Challenges Faced in the Management of Asthma in Elderly Patients

This article discusses the challenges in managing asthma in elderly patients and explores interventions for better progress in symptoms. It presents findings from a systematic literature review.

CHALLENGES FACED IN THE MANAGEMENT OF ASTHMA IN
ELDERLY PATIENTS
BY
Minil Thomas
GDCN (Chronic diseases)
BSc Nursing
Submitted in partial fulfilment of the requirements for the degree of
Masters of Clinical Nursing
College of Nursing & Midwifery
Charles Darwin University
(May, 2019)

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Keywords
1. Asthma
2. Challenges
3. Elderly patients
4. Older adults
5. Young adults
6. Management
Author: T Minil May 2019

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Abstract
Background: 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?”
Method: Systematic review of 11 articlesfrom PubMed, Medline, CINAHL,
EMBASE and Google scholar database and search engine. The articles were published on or
after 2009, and were evaluated using the JBI tool for analysis. Search terms were “aged”,
“elderly”, “elder”, “older”, “senior”, “asthma”, “respiratory disorder”, “respiratory illness”,
“respiratory disease”, “asthma attack”, “adult”, “grownup”, “asthma disorder”, “asthma
illness”, “management”, “supervision”, “administration”, “challenge”, “difficulty”, “cure”,
“trail”, “exertion” and “treatment”.
Results: Of the 11 articles obtained, two were of high quality, and rest 9 were of moderate
quality. Three notable themes emerged namely, (i) The impact of comorbidity on the
treatment challenges in elderly people with Asthma disease, (ii) Challenges faced in
management of medication and compliance among older adults who have been diagnosed
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with asthma, and (iii) Challenges encountered at the time of asthma under-diagnosis amid
elderly patients.
Conclusion: Poor adherence to medications, overlapping symptoms, co-morbidities, lack of
health literacy, and depression increase the exacerbation of asthma symptoms among older
adults and worsen their quality of life.
Author: T Minil May 2019

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Table of Contents
List of figures.............................................................................................................................5
List of tables...............................................................................................................................6
List of appendices......................................................................................................................7
Statement of original authorship................................................................................................8
Acknowledgements....................................................................................................................9
Introduction..............................................................................................................................10
Aim:......................................................................................................................................12
Objective:.............................................................................................................................12
Research question:...............................................................................................................12
Pico Framework...................................................................................................................12
Methodology:...........................................................................................................................15
Standards for including the studies:.....................................................................................15
Identification of studies:.......................................................................................................16
Result:......................................................................................................................................18
The impact of co-morbidity on the treatment challenges in elderly people with Asthma
disease:.................................................................................................................................18
Challenges faced in management of medication and compliance among older adults who
have been diagnosed with asthma........................................................................................22
Challenges encountered at the time of asthma under-diagnosis amid elderly patients........25
Discussion................................................................................................................................28
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Implications for clinical practice and recommendations.........................................................31
Conclusion................................................................................................................................32
References................................................................................................................................34
Appendix 1...............................................................................................................................38
Appendix 2...............................................................................................................................49
Appendix 3...............................................................................................................................50
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List of figures
Appendix 3- PRISMA flowchart
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List of tables
Appendix 1- Critical appraisal
Appendix 2- Quality assessment
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List of appendices
Appendix 1- Critical appraisal
Appendix 2- Quality assessment
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Statement of original authorship
The work contained in this review has not been previously submitted to meet requirements
for an award at this or any other higher education institution. To the best of my knowledge
and belief, the review contains no material previously published or written by another person
except where due reference is made.
Signature: _________________________
Date: _________________________
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Acknowledgements
I would like to articulate the deepest admiration towards the Dr.Benjamin Tanwho holds the
outlook and the essence of a genius: he repeatedly and compellingly conveyed strength of
venture in regard to investigation, Research, and exhilaration in regard to coaching. Without
his leadership and importunate assistance this thesis would not have been achievable.
I would like to express thanks to my unit coordinatorDr.Belinda Chaplinwhose labor
confirmed to me that anapprehension for global dealings facilitated by an “engagement” in
health and social care, should always rise above academic world and provide an expedition
for our period.
Author: T Minil May 2019

