REVIEW URRENT C OPINION
Allergy in the geriatric population Karen H. Calhoun
Purpose of review Allergies and asthma have long been considered diseases of children and young adults. They are, however, prevalent among older patients also. This article summarizes findings on the diagnosis and treatment of allergies and asthma in the older population. Recent findings Allergies and asthma occur with fair frequency in older patients. Remembering to look and test for these problems enables better treatment and symptom control for these patients. Immunotherapy works well in this population. Summary Regardless of the patient’s age, the differential diagnosis for sinonasal and dyspnea complaints should include allergies and asthma. Diagnosis is straightforward, and appropriate treatment improves quality of life. Keywords allergies, asthma, elderly, geriatric, immunotherapy
INTRODUCTION Answer True or False: Q: People outgrow their inhalant allergies, so allergies rarely play a significant role in older patients. Q: Asthma is mainly a disease of kids and teens – it rarely persists or starts anew as people get older. A: (to both questions!): Mostly False. Bottom line: There is some evidence that allergic reactivity decreases after age 50, but, new onset allergies, worsening of existing allergies, and onset or worsening of asthma definitely do occur in this age range [1]. If you think allergies could not be a problem in the older patient, you are going to miss many opportunities to diagnose and treat these problems in this population.
allergy tests, significant bronchial hyperreactivity on spirometry (or both), treatment results in improved quality of life. Failing to consider these diagnoses based on the patient’s age means missing a chance for treating with a great risk/benefit ratio!
What happens to the allergy part of the immune system – especially Th1/Th2 balance part – as people age? Aging brings immunosenescence. All parts of the immune system function less robustly than they did when the patient was a teen. Age-related thymic atrophy results in decreased naive T-cell diversity. Immunosenescence, however, does not diminish total immunoglobulin E (IgE) levels in patients with atopic dermatitis. Similar studies have not been performed for allergic rhinitis and asthma [2 ]. &&
Why should I even think about atopic disease in the elderly? In my practice I see many older patients. My practice is currently limited to allergy and asthma, so of course all who come have allergy or asthma concerns – a bit different from the general ENT or ENT subspecialist’s office. Still, many of these patients will visit the rhinologist’s office, the otologist’s office, and others. And they may have allergies affecting their chronic sinusitis, eustachian tube dysfunction, and others. When there are positive
Department of Otolaryngology Head and Neck Surgery, Wexner School of Medicine, Ohio State University, Columbus, Ohio, USA Correspondence to Karen H. Calhoun, MD, FACS, FAAOA, Department of Otolaryngology Head and Neck Surgery, Ohio State University, Wexner Medical Center, 915 Olentangy River Rd, Suite 4A Columbus, OH 43212, USA. E-mail: [email protected] Curr Opin Otolaryngol Head Neck Surg 2015, 23:235–239 DOI:10.1097/MOO.0000000000000157
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Allergy
KEY POINTS Allergies and asthma occur much more commonly in the geriatric age group than is generally thought. Immunosenescence does occur, but it does not result in the absence of allergies and asthma in older patients. Diagnosis of allergies and asthma in geriatric patients is straightforward and very similar to approaches used in younger patients. When allergies are present, the use of nondrug avoidance measures is very useful. Immunotherapy [shots (subcutaneous immunotherapy) or drops (sublingual immunotherapy)] works well in older patients, and should be strongly considered for another method of nondrug symptom improvement in this age group.
