Systematic Review on Managing Asthma in Elderly Patients: Interventions and Challenges

In this document we will discuss about Systematic Review on Managing Asthma in Elderly Patients and below are the summary points of this document:- Asthma is an incurable respiratory disease that causes respiratory suffering, particularly in elderly patients. Elderly patients suffering from asthma remain at high risk of ill health due to under-diagnosis and under-treatment. A systematic literature review was conducted to understand interventions that can provide better progress in asthma symptoms for elderly patients.

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Abstract:
Asthma is an incurable health condition of the respiratory system which causes
respiratory suffering in patients. The disease roots irritation and narrowing inside of the lung,
limiting air supply. This respiratory condition has a major influence on aged population. It
has been observed that elderly patients suffering from asthma remain at high risk of
witnessing ill health due to asthma and the death rate is also found to be high. And the main
reason behind the issue is the ageing pathophysiology. In older patients, the under-diagnoses
of asthma are quite common hence the under-treatment occurs. And it has been observed that
management of aged asthma patient is challenging. In this systemic literature review, the
research problem considered will focus on the poor management of elderly asthma patient
and the research question “what interventions can provide better progress in asthma
symptoms for elderly asthma patients?”. The purpose of conducting this systematic review is
to develop a proper understanding about the interventions which can be helpful for aged
asthma patients and highlighting the factors that are creating challenges for these patients.
The review was performed in a planned and thorough way using proper database. The results
and conclusion has been provided in the paper.

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Table of Contents
Introduction:...........................................................................................................................3
Aim:........................................................................................................................................5
Objective:...............................................................................................................................5
Methodology:.........................................................................................................................6
Standards for including the studies:.......................................................................................6
Identification of studies:.........................................................................................................7
Study selection:......................................................................................................................8
Data extraction:......................................................................................................................9
Quality Assessment:...............................................................................................................9
Data Analysis:......................................................................................................................10
PRISMA Flow chart:........................................................................................................11
Results:.................................................................................................................................12
The impact of comorbidity on the treatment challenges in elderly people with asthma
disease..............................................................................................................................13
Challenges in the medication management and the adherence in elderly population
suffering with asthma.......................................................................................................14
Challenges due to the under-diagnosis of asthma in elderly people................................17
Appendix:.............................................................................................................................21
Discussion:...........................................................................................................................31
Conclusion:..........................................................................................................................38

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References:...........................................................................................................................41

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Introduction:
Asthma is a medical condition where the airways of the respiratory system starts becoming
narrow and swollen and excessive amount of mucus production is observed, causing
difficulty in breathing and induces, wheeziness, coughing and rapidity of breath (Ozturk &
Iliaz, 2016). According to th study conducted by the World Health Organization in the year
2016, it was reported that around 383000 death occurred throughout the world because of
asthma (World Health Organization, 2017). These death cases have become a major concern
for public health care in high revenue as well as low and mid revenue countries. And the most
of the cases of asthma related deaths are from low and mid income countries (D’amato et al.,
2015). Asthma is recognised as a disease of earlier adults but the death rate has been seen to
be higher in adults beyond 55 years of age. The disease is common in adults beyond the age
of 65 years and the risk is related to those of the younger asthma suffering patients (Gillman
& Douglass, 2012). The diagnosis of the disease can decrease the psychological and physical
value of life of older individuals. It is also being observed that the burden of disease has
increased with age and people in the age group of 75-79 witness the utmost effect
(globalasthmareport.org, 2014). The health management of asthma in older individuals gains
more attention because of the uneven burden of the disease in older and various risk factors in
the older group.
With the increasing aged people, the burden of the health care system should be
reduced focusing on the diseases that are common is elder population. The risk of asthma in
older people increases as their pulmonary tract changes because of ageing, challenges while
diagnosing and sever effects of treatment because of co-morbidities. These factors induce
challenges and complications for healthcare facilities while treating an elderly patient with
asthma. A review literature proposes under-diagnosis can be one of the management
experiments in asthmatic elder population. Pandya et al. (2016) stated that diagnosis is

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complicated because most of the cardiovascular diseases mimic symptoms of asthma mostly
found in older population compared to the younger once. Chronic airflow hindrance and
symptoms of asthma may also get misdiagnosed as chronic bronchitis. Unpredictable
outcome in spirometry also induces challenges in elderly population (Gillman & Douglass,
2012). This research was not a population based and as it was conducted in a particular
hospital, only a narrow information was provided regarding the elderly asthma patient
diagnosis challenges. Benfante and Scichilone (2016) examined management challenges in
older individuals surfing from asthma and the research disclosed that less number of studies
have assessed the effect of various co-morbidities for controlling symptoms of asthma in the
elderly population. The research generally highlights the fact that there are various areas for
additional research for asthma management in older population.
The gaps in the research data remains concerning suitable mediations to overcome
some management challenges in asthma patients, performing a systematic review of
literature, focusing on the identification of the challenges in the asthma disease management
is essential. The systematic review and analysis of the research article focusing on the
involvements for asthma management and the connected issues can help in understanding the
barriers in the recovery process and refining the standard of life for the elderly asthma
patients. The main issue identified in the paper is the occurrence of the disease in elderly
patients and the growing health burden because of bad management in health care services.
The question in the research that would help in guiding the systematic review is as follows:
what interventions can provide better progress in asthma symptoms for elderly asthma
patients?

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Aim:
The aim of the research is to progress on an understanding of all the variety of
interventions for older people suffering from asthma and the factors that are increasing the
challenges in the elder population, using systematic review.
Objective:
The key objectives of the systematic review are:
 To achieve understanding about the management of the elderly asthma patients
 To know the properties of the interventions for the older asthma population
 To assess interventions executed for the management process for aged people.
Methodology:
For the aim of alignment of the result of the research at the end of the study with the
objective defined at the primary stage, it was found to be beneficial to perform the systematic
review. According to LoBiondo-Wood and Haber (2014), systematic review of a literature is
inclusive yet informative which focuses on empathy and following synthesis of current
studies. The main purpose of such studies is to précis the key findings of the present studies.
The systematic review of literature intended to associate important and significant research
outcomes on the management of the asthma disease in the elderly population so that the
participants remain informed about the exercise changes in the healthcare services in relation
to the management of asthma illness. In the systematic literature appraisals, the integrative
valuation of important data is organized from a chunk of information so that suitable
assumptions can be strained from it. As stated by Alligood (2017), a systematic review of
literature is to be taken as a process determined and inclusive review that centres on a specific
question. A refined methodology is to be followed for permitting a better result of the review.

