Systematic review proposal on 'Challenges in the management of asthma in the elderly population'

To understand the main objectives of the systematic review of asthma in the elderly population: The main criteria for asthma management in the elderly population is as follows: The main criteria for asthma management in the elderly population is as follows: The research question is to gain insight in the systematic review of asthma in the elderly population. Aim of the research is to gain insight in the systematic review of asthma in the elderly population: The main criteria for asthma management in the elderly population is as follows: The research question

Running head: SYSTEMATIC REVIEW PROPOSAL
Systematic review proposal on ‘Challenges in the management of asthma in the elderly
population’
Name of the student:
Name of the University:
Author’s note

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Table of Contents
Background:.....................................................................................................................................2
Research question:...........................................................................................................................3
Aim and objectives:.........................................................................................................................4
Criteria for including studies in the review:....................................................................................4
Search methods:...............................................................................................................................5
Methods of review:..........................................................................................................................6
Meta-analysis:..................................................................................................................................8
Presentation of result:......................................................................................................................9
Timeline for review:......................................................................................................................12

2SYSTEMATIC REVIEW PROPOSAL
Title of the review: Challenges in the management of asthma in the elderly population
Background:
Asthma is a chronic inflammatory disease condition affecting health of more than 300
million people globally (Ozturk & Iliaz, 2016). The symptom of wheeziness, breathlessness and
coughing occurs because of underlying processes like chronic inflammation of the airways,
reversible obstruction of the airways and reaction of airways to stimuli (Bonini & Usmani,
2015). Although the disease is most commonly observed in children, however asthma can be
diagnosed in adulthood too. The diagnosis of asthma is associated with substantial disease
burden and reduction in the quality of life. The burden of disease is measured by disability and
premature death (Ehteshami-Afshar et al., 2016). 14% of total children in the world are
diagnosed with asthma and 8.6% adults between 18-45 years experience symptoms of asthma.
Young people between the age of 30-34 years have lowest impact, however children aged 10-14
and elderly people ages above 75-79 years experience greatest burden. In older people, burden of
the disease is defined by premature death (globalasthmareport.org, 2014). Although the
prevalence of condition in children has been widely published, much less information exists
regarding prevalence in older adults. Hence, focusing on the elderly population group is
necessary to reduce the burden of asthma in developing countries.
With the increase in ageing population, asthma in the elderly will be one major public
health concern. The number of people above 65 years of age is increasing rapidly and it is
expected that by 2030, the number of people above 65 years in developing countries will double
(Ortman, Velkoff & Hogan, 2014). Due to such expected increase in the ageing population and
prevalence of asthma in the elderly, having understanding about asthma in the elderly population

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is essential. It may help to gain information regarding severity, spectrum of symptoms, treatment
response and level of inflammation in the elderly population (Song & Cho, 2015). Research in
this area is essential because due to ageing factor, the presentation and management of asthma is
phenotypically different compared to young population group. Some of the ageing related factors
that increase risk of uncontrolled disease due to asthma in elderly population include poor
memory, poor hearing and vision, low education and neuromuscular issues in learning about
self-management plans and inhaler use (Ozturk & Iliaz, 2016). Hence, these factors can increase
the likelihood of comorbidities and symptom deterioration in elderly population. Therefore, in-
depth exploration of challenges in management of asthma is necessary to understand the factors
that deteriorates or improves condition of elderly people and find out solution to effectively
manage asthma in elderly population (Scichilone et al., 2014). The main purpose of the research
is to conduct a systematic review to understand how multiple chronic disease and comorbidities
lead to poor asthma outcomes in patient and evaluate interventions to manage asthma and its
comorbidities in the elderly.
Research question:
The main research problem is increase in elderly population and risk of uncontrolled
disease due to diagnosis of asthma and presence of multiple chronic disease. The research
question related to the research problem represented in PICO format is as follows:
P (Population)- Elderly population
I (Intervention)- management of asthma
C (Comparator)- no action

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Outcome- Challenges
The PICO question for the systematic review proposal is
‘Is management of asthma (I) easier for elderly population (P) compared to young population
group (C) in reducing asthma symptoms (O)?
Aim and objectives:
The main aim of the systematic review is to gain in-depth understanding about the range
of factors increasing challenges for elderly patient in the management of asthma. The main
objectives of the systematic review are as follows:
 To gain insight about challenges faced in management of asthma in elderly population
 To link comorbidities in elderly patient with management of asthma symptoms
 To understand the effect of interventions on asthma interventions for elderly
 To evaluated intervention implemented for asthma management in the elderly population
group.
Criteria for including studies in the review:
The main criteria for inclusion of articles in the systematic review will be as follows:
 Population/participants: Only those research articles will be included in the review
which has elderly population as the research subject. Intervention/exposure: Another criteria for selection of article is that all research articles
must report about any intervention or management process for asthma