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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 the study conducted by the World Health Organization
(WHO) in the year 2016, it was reported that around 383000 death occurred throughout the
world because of asthma (WHO, 2017). These death cases have become a major concern for
public health care in high revenue as well as low and mid revenue countries. Most of the
death related cases of asthma are from low and mid income countries (D’amato et al., 2015).
Asthma is recognised as a disease of youngeradults 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(Bozek, Rogala &
Bednarski, 2016). These factors induce challenges and complications for healthcare facilities
while treating an elderly patient with asthma. From the extensive literature review it was
proposed that under-diagnosis can be considered as one of the management experiments for
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asthmatic elder population. Pandya et al. (2016) stated that diagnosis is 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). The
research conducted was not population-based, instead it was conducted in a particular
hospital, where only a limited information was provided regarding the elderly asthma patient
and the diagnosis challenges faced by them. 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 research question was developed that to gather relevant information from the systematic
review articles is as follows:
“What are the challenges that can affect the interventions for 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 differenttype of
interventions for older people who are suffering from asthma and also consider the factors
that are increasing the challenges in the elder population, using the systematic review of
research article.
Objective:
The key objectives of the systematic review are:
 To achieve understanding about the management of the elderly asthma patients
 To evaluate about the factors that affects in asthma interventions for elderly.
 To assess interventions executed for the management process of aged people.
Research question:
“What are the challenges that can affect the interventions for better progress in asthma
symptoms for elderly asthma patients?”
Methodology:
Systematic review of the literature is conducted to determine the methodology of the
study that was considered beneficial in determining the objective of the study. According to
Nanda et al., (2019), systematic review of literature survey provides inclusive information on
the objective of the study and determining the intervention that will provide better
advancement in symptom of asthma among the elder population of the patient. Operative
changes are recommended for the patient that will provide better and enhanced health
outcome in effective management of asthma. Different exercise program and lifestyle
changes are included in the intervention method of the healthcare facilities associated with
effective asthma management. According to systematic literature evaluations, integrative
assessment of significant data is included and organized from the portion of important
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information essential for gathering knowledge and assumption of the study. Ricketts and
Cowan (2019)stated that systematic review of research literature is an effective strategy to
determine all the inclusive information and review that is important in determining the
primary concept of the research question. A comprehensive methodology is conducted that
will assist in yield gathering relevant outcome, which would focus on the objective of the
study.
Standards for including the studies:
Systematic review consists of both inclusion and exclusion criteria of methodology
that is also responsible for setting research limitation in the study. Reviewing relevant articles
before commencing the study is considered as a crucial part of performing methodology were
two different standard groups are expressed and used in the study. There are various factors
that are considered in the inclusion and exclusion criteria, which includes set of standards
required for the study. Inclusion standard is defined as the set of required articles that is
necessary in the study and that the methodology must possess whereas exclusion standards is
defined as the set of required articles that must be prohibited from the study. The inclusion
and exclusion standards were set initially for carrying out the systematic review of the
research literature. The inclusion criteria consist of peer-reviewed journal article that is
extracted from multiple sources and the most relevant and useful journal article are selected
with easy accessibility. The second important criteria included in inclusion standard is the
publication year that should be after 2009 and must be in English language that will be easy
for the reader to understand and read the article. The final important criteria in inclusion
standard are the human participant that is a very important factor in systematic review of
articles. The last 10 years old articles are considered and included in the study that will
provide main inferences of the research objective and develop the condition of asthma with
updated healthcare facilities. Exclusion standard criteria consisted of partial copy of articles
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that are not published and available in English language and were also published before 2009
that lacked sufficient involvement of human volunteers. Hence, inclusion and exclusion
criteria is used in the methodology.
Identification of studies:
Databases- Electronic database tool is use to carry out the research methodology that
is considered as the consistent and influential tool in carrying out the secondary research of
the article that comprise of systematic review of research article. Appropriate electrical
database is recognized that is further used to examine the systematic analysis successfully.
There are various types of electronic databases, which are used in evaluation for health-
associated research. The databases used in this systematic review study are PubMed,
Medline, CINAHL, EMBASE and Google scholar. The above mentioned databases are the
most frequently accessed databases that is used to retrieve relevant information from the
research article. The databases are very simple and easy to access that in turn provides the
best relevant articles, which are peer-reviewed and English language. These article consist of
the most recent information regarding asthma that is clear and relevant with the objective of
the research (Bramer, Giustini& Kramer, 2016).
Search Terms- Relevant search terms are considered as the most crucial part of
systematic literature review that are basically composed of short phrases, words or terms,
which is beneficial in searching and identifying the applicable or relevant articles. The
specific terms that are used in this electronic database are set by using the primary objective
of the study that is comparatively convenient and faster. The search items used in the
systematic review of research article are “aged”, “elderly”, “elder”, “older”, “senior”,
“asthma”, “respiratory disorder”, “respiratory illness”, “respiratory disease”, “asthma attack”,
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“adult”, “grownup”, “asthma disorder”, “asthma illness”, “management”, “supervision”,
“administration”, “challenge”, “difficulty”, “cure”, “trail”, “exertion” and “treatment”.
Boolean Operation- The use of search items constructed for this systematic review of
literature is not sufficient, an effective Boolean operation is also required and is taken into
account. Boolean operation is defined as the relevant terms that are reasonable and hence the
researcher includes these operation with the search terms for extracting the most relevant
research article. This would allow the researcher to develop a relevant, efficient and precise
search of the journal article that would also assist the researcher to easily remove the
unsuitable and unwanted search terms hence making the end result precise and useful. The
Boolean operation used in this systematic review of journal article are AND and OR that
entirely depends on the circumstances of the database used (Zhang et al., 2015).
Study Selection: Study selection is one of the most important criteria that is important
in extracting suitable outcome. In order to confirm the research implication derived from the
search terms were chosen and accordingly screened. In case of systematic review of research
article, the most relevant article is chosen or selected from the entire bunch of article that is
extracted from by using search terms in order to meet the relevance of the research objective.
The article published in English was selected, which were not older than 2014. The articles
were screened and the articles that discussed about asthma and its administration in elder
people were considered and included in the study. A great in-depth is provided to the readers
that highlights the important information presented from the research article where every
database is examined independently and most relevant articles are then considered.
Data extraction: The prior stage in the systematic review study after the recovery
process of the articles is to look through the overall text of the articles which aims to be
involved in the systematic review in order to achieve and provide appropriate and relevant
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data. The process of data extraction must be very accurate and précised in any systematic
study in order to retain an error free and detailed outcome for better being. The process is
found to be an effective practice in reducing the time duration to obtain the results and also
the duration of the time needed to prepare a review is found to be decreased. The Systematic
reviews is also found to be helping in the documentation process, the production and the
understanding of the total amount of data on the asthma intervention’s effectiveness in the
elderly population (Jonnalagadda, Goyal& Huffman, 2015).
PICO Framework
The above mentioned research question is fabricated in account to the focused
framework that are used in order to perform a better research which is called PICO which
states the population or patient problem, intervention, comparison or control and the outcome
of the research which is found to be used very often by the researcher in any kind of
evidence-based practice.
Population
The participants or the population which are the elderly people with asthma suffering
both men and women those who belong to the age group of 65 years and are suffering with
asthma (Boulet, 2016). The research population is not bound to any region and are selected
based on the age group and suffering.
Intervention
The interventions that are provided to the elderly asthma patients are the staff nurse,
doctors and respiratory specialist that are targeted towards the individual adults those are
diagnosed with asthma (Neumann et al., 2015).Staff nurse will help the patient to gain
knowledge regarding the management of their asthma and also assist the patient to determine
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the intervention that will help them to recover from their health condition. These
interventions are also associated with the education interventions and other treatment process.
The educational interventions that are provided by the nurses include the following processes:
1) Providing the patients the detailed information regarding the disease, the difficulties, the
treatment and the better results after the treatment.
2) Counselling of these patients and providing them knowledge
3) The process of home peak flow meters for the elderly population
4) Advice the patients regarding the side-effect of allergens and in order to avoid any kind of
rise in trigger factors
5) Symptoms of the asthma in the elderly population will be monitored in a time duration by
the nurses
6) A proper management plan with detailed information for the better outcomes of the
elderly people suffering asthma.
7) Self-management of the elderly people and training them regarding the management
practice.
Comparator
The comparison will be conducted among the elderly population, who are diagnosed
with asthma and are receiving nursing interventions and proper medical care. The standard
asthma care is defined as the effective medical care that are provided to these elderly asthma
patients, who are included under the interventions, which are valuation, diagnostic
assessment, pharmacological and medicinal management and the general instructive advice;
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the nursing interventions are applied to the elderly asthma patient by the trained healthcare
specialists keeping their focus towards the policies, ethics and the measures of the research
study situations ( Masefield et al., 2017). All these contributors in the research group are the
patients of the age group of 65 years and who are also receiving the proper standard nursing
and asthma care as required which excludes any kind of self-management and self-
monitoring intervention of these asthma symptoms, and the reviews and updates by doctors
and nurses.
These interventions for the asthma management for the elderly people might take
place either before or after treatment and discharge of these patients or in a group or
emergency wards, and the outdoor as well as in the community settings.
Outcomes
The primary results that was found was the healthier understanding, information,
knowledge about the condition of elderly patient suffering from asthma and different ways
for the improvement of the quality of care that are being provided to the asthma patient of age
group 65 and above and the different outcomes of interest were measured such as computing
the efficiency of the clinical interventions on the lung function of the elderly asthma patients;
asthma-detailed self-efficacy, psychological impacts and self-management behaviours which
includes patient obedience with the usage of medicines, devotion to asthma management plan
for elderly population, asthma self-care proficiency, asthma control in clinical practice, and
the health care utilization (Parkkinen et al., 2018).
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Result:
The impact of co-morbidity on the treatment challenges in elderly people with Asthma
disease:
Kannan et al. (2015) also elaborated on the fact that mortality and morbidity due to
the presence of asthma in high amid older adults, and they identified the presence of low
quality of life among the patients. On determining the predictors that are responsible for
controlling the quality of life among older asthma patients, the researchers found that the
completemAQLQ (mean ± SD 5.4 ± 1.1) and emotional, signs, and activity domain factors
were comparable to the scores that were found in populations comprising of younger people.
However, this was in clear contrast to the fact that the scores related to environmental domain
were lower(4.4 ± 1.7). Furthermore, poorer scores of mAQLQ were meaningfully related
with regular visits to the emergency department (adjusted β [aβ] = −1.3, with the β values
elaborating on the direction and the strength and of relationship, p< .0001). These were also
allied withreduced values on the Asthma Control Questionnaire (aβ = −0.7, P < .0001).
Superior ECAT exposure (aβ = −1.6, P < .02), nonatopic status (aβ = −0.5, P < .002), body
mass index near or more than 30 kg/m2 (aβ = −0.4, P < .01), women gender
(aβ = −0.4, P < .006),gastroesophageal reflux (aβ = −0.4, P < .01), and onset of asthma prior
to the age of 40 years (aβ = −0.5, P < .004) also demonstrated significant correlation with
reduced scores of mAQLQ, thereby providing evidence for the fact that comorbidities created
a noteworthy negative impact on the effective management and treatment of asthma.
The effect of comorbidities and challenges associated with such conditions, while
treating asthma were also illustrated by Ross, Yang, Song, Clark and Baptist (2013) who
identified the presence of poor quality of life among older asthma patients, and also
acknowledged the effect that it created on utilisation of healthcare resources. However,
theyalso elaborated on the fact that several factors that contributed to the onset of such
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challenges had not yet been completely explored. Thus, the primary purpose of the study was
to explore themental, physical, and demographic physiognomies connected to quality of life
amid asthma patients. This made the researches conduct a cross-sectional study among
asthma patients aged more than 65 years, with a confirmed diagnosis of asthma. The
researchers determined the associations between these elements, besides using the Asthma
Control Questionnaire, mini Asthma Quality of Life Questionnaire, and utilisation of
healthcare amenities. Upon conducting the research on an estimated 70 patients, having a
mean age of 73.3 years, and being diagnosed with asthmatic condition for an average of 28.5
years, the researchers found that most of the patients reported the presence of an increased
level of depression, which in turn was closely associated with a deterioration in their quality
of life. It also creates significant negative impacts on asthma treatment and management, as
observed after adjusting for the confounding variables. In addition, the researchers were also
able to develop a correlation between a worsening in functional status of the asthma patients,
with an inferior quality of life (P < .01). Further association was also found between reduced
utilisation of healthcare resources and presence of atopy (P < .01). Furthermore, it was also
found that asthma patients who generally resided alone, and did not have any caregivers,
displayed an increased likelihood of demonstrating a spontaneous appointments to the office
of the physician(P = .06). This made the researchers conclude that the presence of co-morbid
depression often deprived the elderly patients from accurate management of asthma and
prevented them from gaining a control over their life. Hence, the major outcomes of the study
anticipated that subjecting the asthma patients to adequate screening programs for depression
would bring about an improvement in their health status.
These findings were in accordance to those presented by Patel, Patel and Baptist
(2017) who illustrated that high rates of mortality and morbidity are found among older
adults who suffer from asthma, besides elaborating on the presence of increased prevalence
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of depression amid them. 110 articles were retrieved from this method out of which 40
articles were most relevant and applicable for the second screening process. The articles were
also screened on the basis of abstract and the depth of matter understanding and knowledge.
After the screening process 20 articles were screened and considered further in this
systematic review of research article. The overall screening of the research article helped the
researcher to identify the appropriateness or relevance of the article. The final 11 articles
were considered and incorporated in this methodology of the systematic review of research
article.The researchers also recognised the absence of sufficient nationally
characteristicresearchesthat provide evidence on the impact of depressive symptoms on the
crucial asthma related health consequences such as, visits to the emergency department (ED)
amid older adults. On analysing data obtained from the NHANES survey (2007-2012), with
the use of multivariate and bivariate analysis, the researchers found that an estimated 7.01%
(n = 509) of all the asthma patients recruited for the study, reported for being diagnosed of
the condition by their physicians. Elder adults who had both depression and asthmatic
conditions (n = 196) were found to report an increase in their asthmatic episodes (prevalence
ratio [PR], 1.53; 95% confidence interval [CI], 1.00-2.35), occurrence of sleep disorders due
to asthma (PR 2.75; 95% CI, 1.54-4.92), visits to the urgent care clinics or emergency
department for asthma management (PR, 2.24; 95% CI, 1.15-4.34), and limitations in activity
(PR, 1.77; 95% CI, 1.00-3.18; P = .05), in contrast to the elderly asthma patients who were
not suffering from depression. Furthermore, presence of depression among the patients was
also allied with an inferior health-associated quality of life, across different domains that
primarily comprised of the number of days of reducedoverall health, mental health, physical
health, and sedentariness (P < .001 for all). Nonetheless, the researchers failed to find
anynoteworthyvariances in the Spiro metric values, thereby elaborating on the fact that
elderly patients suffering from asthma, as well as depression, are more susceptible to
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reporting poor health outcomes that creates significant challenges in management of the
chronic condition.
Association between asthma and the challenges that occur due to comorbid conditions
were also investigated by Hsu, Chen andMirabelli (2018) also identified that
asthma morbidity is larger amid older adults, particularly older adult females. Mediations to
advance asthma mechanism in the target population are not well defined. The researchers
aimed to explore the risk factors that were directly related with asthma-associated
hospitalizations and visits of the patients to urgent care clinics or emergency departments
(ED/UCV). On obtaining data from 14,076 elderly people, aged more than 65 years, and with
confirmed diagnosis of asthma, the researchers found that one or more than one asthma-
associated hospitalization cases, in the previous year were testified by 5.7% of the patients
(95% CI= 5.0% to 6.4%). In addition, 10.6% (95% CI= 9.7% to 11.5%) of the patients
reported attending the ED/UCV more than once, for treatment of asthma-related signs and
symptoms. In comparison tothe elderly patients without asthma-associated hospitalization
instances, the adjusted odds were found to be greater among patients who had been admitted
more than once in hospitals for treatment of asthma-related comorbidities that occurred due
to coronary artery disease, chronic obstructive pulmonary disease(COPD), depression,
and different price barriers to medication access. Furthermore, on comparison with males, the
adjusted odds were found to be greater among females with COPD, obesity, depression, and
price barriers to management of the chronic condition.
Challenges faced in management of medication and compliance among older adults who
have been diagnosed with asthma.
The systematic review also facilitated the identification of another recurrent theme
elated to the challenges that are encountered by patients, while showing adherence to the
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medications that have been prescribed for asthma management. A plethora of factors have
been identified that significantly make the patients face difficulties while showing
compliance to the asthma medicinessuch as, cognitive impairment and poor health
literacy.Sasaki et al. (2018) aimed to determine the barriers to adherence of inhaled
medicines that are commonly prescribed for asthma patients, among the elderly population
that has been diagnosed with the chronic condition, in comparison to their younger
counterparts. On evaluating the adherence barriers among 113 younger and 251 older
Japanese asthma patients, with the use of the “Adherence Starts with Knowledge 20” (ASK-
20) survey, the researchers found that there were lessnumber of elderly adults who reported
poor compliance to the inhaled medicines, when compared to the younger asthma patients.
Responses from the ASK-20 questionnaire alsodiscovered (odds ratio [95% confidence
interval]) the element Q11 (“My doctor/nurse and I work together to make decisions”; 2.94
[1.31, 6.61]; p < 0.05) to act in the form of anautonomous adherence hurdle to inhaled
medicines amid the older patients. This was in clear contrast to the fact that the younger
asthma patientsdescribedelement Q3 (“My use of alcohol gets in the way of taking my
medicines”; 3.91 [1.02 to 15.1]; p < 0.05) and element Q16 (“Taken a medicine more or less
often than prescribed? “; 2.31 [1.32 to 4.06]; p < 0.05) as the significanthurdles. In addition,
the elderly asthma patients with reducedcompliance to inhaled medicines also acknowledged
element Q1 (“I just forget to take my inhaled medicines some of the time”; 4.43 [1.77,
11.1]; p < 0.05) as a major obstruction, even though the over-all ASK-20 scores and number
of barriers were suggestivelygreateramong the elderly (both, p < 0.05) and young asthma
patients (both, p < 0.05) who demonstrated reduced medication adherence, in contrast to
patients who reported good adherence. This helped the researchers conclude thatelderly
Japanese patients were able to better show compliance to the inhaled medicines, in
comparison to their younger counterparts.
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This was in accordance to the findings of Soones, Lin, Wolf and O’Connor (2016)
who identified the presence of inadequate on the association between health literacy and
adherence to medications that are imperative in asthma prevention and management, amid the
elderly patients. With the aim of exploring the underlying factors that are responsible for
creating an influence on themedication compliance rates and health knowledge among
asthma patients, the researchers based their investigation on asthma illness model and
considered the medication perceptions as major mediators. It was found that of the 433
patients, aged 60 years or more, with average age of 67 ± 6.8 years, there were 31% non-
Hispanic blacks,39% Hispanics, and 84% women. 36% of asthma affected patients
demonstrated the presence ofinadequate health literacy, and were found to be at an increased
likelihood of having several misconceptions regarding the presence ofasthma symptoms
(P < .001) and asthma relatedprescriptions(P < .001). In addition, the researchers also found
that presence of poor health literacy created a significant impact on the patients
(β = 0.089; P < .001), besides exerting an indirect influence on their medication adherence,
which was arbitrated by concerns over medications (β = 0.033; P = .002). Nonetheless,
neither medication requirement (β = 0.044; P = .138) nor illness related opinions
(β = 0.007; P = .143) were able to demonstrate any mediational impact between adherence
and health literacy.
Similar findings were presented by O'Conor et al. (2015) who conducted an
exploration with the aim of investigating the impact of cognitive skills on health literacy and
knowledge about asthma medications among the elderly patients. The researchers conducted
the study among patients aged 60 years or more, who were provided care at eight outpatient
clinics in Illinois. The researchers conducted in-depth personal interviews for the patients, as
a component of the Asthma Beliefs and Literacy in the Elderly (ABLE) study and also
assessed their cognitive function, in relation to different aspects such as, processing speed,
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working memory, executive function, and verbal ability. It was found that of all patients, with
mean age of 68 years, 30% were non-Hispanic blacks and 40% were Hispanics. In addition,
an estimated one-third (38%) of the patients were found to demonstrate compliance to their
controller medicine. Furthermore, 53% patients confirmedappropriate DPI technique, and
38% of them establishedaccurate MDI technique. On conducting a multivariable analyses, the
researchers were able to establish association of inadequate literacy with poorer compliance
to controller medication (OR, 2.3; 95% CI, 1.29-4.08), MDI (OR, 1.64; 95% CI, 1.01-2.65),
and improper DPI (OR, 3.51; 95% CI, 1.81-6.83). The researchers also confirmed the
presence of definite independent association of crystallizedand fluid abilities with the
medication behaviour among patients. Nonetheless, on adding fluid abilities to the model,
they found a significant reduction in literacy associations.
Federman et al. (2014) aimed to explore the self‐management characters, including
adherence to medication and inhaler method, amid older adults who had been diagnosed
withasthma, and their relation with the presence of health literacy. For this purpose, the
researchers conducted an observational cohort study in pulmonary a primary care and
speciality practices across tertiary medical centres in Illinois. On recruiting 433 asthma
patients, aged more than 60 years, the researchers measured their adherence to medications,
dry powder inhaler (DPI), and metered dose inhaler (MDI), in addition to exploring the ways
by which the patients avoided asthma triggers. It was found that the participants had a mean
age of 67 years, of whom an estimated 36% reported the presence of low or marginal health
literacy. Furthermore, medication adherence was also found to be low (38%) in general, and
pooreramong individuals who demonstratedpoor health literacy (22%), in comparison to
individuals who reported satisfactoryhealth literacy (47%, P < .001), following the
adjustment of different socio-demographic factors andtheir health position (odds ratio
(OR) = 0.48, 95% confidence interval (CI) = 0.31–0.73). Correspondingly, adherence to
Author: T Minil May 2019

