Diagnosis, Treatment and Management of Asthma in Older Adults (65+)

This report provides a comprehensive overview of asthma diagnosis, treatment, and management specifically tailored for older adults aged 65 and above. It highlights the high prevalence of asthma in this demographic and the challenges posed by comorbidities, medication burdens, and age-related pulmonary changes. The report emphasizes the importance of accurate diagnosis, including detailed medical history, physical examinations, and spirometry to assess airflow obstruction. It explores various treatment interventions, including the use of inhalers and nebulizers, with a focus on the effectiveness of ipratropium bromide and salbutamol. The report also outlines the rationale for diagnosis, treatment, and management, addressing the difficulties in successful asthma treatment, medication issues, and the impact of comorbidities. It incorporates a PICO question to guide research into the efficacy of nebulized ipratropium bromide and salbutamol in severe asthma cases. The research methodology includes systematic reviews, meta-analysis, RCTs, and cross-sectional surveys. Furthermore, the report analyzes data from Fiona Stanley hospital and TLC aged care hospital, using the CASP tool for critical appraisal. The report also discusses the need for tailored treatment approaches and early interventions to mitigate the adverse effects and comorbidities associated with asthma in the elderly, referencing several research articles and databases like Medline and PubMed. The report concludes by emphasizing the role of primary healthcare providers in identifying at-risk patients and managing asthma effectively.

Diagnosis, treatment and management of asthma in older adults 65 years and above
Introduction
There is a high prevalence of diseases in the older people. The older people are referred to those
aged 65 and above. Currently, various people of this age have been diagnosed with various
conditions and are under medications. Other people in the elderly population have been under
home based care due to their high need of special care as a result of sicknesses. These diseases
include diabetes, coronary heart diseases, arthritis, dementia and cataracts among others (Li et
al.2015). these comorbidities have been the highest percentage cause of morbidity and mortality
amongst the elderly. Many older people have been diagnosed with asthma and it has greatly
impacted their health and wellbeing. Statistics show that the people who mostly die of asthma
and other airway diseases are aged 55 and above. They mostly suffer this condition because of
the ageing pulmonary changes, the old people perception of dyspnea, asthma diagnosis
difficulties, medication and comorbidities burden. Asthma diagnosis difficulties, medication and
comorbidities burden has made asthma a distinct problem amongst the elderly that needs specific
examination, research and therapeutic intervention.
Background
There are key points that should be considered when making the diagnosis of asthma. Clinicians
have the responsibility of determining the episodic symptoms that led to the obstruction of the
airway / deterred the airflow, he/she has to determine whether the airflow obstruction is partially
reversible and determine the exclusion of the alternate diagnoses (U. S. Department of Health
and Human Services, Health, & National Heart Lung Institute, 2012).The health practitioner has
the responsibility of coming up with the right diagnoses through making focus of a detailed

medical history of the patient, focusing on the upper respiratory tract physical examination which
includes the chest and skin and also perform spirometry to assess reversibility and demonstrate
the underlying obstruction ("Asthma: pathophysiology, causes and diagnosis " 2014). This
should be done across all the ages when an asthma case is reported. Determination of an
increased FEV1 to 12% or more shows reversibility or a prediction of an FEV1 more than 10%
after a patient uses a short acting bronchodilator shows reversibility. There are special
considerations that should be made when making diagnosis of an elderly asthmatic patient.
His/her past history of any prior lung disease should be examined in which the inhaling of a
bronchodilator shown a FEV1 that is less than 60%. Nocturnal symptoms should be considered
as well to asthmatic patients who had earlier cases of COPD, the patient’s adverse drug reactions
and any other additional medical problem. The period of sickness should be examined to
establish any allergic components (Epstein & Nyenhuis 2019).
After making the nursing diagnosis, various interventions for treatment are made. One of these
interventions include giving an inhaler that should be used for daily basis to prevent
inflammation. nebulizers are given out which in solution form can be inhaled via inhalers
(Epstein & Nyenhuis, 2019). Nebulizers are composed of different types of medications. In this
study, we shall examine whether the commonly used nebulizer called ipratropium bromide
together with salbutamol is effective in the treatment of asthma in the elderly.
The Rationale for diagnosis
The rationale for the diagnosis, treatment and management of Asthma in the elderly is that there
are difficulties in successful treatment of asthma, medications and associated comorbidities. This
has made it a burden to the elderly and their families to treat the condition and has rendered them
medical seekers at most of the times for asthma treatment or its associated comorbidities.

