Challenges Faced in Asthma Management in Older Adults

This systematic review aims to understand the factors that enhance difficulties for elderly patients in the management of asthmatic symptoms. The research question is whether asthma management strategies are less complicated for elderly population compared to that of the younger group of population in reducing asthma symptoms. The review will include research articles with only elderly participants, younger people as the control group, improvement in various asthmatic symptoms, primary care settings providing asthma management services, and both qualitative and quantitative papers. The thematic analysis process will be used to analyze the research evidence.

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This template is intended to help you plan your integrated literature review in a systematic way.
TITLE OF THE REVIEW Challenges faced in asthma management in older adults
STUDENT
SUPERVISOR
BACKGROUND TO REVIEW Asthma is a long term inflammatory disease of the airways that causes the burden of asthmatic
attacks over 3 million people all over the world (Ozturk & Iliaz, 2016). The main clinical
manifestation of asthma are wheezing, coughing, chest tightness, reversible airway obstruction
and bronchoconstriction (Bonini & Usmani, 2015). Although asthma is a common within the
pediatrics, the symptoms are also common in many elderly people having chronic asthma. The
disease burden of asthma is associated with a great reduction in the quality of life affecting the
social, personal and the professional life (Ehteshami-Afshar et al., 2016). 15% of the children
population has been diagnosed with the asthmatic symptoms. Young adults within the age
range 30-34 years have been found to have the lowest impact and pediatrics and the geriatric
population experience the greater burden of the clinical condition. Extreme asthma
exacerbations in the elderly people have been linked high number of comorbidities within the
geriatric population experiencing asthma symptoms (globalasthmareport.org, 2014). Although a
wide range of scientific articles exists about the prevalence of asthma in children but less focus
is given on the geriatric population.
Asthma among the older adults helps is a major public health concern. With the continuous
growth of the aged population, it can be expected that the number will get doubled by the year
2030 (Ortman, Velkoff & Hogan, 2014). Hence it is important to have a clear understanding of
the pathophysiology , assessment, interventions , treatments and the barriers to asthma
interventions among the adults. Older population are subjected to multiple comorbidities and
are also phenotypically different from the other population groups that provides the rationale for

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research using this population group. The main risk factors for asthma are poor hearing, poor
level of hygiene due to frailty, poor self-management skills and poor education about the
asthma management strategies (Ozturk & Iliaz, 2016). Hence an in depth research is required
to understand the risk factors and eradicate the barriers to asthma management among the
elderly population. The main aim of this research is to conduct a systematic review for
understanding how comorbidities may lead to poor asthma outcome and evaluating the asthma
management interventions for the elderly population.
RESEARCH QUESTION (PICO
Format)
The main clinical issue is the increase in the older population and poor quality of life among the
elderly population due to the diagnosis of asthma and the presence of multiple chronic
diseases. The clinical question is represented in the PICO format written below:-
 P (Population)- Elderly population
 I (Intervention)- management of asthma
 C (Comparator)- no action
 O (Outcome)- Challenges
The PICO question can be written as -‘Are asthma management strategies (I) less complicated
for elderly population (P) compared to that of the younger group of population (C) in reducing
asthma symptoms (O)?
SPECIFIC AIM The main objective of the systematic review is to understand about the factors that enhances
the difficulties for the elderly patients in the management of asthmatic symptoms.
OBJECTIVES Objectives:-
 To provide a vivid understanding regarding the asthma management in the elderly