27
inhaler technique was less among them, and only 54% and 38% patients demonstrated good
DPI and MDI method, respectively. The technique was found to be poorer amid asthma
patients who had low health literacy (DPI technique: OR = 0.42, 95% CI = 0.25–0.71; MDI
technique: OR = 0.57, 95% CI = 0.38–0.85). Furthermore, self‐monitoring of asthma and
prevention of triggers occurred occasionally, nonetheless were less steadily related with poor
health literacy.
Challenges encountered at the time of asthma under-diagnosis amid elderly patients
In a study conducted by Skloot, Busse, Braman, Kovacs and Dixo (2016) the
researchers identified the widespread prevalence of asthma among patients aged more than 65
years and also confirmed the association of the condition with an increased rate of mortality
and morbidity. They elaborated on the fact that presence of poor health outcomes among the
patients can be accredited to under-treatment of the condition, which in turn is a direct
manifestation of asthma under-diagnosis. They identified a plethora of factors linked to the
process of aging that bring about an impact on the presentation of asthma symptoms in
elderly patients, and directly govern the diagnosis and treatment of the condition. It was also
postulated by the researchers that several structural changes occur in the lungs, due to normal
aging process that worsen the manifestation of the disease, and deteriorate the patient’s
physiologic function. Variations in the aging immune system create an effect on the cellular
function and composition in asthma affected airways. Furthermore, on asking the members to
present their current knowledge on asthma management in elderly patients, the researchers
found that asthma progression and health deterioration in older adults are directly influenced
by a range of confounding factors such as, decreasedmotor skills, impaired cognitive skills,
adverse impacts of medications due to old age and psychosocial features ageing. These
factors were found imperative in guiding the onset and progress of asthma in older adults.
Author: T Minil May 2019

28
With the aim of determining the impacts of asthma under-diagnosis among older
adults, Pandya, Shah, Francis, Shah, Shah and George (2016) conducted a prospective
research that involved 350 clinically identified patients suffering from obstructive airway
diseases (OADs) at the SBKS Medical Institute and Research Centre. The research was based
on the fact that the idea of asthma creating an impact on older adults has been collectively
repudiated in past. Consequently, in place of questioning the presence of asthma in elderly
patients, the condition often remains misinterpreted in the form of chronic obstructive
pulmonary disease (COPD), thereby resulting in sub-optimal disease management. Thus,
taking into consideration the fact that COPD develops amid one in five people who are life-
long smokers, the researchers recognised the need of not blindly diagnosing the condition
among older adult smokers, who have not been subjected to clinical evaluation. The
researchers also recognised the importance of conducting spirometry while differentiating
asthmatic conditions. Nonetheless, they elaborated on the fact that demonstrating the
presence of small extent of reversibility, in relation to bronchodilators is not sufficient for
distinguishing COPD from asthma. The presence of several comorbidities amid older adults,
or the medications that were generally prescribed for treating the comorbid conditions were
also found to exacerbate asthmatic conditions. The findings of the research suggested that of
the 350 patients who clinically manifested patterns of obstructive airway disease, 292
demonstrated the presence of obstructive pattern in their pulmonary function tests. Of these
292 patients, 100 patients were affected with asthma, and the rest 192 were COPD patients.
Furthermore, of the 100 patients diagnosed with asthma, 16 were aged more than 60 years,
and five of them had been previously subjected to COPD treatment.
Dunn, Busse andWechsler (2018) also elaborated on the fact that older adults diagnosed
with asthma display an increased likelihood of suffering from increased risks of mortality and
morbidity, when compared to their asthmatic younger counterparts. There are significant age‐
Author: T Minil May 2019

