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

Running head: NURSING
Master project in nursing
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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.

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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

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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

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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

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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

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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.

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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