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population.
 To link the elderly comorbidities with the symptoms of asthma.
 To understand the effectiveness of the asthma intervention in the older patients.
 To evaluate the outcome of the implemented intervention in the older population.
CRITERIA FOR INCLUDING
STUDIES IN THE REVIEW
 Population/Participants
 Interventions/
Exposures
 Comparisons/Control
Group/s
 Outcomes Of Interest
 Setting
 Study Designs To Be
Included
Inclusion criteria-
 Population/participants: Research articles with only elderly participants were
included.
 Intervention/exposure: Research articles that contain younger people as the control
group were taken in to consideration to facilitate comparison.
 Outcome of interest: Improvement in the various asthmatic symptoms like
breathlessness, wheezing and bronchoconstriction due to formation of the mucus plugs.
 Setting: Primary care settings providing asthma management services.
 Study designs to be included: Both qualitative and quantitative papers will be taken in
to consideration that is relevant to the clinical question.
SEARCH METHODS
 Electronic Databases
o please list all
databases that are
to be searched and
include the interface
(eg nhs, ebsco, etc)
and date ranges
searched for each
 Other Methods Used For
Identifying Relevant
Electronic databases:
A wide range of biomedical databases like CINAHL, PubMed, Medline and EMBASE will be
brainstormed using the relevant keywords. In order to search the databases the interface that
will be used are NHS and EBSCO. The search filters that will be used for searching the
databases are the publishing date of the articles within 2009 to 2018. This will help in the
inclusion of the articles within the recent 10 years. Primary search terms like ‘asthma in
elderly”, “asthma management strategies”, “barriers to asthma management”. Addition of more
specific search terms help in advanced search. Boolean operators such as AND, OR is
normally used to conduct search in the CINAHL database. Use of appropriate search terms
and keywords is an essential step for research (Peters et al., 2015).
Other search methods:

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Research
o ie contacting
experts and
reference checking
 Journals Hand Searched
o if any are to be hand
searched, please list
which journals and
date searched from,
including a rationale
Other inclusion criteria for the research articles are full text articles and peer reviewed journals.
Final selection of the research articles will be validated by two experts in this field. Both the
experts will be checking and reviewing the summary and the title of the papers, followed by
checking of the reference list.
METHODS OF REVIEW
Details Of Methods
 Number Of Reviewers,
How Agreements To Be
Reached And
Disagreements Dealt
With, etc
 Quality Assessment
Tools Or Checklists
Used With References
Or Urls
Data Extraction
 what information is to be
collected on each included
study. if databases or
Details of methods:
The main eligibility criteria for the selection of the articles is the inclusion criteria. The two
articles will be reviewed by the reviewer and will possibly eliminate the presence of any
selection bias (Whiting et al., 2016). Elimination of the selection bias will prevent the effect of
the individual bias at the time of the selection procedure. Initially the two reviewers would
choose screen the title and the abstract of the papers and the body of the articles. The
reference list of the selected papers will also be checked for finding associated research
articles relevant to the clinical question. Articles other than English articles are excluded from
the study. Independent extraction of the data for research was carried out by each of the
reviewers and incase of any conflict of interest, an independent researcher will be taking care
of the issue and settling the disagreement.
In order to increase the credibility and the validity of the research, it is necessary to perform a
quality assessment of the studies, which will make the research more transparent and credible
(Almeida & Goulart, 2017). Relevant assessment tools and representation of the research
findings systematically based upon the research rigor (Ahmed, Sutton & Riley, 2012) .
Cochrane Risk of Bias Assessment tool is used for the bias assessment, as a part of
evaluation techniques. This tool is appropriate for assessing different kinds of biases such as
the performance bias, the selection bias, attrition bias and the detection bias. The tool consists

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forms on word or excel are
used and how this is
recorded narrative
synthesis
 details of what and how
synthesis will be done
Meta-Analysis
 details of what and how
analysis and testing will be
done. if no meta-analysis is
to be conducted, please
give reason.
of six domains like allocation concealment, random sequence generation, blinding of the
participants, blinding the assessment of the outcome, incomplete outcome data, selective
reporting and other biases for rating the study quality (Cochrane Methods, 2018). The quality of
the papers will be judges based upon these six domains.
Data extraction:
In order to reduce the time taken for completing the review specific methods will be used to
extract the data. A systematic review helps in the identification, synthesis and interpretation of
the evidences for improving the decision making process for the policy makers, health care
professionals and other stakeholders involved. The strategies use for extracting the data is the
time taken to conduct the review (Jonnalagadda, Goyal & Huffman, 2015). A summary table
will be used for summarising the studies. These are the information that will be extracted from
the studies-
 Author details
 Country and publication year
 Participants of the study
 Research setting
 Severity of symptoms for asthma
 Interventions
 Study duration
 Study design
 Outcome measures
Meta-analysis:
Thematic analysis process will be used to analyse the research evidence (Thomas &
Harden 2008). Meta- analysis for this systematic review is not appropriate as meta-analysis
aims to identify the consistency between the research studies done to analyse any treatment
effect and analysis pf the effect of the treatment is not the main aim of this systematic review.
Instead the different barriers faced by the patients will be categorised under different themes.
This can be considered as an effective approach for linking the chosen studies and with the