Asthma has to some extent remained fatal to the elderly due to poor diagnosis. Research in this
topic shall make it possible to identify the right diagnosis for asthma and its associated
comorbidities and how to treat them to reduce an all-time care burden from the elderly and their
families. The PICO question in this research is that majority of the elderly are treated with
nebulizers whose components are ipratropium bromide and Salbutamol. what evidence is there to
show that nebulized ipratropium bromide should be combined with salbutamol to successfully
treat patients with life – threatening or acute severe asthma?
The aim and objectives of this review
One of the aims of this review is to identify the present nursing diagnosis towards the asthmatic
elderly patients and to assess the common treatment used in treating asthmatic patients. The
effectiveness of the treatment currently used shall be examined through research from Fiona
Stanley hospital and TLC aged care hospital. The respondents shall be inpatients in both the
hospitals and outpatients who have been diagnosed of asthma. Data shall be collected using
various data collection methods after which they shall be analyzed to determine the effectiveness
of the current asthma diagnosis and treatment.
Research methodology
Data collection methodology shall involve systematic reviews and meta-analysis, Randomized
control Trials and cross sectional surveys. Systematic reviews and meta-analysis are
advantageous over the other methods because they give a definite answer towards a specific
research question based on the current available evidence. Its implications are very reliable as
compared with other methods. They summarize various studies findings to create more
understanding and reduce bias due to accurate conclusions made. They help in establishing the

efficacy and safety of a particular medication, identify knowledge gaps, practical advantages are
provided and they are cost effective (Clinician's Guide to Systematic Reviews 2013). RCTs help
in comparative issues, reduce bias, reduce confounding factors, they are good for statistical
reliability and are good for printing purposes (Bulpitt, 2013). According to Abramson &
Abramson (2011) surveys are good for research purpose because they use the sources that are
easy to read, their sample size is of a wide scope, they are cost effective and are able to provide
candid responses. Systematic reviews were done in both Fiona Stanley hospital and TLC aged
care hospital. To make the reviews, the research question was stated and decisions of what
studies to include in the review were made based on the CINAHL guidelines. Trained search
coordinators searched for both published and unpublished materials about nebulizers whose
components are ipratropium bromide and Salbutamol. Patient’s files were assessed and
information gathered in the outpatient and the inpatient cases. The studies were selected and data
was collected in the hospital data system. The data was then presented for analysis (Higgins &
Thomas 2019).
The eight articles for analysis about asthma diagnosis, treatment and management.
Research methodology from the systematic review of articles
A Medline search using ‘asthma’ and the ‘elderly’ as MESH has led to discovery of various
articles with time, which has enabled more understanding and more attention on the diagnosis,
treatment and the management of asthma in the elderly, ("Asthma in the Elderly: a Different
Disease?,"). There is little information available about the relapse that happens after asthma
remission at an old age. The prevalence of asthma in the people aged 65 ranges between 1.8 to
10,9 percentages and its treatment cost is high associated with poor quality of life, hospitalization
and death. The elderly suffers most under diagnosis and poor treatment as compared with the

young asthmatics and they have a high mortality rate of 51.3% per million people across all the
ages, ("Asthma in the Elderly: Current Understanding and Future Research Needs: A Report of a
National Institute on Aging (NIA) Workshop,”). Most of the women are hospitalized more than
men do. Its physiologic and clinical consequences are the same but the comorbidities and
psychosocial effects displayed in the elderly mostly affects the diagnosis, care and the
management of asthma.
there are different pathophysiological mechanisms in the elderly are different from those found
in the young an issue that affects the outcomes and clinical course of asthma. Another article in
PubMed, ("Asthma in the elderly patient,”), states that the elderly are associated with a very
severe asthma phenotype. This phenotype is very resistant to the treatment of asthma and leads to
very poor treatment outcomes. The elderly suffers a low grade inflammation where senescence
lead to high inflammatory status. Cell functioning is altered because of the senescent cells
damaged replicative capacity. As shown in the above named article, Patients receiving step 3 to 4
of the antiasthmatic therapy shown a test score less or equal to 19, where ¼ of the patients
reported exacerbation of asthma in the previous year. 1/3 of the patients were reported to have
ACOS as a result of chronic bronchitis. Patients with ACOS were reported to have suffered
asthma in their early ages and at their old age, were the highest hospitalized. According to this
article, there are very many other factors that can lead to poor treatment outcome in the elderly
across the world.