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 Comparison/control groups: The research articles must give idea about special needs of
elderly population during the management of asthma compared to young people or
chidren Outcome of interest: The main outcome of interest for each studies should be
improvement in symptoms of asthma such as wheezing, breathlessness and other
common symptoms
 Setting: The research can be done in any clinical setting or asthma related health care
services
 Study designs to be included: As the aim of the research is to explore about challenges
and it is not restricted to perception of participants only, all types of research addressing
the research question will be included in the study.
Search methods:
Electronic databases: To find research articles suitable to the research question, all health and
social care and biomedical databases like Medline, CINAHL, PubMed and EMBASE will be
searched. The interface that will be used for databases searching includes EBSCO and nhs,
which are the leading provider of research databases, e-journals, books and other work. The main
search filter that will be used for all databases included setting publishing date of articles from
the year 2009 to 2018 and setting type of resource to journal articles. This will help in the
inclusion of research articles published within 10 years and evaluate effect of recent
interventions on management of asthma in elderly people. Relevant articles related to the
research question will be obtained by adding primary search terms like ‘asthma management in
elderly’ and ‘challenges in the management of asthma in the elderly population’. After review of
research articles by entering primary search terms, more specific search terms related to

6SYSTEMATIC REVIEW PROPOSAL
intervention uses for elderly people or other ideas will be used as secondary search term to
enhance the search process. Boolean operators such as ‘AND’ and ‘OR’ will be used for
conducting search in CINAHL database. Use of this approach will help in the selection of
relevant articles related to the topic (Peters et al., 2015).
Other methods used for identifying relevant research:
The inclusion criteria will be the eligibility criteria for the selection of articles. However,
extraction of research articles will be done after the review of full-text article and reference list
of the article. To include research articles in systematic review, two experts from the field of
epidemiology will be contacted regarding the decision for final selection of research articles.
Both the reviewers will cross check abstract and title of the articles first. In the second phase of
searching, reference will be checked and included after achieving consensus for eligibility.
Methods of review:
Details of methods:
The inclusion criteria is the main eligibility criteria for selection of articles and the
evaluation of the two articles will be done by two reviewers on the basis of research question
(Whiting et al., 2016). The main rational for including two reviewers is to eliminate selection
bias and prevent influence of individual judgment during the selection process. The two
reviewers will first screen title and abstracts of articles for relevance and then full-text article
will be reviewed to fulfill study objective. The reference list of selected articles will also be
reviewed to find additional articles relevant to the research question. At this point, the reviewers
will also exclude research articles which are not published in English language, which has no
human participants and those which does has asthma as the study of interest. The two reviewers

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will independently extract data for research, however in case of disagreements, an independent
researcher will settle cases of disagreement.
To enhance the validity and credibility of the research work, quality assessment of
included studies is necessary. This process will be necessary to make the research more specific
and transparent (Almeida & Goulart, 2017). By the use of relevant quality assessment tools,
assessment of research articles based on research rigour, clear research objective and systematic
representation of research findings can be done (Ahmed, Sutton & Riley, 2012). To evaluate the
quality of research articles selected for the literature review, risk of bias assessment will be done
by using the Cochrane Risk of Bias Assessment tool. It is an appropriate tool for assessment of
different kinds of bias in research such as selection bias, performance bias, detection bias,
attrition bias, reporting bias and other kinds of bias. The tool contains six domains such as
random sequence generation, allocation concealment, blinding of participants, blinding of
outcome assessment, incomplete outcome data, selective reporting and other source of bias to
rate the quality of studies (Cochrane Methods, 2018). Based on these six domains, the judgment
for quality of research articles will be done by the use of three categories such as low, moderate
and high quality study.
Data extraction:
To reduce the time taken to complete a systematic review, the specific method used to
extract data can be useful. Systematic review aims to identify, synthesize and interpret published
evidence to improve decision making process for clinicians, policy makers and other
stakeholders. The strategies used to extract data determine the time consumed in conducting the
review (Jonnalagadda, Goyal & Huffman, 2015). For the research on challenges in management