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Standards for including the studies:
The inclusion and exclusion standard that is considered in a systematic review are the
reason behind setting limitations of the study. The two groups of standards expressed after
the question of the research is agreed, and before performing the research the search of the
essential articles are accompanied. Diverse factors can be considered as the inclusion and
exclusion standard (LoBiondo-Wood & Haber, 2014). These inclusion standards are the set
of features that the study selected should possess and the exclusion standard are the set of
features that prohibits the article from being incorporated in the systematic review. And for
this systematic review literature these standards of inclusion and exclusion was set early. The
inclusion standard comprised peer-reviewed research journals that has being recovered from
various sources and only those articles were selected, whose full excess was available. The
other criteria for the inclusion was the year of publication, which was after the year of 2009
and those who were available in English language. At last, the articles which had human
participant in them were important for the review purpose. Articles of last ten years were
taken in to account for developing main inferences from updated and current studies in
contrast to developing healthcare facilities in relation with asthma (Alligood, 2017).
Exclusion standards therefore were partial copy articles, those which were not published in
English and were before the year of 2009, and absenteeism of human volunteers in the
research. Articles from throughout the world were measured for growing the generalisability
of the research findings.
Identification of studies:
Databases- Electrical databases are influential and consistent tools that can be used by the
researchers throughout the world to engage in the secondary research which includes
systematic literature review. Suitable electrical databases need to be recognized and used for
performing the systematic examination successfully (LoBiondo-Wood & Haber, 2014). There

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are an extensive range of electrical databases that are useful in healthcare research. For the
systematic review, the databases that were kept in account were CINAHL, PubMed, Goggle
scholar, Medline and EMBASE. All these databases are the most commonly used databases
for retrieving a varied series of research articles in the field of research topic. It is very simple
to get access to the full-text articles from all these databases and getting access to diverse
research journals is potential, and as peer reviewed articles are used, these databases
comprise of a huge assortment of the most current information and lessons.
Search Terms-Search terms are a very critical part in any kind of systematic review of
literature. These are the short phrases, terms or words that are used in searching the
applicable articles in an electrical database. The terms mostly relay to the objectives of the
research. The use of these suitable terms sorts the research method in a faster and convenient
manner (Peters et al., 2015). For this systematic review, the search terms that is used were
“elderly”, “aged”, “senior”, “asthma”, “respiratory illness”, “respiratory disorder”, “asthma
attack”, “respiratory disease”, “older”, “adult”, “grownup”, “elder”, “senior”, “management”,
“administration”, “supervision”, “difficulty”, “exertion”, “challenge” “trail”, “cure” and
“treatment”.
Boolean Operation- The usage of proper search terms is not the only sufficient aspect for
constructing the search an easy method. The use of Boolean operations comes into account in
this respect. These operations are reasonable terms that the researchers use along with the
recognized search terms for constructing the research process more advanced. One of the
more precise and efficient search is hence allowed. The usefulness of the operation is that the
unsuitable search can be more certainly removed, making the end result to be more useful
(LoBiondo-Wood & Haber, 2014). Boolean operations that was considered for the use in the
current review were OR and AND, focusing on the condition of the respective database used.

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Study selection:
A particular search is essential for suitable study outcomes. To confirm that the implications
drawn from the research paper bring into line the research objectives, the assignment is to
choice the articles over suitable screening (Parahoo, 2014). In situation of the systematic
review of literature, thorough actions are required in order to assess an enormous pool of
research studies to categorize only those which meet the appropriateness of the criteria. A
bird’s eye vision is required for making a full review paper, to enable the readers to achieve
depth information of the articles that is to be presented (Gibson & McDonald, 2017). An
investment in respected resources was required in this systematic review to spot the
challenges in managing the asthma in elderly population. Each and every database were
examined individually for the related articles. The total number of articles that were retrieved
was 106. Thirty-five articles were then selected for the second round of the screening process.
The label of the articles and the abstracts were then scrutinised in order to understand their
strength. Twenty-eight articles subsequently were send forward for the next step. The
appropriateness of the articles was decided after understanding the full articles. From thirteen
articles were lastly incorporated in the systematic review.
Data extraction:
The next stage of the systematic review after recovering articles is to go through the
full text of the articles that is to be involved in the systematic review in demand to obtain
relevant data. The extraction of data in a systematic review should be précised in account to
enhance the outcome of the research. This is also found to help in decreasing the amount of
time to be taken for concluding the review. Systematic reviews help in the documentation,
production and understanding of an available pool of data on the focused topic for refining
decision making for the participants such as clinicians and policy makers (Jonnalagadda et
al., 2015). For this research on interventions that provides the best development in symptoms

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of asthma in the aged population, some key perceptions from the research articles were
witnessed. For this systematic review, a tabular format was used to summarise the important
sets of information from the adequate studies. The information that was included in the
summary table was country, author details, and study aim, study setting, year of publication,
study design, research sample and results. The table delivers a summary of the research
papers and the key findings.
Quality Assessment:
The quality assessment of the quantitative research articles was completed
with the assistance of the PRISMA checklist. Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) is an evidence cantered set of substances that are
discussed for writing on reviews. The checklist suggests accurate outlines on what needs to
be incorporated in the systematic review of literature. It covers several features stretching
from the methodology to results. It is considered as an exceptional template for reporting on
the systematic reviews.
Data Analysis:
The content of the research articles that was selected for the systematic review are
analysed in a suitable way and offered in a clear form. Systematic review targets to evaluate
the value of the study and efforts given in to the research. In this systematic review, a
thematic study was chosen as a process of data analysis instead of meta-analysis. Meta-
analysis is conceded when the purpose of the research is being identification of reliability in
the research studies and a definite treatment outcome is needed (Parahoo, 2014). The
thematic method was agreed for the analysis of articles and to categorise them below diverse
domains. Thematic analysis is defined as a process of recognizing themes in qualitative data.
A process of analysing, identifying and recording themes in data. Hence, this method will be
used to gain knowledge and insight from the collected data. As stated by LoBiondo-Wood