29
related immunologic and physiologic alterations that typically createdifficulties inthe
manifestation, diagnosis, and treatment of asthma symptoms, in the elderly population. They
also based their research on the fact that elderly asthmatics have been found to be more
susceptible to be undertreated and/or underdiagnosed with the chronic condition. This
underdiagnoses of the condition among elderly patients with asthma commonly elevated their
rates of morbidity and mortality, compared to the younger patients. Furthermore, the research
also elaborated on the fact that inflammation of the underlying airways, on occurrence of
asthma among older adults,probablyvaries from the younger patients, and is
generallypresumed to be non‐type 2 facilitated. Though elderly patients affected with asthma
are underrepresented in experimental trials, subcategoryexamination of large experimental
trials proposed that they demonstrate a reduced likelihood of responding tothe therapies used
for asthma management such as, administration of corticosteroids. With an expansion of the
armamentarium of pharmacologic therapies for asthma, the researchers also recognised it
essential to take account of theelderly asthmatics in big experimental trials, with the aim of
tailoring and customising the therapy to the high‐risk and increasing population.
Discussion
It can be suggested from the 11 articles discussed in the previous sections that the elderly
population is at a significant risk of suffering from asthma, and when left untreated or under-
diagnosed, it creates severe impediment in the pathway of providing care. In case of the
elderly patient suffering from asthma, the airways of the lungs get inflamed. During the
disease the air pathway of the lungs gets swollen and hence the muscles gets tighten and leads
to chest tightness, wheezing, coughing and shortness of breathing. Asthma is a chronic
disease which is commonly observed in the people of age group of 60 and above. Treatment
such as taking medication in correct timing is used as intervention in the people suffering
from asthma. Other intervention used in the treatment of the patient having asthma is the use
Author: T Minil May 2019

30
of inhalation therapy or use of oxygen pumps. Involvement in physical exercises is also
helpful in the treatment of asthma in elder patient (Curto et al., 2019).
Elder patient usually suffers from different disease which becomes hurdles in the
treatment of the elderly patient. Physical disability is common in elder patient and hence in
such cases, the patient is unable to continue with the physical activity. These comorbidities
create different problems in the treatment of the asthma such as in the case of medication
management, it creates problem with other disease. Asthma is a severe disease that requires
ongoing management such as, using proper medication to reduce the airway inflammation or
to control the inflammation in future. Sometimes management of asthma leads to the
development of another disease. In addition, several comorbidities are associated in patient
suffering from asthma which creates hurdles in the treatment of asthma. In elderly patient,
obesity is also commonly observed which increases the risk of breathing complication.
Chronic obstructive pulmonary disease, which is a common disease and is commonly
observed in individual suffering from asthma. These comorbidities increase the amount of
hurdles during the treatment of asthma in elder patient (Shum, Poureslami & FitzGerald,
2017).
In case of asthma management, medication should be taken correctly, triggers that can
worsen the situation of the patient should be avoided, level of the asthma is continuously
measured to ensure that illness is under control and responding to the asthma attacks that
occurs frequently in case of elderly patient. In order to manage asthma in elderly patient,
different medication was applied which creates problem in the elder patient because they
usually suffer from multiple disorder. To understand the challenges that arise in asthma
treatment of the elder patient different types of survey were conducted. Respiratory problems
which is increased due to the use of smoking, working in factories that increases the risk of
Author: T Minil May 2019

31
breathing problem which also leads to the development of cardiac disease which affects the
treatment process. Physical disability is also observed in the geriatric patient. In such cases
they are unable to perform physical activity which is used as an intervention for the patient
suffering from asthma (Torres et al., 2015).
Severity of the signs and symptoms related to asthma give rise to a situation that
makes the older adults more prone to manifest signs of a range of co-morbid conditions,
which in turn increases the rate of mortality. The findings presented above are in accordance
to the fact that an estimated 15–20% of COPD patients have been presumed to suffer from
asthma–COPD overlap syndrome (ACOS). Furthermore, such patients with ACOS are
categorized by augmented reversibility of airflow impediment, eosinophilic systemic and
bronchial inflammation, and an amplified response of the patients to inhaled corticosteroids,
in comparison toCOPD patients. Hence, it can be suggested that overlap of symptoms
between asthma and COPD often act in the form of an impediment in the accurate diagnosis
of the condition, and threaten the health and safety of the older adults. Hence, there is a need
to shift the interest of ACOS towards eosinophilic COPD, which has been found simpler to
diagnose and creates direct therapeutic implications. The findings were also congruent to
those presented by Song and Cho (2015) who aimed torecapitulate the relations between
asthma and comorbidities in elderly patients, based on pieces of scholarly evidences. On
drawing excerpts from the Severe Asthma Research Program (SARP), the researchers
provided evidence for presence of severe asthma among 54% of patients who reported history
of sinusitis, in comparison to 37% with moderate asthma, and 33% patients with mild asthma
(P<0.001). Furthermore, obesity has also been related with poor asthma related health
outcomes that comprise of an increased frequency of signs and symptoms, and noteworthy
corticosteroid insensitivity amid older adults. However, the condition has not been found to
be directly correlated to asthma severity.
Author: T Minil May 2019

32
The same has been confirmed by Ban, Trinh, Ye and Park (2016) who also illustrated
that some frequent comorbidities that create challenges during the diagnosis of asthma among
older adults commonly comprise ofchronic sinusitis, chronic obstructive pulmonary disease
(COPD), obesity, and depression, and are significantly related with unmanaged and severe
asthma in the target population. In addition, the researchers also elaborated on the fact that
severe smoking status amid older adults who have been identified as asthma patients are
suggestively related with more recurrent exacerbations. Hence, appropriate management and
treatment of the comorbidities must always be taken into consideration, at the time of
implementing treatment modalities for the elderly asthmatic patients. Poor adherence to the
treatment strategies, which is prevalent elderly asthmatic patients has been found crucial in
predicting deteriorated asthma control status. In addition, patients with asthma who report
reduced knowledge and awareness on the condition, have an impairment in their cognitive
function, and use inappropriate inhaler techniques generally report reduced treatment
adherence that is a major challenge.
Gemicioglu et al. (2018) also aimed to assess the features that create an impact on
asthma management andcompliance to the treatment modalities, amid elderly asthmatics who
have been recently diagnosed in Turkey, when comparedto their younger counterparts. The
researchers subjected 1037 adult asthma patients, aged less than 65 years, and 79 older
asthma patients, aged 65 years or more, to a web-based questionnaire. Congruency of the
findings with those presented in the previous section can be associated with the fact that the
proportion of patients having complete control among the young and older adult asthma
groups were namely, 37.1% and 33.9%during visit 1, 42.1% and 20.0% at visit 2 (p = 0.012),
and 49.8% and 50.0% at visit 3, respectively. Furthermore, there was no significant
difference, in relation to compliance among the patients to the implemented treatment,
between the two groups. Compliance rates to visit was found to be superior in the group
Author: T Minil May 2019

33
comprising of older adults, when compared to their younger counterparts at visit 3 (32.9% vs.
19.4%, p = 0.004), visit 2 (51.9% vs. 34.9%, p = 0.002), and visit 1 (72.2% vs. 60.8%, p =
0.045), respectively. Furthermore, the researchers could also provide evidence for an increase
in compliance to treatment, in relation to asthma control in both the groups (both p < 0.001).
However, the impact of comorbidities on asthma management was confirmed by the fact that
patients demonstrated a reduction in adherence rates under circumstances when they suffered
fromgastroesophageal reflux, gastritis/ulcer, and coronary artery disease.
Implications for clinical practice and recommendations
The findings discussed above have significant implications in current clinical practice,
owing to the fact that they helped in identification of the most common challenges and
problems that are typically encountered at the time of diagnosing and treating older adults
affected with asthma. The research findings suggested that presence of comorbidities and
health complications such as, obesity, gastroesophageal reflux, rhinosinusitis, and obstructive
sleep apnoea created difficulties in asthma management, and increased the mortality rates
among the patients. It was also found that poor inhaler techniques, poor adherence to
medications, and incorrect diagnosis of the condition, due to overlap of symptoms with
COPD were also recognized, which must be addressed by the healthcare professionals in their
future practice. Hence, the primary goal of successful asthma management among older
adults should focus on accomplishing and maintaining accurate control of the symptoms,
maintenance of normal activity, maintenance of pulmonary function of the patient near
normal levels, prevention of asthma exacerbation, and prevention of asthma related mortality.
Furthermore, there is a need to improve management of asthma conditions in older
adults in current days, owing to thesnowballingincidence and prevalence of asthma cases in
the elderly. It should be taken into consideration that there is a need for all healthcare
Author: T Minil May 2019

34
organisations to hold responsibility and accountability for the formulation and
implementation of intervention strategies that aredirected toward the care givers. This in turn
wouldinspire and encourage them to participate in effectiveasthma management that reduces
the mortality rates of elderly patients. Furthermore, with the aim of ensuring that the
condition does not remain under-diagnosed, spirometry must be used to document airflow
obstruction. There is also a need for the healthcare professionals to conduct a thorough and
comprehensive physical examination, while taking into account, the asthma-related medical
history of the patients.It was exhibited from the researcher findings that usually the condition
and diagnosis of asthma is misinterpreted with the condition of chronic obstructive
pulmonarydisorder (COPD) and due to lack of patient literacy, the patient are unaware of the
confounding factors that might trigger their condition of asthma. It was also exhibited from
the research finding that the elder adults who had both depression and asthmatic conditions
had reported an increase in their asthmatic episodes associatedwith poor compliance to the
inhaled medicines, when compared to the younger asthma patients.
Conclusion
Thesecondary research highlighted the various challenges that are encountered
duringmanagement and treatment of asthma in elderly individuals. The challenges
particularly associated with disease under-diagnosis, manifestation of comorbidities, overlap
between signs and symptoms, physiological variations, and poor treatment adherence.
Furthermore, low levels of health literacy, and psychological manifestations of ageing were
also found to contribute to the disease burden. Hence, there is a need to show adherence to
nursing guidelines for the management of asthma among the elderly. Healthcare professionals
must take efforts to educate the older adults on the risk factors and signs and symptoms of
asthma, which in turn will prevent delay in treatment. Hence, patient education will play an
important role in effective management of the condition. To conclude, by providing
Author: T Minil May 2019