8SYSTEMATIC REVIEW PROPOSAL
of patient with asthma, a summary table will be used to summarize eligible studies. The
following information will be extracted from eligible research articles:
 Author details
 Country and year of publication
 Study participant
 Research setting
 Severity of asthma symptoms
 Details of intervention
 Duration of study
 Study design and
 Outcome measures
Meta-analysis:
After the extraction of research data, the analysis of research evidence will be done by
thematic analysis process (Thomas & Harden 2008). Meta-analysis has not been chosen for this
systematic review because meta-analysis is done when the purpose is to identify consistency
between research studies based on treatment effect. However, the effect of treatment is not the
main purpose of this systematic review. Hence, meta-analysis is not necessary for the research.
Instead of meta-analysis, thematic review method will be adopted for analysis to categorize
challenges for elderly patient under different themes. Thematic analysis is an effective approach
to link selected studies with the research objective and study conclusion. Thematic analysis is a
commonly used approach to analyze qualitative data and it helps to refines research findings into
major themes (Bearman & Dawson, 2013). The categorization of research finding into different

9SYSTEMATIC REVIEW PROPOSAL
themes will help to process text and refine study findings. This process will also help reader to
make critical assessment of the work.
Presentation of result:
The following tables will be included in the final paper after the completion of research:
Table 1: Summary table:
Autho
r
Country
and year
of
publicatio
n
Researc
h sample
Study
settin
g
Details of
symptom
s
Type of
interventio
n
Duratio
n of
study
Study
desig
n
Outcom
e
Table 2: Quality assessment table (Risk of bias summary)
References Sequence
generation
Allocation
concealment
Blinding of
participants
Blinding of
outcome
assessor
Incomplete
Outcome
date
Other source
of bias
Author et al.
year
+ + ? - + -

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The above signs in the table indicate the signs that will be used judge high, low and unclear risk
of bias. Positive sign will indicated by high risk of bias, negative sign will indicate low risk and
question mark sign will mean unclear risk of bias.
The flow chart of results included and studies summarized will also be included which
will give detail on identification, screening, eligibility and number of articles included for the
study.

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Records identified through
database searching
(n = 80)
Additional records identified
through other sources
(n = 15 )
Records after duplicates removed
(n = )
Records screened
(n = )
Records excluded
(n = )
Full-text articles assessed for
eligibility
(n = )
Studies included in
qualitative synthesis
(n = )
Studies included in quantitative
synthesis (meta-analysis)
(n = )
Full-text articles
excluded, with
reasons
(n = 2 )
Table 3: Flow chart for article selection process

12SYSTEMATIC REVIEW PROPOSAL
Timeline for review:
The systematic review process will be completed in several stages like literature
searching, quality appraisal, data extraction, synthesis and writing up. The timeline for each of
the stages are as follows:
Stages of
systematic
review
June 2018 July 2018 August 2018 Sept 2018 Oct 2018
Literature
searching
Quality
appraisal
Data
extraction
Synthesis
Writing up

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

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Jonnalagadda, S. R., Goyal, P., & Huffman, M. D. (2015). Automating data extraction in
systematic reviews: a systematic review. Systematic reviews, 4(1), 78,
doi: 10.1186/s13643-015-0066-7
Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: the older population in the
United States (pp. 25-1140). United States Census Bureau, Economics and Statistics
Administration, US Department of Commerce,
http://bowchair.com/uploads/9/8/4/9/98495722/agingcensus.pdf
Ozturk, A. B., & Iliaz, S. (2016). Challenges in the management of severe allergic asthma in the
elderly. Journal of asthma and allergy, 9, 55, doi: 10.2147/JAA.S85420
Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015).
Guidance for conducting systematic scoping reviews. International journal of evidence-
based healthcare, 13(3), 141-146, DOI: 10.1097/XEB.0000000000000050
Scichilone, N., Pedone, C., Battaglia, S., Sorino, C., & Bellia, V. (2014). Diagnosis and
management of asthma in the elderly. European journal of internal medicine, 25(4), 336-
342, DOI: https://doi.org/10.1016/j.ejim.2014.01.004
Song, W. J., & Cho, S. H. (2015). Challenges in the management of asthma in the
elderly. Allergy, asthma & immunology research, 7(5), 431-439.
Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in
systematic reviews. BMC medical research methodology, 8(1), 45, Doi:
https://doi.org/10.1186/1471-2288-8-45