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and Haber (2014), the thematic analysis is recognized to be an operative and proficient
approach for connecting designated studies with the study objective, thus illustrating
conclusions. The categorisation into various subjects has been found to be helping the
researchers to practice writing after calming key findings.
PRISMA Flow chart:

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Results:
Use of the inhalation therapy in the asthma suffering elderly population
Inhalation therapy is one of the interferences that are used for treatment of individuals
with asthma. Inhalation therapy supports the process of medication to the correct location for
accomplishment. The efficiency of therapy is reliant on the choice of scheme and precise use
of the inhalation technique. It has a chief influence in regulating asthma and avoiding the
affected individuals from upcoming exacerbation (Scichilone, 2015). The systematic review
of research literature centres on the significance and exclusive challenges in providing
directions on inhaler used by elderly patients with asthma disease.
The article proposed by Turan, Turan and Mirici (2017) also concentrated on
difficulties related to treatment of the elderly patients suffering with asthma and the main
purpose was to recognize the aspects that distress the success of consuming inhalers and the
factors which are affecting treatment observance rate. COPD or asthma suffering patients
above the age of 65 years were the chief research contributors. Valuation of cognitive
deficiency in contributors was directed using Mini Mental state test and treatment observance
was restrained by utilising the Morisky Medication Adherence Scale. Evidence on the
practice of inhalers and assistances in consuming inhaler device techniques was collected
using a questionnaire. The analysis of the research findings exposed that the process breath
out earlier and afterward of inhalation as the utmost common error in the elderly patients.
Numerous other forms of errors associated to inhaler usage were also observed. An
association among the cognitive deficiency and inhalation device usage was similarly found.
The outcomes recommended that the cognitive dysfunction in the elderly people can become
a major obstacle in the effective usage of the inhalation device method. The study has the
restriction of a lesser sample size; the outcomes can notify the health care specialists to
discover ways to enlighten the inhalation technique to the elderly patients with the cognitive

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impairment. These conclusions are sustained by Elliott, Lee, Beanland, Vakil and Goeman,
(2016). As the author describes that cognitive impairment in the elderly individuals harms
practical status of elderly individuals such as self-administration of the medication. Thus,
identification of the impaired ability to accomplish medication is important in averting risk of
medication faults and then hospitalisation of the elderly patients.
The impact of comorbidity on the treatment challenges in elderly people with
asthma disease
Asthma is a very common disease in individuals above the age of 65 years, however
challenges in the treatment and management process is increasing because of the presence of
difficult co-morbidities in patient. This is the cause for recurrent hospitalizations, poor
observance to treatment, high death rate and deprived quality of life (Song & Cho, 2015).
Wardzyńska, Kubsik and Kowalski (2015) highlighted the matter of comorbidities
and their relation to the resistor of asthma and the asthma management. Aged people above
65 years and the younger asthmatic patients were carefully chosen and contributors were
estimated cantered on survey, spirometry and perforate testing. The questionnaire concealed
matters like respiratory symptoms, smoking, use of health services and past of the comorbid
chronic disease. In associating obtained data from the younger and the older contributor
groups, it was found that the elderly patient had shorter involuntary expiratory volume and
greater number of co-morbidities compared to the younger asthmatics. Adult patients were
found to be using the non-asthma medications more frequently. Though, one important
outcome is that, the study exposed no link between co-morbidities and the asthma control.
This is a differing result and might have happened because the diagnosis of co-morbidities
remained expected based on the answers of the questionnaire. Although this restriction, the
study indicated result of the non-asthma medication on the asthma control. Milanese et al.
(2014) similarly supports the argument as the writer enlightened that co-morbidities is one of

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the symbols of elderly individuals and this may justify for poorer results in the elderly
patients when compared to the younger patients.
Ross, Yang, Song, Clark and Baptist (2013) stated that elder adults who are
suffering from asthma frequently experience deprived value of life, bad asthma regulator, and
need amplified health care. However, the aspects that lead to this stay undefined. The
scientists carried out a study in order to identifying physical, mental and demographic
characteristics related to value of life of the asthma patients. A cross-sectional study strategy
was utilised for examining people, aged above 65 years. All contributors had a past of
asthma. Association was attained for the basic study regions, and the little Asthma Quality of
Life Questionnaire, Asthma Control Questionnaire and the health care utilisation was
observed and verified. Seventy contributors registered in the study with the mean age of 73.3
years. It was specified that greater depression screening marks and self-reported sadness had
strong relationship with deprived quality of life. General deprived functional position also led
to reduced levels of inspiration among patients to be able to bring about any developments in
their situation. Volunteer who stated to be living all alone were found to have spontaneous
visits to the physician's office (P = .06). It was thus concluded that co-morbid sadness led to
deprived management of asthma in the elderly population and bad control over their life.
Consequences from the study propose that the screening for depression may lead to better
healthcare results.
Challenges in the medication management and the adherence in elderly
population suffering with asthma
From the systematic review of the research literature, another common subject is
identified related to the treatment challenges which includes bad adherence to the asthma
medications in the elderly people. Many factors were recognized in order to contribute to
deprived adherence and challenges in treatment in the asthma management in the elderly

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population. For example, cognitive skills, health literacy and various other factors were
identified as points which influence the medication observance in elder adults suffering with
the asthma.
Soones, Lin, Wolf and O’Connor (2016) together pointed out that the limitations in
health knowledge are significantly related with lesser level of adherence to the controller
medications of asthma disease in older adults. There are numerous issues that lead to
incorrect and inadequate usage of asthma controller medicines. The barriers range from those
related to expensive handlings, multifaceted regimens, provider-patient close challenges, and
insight concerning the period taken for achievement of patient therapy. The scientists
intended to define the underlying pathway that contacts health knowledge and obedience to
medicine through moulding of asthma sickness and medication principles. Enrolment of
elderly asthma patients above the age of 60 years from diverse community practices and
clinics in New York and Chicago was directed. Health knowledge was measured along with
the medication observance with the assistance of the Short Test of Functional Health Literacy
in Adults and the Medication Adherence Rating Scale. Authenticated instruments were used
for valuation of asthma and medication principles. Cognitive assessment was commenced
with the support of a cognitive assessment series (CAB). The outcomes specified that there
was a direct affiliation between health knowledge and observance to medication (beta =
0.089; P < .001). It was further specified that 36% of people in the research with minor levels
of health knowledge had further chance of emerging misunderstandings about asthma
medications (P < .001) and asthma (P < .001). Disease opinions did not demonstrate among
medication obedience and health knowledge (beta= 0.007; P =.143). It was hence concluded
that enhanced asthma controller medication obedience can be attained through suitable
attention given on to communication approaches as appropriate for cognitive injuries and
minor level of health knowledge.