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clinical question and the research objectives. Thematic analysis helps in refining the research
findings in its themes and is normally used in the analysis of the qualitative data (Bearman &
Dawson, 2013). This classification of the findings in to defined themes would help in the
processing of the text and refining of the study findings. This would further help in critical
assessment.
Presentation Of Results
 additional material
 summary tables,
flowcharts, etc, to be
included in the final paper
 outputs from review
 papers and target journals,
conference presentations,
reports, etc
A Summary table has been attached below:-Table 1- Summary table

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Table 2- Quality assessment table
The positive and the negative signs will be used to measure the risk of bias from high, unclear
to low. Positive sign would represent high bias, negative signs would indicate low risk bias and
the question mark would mean an unclear risk for bias.
Prisma Chart

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7. Timeline For Review – When
do you aim to complete each
stage of the review
Different stages of systematic review such as the searching of literature, appraisal of the
quality, extraction of the data, synthesis and the establishment of the write up require ample
time. The timeline for the completion of each of the stages are provided below-

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 Literature Searching
 Quality Appraisal
 Data Extraction
 Synthesis
 Writing Up

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References:
Ahmed, I., Sutton, A. J., & Riley, R. D. (2012). Assessment of publication bias, selection bias, and unavailable data in meta-analyses
using individual participant data: a database survey. Bmj, 344, d7762, doi: https://doi.org/10.1136/bmj.d7762
Almeida, C. P. B. D., & Goulart, B. N. G. D. (2017). How to avoid bias in systematic reviews of observational studies. Revista
CEFAC, 19(4), 551-555, Doi: http://dx.doi.org/10.1590/1982-021620171941117
Bearman, M., & Dawson, P. (2013). Qualitative synthesis and systematic review in health professions education. Medical
education, 47(3), 252-260, doi:10.1111/medu.12092
Bonini, M., & Usmani, O. S. (2015). The role of the small airways in the pathophysiology of asthma and chronic obstructive
pulmonary disease. Therapeutic advances in respiratory disease, 9(6), 281-293.
Cochrane Methods (2018). Assessing Risk of Bias in Included Studies. Retrieved from: http://methods.cochrane.org/bias/assessing-
risk-bias-included-studies
Ehteshami-Afshar, S., FitzGerald, J. M., Doyle-Waters, M. M., & Sadatsafavi, M. (2016). The global economic burden of asthma and
chronic obstructive pulmonary disease. The International Journal of Tuberculosis and Lung Disease, 20(1), 11-23,
DOI: https://doi.org/10.5588/ijtld.15.0472
globalasthmareport.org (2014). The Asthma Global Report 2014. Retrieved from:
http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
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
Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: the older population in the United States (pp. 25-1140). United
States Census Bureau, Economics and Statistics Administration, US Department of Commerce,
http://bowchair.com/uploads/9/8/4/9/98495722/agingcensus.pdf

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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
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
Scichilone, N., Pedone, C., Battaglia, S., Sorino, C., & Bellia, V. (2014). Diagnosis and management of asthma in the
elderly. European journal of internal medicine, 25(4), 336-342, DOI: https://doi.org/10.1016/j.ejim.2014.01.004
Song, W. J., & Cho, S. H. (2015). Challenges in the management of asthma in the elderly. Allergy, asthma & immunology
research, 7(5), 431-439.
Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical
research methodology, 8(1), 45, Doi: https://doi.org/10.1186/1471-2288-8-45
Whiting, P., Savović, J., Higgins, J. P. T., Caldwell, D. M., Reeves, B. C., Shea, B., … ROBIS group. (2016). ROBIS: A new tool to
assess risk of bias in systematic reviews was developed. Journal of Clinical Epidemiology, 69, 225–234.
http://doi.org/10.1016/j.jclinepi.2015.06.005