35
satisfactory information to patients, recognising symptom overlap, targeting comorbidities,
and increasing medication adherence, older adults diagnosed with asthma will gainincreased
physical comfort. This will unswervinglyreduce recurrent hospitalisation, and also decrease
mortality rates.
Author: T Minil May 2019

36
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Author: T Minil May 2019

41
Appendix 1
Authors Aim Methods Setting
and
Participan
ts
Key findings
/conclusions
Kannan
et al.
(2015),
Ohio
To
explore predictors
of asthma-related
quality of life
among older
adults.
Mini-Asthma Quality
of Life Questionnaire
(mAQLQ)
questionnaire,
medical history,
demographics and
mean elemental
carbon calculated
n = 164,
pulmonary
and allergy
outpatients
Complete mAQLQ
(mean ± SD 5.4 ± 1.1)
and emotional,signs,
and activity domain
factors were
comparable to the
scores that were found
in populations
comprising of younger
people. Poorer scores
of mAQLQ were
meaningfully related
with regular visits to
the emergency depart
ment (adjusted β
[aβ] = −1.3, with the
β values elaborating
on the direction and
the strength and of
relationship, p< .0001)
.
Hsu,
Chen
andMira
belli
(2018),
Atlanta
To recognize risk
factors and
modifiable factors
connected with
asthma-associated
hospitalizations
and urgent
care center
Cohort study using
data from 2006-
2010 Behavioural
Risk Factor
Surveillance
System Asthma Call-
back Survey
14,076
older
adults
aged 65
years or
more
One or more than one
asthma-associated
hospitalization cases,
in the previous year
were testified by 5.7%
of the patients (95%
CI= 5.0% to
6.4%).10.6% (95%
Author: T Minil May 2019

42
or emergencydepa
rtment visits
(ED/UCV) amid
older adults.
CI= 9.7% to 11.5%) of
the patients reported
attending the ED/UCV
more than once, for
treatment of asthma-
related signs and
symptoms.
Ross,
Yang,
Song,
Clark
and
Baptist
(2013),
Michigan
To recognize
psychological,
demographic, or
physiologic
distinctiveness
connected with
asthma-related
quality of life,
control and
utilisation of
healthcare amid
older adults.
Cross-sectional study
using Asthma Control
Questionnaire, mini
Asthma Quality of
Life
Questionnaire, psycho
logical, demographic,
and physiological
characteristics
n=70,
mean age
73.3 years
Most of the patients
reported the presence
of an increased level
of depression, which
in turn was closely
associated with
deterioration in their
quality of life.
Significant correlation
between a worsening
in functional status of
the asthma patients,
with an inferior
quality of life
(P < .01). Co-
morbidity also linked
to reduced utilisation
of healthcare
resources and
presence of atopy (P <
.01).
Patel,
Patel and
Baptist
(2017),
Ann
To explore the
relationship of
depression with
asthma
consquences in
Cohort study using
data from NHANES
survey (2007-2012)
n=509
with
physician
diagnosed
asthma
Elder adults who had
both depression and
asthmatic conditions
(n = 196) reported an
increase in their
Author: T Minil May 2019

43
Arbor older adults asthmatic episodes
(prevalence ratio [PR],
1.53; 95% confidence
interval [CI], 1.00-
2.35), occurrence
of sleep disorders due
to asthma (PR 2.75;
95% CI, 1.54-4.92),
visits to the urgent
care clinics or
emergency department
for asthma
management (PR,
2.24; 95% CI, 1.15-
4.34), and limitations
in activity (PR, 1.77;
95% CI, 1.00-
3.18; P = .05), in
contrast to the elderly
asthma patients who
were not suffering
from depression.
Sasaki et
al.
(2018),
Japan
To explore
adherence
obstructions to
inhaled
medications amid
older adults, in
comparison to
younger adults
diagnosed with
asthma in Japan
Observational study
using “Adherence
Starts with
Knowledge 20”
(ASK-20)
questionnaire
n=251
older and
113
younger
patients
There was less
number of elderly
adults who reported
poor compliance to
the inhaled medicines,
when compared to the
younger asthma
patients. Element Q11
acted as an
autonomous
adherence hurdle to
Author: T Minil May 2019

44
inhaled medicines
amid the older
patients. Element Q3
and Q16 were
identified as major
barriers by younger
asthma patients
Soones,
Lin,
Wolf and
O’Conno
r (2016),
New
York
To explain the
causal pathway
relating medicatio
n compliance to
health literacy by
modeling asthma
disease and
medication idea
as mediators.
Observational study
using Medication
Adherence Rating
Scale and Short Test
of Functional Health
Literacy in Adults.
n=433
with
67 ± 6.8 ye
ars mean
age
31% non-Hispanic
blacks, 39%
Hispanics, and 84%
female. 36% asthma
patients demonstrated
the presence
ofinadequate health
literacy, and were
found to be at an
increased likelihood of
having several
misconceptions
regarding the presence
ofasthma symptoms
(P < .001) and asthma
relatedprescriptions(P
< .001). Presence of
poor health literacy
created a momentous
effect on the patients
(β = 0.089; P < .001).
O'Conor
et al.
(2015),
Chicago
To examine the
extent to which
cognitive skills
elucidate relations
between asthma
Observational study
using participants
from Asthma Beliefs
and Literacy in the
Elderly (ABLE) study
n=425,
aged ≥ 60
years,
recruited
from eight
38%patients were
found to demonstrate
compliance to their
controller medicine.
53% patients
Author: T Minil May 2019

45
associated
medications
and health
literacy of older
adults
outpatient
clinics
confirmed appropriate
DPI technique, and
38% of them
establishedaccurate
MDI technique.
Significant association
of inadequate literacy
with poorer
compliance to
controller medication
(OR, 2.3; 95% CI,
1.29-4.08), MDI (OR,
1.64; 95% CI, 1.01-
2.65), and improper
DPI (OR, 3.51; 95%
CI, 1.81-6.83).
Federma
n et al.
(2014),
New
York
To explore the
self‐management
characters,
including
adherence to
medication and
inhaler method,
amid older adults
who had been
diagnosed with
asthma, and their
relation with the
presence of health
literacy.
Observational cohort
studyusing Short Test
of Functional Health
Literacy in Adults
n=433,
having
severe or
moderate
persistent
asthma
36% patients reported
the presence of low or
marginal health
literacy. Medication
adherence was also
found to be low (38%)
in general, and poorer
among individuals
who demonstrated
poor health literacy
(22%), in comparison
to individuals who
reported satisfactory
health literacy
(47%, P < .001),
following the
adjustment of different
Author: T Minil May 2019

46
socio-demographic
factors and their
health position (odds
ratio (OR) = 0.48,
95% confidence
interval (CI) = 0.31–
0.73).
Skloot,
Busse,
Braman,
Kovacs
and Dixo
(2016),
New
York
To provide
guidelines for
management and
evaluation of
asthma in older
adults
Secondary research Clinical
guidelines
Several structural
changes occur in the
lungs, due to normal
aging process that
worsen the
manifestation of the
disease, and
deteriorate the
patient’s physiologic
function. Variations in
the aging immune
system create an effect
on the cellular
function and
composition in asthma
affected airways.
Pandya,
Shah,
Francis,
Shah,
Shah and
George
(2016),
To highlight
asthma
misdiagnosis in
old age
Prospective cohort
study
n=350,
SBKS
Medical
Institute
and
Research
Center
COPD develops amid
one in five people who
are life-long smokers,
the researchers
recognised the need of
not blindly diagnosing
the condition among
Author: T Minil May 2019

47
India older adult smokers,
who have not been
subjected to clinical
evaluation. Of 350
patients, 292
demonstrated the
presence of
obstructive pattern in
their pulmonary
function tests. Of
these 292 patients, 100
patients were affected
with asthma, and the
rest 192 wereCOPD
patients. Furthermore,
of the 100 patients
diagnosed with
asthma, 16 were aged
more than 60 years,
and five of them had
been previously
subjected to COPD
treatment.
Dunn,
Busse
and
Wechsler
(2018),
Australia
To explore asthma
in elderly
population
Secondary research Literature
review
Elderly asthmatics
have been found to be
more susceptible to be
undertreated and/or
underdiagnosed with
the chronic condition.
Inflammation of the
underlying airways,
on occurrence of
Author: T Minil May 2019

48
asthma among older
adults, probably varies
from the younger
patients, and is
generally presumed to
be non‐type 2
facilitated.
Appendix 2
Authors/country Quality assessment
Kannan et al. (2015), Ohio Moderate
Hsu, Chen andMirabelli (2018), Atlanta Moderate
Ross, Yang, Song, Clark and Baptist (2013),
Michigan
Moderate
Patel, Patel and Baptist (2017), Ann Arbor Moderate
Sasaki et al. (2018), Japan Moderate
Soones, Lin, Wolf and O’Connor (2016),
New York
Moderate
O'Conor et al. (2015), Chicago Moderate
Federman et al. (2014), New York Moderate
Skloot, Busse, Braman, Kovacs and Dixo
(2016), New York
High
Pandya, Shah, Francis, Shah, Shah and Moderate
Author: T Minil May 2019