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Asthma in elderly people is repeatedly connected with under-diagnosis and unwell
controlled sickness leading to poor worth of life, and eventually morality. Prior research
specifies that in elderly patients practical and mental conditions, and depressing indications
are prominent in patient’s obedience to asthma treatment. The involvement of medical
operate as well as doctors is often considered in the literature as basic. Inadequate role
assignment in terms of treatment observing can principal to poor obedience to treatment
(Bozek & Jarzab, 2010). Research estimations extent of anti-asthmatic treatment devotion
prior to and afterward of one year of treatment monitoring over a valuation conceded out with
anti-asthmatic drugs. Patients beyond the age of 65 years were enrolled for the study, and a
reflective analysis was directed for the assessment of adherence using the Modified Morisky
(MM) scale and a graphic analogue scale (VAS). As a component of the study, observation of
asthma was commenced for a year on the basis of the drug usage. The researchers considered
the assessment over VAS, MM scale and valuation of functional status, depressing
indications and cognition earlier to the observation and after conclusion of the observation.
The outcomes specified that out of the 117 number of contributors, only 21% and 9% of the
total had obedience to the therapy as per the VAS and MM scale individually. Observance of
adherence directed to a rise in the compliance, from 3.08 ± 0.97 to 3.85 ± 1.01 as measured
by the MM scale, and then from 44% ± 7.8% to 90% ± 5.9% as measured by VAS.
Additionally, it was established that a numerical correlation was obvious between the
adherence, cognition and the depression symptoms, as associated to practical status. It was
thus concluded from the research that the poor compliance with the anti-asthmatic treatment
can be because of poor observation, and use of the drug packages with the cognitive status
and depression signs assessment helpful for confirming better outcomes for the patients.
The research by O'Conor, Wolf, Smith and Martynenko (2015) intended to examine
the extent to which the asthma patient’s intellectual skills can be connected to health

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knowledge. The significance of the study is that it recognises the components of health
knowledge can bound the efficiency of mediations and asthma management approaches and
cognitive skill can be the important factor in facilitating the relationship among health
knowledge and health results (Baker et al., 2008). O'Conor, Wolf, Smith and Martynenko
(2015) showed the study with patients who aged 60 years at eight outpatient hospitals and the
key result of attention for the study comprised medicine adherence, inhaler method, health
knowledge and cognitive capability. Standard tools were utilized to measure each of the
result variables. The statistical analysis of the study results exposed that a very few
contributors (only 38.2%) adhered to the asthma medication. The probability of adhering to
the medication varied based on the level of health knowledge and the sign was that because
the people with limited health knowledge were less probable to obey with asthma
medications. This provides the sign that satisfactory health knowledge turns as an important
analyst of the medication adherence rate. Another significant discovery was that the cognitive
function was an independent analyst of the medication behaviour. Wilson and Wolf (2009)
justified that the skills of public failure with age and because of the cognitive failure, they
need a cautious management procedure. The asset of the study is that it provisions the
application of self-care behaviour intermediations so that cognitive burden related to the
asthma and medication management can be decreased. Though, the results cannot be
generalised successfully because they centre only on the asthma medication behaviour, and
do not consider that elderly public have trouble in managing a numerous medication routine
for multiple number of co-morbidities (Wallace et al., 2015)
Challenges due to the under-diagnosis of asthma in elderly people
Asthma in the elderly people is related with greater death and injury. Skloot, Busse,
Braman, Kovacs and Dixo (2016) recognized that the poor results of asthma in the elderly
people are an effect of, to some extent, under-diagnosis monitored by under-treatment. There

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are various number of factors in relation to the ageing that considerably effects asthma
exhibition in elderly people, thus influencing disease and indication management. The
researchers conceded out a study with scientists and clinicians from diverse clinical
experiences such as immunology, allergy, geriatrics and pulmonary medicine, who had
interest in the ground of asthma in elderly (AIE). An authorized American Thoracic Society
Workshop was accompanied. Members were compulsory to present the existing knowledge
present applicable to AIE. Each performance by the members was monitored by
consultations. Copies were arranged on the basis of data collected. The study established that
confounding effects such as reduced motor skills, decreased cognitive skills, medicine
adverse effects because of age and psychosocial properties of ageing guide action of asthma
in the elderly. Additional studies are essential for understanding that, how patient precise
asthma management can be encouraged in clinical sites.
Pandya, Shah, Francis, Shah, Shah and George (2016) recognized that asthma affects
the older people in a worldwide manner. Instead of the questioning of the state of the older
population, misdiagnosis is also as common as chronic obstructive pulmonary disease
(COPD) chief to suboptimal treatment. The researchers intended at highlighting the degree of
misdiagnosis of the elderly asthma. A potential study was performed which involved 350
patients with a clinical diagnosis of the obstructive airway diseases (OADs). From the total
number of patients, 292 people were seen to be suffering from the obstructive patterns in the
pulmonary function test. Out of these people, only 100 had been analysed with asthma while
192 were found suffering from COPD. Out of the analysed 100 patients, 16 individuals
were older than 60 years and five individuals were earlier provided with treatment for COPD.
It was concluded that if any misdiagnosis occurs, the proper management of asthma in elderly
people is related to main challenges in the diagnosis.

