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Treatment
of Asthma
in Older Adults

A Comprehensive,
Evidence-Based Guide
Tolly E. G. Epstein
Sharmilee M. Nyenhuis
Editors

123
Treatment of Asthma in Older Adults
Tolly E. G. Epstein • Sharmilee M. Nyenhuis
Editors

Treatment of Asthma in
Older Adults
A Comprehensive, Evidence-Based
Guide
Editors
Tolly E. G. Epstein Sharmilee M. Nyenhuis
Division of Immunology, Allergy Division of Pulmonary, Critical Care, Sleep
and Rheumatology and Allergy
University of Cincinnati School of Medicine University of Illinois at Chicago
Cincinnati, OH Chicago, IL
USA USA

ISBN 978-3-030-20553-9    ISBN 978-3-030-20554-6 (eBook)

https://doi.org/10.1007/978-3-030-20554-6

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
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The publisher, the authors, and the editors are safe to assume that the advice and information in this book
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

Asthma is a highly prevalent condition, affecting at least 26 million Americans, and

the global prevalence of asthma continues to rise. Although asthma affects all age
groups, adults age 65 years and older are disproportionately impacted by the dis-
ease. By 2030, the number of asthmatics age 65 years and older is expected to
increase to five million in the USA alone [1]. Despite this high prevalence, the bur-
den of asthma in older adults remains underappreciated. Compared to younger asth-
matics, older asthmatics experience higher morbidity and mortality from asthma, a
higher financial burden related to the disease, and poorer quality of life. This burden
is compounded by a relative lack of research studies and clinical guidelines that
specifically address issues related to asthma in older adults.
For the above reasons, Springer publishing approached us to ask that we compile
a textbook that will assist clinicians who treat older adults with asthma. The result
is the first comprehensive guidebook on the diagnosis and treatment of asthma in
older adults in the past 20 years. This book is a summary of existing scientific evi-
dence presented from the perspective of expert researchers and clinicians on asthma
in older adults. The book is intended to be useful not only to physicians specializing
in asthma but also to primary care physicians, students, case coordinators, and oth-
ers who assist in the care of asthmatics age 65 years and older.
The book begins by defining the scope of the burden of asthma in older adults
and explaining why asthma is more difficult to control in this age group. Included is
a discussion regarding the challenges of diagnosis of asthma in older adults, such as
the common misconception that asthma only begins in childhood, and difficulties
with physician and patient self-perceptions of the disease. Methods to overcome
challenges with objective testing in this age group are examined. Evidence-based
recommendations regarding how to distinguish asthma from other common comor-
bidities are also provided.
The second part of the book is intended to provide methods to optimize effective
treatment of asthma in older adults. This includes a discussion of how to overcome
physical, cognitive, and emotional barriers to effective treatment in older asthmat-
ics. A review of existing literature regarding the use of specific medications, includ-
ing their efficacy and side effects, in older asthmatics is provided. This is coupled
with a discussion of novel and alternative therapies for asthma, with specific refer-
ence to evidence for these treatments in older adults. Ways to overcome other chal-
lenges, including how to manage asthma in patients with multiple comorbidities and

v
vi Preface

with different asthma phenotypes, are considered. Shared decision-making and

strategies to optimize adherence in older adults are also discussed, along with spe-
cific recommendations for case coordinators and other nursing professionals caring
for older asthmatics. Finally, an evidence-based review of the impact of indoor and
outdoor environmental exposures, including allergens, pollutants, and infectious
pathogens, on asthma in older adults is provided. This is followed by suggestions
regarding how to control relevant environmental exposures.
It is our hope that this book will not only offer an evidence-based review of exist-
ing literature on asthma in older adults but also afford clinicians with tools that can
immediately be used to help provide optimal care for this high-risk population.