Another article by (Zein et al. 2015) shows that there is too much asthma severity amongst the
elderly. This is because the elderly people have an increased stiffness of the chest wall, reduced
elastic lung’s recoil and weak respiratory muscles. Decreased expiratory flows are associated
with aging and start to be witnessed after declined small airways diameters at 40 years. Increased
lung closing capacity results due to peri bronchial lung tissue loss. Reduced functioning of the
lungs is expected to be the leading cause towards severe asthma amongst the elderly.
According to (Rance & O’Laughlen 2014), there exists very many deaths associated to asthma
amongst the elderly more than it is in any other age group. Managing asthma in the elderly is a
very complicated task because of various comorbidities experienced in this age group. The other
reason of hard asthma management is adverse effects of medications that these people commonly
use, and other unrecognized nonspecific symptoms. There is an evidence based guide that helps
in the diagnosis and treatment of the elderly patients with asthma. This helps in provision of the
basic and the comprehensive resource needed to care for asthma. It includes earlier interventions
for completely treating asthma at an early age to reduce its adverse effects and comorbidities at
an old age ("Asthma | Annals of Internal Medicine," 2019).
There are very many ways of identifying and managing asthma in primary healthcare facilities.
Many of the patients suffering from asthma are taken care of by the primary health care
providers. These providers can help in identification of patients at risks, provide education and
treatment if put in the frontline to manage this condition (Trevor & Chipps, 2018). In a survey
made on 2012, out of 100% of patients’ cases reported, 22 % of asthmatic patients got regular
treatment from a specialist while 48% never visited a specialist. Asthma severity should be tested
by the healthcare providers who should perform routine assessments of asthma control and ask
the relevant questions to monitor the severity. The primary care providers without the ability to

do pulmonary tests at all times should make sure that they refer the patients’ cases to the
specialists. Pulmonary function testing helps in identification of patients with chronic airflow
obstruction and who have a forced expiratory flow within one second. In this case, FEV1 is less
than 80% of the predicted normal. There is the need for patients’ referral to a specialist to avoid
the long term consequences of severe asthma under treatment. Early research shows that there is
substantial heterogeneity in the phenotypes of asthma in the basis of a patient’s physiologic
characteristics and the clinical presentation. Due to these developments, there has emerged new
targeted therapies which may help in treating asthmatic patients of all ages including the elderly.
A tailored approach for treatment should be made to ensure that there is ultimate control of
asthma amongst all patients under the consultation of a specialist. Below is a review that can
help in the distinction of the severity of asthma and its control which can help every primary care
provider know to recognize the severity of asthma and its consequences when not controlled.
The recent advances that has been made in the pathophysiology of asthma and its new treatment
options for all the patients with asthma severity has been provided.
How to define asthma
Asthma is not only a disease of bronchoconstriction as a result of environmental triggers but also
as a result of a chronic airway obstruction even at its onset. In the recent clinical practice
guidelines, there has been displayed increased understanding towards asthma’s underlying
pathophysiology. The elements of asthma control include exacerbations and symptoms
frequency. The severity of this disease is defined by the type of medications and the dosage
given to a specific patient which must be maintained to ensure that the disease is adequately
controlled. The control of symptoms is independently assessed, incorporated and used in the
definition of how severe the asthma is. In 2014, there were guidelines that were published to

define severe asthma by the task force of International Respiratory Society(ERS) and the
American Thoracic Society (ATS) . They incorporated a step by step approach towards the
approach of asthma to enable proper control of the symptoms, condition (Trevor & Chipps,
2018). The provided guidelines displayed that the asthma in people aged 6 and above requires
step 4 – 5 treatment as according to the global initiative for asthma, associated with a medium to
high dose of inhaled corticosteroids. They also need one or more mediations for control such as
theophylline or systemic corticosteroids that should be used for at least half a year to prevent the
asthma from becoming uncontrolled. Symptoms of uncontrolled asthma according to these
guidelines include poor control of symptoms, serious exacerbations that need hospitalization,
frequent severe exacerbations and /or limitation of the airflow. Regular and proper assessment of
asthma is vital to enhance the control of asthma.
When severe asthma is not treated, there results long term and short term consequences that leads
to limitations in the activity level of a person, sleep impairment and/or obesity. It may lead to
increased symptoms of anxiety and depression as well, functional damage of the airways and
COPD due to airway modelling. Cataracts emerges at a high percentage especially in the elderly
as a result of the use of oral corticosteroid in its control.
How to assess the control of asthma?
This is done by giving 2 patients questionnaires as referred to the guidelines of ERS/ ATS which
the patients should complete. The Questionnaires for asthma control are made up of 7 questions
where 6 of these ask of any symptoms recall from the patient, their frequency and experiences in
the past one week and the percentage of FEV1 normal value predicted through assessment of a
prebronchodilator (http://www.qoltech.co.uk/index.htm). The questions are scored from 0 to 6,
and their mean is obtained to get the final score.