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Other challenges in clinical management of the asthma and the education
impartment in the elderly people
According to McDonald, Higgins, Simpson and Gibson (2011), COPD and asthma in
the ageing population are identified to be a multifaceted situation that have a different
connection with numerous clinical distresses. Asthma recurrently has a co-existence with the
COPD, and research specifies that in the elderly populations, asthma is related with the co-
morbidities. The medical problems that rise in the elderly asthma patients recount to the
symptoms of pathophysiological fluctuations, routine, self-management assistances and
individual difficulties. The problems may not be provoked by the clinician if adequate
probing is performed, highlighting the significance of noble communication and past-taking.
The research supported by McDonald, Higgins, Simpson and Gibson (2011) intended at
evaluating patient’s and physician’s apparent importance of understanding the clinical
problems and then describing the degree of concordance between the physicians and the
patients concerning these problems. Fifty-two contributors who aged above 55 years were
nominated for the problem prioritisation research. A multidimensional valuation was
supported for characterising the prevalence of the clinical problems. The objective remained
to attain ratings for problem significance. The outcomes specified that the developed rated
problems were movement limitation, dyspnoea and air-route irritation. Further, these parts
established reasonable patient-physician concordance. The results also indicated that deprived
concordance was apparent in relation to air-route obstacle, and inhaler method adequacy.
Though worthy agreement, it was found in relation to written action strategies, the
importance to the physicians and the patients was restricted. It was hence concluded from the
research that the patients and the physicians approved on limited features of asthma care in
the elderly patients. It can be concluded that the difficulties faced by these elderly asthma

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patients from time to time not sufficiently elicited and thus not addressed for confirming
better health results.
Goeman, Sanci, Scharf and Bailey (2011) recognized that asthma burden is estimated
to rise significantly in the upcoming decades. The researchers considered the undertaking of a
cross-sectional survey aimed at pinpointing the distresses of elderly asthma patients and the
supposed symptoms of asthma disease. One hundred and ninety-nine personalities beyond the
age of 55 years and grief from asthma were involved in the study directed in Australia. One
hundred and twenty people described that they can control their situations well while 78%
people stated that they followed the asthma treatment. In comparison to this, 105 individuals
stated that they witnessed enough to severe symptoms, Further, it was specified that
exacerbations remained common, and about one-third of the people would necessitate
emergency care in the previous year. However, 80% of the respondents stated that they could
accomplish their condition suitably, only 10% stated that they might visit an emergency
division when they needed severe magnification of symptoms. Those patients with age above
65 years had the chances for less independence in choice making. It was hence concluded that
the asthma educators must identify the individual in need, and the elderly asthma patients to
modify the delivery of complete asthma care.
Asthma instruction delivered to a widespread population of asthma patients
had been seen to be favourable. Asthma is measured as a foremost public health distress that
distresses people throughout the age variety. Research shows that asthma in the aged people
leads to nearly partial of the entire number of deceases due to asthma on yearly basis.
Additional, asthma in elderly people leads to major hospitalisations. Baptist, Talreja, and
Clark (2011) highlighted that however the burden of health costs and healthcare supply
utilisation for elderly asthma is greater, little study has been performed to understand the
techniques by which value of life of the elderly asthma patients can be developed. Patient

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teaching deeds as a vigorous component in asthma management. Very little research has been
directed to understand the issues encountered in educating elderly asthma people so that they
can battle the symptoms they are experiencing. The scientists directed that prior trials to
understand the efficiency of asthma education did not consider the patient population beyond
the age of 65 years. The researchers thus accompanied a study to assess the usefulness of
asthma education in the long term and the short term signs of asthma management in the
people above 65 years of age. The research considered the use of the Four-State National
Asthma Survey (NAS) data. Asthma control measure was valued and associated among
population of aged adults above the age of 65 years who established instruction and those
who did not practice. The elderly asthma patients were educated to use the peak flow meter
(PEM) and asthma action plan (AAP). Evaluation was directed among adult patients who
participated in an asthma course in contradiction of those who did not take part. The
temporary results observed were (symptoms within previous week, daytime and night-time
signs in previous 30 days, and the usage of steroid in past three months), while the elongated
term results studied showed asthma attacks, emergency departmental visits, activity
limitations in the previous year and hospitalisations. No variances were observed in the short
and the long-term asthma effects among elder adults getting and not getting education. It was
thus concluded that directions on the usage of the asthma plan, asthma instruction courses
and education in use of PFM were not operational in changing asthma consequences in the
elderly people. The suggestion drawn is that the education plans need to be prepared
precisely for older people for creating them further effective.
Appendix:
Writer Country
and the
Study goal Study
backgrou
Study Study scheme Results

22NURSING ASSIGNMENT
year of
publicatio
n
nd sample
Bozek &
Jarbaz
Poland,
2010
Valuation
of
adherence
to the anti
asthmatic
treatment
amongst
elderly
asthmatic
patient
Clinic
setting
One
hundred
and
seventeen
participan
ts from
outpatient
allergicall
y and
elderly
clinics,
63
women
and 54
men,
age
around 65
and older
(mean
age: 72 ±
3.9, rnge:
Reflective
study design
Low
adherence
the to anti-
asthmatic
treatment is
usual in the
elderly
people as
the result of
poor
monitoring
progression

23NURSING ASSIGNMENT
65–102),
McDonald
et al.
Australia,
2011
Valuation
of patients’
and
physicians’
observed
significanc
e of clinical
difficulties
in asthma
Respirato
ry
ambulato
ry
attention
clinics at
the John
Hunter
Hospital,
Newcastl
e, NSW,
Australia
100
participan
ts that
aged 55
years and
beyond
Multidi
mensional
assessment
Higher rated
patient
difficulties
are air route
inflammatio
n, activity
restriction
and
dyspnoea
Soones et
al.
USA,
2016
explanation
of label the
causative
pathway
linking
health
knowledge
to the
medication
adherence
by
Public
and the
hospital
practices
Adult
asthma
patients
aged 60
years and
above
Structural
calculation
modelling
Poorer level
of health
knowledge
increase the
chances of
non-
adherence to
the asthma
medication