49
George (2016), India
Dunn, Busse and Wechsler (2018),
Australia
High
Author: T Minil May 2019

50
Appendix 3
PRISMA flowchart
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51
Appendix 4
SEARCH TERMS:
“Aged” AND “elderly” OR “elder” AND “older” OR “senior” AND “asthma” AND
“respiratory disorder” AND “respiratory illness” AND “respiratory disease” OR “asthma
attack” AND “adult” OR “grownup” AND “asthma disorder” AND “asthma illness” AND
“management” OR “supervision” AND “administration” OR “challenge” AND “difficulty”
AND “cure” OR “trail” OR “exertion” AND “treatment”.
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52
Appendix 5
Kannan, J. A., Bernstein, D. I., Bernstein, C. K., Ryan, P. H., Bernstein, J. A., Villareal,
M. S., ... & Epstein, T. G. (2015). Significant predictors of poor quality of life in
older asthmatics. Annals of Allergy, Asthma & Immunology, 115(3), 198-
204.https://doi.org/10.1016/j.anai.2015.06.021
Answerr 1) Yes, the groups which have been selected for the study is similar but the
popualtion differs in trems of age. Age of the test population is over 65, whereas the age of
the control population is below than that. For a high quality cohort study, it is extremely
important that the both the groups, the test group and the control group should be similar.
Answer 2) yes, both the groups, test groups and the control group have been exposed to the
expsure such as air pollution. In eliminates the baisness of the result and also there is chances
that the result is more precised and accurate. For a good quality cohort study, both the groups
should be exposed to the exposure.
Answer 3) yes, the expoure which have been provided by the researchers to the respondents
of both the groups. It is measured in the experiment by a mini questionnaire. Questionnaire is
one of the most reliable method of the measurement. As the questionnaire is distributed
among the 175 popultion, it is valid.
Answer 4) yes, identification of the confounding factors are extrmely important for a good
quality cohort study. In the article, the cofounding factors are identified which might effect
the result of the experiment. The cofounding factors identified in the essay are obesity and
smoking. Both the factors are said to be effect the health condition of the asthma-related
severity.
Answer 5) NO, the factors which were identified as the cofounders might effect the result of
the study, but no strategies were implemented to reduce the effect of the factors. In order to
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53
get a result which is not biased, it is necessary to implement strategies that deal with the
cofounding factors.
Answer 6) yes, the population who were taken as respondent are free of the measured
outcome. The data collection of the experiment is conducted through survey with the help of
mini questionnaire. For the high quality cohort studies, it is important that each and every
respondent is free of the measured outcome from the beginning of the studies.
Answer 7) Yes, the outcome of the studies is measured in valid and reliable way. If the
outcome of the experiment could be implemented as a fact or is similar to the result of the
similar experiment, it is considered to be realible and valid. The outcome of the experiment is
measured by the help of statistical analysis by calculating p value and mAQLQ scores.
Answer 8) Yes, the follw time reported is sufficient and long enough for the measured
outcome to error. The standard follow up time reported for the experiment should be
minimum 1 year. In this article, the follow up time provided is 2 years which is long enough
for the outcome to error.
Answer 9) No, the follow up was not completed as some of the respondents who have
participated in the experiment have withdrawn their participation. Total number of
respondents who have participated in the experiment are 175 where as only 165 respondent
have completed the survey.
Answer 10) No, the strategies which can address the incomplete follow up are not utilized.
Total 11 respondetns have withdraw their participation from the experiment as they have
deceased during the follow up period. However, to manage the withdrawl no additional
strategies were involved.
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54
Answer 11) Yes, in the article the proper statistical analysis were used. The p value has been
calculated which is less than that of the 0.0001. The mean of the statstics and the standard
deviation has also been calculated which is 5.4.
Ross, J. A., Yang, Y., Song, P. X., Clark, N. M., & Baptist, A. P. (2013). Quality of life,
health care utilization, and control in older adults with asthma. The Journal of
Allergy and Clinical Immunology: In Practice, 1(2),
157-162.doi.org/10.1016/j.jaip.2012.12.003
Answer 1) No the criteria for the inclusion were not clearly mentioned in the research study.
The inclusion criteria included patients of age more than 65 years of age, however the
number of the participants were not mentioned. The diagnosis of the asthma was done based
on the National Asthma Education and Prevention Control guidelines. The medicines that
were given to the patient was also not mentioned.
Answer 2) No the study subjects and the settings were not described in details. The number
of subjects involved in the experiment is not mentioned, only the age limit has been
mentioned. The settings of the experiment is also not described properly in the study.
Answer 3) Yes the exposure that was measured was very much valid and also reliable. The
higher depression scores were measured and the depression was reported by the participants.
Answer 4) Yes the standard criteria and the objective was used for the measuring of the
conditions. The patients that were used for the study were all suffering asthma and also those
patients were taken for the experiment who were also under the medications of asthma.
Answer 5) Yes, the confounding factors were identified in the study which involves
occurrence of atopy and decreased number of cases in hospitalization. The unscheduled cases
Author: T Minil May 2019

55
if the visits of the primary healthcare or the specialists of asthma and also the number of
steroids given to the patients are considered.
Answer 6) No, the strategies to deal with the confounding structures were not stated properly.
Only it has been state that the atopy remained significantly statistically after the logistic
regression was analysed.
Answer 7) Yes, the outcomes were measured in a quit valid and the reliable way. The
primary outcome was obtained based on the questionnaire set to ask questions to the
participants. There were 15 interview administered survey which was conducted to identify
the functional impairments and also most problematic to the patients suffering from asthma.
From the interview, the four domains including the symptoms, limitations of the activities of
the patients, the functions of the emotions and also the environment stimuli were identified.
The control patients were administered with 6 questionnaire , the asthma control was
measured based on the goals of the managements involving the nighttime symptoms and the
symptoms of the daytimes. I order to assess further the control samples, the measures of the
health care utilization over the last 12 months were collected. This includes the number of
attacks of asthma and unscheduled visits to the hospitals.
Answer 8) Yes the statistical analysis was done properly. The chi square test was used to for
the purpose of the conduction of the univariate analysis of the questionnaire. The results of
the univariate analysis was used to do the regression analysis of the experiment.
Patel, P. O., Patel, M. R., & Baptist, A. P. (2017). Depression and asthma outcomes in
older adults: results from the National Health and Nutrition Examination
Survey. The Journal of Allergy and Clinical Immunology: In Practice, 5(6), 1691-
1697.https://doi.org/10.1016/j.jaip.2017.03.034
Author: T Minil May 2019

56
Answer 1) Yes, the groups were selected from the same population. The sample included
men and women who were adults and also having age of 55 years and above. This age was
used previously as the cut off as set in studies of NHANES for the older adults.
Answer 2) The groups of the experiment involved patients suffering from asthma with
depression and the patients suffering from asthma without depression. Yes the exposures that
were measured were similar to assign the people from all the groups.
Answer 3) Yes, the exposures were measure in a valid way and also in a reasonable way. The
analysis of the data from the NHANES survey from the year 2007 to 2012 were done.
Statistical analysis were done to find the associations between the association in between the
asthma and the depression among only those patients having age above 55 years.
Answer 4) Yes, confounding factorshave been identified and those are sleep disturbances,
symptoms of the symptoms of asthma, emergency department and the limitation of the
activities.
Answer 5) Yes the strategies about how to deal with the confounding factors were stated. The
episodes of the symptoms of asthma were analyzed by measuring the episodes of the
sneezing, by measuring about how many times the persons sneezed in the past 12 months.
The patients were asked that how many times the patient was admitted to the emergency
conditions in the last 12 month. The patients were also asked the average time of sleeping in
the last 12 months and also ij the last 12 months how much the patients have utilized their
activity levels.
Answer 6) No, the participants who were involved in the study were not free of the outcomes
of the experiment.
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57
Answer 7) Yes, the outcomes were measured in a valid and quite reasonable way.The
analysis of the data from the NHANES survey from the year 2007 to 2012 were done.
Statistical analysis were done to find the associations between the association in between the
asthma and the depression to patients of age above 55 years.
Answer 8) Yes the follow up time reported was much sufficient for the outcomes to be
happened as the results that were obtained were according to the expected outcomes. In the
cohort studies, the time span is normally very long and in the given study, analysis were done
from the results obtained from the years 2007 to 2012.
Answer 9) Yes, the follow up was completed as no such inclusion and exclusion of the
participants were found in the study.
Answer 10) No such strategies were addressed to utilize the incomplete follow up.
Answer 11) Yes, the statistical analysis has been done properly as bivariate analysis and
multivariate Poisson regression were done.
Sasaki, J., Kawayama, T., Yoshida, M., Takahashi, K., Fujii, K., Machida, K., ...&
Kyushu Asthma Seminar Investigators. (2018). Adherence barriers to inhaled
medicines in Japanese older patients with asthma evaluated using the
“Adherence Starts with Knowledge 20”(ASK-20) questionnaire. Journal of
Asthma, 1-10.doi.org/10.1080/02770903.2018.1484132
Answer 1) Yes the inclusion criteria for the study is clearly mentioned. The Japanese patients
who were above the age of 20 years were and was suffering from asthma were selected for
the interview. The inclusion criteria included people with at least one medicine, involving
regular use of the ICS, regularly attending the clinic having medical records since 6 months
were included in the experiment.
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58
Answer 2) No, the study subjects and the settings were not described in details. The study
was conducted among the Japanese adults but is not been mentioned that the adults were
male or the female. Even the location where the experiment was conducted was not
described. Only the time period of the study design has been described in details.
Answer 3) Yes, the exposure measured was measured in a valid and reliable way. In the
given study, the adherence barriers to the medicines that are inhaled were evaluated to 251
participants. The number of participants were also very high so appropriate results would be
expected. Out of all the participants 138 were older adults and 123 were younger adults
having asthma were interviewed.
Answer 4) Yes, the standard criteria were used according to the objectives of the
experiments. The patients who were involved in the study, were suffering from asthma. The
objective was such that it reduces the risk of the occurrence of any kind of bias and also the
answers that were obtained were correct as they obtained from questionnaire.
Answer 5) The confounding factors of this study includes the age factors. If any person of
different age was included in the experiment by mistake, then the result would have been
altered. Another confounding factor was the economic factors, some participants were
included in the experiment belonging from poor backgrounds.
Answer 6) Yes the strategies were used properly while dealing with the confounding factors.
The participants were selected by considering the confounding factors. The poor people were
grouped in different group and also the medicines were considered while the grouping of the
participant were done.
Answer 7) Yes, the outcomes of the experiment was measured is a valid and reliable way. In
the given study, the adherence barriers to the medicines that are inhaled were evaluated to
251 participants. The number of participants were also very high so appropriate results would
Author: T Minil May 2019