Cincinnati, OH, USA Tolly E. G. Epstein

Chicago, IL, USA Sharmilee M. Nyenhuis

Reference
1. Stupka E, deShazo R. Asthma in seniors: part 1. Evidence for underdiagnosis, undertreatment,
and increasing morbidity and mortality. Am J Med. 2009;122(1):6–11
Contents

1 Scope of the Burden of Asthma in Older Adults ������������������������������������   1

Sharmilee M. Nyenhuis and Tolly E. G. Epstein
2 Difficulties in Physician and Self-­Perception of Asthma
in Older Adults ������������������������������������������������������������������������������������������   7
Gayatri B. Patel and Carol A. Saltoun
3 Objective Testing for Asthma in Older Adults���������������������������������������� 17
Rohit Divekar
4 Distinguishing Asthma from Comorbid Conditions
in Older Adults ������������������������������������������������������������������������������������������ 25
Joram S. Seggev
5 Recent Barriers to Effective Treatment of
Asthma in Older Adults and Strategies to Address Them��������������������� 45
Alan P. Baptist
6 Medication Efficacy and Side Effects in Older Asthmatics������������������� 53
Pinkus Goldberg
7 Treatment of Asthma in Older Adults with Significant Medical
Comorbidities �������������������������������������������������������������������������������������������� 71
Anil Nanda and Anita N. Wasan
8 Shared Decision-Making and Strategies to Optimize Adherence
in Older Asthmatics ���������������������������������������������������������������������������������� 79
Don Bukstein and Dennis K. Ledford
9 How Care Coordinators and Other Nursing Professionals
Can Help Optimize Care of Asthma in Older Adults ���������������������������� 101
Cheryl K. Bernstein and Concettina (Tina) Tolomeo
10 Asthma Phenotypes of Older Adults�������������������������������������������������������� 113
Sameer K. Mathur

vii
viii Contents

11 Controlling Triggers for Asthma in Older Adults: Environmental

Allergens, Indoor and Outdoor Air Pollutants, and Infection�������������� 119
Marissa R. Shams and Tolly E. G. Epstein
12 Novel and Alternative Therapies for Asthma in Older Adults�������������� 135
Dharani K. Narendra, Ali Cheema, and Nicola A. Hanania
Index�������������������������������������������������������������������������������������������������������������������� 155
Contributors

Alan P. Baptist, MD, MPH Division of Allergy and Clinical Immunology,

Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
Cheryl K. Bernstein, RN, BSN, CCRC Bernstein Clinical Research Center, LLC,
Cincinnati, OH, USA
Don Bukstein, MD Allergy Asthma Sinus Center, Fitchburg and Milwaukee,
Fitchburg, WI, USA
Ali Cheema, MD Pulmonary and Critical Care Medicine, Baylor College of
Medicine, Houston, TX, USA
Rohit Divekar, MBBS, PhD Division of Allergic Diseases, Mayo Clinic,
Rochester, MN, USA
Tolly E. G. Epstein, MD, MS FAAAAI Division of Immunology, Allergy, and
Rheumatology, University of Cincinnati School of Medicine, Cincinnati, OH, USA
Pinkus Goldberg, MD, FAAAAI, FACAAI Indiana University School of
Medicine, Indianapolis, IN, USA
Internal Medicine, Community Hospitals Health Care System of Indiana,
Indianapolis, IN, USA
Allergy Partners of Central Indiana, Indianapolis, IN, USA
Nicola A. Hanania, MD, MS Pulmonary and Critical Care Medicine, Baylor
College of Medicine, Houston, TX, USA
Dennis K. Ledford, MD Internal Medicine, James A. Haley VA Hospital, Tampa
General Hospital, Moffitt Cancer Center, Advent Health, Tampa, FL, USA
Sameer K. Mathur, MD, PhD Department of Medicine, University of Wisconsin
School of Medicine and Public Health, Madison, WI, USA
Anil Nanda, MD Asthma and Allergy Center, Lewisville and Flower Mound, TX,
USA
Division of Allergy and Immunology, University of Texas Southwestern Medical
Center, Dallas, TX, USA

ix
x Contributors

Dharani K. Narendra, MD Pulmonary and Critical Care Medicine, Baylor

College of Medicine, Houston, TX, USA
Sharmilee M. Nyenhuis, MD FAAAAI Division of Pulmonary, Critical Care,
Sleep and Allergy, University of Illinois at Chicago, Chicago, IL, USA
Gayatri B. Patel, MD Division of Allergy and Immunology, Department of
Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
Carol A. Saltoun, MD, MSCI Division of Allergy and Immunology, Department
of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
Joram S. Seggev, MD Internal Medicine, College of Medicine, Roseman
University of Health Sciences, Las Vegas, NV, USA
Concettina (Tina) Tolomeo, DNP, APRN, FNP-BC, AE-C Yale Medicine and
the Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
Anita N. Wasan, MD, FAAAAI Allergy and Asthma Center, McLean, VA, USA
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