24NURSING ASSIGNMENT
modelling
asthma
disease and
the
medication
beliefs as
the
mediators
Ross et al. USA,
2013
To
recognize
demograph
ic, mental
or
physiologic
features
associated
with the
asthma
quality of
life, control
and the
health care
utilization
in the older
Informati
on in use
from the
universit
y of
Michigan
asthma
registry
Elderly
asthma
patients
with the
mean age
of 73.3
years
Cross sectional
study
Comorbid
despair
leads to the
poor
management
of asthma
disease in
elderly
patients

25NURSING ASSIGNMENT
adults
Skloot et
al.
USA,
2016
To evaluate
the
challenges
witnessed
in the
managing
of asthma
in elderly
American
Thoracic
Society
Specialist
s and
clinicians
Workshop with
focus on the
group
discussions
Confoundin
g effects,
such as
comorbiditie
s reduced
cognition
and the
motor
abilities,
psychosocia
l properties
of aging,
and the
growth-
related
adverse
effects of
the
treatments,
have a
major
impact on
the
treatment of

26NURSING ASSIGNMENT
the asthma
in the
elderly
people
Pandya et
al.
India
2016
To
recognize
the
mishandlin
g of the
asthma
disease in
elderly
people
Patients
at SBKS
Medical
Institute
and
Research
Centre
350
clinically
analysed
with
obstructiv
e airway
diseases
(OADs)
Approaching
study
Misdiagnosi
s of asthma
centrals to
suboptimal
handling in
elderly
people
Wardzynsk
a et al.
Japan,
2015
To conduct
an
assessment
of the
effect of
comorbiditi
es on the
asthma
severity
and its
manageme
nt in older
Patients
nominate
d through
database
93 elderly
asthma
patients
who aged
65 years
and above
Assessment
through
questionnaire
Greater
occurrence
of
comorbiditie
s have no
important
relation with
the asthma
control

27NURSING ASSIGNMENT
adults
O’conor et
al.
USA,
2015
To
examine
the extent
to which
cognitive
abilities is
linked to
health
knowledge
and
medicine
adherence
in asthma
people
8
outpatien
t
hospitals
Patients
who aged
60 years
and above
In person
discussion
Limited
knowledge
leads to the
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,
Cog
nitive
dysfunction,
socio-
economic
status,
pulmonary

28NURSING ASSIGNMENT
symptoms,
smoking,
have effects
on the
adherence to
inhalation
therapy
Buranello
et al.
Brazil,
2016
To evaluate
the
knowledge
possession
among the
older
people with
asthma
Medical
clinic
departme
nt of
private
hospital
52 elderly
asthma
patients
with the
mean age
75 years
Observational,
descriptive
cross-sectional
study
Low level of
standardized
information,
prescription
s and
monitoring
leads to the
poorer
outcome of
the oxygen
inhalation
therapy
Milanese et
al.
Italy
2014
To explore
the extent
of the
asthma
control in
elderly
Hospital
setting
350
patients
that are
aged 64
years and
Observational
study
Coexistence
of COPD
negatively
influences
asthma

29NURSING ASSIGNMENT
asthma
subjects
above 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
Centre
for
Environ
mental
Health
Older
adults
above age
of 65
years
Cross sectional
study
Engagement
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
recognize
the unmet
needs of
elder
Commun
ity
pharmaci
es in
Victoria,
120
asthma
patients
of age
above 55
Cross sectional
survey
Asthma
instructors
are to
deliver
tailored

30NURSING ASSIGNMENT
people with
asthma
disease
Australia years education
program
after
identificatio
n of
individual
the needs of
the patients

31NURSING ASSIGNMENT
Discussion:
Asthma is a form of respiratory disease due to which patients suffer from variable
respiratory symptoms along with obstruction of airway in relation to airway hyper-
responsiveness (AHR). The features mentioned are caused due to an inflammatory process
that is marked by progressive bronchial remodelling (Iwanaga, Sano, & Tohda, 2017). The
occurrence of asthma among the elderly people is stated to be equal to or in some cases even
advanced than the overall 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 about one out of seven people in the country are asthmatic. This statistic includes
individuals who are diagnosed with asthma in the later stages of life, and those who are
diagnosed with the condition in the early stages (Braman, 2017). Asthma in the older
population of Australia is found to be distinct in number of ways. The disease is known to be
highly persistent and severe in elderly people, making the management of this group highly
challenging. Data indicate 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
compared to males (10.8% compared to 7.4%) (Inoue et al., 2014).
Management of the asthma in the elderly is known and understood to be highly
challenging due to a number of reasons. This review aimed at understanding the challenges
faced by healthcare professionals in address asthma presentations in the elderly population
and managing the condition. The objective of the review is to recognize the underlying
aspects related to the poor management of the 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 a systematic review on contests in the management of asthma in elderly people,
the purpose was to develop a thorough understanding of different interventions that can be

32NURSING ASSIGNMENT
applied to the elderly asthma population in addressing their concerns and enabling better
patient outcomes. Several issues particular to asthma management in elderly people and their
subsequent clinical implications have come to light through this systematic review.
The review indicates that the severity of asthma in the elderly population is significant
and disrupts the course of care given. The harshness of the situation leads to the co-morbid
situations in the selected population, which in shot can result in problems of management of
the situation. Co-morbidities hold the possibility to affect the digestion and elimination of the
respiratory drugs, and can harmfully impact observance and perseverance with the chronic
treatment. The influence of comorbidities on the asthma management is of importance and
the common co-morbidities which influence the effective results of the treatment are
existence of COPD, reduced cognition and motor assistances, and psychosocial properties of
ageing. As conferred by Ban et al., (2016), comorbidities such as the COPD, cognition and
motor abilities, psychosocial effect of ageing are very common in the elderly asthma patients
and it can effectively lead to the alteration in the usual history of the asthma disease, further
complicating the asthma management process and growing the risk of the suffering opposing
drug reactions. Yáñez, Cho, Soriano, and Rosenwasser, (2014) further mentioned that
patients who are suffering from numerous co-morbidities are also exposed to the complicated
medication schedule adherence, leading to the risks of the treatment failure. There has been
various lack of studies which focus on the recruiting older patients in the drug efficacy
prosecutions. In this regard, Lombardi et al., (2016) specified that covering symptoms of
various lung diseases and other chronic diseases later lead to the confusion regarding the
asthma self-management. For example, significant overlap of the asthma and COPD in
elderly people is distinct. A key distress that has been highlighted through this systematic
review literature is misdiagnosis and under-diagnosis of the asthma in the elderly people.
Diagnosis of asthma disease in the elderly people is regularly based on the flexible airflow