59
be expected. Out of all the participants 138 were older adults and 123 were younger adults
having asthma were interviewed. Four categories of adherence level were set, among
whichthe patients were required to be reported. This method was even reliable.
Soones, T. N., Lin, J. L., Wolf, M. S., O'conor, R., Martynenko, M., Wisnivesky, J. P., &
Federman, A. D. (2017). Pathways linking health literacy, health beliefs, and
cognition to medication adherence in older adults with asthma. Journal of
Allergy and Clinical Immunology, 139(3), 804-
809.doi.org/10.1016/j.jaci.2016.05.043
Answer 1) No, the inclusion criteria of the participants were not defined clearly. Only those
were selected who were able to speak English or Spanish. The exclusion criteria was
mentioned properly as it was stated that those who had suffered from chronic obstructive
pulmonary disease. The age was mentioned as only those who were only above 60 years were
included in the experiment. Much elaboration were required regarding the inclusion of the
participants.
Answer 2) Yes the subjects of study and the settings were described in details. Only people
above 60 years of age took participation in the interview. The exclusion criteria was also
mentioned, the patients were selected from the year 2009 to 2012.
Answer 3) Yes the exposure that was measured in a quite valid and reasonable way. Personal
interviews were taken of the patients and the results were noted. This exposure measure is
quite valuable as the results obtained can be compared with the previous such observations
and also this result can be kept for any future references.
Answer 4) Yes the standard criteria was according to the objectives of the experiment. The
objective of this study was the description of the casual pathway which links the health
literacy to the medications of the patients by modelling the disease asthma and the
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60
participants were selected by considering the objective. The criteria were matching the
groups or the participants of the experiment.
Answer 5) Yes so many confounding factors were identified. The factors included literacy
regarding the health of the patients, illness and the beliefs of the medications, cognition,
adherence of the medical conditions, sociodemographics.
Answer 6) Yes, the strategies were stated to deal the confounding factors. The health literacy
were tested by taking a small test of the functional health literacy of the adults. The reading
comprehensive test were also done. Interview was taken to know about the disease of the
patient, how the patient has suffered from the disease. This would provide the frame work for
understanding the experiences of the patients about the diseases, the range of the diseases
from which the patient is suffering. The cognition was another important confounding factors
as from which it can be assessed the immediate recall of the patient. Adherence to the asthma
controller were also considerd.
Answer 7) Yes, the outcomes were measured in a valid and reliable way.Personal interviews
were taken of the patients and the results were noted. This exposure measure is quite valuable
as the results obtained can be compared with the previous such observations and also this
result can be kept for any future references. 433 people were enrolled in the study and the
results showed that the medical adherence of the older adults can be identified.
Answer 8) Yes, the statistical test were done properly, by following the chis-square or the
ANOVA test.
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61
Hsu, J., Chen, J., & Mirabelli, M. C. (2018). Asthma morbidity, comorbidities, and
modifiable factors among older adults. The Journal of Allergy and Clinical
Immunology: In Practice, 6(1), 236-243.https://doi.org/10.1016/j.jaip.2017.06.007
Answer 1) No, the two groups included in the study are not similar as the individuals
included in the test groups are of at least 65 years, whereas the age range of the controlled
group is 18 to 65. However, the respondents were recruited from the similar population that is
both the groups have active asthma.
Answer 2) No, in this article the exposure measure were different for the two groups. The
exposed groups were allowed to talk to general practitioner or other health professional if
needed. They took medication for asthma if experienced any kind of symptoms related to
asthma. The exposure measures of the unexposed measures are not clearly stated.
Answer 3) No, the methods used to exposure measures are not mentioned clearly. The
exposure measures is allowed in the article for the exposed group. This measures may effects
the result of the experiment. The result which is acknowledged after the experiment may be
biased. In order to avoid that biasness, the exposure is measured. Validity and reliability of
the result also is based on the exposure measurement. However in this article it the exposure
method are measured, hence the validity and reliability of the exposure cannot be measured.
Answer 4) No, the counfounding factors were not claerly detrmined in the article . the
counfonding factors re the facrors which can influnece the result of the experiment. The
counfounding is said to be happened where the intervetion of the experiment is biased and is
not similar between the expermental group and the test group. The cofounder is not directly
indentified in the article. However the differnce in the age group and sevrity of the population
is said to be effected the result of the experiment.
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62
Answer 5) No, the strategies to deal with the confounding factors are not stated in teh article.
Though most of the factors such as sex, smoking factors are considered in the eassy but the
confounding fcators are not taken into consideration and the satrategies to maintain the
cofounders are not stated.
Answer 6) yes, the respondents who have participated in the in the study are free from the
outcome measured. For ah high quality article it is very important that all the respondents are
free from the outcome measured. The groups are also free from at the moment whne they are
exposed.
Answer 7) yes, the outcome of the experiment is measured in realiable and valid ways. As teh
number of respondetnts taken are quite good and the result is measured by the help of
fimding the comfidence interval which is a reliable and valid method.
Answer 8) Yes, the follw time required in the experiment is 4 years that is 2006 to 2010 years
which can be considered as long enough for an error to occur.
Answer 9) No, the followup was not completed at the end of the reaction. The total number
of participant who were surveyed are 74,209 out of which only 14,706 answered all the
questions at the end of the experiment and the data were analyzed.
Answer 10) yes, the participant who did nnot answered all the questions of the survey clearly
are excluded from the study sample to obtain a precise result.
Answer 11) yes, odds ratio is used to analyze the data. The confidence interval of the study is
95% and the p value is less than 0.5
O'Conor, R., Wolf, M.S., Smith, S.G., Martynenko, M., Vicencio, D.P., Sano, M.,
Wisnivesky, J.P. and Federman, A.D., 2015. Health literacy, cognitive function,
Author: T Minil May 2019

63
proper use, and adherence to inhaled asthma controller medications among
older adults with asthma. Chest, 147(5), pp.1307-1315.
Answer 1) Yes, the two groups were similar and were recruited from the same population,
which belonged to the elder group of people aged more than 60 years.
Answer 2) Yes, the exposure measured were similar for both the groups that comprised of
cognitive measures as the primary aim of the study was to analyze the relationship among the
patient’s health literacy and their individual cognitive measures.
Answer 3) Yes, the exposure were measured in a reliable and valid way that comprised of
authentic sources and description stating the precise reason of selecting individual measure.
Answer 4) No, the confounding factors were not identified in the study that could affect the
parameters of the study.
Answer 5) No, the strategies to deal with the confounding factors were not stated as no
confounding factors were identified in the study.
Answer 6) No, the participants were not free from the outcome at the start of the study
because the participantsincluded were already present in the outpatient clinics in different
places suffering from asthma.
Answer 7) No, the outcomes were not measured in a reliable and valid way, as the researcher
focused on the self-reported result that can be biased as it depend on individual participants
and their self-report assessment. The method of inhaler technique was also used that was
assessed by the interviewer only once and no reliability or validity tool.
Answer 8) No, follow up time was reported in the study as the primary objective of the study
was to investigate the extent of cognitive skills related to the asthma-associated medicine and
health literacy in the elder adults suffering from asthma. Hence, measuring the time was not
Author: T Minil May 2019

