati, M., ... & Milanese, M.
(2015). Choosing wisely: practical considerations on treatment efficacy and safety of
asthma in the elderly. Clinical and Molecular Allergy, 13(1), 7.
https://doi.org/10.1186/s12948-015-0016-x
Skloot, G. S., Busse, P. J., Braman, S. S., Kovacs, E. J., Dixon, A. E., Vaz Fragoso, C. A., ... &
Hanania, N. A. (2016). An official American Thoracic Society workshop report:
evaluation and management of asthma in the elderly. Annals of the American Thoracic
Society, 13(11), 2064-2077. 10.1513/AnnalsATS.201608-658ST
Song, W. J., & Cho, S. H. (2015). Challenges in the management of asthma in the
elderly. Allergy, asthma & immunology research, 7(5), 431-439.
https://doi.org/10.4168/aair.2015.7.5.431
Song, W. J., & Cho, S. H. (2015). Challenges in the management of asthma in the elderly.
Allergy, asthma & immunology research, 7(5), 431-439.
https://doi.org/10.4168/aair.2015.7.5.431

36
NURSING
Soones, T. N., Lin, J. L., Wolf, M. S., O'conor, R., Martynenko, M., Wisnivesky, J. P., &
Federman, A. D. (2017). Pathways linking health literacy, health beliefs, and cognition to
medication adherence in older adults with asthma. Journal of Allergy and Clinical
Immunology, 139(3), 804-809. https://doi.org/10.1016/j.jaci.2016.05.043
Tousman, S., Zeitz, H., & Taylor, L. D. (2010). A pilot study assessing the impact of a learner-
centered adult asthma self-management program on psychological outcomes. Clinical
Nursing Research, 19(1), 71-88. 10.1177/1054773809354290
Turan, O., Turan, P. A., & Mirici, A. (2017). Parameters affecting inhalation therapy adherence
in elderly patients with chronic obstructive lung disease and asthma. Geriatrics &
gerontology international, 17(6), 999-1005. https://doi.org/10.1111/ggi.12823
Wallace, E., Salisbury, C., Guthrie, B., Lewis, C., Fahey, T., & Smith, S. M. (2015). Managing
patients with multimorbidity in primary care. bmj, 350(176), 10-1136. Retrieved from:
https://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1090&context=gpart
Wardzyńska, A., Kubsik, B., & Kowalski, M. L. (2015). Comorbidities in elderly patients with
asthma: association with control of the disease and concomitant treatment. Geriatrics &
gerontology international, 15(7), 902-909.
Webb, L. (Ed.). (2011). Nursing: Communication skills in practice. Oxford University Press.
Retrieved from https://books.google.co.in/books?
id=kr_MFpuJNuYC&printsec=frontcover&dq=nursing+communication&hl=en&sa=X&ved
=0ahUKEwjaks_IvcHcAhUKv48KHW_sDrcQ6AEIJjAA#v=onepage&q=nursing
%20communication&f=false
Wilson, E. A., & Wolf, M. S. (2009). Working memory and the design of health materials: a
cognitive factors perspective. Patient education and counseling, 74(3), 318-322,
https://doi.org/10.1016/j.pec.2008.11.005
World Health Organization (2017). Asthma. Retrieved from: http://www.who.int/news-room/fact-
sheets/detail/asthma
Yáñez, A., Cho, S. H., Soriano, J. B., Rosenwasser, L. J., Rodrigo, G. J., Rabe, K. F., ... &
Fabbri, L. M. (2014). Asthma in the elderly: what we know and what we have yet to
know. World Allergy Organization Journal, 7(1), 1. https://doi.org/10.1186/1939-4551-7-8

37
NURSING