33NURSING ASSIGNMENT
restriction, variable breathing symptoms, diurnal PFT, and greatest expiratory flow rate
inconsistency. These may be problematic to diagnose disease in the elderly people.
Generally, asthma disease may be misdiagnosed in the elderly people for individuals with a
past of smoking. It has been prominent that asthma is characterised by the reversible airway
barrier. In case of the elderly people, it is very common to find the incomplete reversibility,
since asthma disease is likely to be determined or severe in this population in specific. The
diagnosis is thus more problematic in th e elderly people (Battaglia et al., 2016).
Further, it is highlighted from this systematic review of literature that age linked
adverse properties of medications of the asthma disease also position difficulties for patient
situation management. The chief method of the asthma treatment may be alike through age
groups as the objective of therapy is similar for both the elderly and the younger populations.
Though, the drugs may be under-used in the case of the elderly patients due to the opposing
effects brought about by their usage (Adams & Urban, 2015). In a research by Ray et al.,
(2016) it is reported that these pathophysiologic mechanism of the asthma is different among
the elderly and the younger populations, inducing clinical results to a great extent. The
symptoms that these elderly population witness are not simply addressed through the drug
therapy as the patients might be impervious to steroids. Rance and O’Laughlen (2014)
highlighted that a main medication for the chronic and the acute asthma is beta-adrenergic
agents; though, elderly patients might not show any response sufficiently to such
bronchodilator because of ageing. In these cases, the anti-cholinergic and the beta agonist
agents can be used that are not influenced by age of the patients.
The elderly people also may face distresses about the poor inhalation techniques and
the deficient inspiratory flows. Difficulties in the relation to deprived medication have been
recognized to unsuitable use of inhaler strategies. The choice of the inhaler has been
described to be critical in the treatment outcome achievement. Visual acuteness, neuromata

34NURSING ASSIGNMENT
weakening and dexterity may affect the level of understanding in the patient concerning the
use of the inhaler (Carnegie & Jones, 2013). Nurses normally do not converse about the
essential inspiratory flow rate with the suffering patient which may also lead to problems. In
the lack of inhalation airflow meter devices, the patients cannot evaluate the necessary
inspiratory flow rate for the device that to be used (Boulet, 2016). Further, specialists might
not be sympathetic of the requirement of an asthma patient to use an insertion and the
consistent mode of distribution. In addition, the lack of a proper review by the nurses of the
devices used may also contribute to various challenges (Guilbert et al., 2017).
It is also clear from this systematic review that bad monitoring by these care
professionals, then comes the communication gaps with professionals, and then the
perception of specialists concerning clinical difficulties to be not as much of importance to
the patient, also add to the difficulties in the managing of asthma in the elderly people.
Deprived quality physician-patient relationship has a very negative impact on the treatment
adherence amongst the elderly asthma patient. If sustenance from care specialists is not
suitable, patients can be discouraged from the adhering of the self-management plan or the
medication regime (Webb, 2011). When the doctors and nurses sufficiently recognise the
clinical difficulties witnessed by the patient, the patient’s self-assurance to carry out the
process of self-management behaviour becomes stronger. Riley’s (2015) research reported
that greater levels of provision from specialists and effective communication has increased
the self-efficacy of the patients and led them to a better quality of life. Based on a evaluation
of the factors backing to the challenges in managing the asthma in elderly people, the
researcher piercing out that one class of factors professed to be significant in the asthma
management is patients’ principles and outlooks regarding the treatment process as a outcome
of education delivered by specialists. Patients might not be pleased with the quality of care

35NURSING ASSIGNMENT
delivered to them from the side of the clinician’s, donating to bad adherence to the regimen
(Roberts et al., 2016).
This systematic review further specifies that the non-adherence to the treatment
regimens can be because of the low socioeconomic condition, and lower levels of education.
As testified by Gemicioglu et al., (2018) the treatment and medication schedule non-
adherence may be deliberate or accidental among the elderly asthma patients. Deliberate
under-use as an effect of cost respects has been related with financial vulnerability. Other
issues that affect adherence comprise dependency growth, insight regarding the requirement
of medications and their efficiency (Iwanaga et al., 2017). Distresses regarding definite side
effects that can be voice variations, osteoporosis, glaucoma, cataracts and infections are
reported by the elderly asthma patients. These distresses also pay to lower level of devotion
to treatment schedule (Abreu et al., 2018). As found in the research by Boulet (2016) literacy
heights of these patients are a crucial factor in adherence to treatment schedules. A rich pool
of the evidence proposes that demographic and the social factors have a crucial association
with accidental non-adherence to routines. Education level is associated with the capability of
the patient to recognize the inferences of self-management and the conclusions in the longer
time. Patients might fail to observe the symptom harshness that centrals to delays in
retrieving suitable medical help and applying the required self-management asthma protocols.
In addition, community relationship disturbances suffered by those with little level of literacy
also has a major impact on the management of asthma disease. Those who actions as primary
care contributors to the other patients within the community setting might every so often
remain silent concerning their requirements of the asthma management. Access to
dispensaries might also be a challenging process for those with inferior socio-economic
experience.