64
exhibited as the health literacy was examined using Short Test of Functional Health Literacy
in Adults. Therefore, no information regarding the time management was stated that could be
sufficiently used to report the long-term benefit of the study.
Answer 9) Yes, the follow-up was complete because the outcome comprised of an extensive
action plan steps that were crucial for exhibiting the outcome of the patient that primarily
involved the cognitive components, which included reasoning skills, memory, and capability
to avoid distraction and multitask.
Answer 10) No, the strategies to include or address the incomplete follow-up was not utilized
as the patient only incorporated the strategies that were listed to include the participants in the
study. The exclusion criteria incorporated in the study was that the participants who had
incomplete or lack of health literacy data and cognitive function were not included in the
study that reduced the overall sample size to 425 participants.
Answer 11) Yes, appropriate statistical analysis was used in the study by the researcher that
comprised of descriptive statistics, where Pearson product moment correlations was used to
examine the relation among the cognitive test and the health literacy. Factor score was also
used in this study under statistical analysis followed up by the multivariable logistic
regression model to investigate the relationship among the medication-associated behaviours
and health literacy.
Federman, A. D., Wolf, M. S., Sofianou, A., Martynenko, M., O'connor, R., Halm, E.
A., ... & Wisnivesky, J. P. (2014). Self‐management behaviors in older adults
with asthma: Associations with health literacy. Journal of the American
Geriatrics Society, 62(5), 872-879.
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65
Answer 1) Yes, the two groups were similar and were recruited from the same population,
which belonged to the older adult group of people aged more than 60 years suffering from
severe or moderate persistent asthma.
Answer 2) Yes, the exposure measured were similar for both the groups that included the
strategy to investigate the behavior of self-management comprising of inhaler technique and
medication adherence among the older adults. The exposure also included to relate the
participants on the basis of self-management and identify their association with the concept
of health literacy.
Answer 3) No, the exposure was not measured in a reliable and valid way as the exposure
considered in this study was for the participants with minimum health literacy. Such
participants were not aware of the trigger-associated factors that could increase their asthma
and therefore can act as an exposure reducing the reliability of the research. The exposure
included were animal fur and cigarette smoking but no reliability and validity of the exposure
was measured and exhibited in the study.
Answer 4)Yes, the confounding factors were identified that could affect or hamper the
research findings of the study. The confounding factor included were cigarette smoking and
exposure to allergens, which would affect the participant’s health and also the finding if the
study.
Answer 5) Yes, the strategies to deal with the confounding factors were stated in the study
that comprise of enhanced health literacy among the participants so that the individual gain
knowledge and information regardingtheir health and identify the factors that would hamper
the research findings of the study.
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66
Answer 6) Yes, the participants were free form the outcome at the staring of the study asthe
participants who were suffering from uncontrolled asthma were included in the study
irrespective if they are included in the control or experimental group.
Answer 7) Yes, the outcomes were measured in a reliable and valid way. The outcomeswere
assessed under different factors that included observance to controller medicines, asthma
inhaler method, self-observation of asthma regulator, and evasion of various asthma triggers.
Each of the above factors were evaluated individually for checking the validity and reliability
of the study.
Answer 8) No, follow up time was reported in the study as the primary objective of the study
was to investigate the behavior of self-management that include inhaler technique and
medication adherence among the older adults and examine their association with the health
literacy that will not comprise of any definite time. Hence, no follow up time was exhibited
by the researcher in the study.
Answer 9) Yes, the follow-up was completed as it was elaborately explained by the
researcher that inhaler technique and medication adherence was poor among the older adults
suffering from asthma and it was worse among the participants belonging to the low health
literacy.
Answer 10) No, strategies was exhibited to address the incomplete follow up because the
researcher had explained the follow-up procedure and had fulfilled the requirementofthe
researchstudy.
Answer 11) yes, appropriate statistical analysis was used in the study that comprised of
student t-test, chi-square test and logistic regression. The researcher had also performed a
complete statistical analysis used in the study using SAS statistical software.
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Skloot, G. S., Busse, P. J., Braman, S. S., Kovacs, E. J., Dixon, A. E., Vaz Fragoso, C. A.,
... & Hanania, N. A. (2016). An official American Thoracic Society workshop
report: evaluation and management of asthma in the elderly. Annals of the
American Thoracic Society, 13(11), 2064-2077.
Answer 1) Yes, the research question is explicitly and clearly stated. The focus of the
researcher question was to determine whether the pathophysiology process of asthma in
elderly patient (AIE) was different from the asthma in the younger patients.
Answer 2) No, the inclusion criteria was not stated appropriately. The researchers had only
focused on asthma as the common factor that was severe in nature and is related with
increased death rate among the older population who were more than 65 years. Therefore, in
this study the author had presumed to include both older and younger patients who were
suffering from asthma.
Answer 3) Yes, the search strategy was appropriate that included various researcher and
clinicians included from diverse background, who were specialized in the field of asthma and
were interested in evaluating the research related to asthma in elder population. Extensive
literature review was also includedin the search strategy that helped the researcher to gain
appropriate knowledge of severe asthma in both younger and older population.
Answer 4) No, the sources and resources were not used adequately in the study because the
researcher had conducted an extensive literature review that helped the researcher to gain
appropriate knowledge regarding the objective of the study. The researcher had not explored
any further resources that will elaborate the consequences of the study.
Answer 5) Yes, the criteria for apprising the studies was appropriate because the researcher
had selected article on the basis on different criteria that would help them to evaluate the
result in a better way. The criteria included are epidemiology of asthma in elder population
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(AIE), evaluating the structure and function of lung based on the effect of ageing for the
people suffering from asthma, assessing the influence of ageing on the airway inflammation
and immune function, evaluating the phenotypes of asthma in elder population and
identification of the strategies that would handle asthma among the elder population.
Answer 6) No, critical appraisal was not conducted in this study. The researcher had
includedthe articles that was extracted through extensive literature review search.
Answer 7) No, there were no methods that were highlighted in the study focusing on the
method to minimize the error in the process of data extraction as the researcher had not
conducted any data extraction procedure in this study.
Answer 8) Yes, different methods were usedto combine the studies appropriately that had
focused on different components of the requirements like autopsy assessment and computated
tomography (CT) scan that would highlight the component of large and small airway wall
thickness and area among older population as compared to the younger population.
Answer 9) No, the likelihood of publication biased was not assessed as the researcher have
included articles that were publishedin the year 2012 and that comprisedof the participants
who aged more than 95 years.
Answer 10) Yes, different recommendations were suggested by the researcher to support the
data that would assist the researcher to overcome the imitation of the study that would further
help the researcher to reduce the limitation of the study and enhance the research finding.
Answer 11) No, the researcher did not highlight any specific directives that could be
appropriate for the new research approach.
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Pandya, R., Shah, A., Francis, S., Shah, K., Shah, P., & George, A. (2016). Under-
diagnosis of asthma in elderly. Indian Journal of Allergy, Asthma and
Immunology, 30(1), 27
Answer 1) No, the inclusion criteria was not clearly defined in the study as the researcher
conducted a prospective study that included 350 clinically diagnosed obstructive airway
diseases (OADs) patient present at the research centre and SBKS Medical Institute. The
researcher had specifically evaluated the observation that was exhibited by each individual
patient. The patient who were in between the age of 15 to 80 years were included in the study
and a proper consent was taken from each participant.
Answer 2) No, the setting and the study subject were not described in detail. The researcher
had included the patient andexamined them for different clinicalcomplaint that can hamper
the research funding and also considered their family history followed by thorough clinical
examination. The experimental setting detail was not elaborate din detail by the researcher.
Answer 3) Yes, the exposure were measured in a valid and reliable method. The researcher
had evaluated each patient and according to each patient exposure criteria, the researcher had
used pulmonary function test to validate the exposure. Based on the validation of individual
exposure and the values obtained from pulmonary function test (PFT), the participants were
further treated and intervention was given to each individual.
Answer 4) Yes, the standard criteria and objective was used for the measurement of the
participant condition included in the study that included that the participant who were
suffering from asthma and it is usually misdiagnosed in the form of chronic obstructive
pulmonary disease (COPD). Hence, the researcher had only included those patient who were
suffering from asthma and require immediate diagnosis. The participantsconsidered in the
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study were in between the age group of 15 to 80 years and each of them were diagnosed with
chronic obstructive pulmonary disease (COPD).
Answer 5) Yes, the confounding factors were identified in the study that included genetic
factors, developmental factors and environmental factors. The environmental confounding
factors comprise of allergens, airborne infections, air pollution, indoor pollution and dust
mites. There are more than 100 different genes that act during the condition of asthma and
can act as major confounding factor in the study.
Answer 6) No, the researcher did not highlight any strategies to deal with the confounding
factors. The researcher only highlighted that effective differentiation between the
pathological and physiological changes is crucial to differentiate if the condition is affecting
the senile population. Therapeutic intervention was stated by the researcher that was followed
by allergen0induced strategy to reduce the condition of lung function.
Answer 7) Yes, the outcomes was measured in a validated and reliable way asthe researcher
has used three different method to validate the outcome and conclude the research on basis of
the research objective. The Method used for validation and reliability was pulmonary
function test (PFT), Forced expiratory volume test and Forced vital capacity test.
Answer 8) Yes, appropriate statistical methods were used in the study that included mean,
median, mode, percentage, sensitivity, correlation, standard deviation and confidence
interval. This statistical methods are used to appropriately analyse the collected data that was
screened by the researcher.
Dunn, R. M., Busse, P. J., & Wechsler, M. E. (2018). Asthma in the elderly and late‐
onset adult asthma. Allergy, 73(2), 284-294.doi.org/10.1111/all.13258
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Answer 1) Yes, the statement of the literature review is very clearly and explicitly stated. The
review is about the asthma of adults and the late onset of asthma among the adults.
Answer 2) Yes, the inclusion criteria was appropriate for the stated problem of the review
question. The papers that were included in the systematic review were appropriate for the
review question. The older adults and the disease asthma of the older adults were considered
for the systematic review. The older people have the highest tendency to get infected by
asthma. So the selection criteria was appropriate.
Answer 3) Yes the search strategy was appropriate as systematic review is the best way to
find the history about any particular disease and also the older people mostly get effected by
the disease asthma.
Answer 4) Yes, adequate resources were found at the time of searching the articles. Key
words were used to find the articles, like asthma, aging, late-onset, elderly, adult-onset. This
research paper was prepared by properly analyzing all those papers only.
Answer 5) Yes, the criteria used in the paper were also appropriate like cellular biology of
aging, aging and lung cancer, epidemiology of the disease, airways remodeling, the
phenotypes of this disease among the aged person, diagnoses of asthma, the management of
the disease, environment and exposures of the medicines, management of the medicines.
Even the future directions were also considered.
Answer 6) No, the paper was not reviewed by two or more reviewers independently.
Answer 7) No such methods were adopted to reduce the errors in the extraction of data.
Normally, chances are there for the occurrence of bias in the systematic reviews as the data
that are collected from different papers may either coincide with each other or may get
differed. No such methods were there to reduce the biases.
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Answer 8) No the methods that were used to combine the studies were not appropriate. The
combination of all the significant points could have done in a much better way. If some more
key words were used to search the research papers for the preparation of this paper. No meta-
analysis were done in this research paper.
Answer 9) The systematic research study includes the highest chance of creating bias. But in
this paper, no statistical tables or data are presented, so the chances of creating the
publication bias is less.
Answer 10) Yes the strengths of the findings and the quality of the research can be
considered for the formulations of new recommendations.
Answer 11) Yes there are future prospective from this research paper. New targeted therapies
can be produced for those suffering from long term asthma and long onset of asthma.
Author: T Minil May 2019