36NURSING ASSIGNMENT
The efficiency of asthma education progression and directions on the asthma care
strategy are as well to be studied at the end of the discussion process. From the systematic
literature review it can be decided that patient teaching should be at an optimum level and
much more precise for attainment of the desired results. Tailored patient education programs
are required for reaching the mark people. Patient learning grips the potential to be a vital
constituent of the asthma management in the elderly people. Patients can be assisted to gain
self-assurance, inspiration and abilities for controlling their asthma condition (O'Conor et al.,
2015). Hence much larger importance requests to be agreed to this area of the asthma
management. Asthma education plans have diverse components, such as data about breath
techniques, need for a follow-up, and need for a proper communication, and the criteria for
using the control measures. When an individualised method is applied, elderly patients can
thus be educated in a better manner, and authorized to manage their disease by themselves.
Tailored plans linked to the age of the patient, the education level, the desire for
independence and psychological position might be more useful for managing the asthma in
the elderly people.
Implications for clinical practice and recommendations:
The important inference strained from the beyond discussion is that the better
understanding of asthma in the elderly people is suggested for addressing crucial challenges
tackled by professionals in management of the condition. The Healthcare specialists,
especially the nurses, require to improve their level of information concerning the progress
and impact of the situation in the elderly people. Knowledge of the nurses might be
incomplete concerning the pathophysiology of ageing and asthma disease (Song & Cho,
2015). Improvement of the asthma management in elderly individuals is of growing
consequence in the present days, owing to the increasing frequency of elderly asthma cases.
Healthcare organisations are the responsible one for developing the intervention strategies

37NURSING ASSIGNMENT
which are directed at care suppliers for inspiring them to treat the asthma as a condition
specifically presented in the elderly people. There is also a need of growth in the adherence
level of the professionals to the set medical guidelines for the acknowledgement of the
barriers to asthma management ( Scichilone et al., 2015).
Amplified consciousness and consideration of elderly asthma is necessary. Healthcare
professionals must engage in research to determine the greatest ideal strategies through which
there may be an increase in public awareness level of asthma in the elderly age. The elderly
people often proves underestimation of the significance of asthma occurrence. Both the non-
government and the government public health care organisations are in vital need of
evidence-based supervision for efficiently facilitating communication of the health messages
to the asthma patients. The nature of the issue regarding the asthma management is apparent
when the overall population considers asthma disease to be a health condition stirring in
childhood and not in adulthood. Specialists are also known to study on intermediations that
can expand approval of elderly asthma amongst the elderly people (Jones et al., 2011).
The Healthcare providers should have a practical approach in classifying
effectual and effective approaches of providing a personalised and a detailed data to the target
people concerning the asthma management so that their needs are met adequately (Newcomb
et al., 2010). Medication management is vital for successfully managing symptoms of
asthma. Elderly people suffering from asthma may lack a clear idea about self-management
aspects. They however do may seek help in an adequate manner. Patients receiving
information regarding management would likely demonstrate higher self-care behaviours,
encompassing medication regimen adherence, self-confidence and self-monitoring. Education
topics influence contain parts such as introduction to smoke and nuisances, air pollution,
workout and injections (Tousman et al., 2010). In this respect, it is suggested that elder
people with asthma need increased consideration and must be provided with data so that they

38NURSING ASSIGNMENT
come in a position to recognize the need to use the medical help, or use the reliever
medicines. Implements for accumulative patient confidence and supplying education include
a personalised action plans, delivery of accessible health data and patient-held accounts. The
plans have revealed to be planned in such a way that care givers are cheered to take up extra
accountability in managing the asthma patient (Goeman et al., 2009).
Tailored self-management procedures can be established that can improve
proper management of asthma disease. All efforts in refining asthma management in the
elderly people need to be consider knowledge level, cognitive capability and self-confidence
level. Hence, care suppliers, particularly nurses must use the optimal properties for inducing
the viewpoints and attitudes of the elderly patients towards the asthma care and management
process (Gemicioglu et al., 2018).
Conclusion:
This evaluation has directed us to the appropriate documentation of position of
current research on the asthma management in the elderly people. The occurrence of asthma
among the elderly people has been prominent to be great throughout different areas of the
world, counting Australia. Asthma is repeatedly found to be simultaneous with other
situations such as COPD and cardiac difficulties. The clarification of poor results of asthma
disease in the elderly people can be recognized to change in the asthma exhibition with
growing age. It has been informed that the harshness of asthma grows with age, and women
are more possible to undergo suffering from the disorder. Amplified airway irritation, activity
restriction and dyspnoea are all connected to the asthma suffered by the elder people. These
medical features are to be measured as the major focus for effective management of the
situation among the chosen population.

39NURSING ASSIGNMENT
This assessment highlights the various contests that appear in the progression
of managing asthma in the elderly people. The challenges are extremely exclusive in nature,
and are partly due to the under-diagnosis and the under-treatment. The Co-morbidities and
physiological variations are connected to the course of management. Along with the low
levels of knowledge and psychosocial properties of ageing, the co-morbidities and
physiological variations contribute to chief care burden. Even with the acknowledgement of
these challenges witnessed by care suppliers and the patients alike, much is still required to
be completed for allowing better results. Numerous other matters regarding the practice of the
nurses also come to the light which are responsible for the poor management of asthma. In
the absenteeism of role designation of professionals, the process of management is
challenging. This is further intensified if the communication among the patient and the care
givers is not operative. Inadequate patient education is also a key contributory factor to the
poorer outcomes
It can be then concluded that the management of asthma in the elderly people
is complicated. It is estimated that evidence-based approaches when applied, it would
discourse several challenges at a distinct time. Older individuals should be fortified to
recognize the seriousness of their health condition so that they can pursue appropriate help
when in need. Amplified patient education is needed in this respect. The prime objective of
the nursing care for the asthma patients is to improve the value of life and re-claim patient
functionality. Nurses responsible for helping the older patients must thus validate a high level
of information and abilities for breaking the treatment barriers. They need to deliver their best
determinations for delivering the pharmacological treatment which are age-appropriate and
non-pharmacological treatments comprising self-management implements and the
individualised education. It is important that care is totally provided in a universal manner.
When presented with satisfactory information and high-quality facilities, older individuals are

40NURSING ASSIGNMENT
better supported in the whole procedure of gaining better psychological and physical comfort.
This will directly lead to less events of hospitalisation and concentrated mortality.
Further, administration of asthma in the elderly people must centre on
recurrent monitoring of the symptoms as well as adversative events related with medications.
More consideration to the probable chances of difficulties is justified. An appropriate and
operative health care model concentrating on better quality of service provision together with
current research would guarantee development of the best practices for further development
of health results of the targeted people.

41NURSING ASSIGNMENT
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