What is the evidence about allergies occurring in older patients? Allergies commonly present with nasal congestion, rhinorrhea, and postnasal drip. Asthma presents with dyspnea, cough, and chest tightness. In older patients, especially, there are many other causes of such symptoms. Vasomotor or gustatory rhinitis, chronic obstructive pulmonary disease (COPD), and bronchitis are often near the top of the differential diagnosis list. Recent studies suggest that allergies and asthma belong right near the top of this list for older patients presenting with such complaints. One study of patients over 60 found that about 14% had allergic rhinitis (self-reported) and about 7% had asthma (doctor-diagnosed) [2 ]. Some patients formerly diagnosed as having vasomotor rhinitis based on negative allergy skin or invitro testing may actually have an allergic origin for their nasal or lung symptoms. Local allergic rhinitis is a recently described entity wherein systemic allergy tests are negative, but nasal washings, brushings or biopsies demonstrate specific IgE. These patients also respond to classic allergy medications and avoidance measures. It is unknown whether immunotherapy will be helpful in these patients [3 ]. Numerous studies compare the rate of allergy test positivity (in vivo or in vitro) in younger groups to that in older groups. Most show a decrease in positivity in the older age groups. This ranges from 50 versus 75% in older versus younger patients with allergic rhinitis symptoms in 36 versus 26% in younger versus older men, and 31 versus 18% in younger versus older women [4,5]. There is a challenge, however, in interpreting these studies. Let us say a theoretical study shows 30% of men in a group aged 25–40-years old have allergies,and 12% ofmen inthe over75 age grouphave &&
&
236
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allergies. One might conclude that the incidence of allergies decreases with aging. But during the 40 years the older patients have lived from 35 to 75, many changes have taking place in our world, our environment and our exposure to toxins and industrial waste, some of which have been shown to facilitate the development of allergies. So, in the example above, does this mean that in the younger men there will be approximately 30% with objective evidence of allergies, and when this same cohort ages to, say, 80-years old, only 12% of them will have allergies with 18% changing from objective evidence of allergies to ‘no objective evidence’ of allergies? Or does it mean that in 2015, 30% of younger patients have allergies, but 50 years ago the prevalence of allergies was only 12% in this same age group, and has remained unchanged over time? Future studies that follow the same patients over decades are needed to define this.
Is not dyspnea in the older population almost always from chronic obstructive pulmonary disease or cardiac issues? Dyspnea can certainly be caused by COPD, or disease in cardiac or other systems. Asthma is not near the top of most clinicians’ differential diagnoses in, say, the 80-year old with dyspnea. Yet evidence suggests that asthma in the elderly may be about as common as it is in younger patients, with studies showing it is often misdiagnosed as COPD [6]. As the treatments are substantially different, this leads to suboptimal or incorrect treatment [7]. Even in this age group, many with asthma have allergic triggers, so failure to diagnose and treat the underlying allergies means the patient will not be as well as they could be. Older patients with dyspnea symptoms are less likely to be referred for specialist evaluation and less likely to have objective tests that could diagnose asthma, such as spirometry [8 ]. &
Which older patients should be tested, and how should we test? Any patient of any age with a history of chronic or recurrent rhinitis, nasal congestion, nasal obstruction, rhinorrhea, postnasal drip, or sinusitis should have allergy testing as a part of their workup. It is important to remember that there may be two or more causes contributing to a symptom complex, for example, allergic rhinitis along with gustatory rhinitis or asthma along with COPD. Excellent treatment requires addressing the allergic component. Photoaging and immunosenesence may conspire to make allergy skin testing less sensitive. In our office, skin prick testing (SPT; epicutaneous testing) is our usual starting point. The older the patient, the more Volume 23 Number 3 June 2015
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Allergy in the geriatric population Calhoun
likely he/she is to require intradermal testing (IDT) to fully define his/her allergic profile. In-vitro testing such as radioallergosorbent test or ImmunoCap testing can be useful, for example, in patients who cannot pause their use of medications that interfere with skin testing such as antihistamine. In my experience, however, in-vitro allergy testing is less sensitive than invivo testing, so reliance on blood testing alone may result in missing the allergic evidence. On the contrary, enthusiasm for the sensitivity of skin testing must be tempered by the consideration of comorbidities, and the likelihood of less cardiopulmonary reserve and a poorer outcome should a systemic reaction or anaphylaxis occur. For older patients presenting with dyspnea, especially new-onset dyspnea, asthma should definitely be considered. Fractional exhaled nitric oxide requires only a gentle breath, and an abnormally high score on this can suggest asthma. Spirometry, although requiring a little more focused effort from the patient, can be successfully performed by most of the elderly. When spirometry is performed before and after administration of albuterol, the asthmatic patient shows a marked increase in breathing capacity. This reversibility is the hallmark of asthma. Both of these tests, fractional exhaled nitric oxide and spirometry, require minimal investment in equipment and can be easily performed in an office setting.
Are best treatments for older patients with asthma and allergies different from the way we treat younger patients with similar problems? Treatment of allergies and asthma in the elderly is often complicated by comorbidities [9]. One study found that older patients with asthma more often than not also had heart disease and/or hypertension, and were unable to discern whether their dyspnea symptoms were from asthma or another cause. Education and a close working relationship between patient and physician will obviously result in better disease control. Allergen avoidance strategies are the front line of allergy control in the elderly population. Often these patients live in older homes with older furnishing that have accumulated dust mites, cockroach and rodent droppings, and mold over the course of a lifetime. A deep cleaning of the house and upholstered furniture and drapes, frequent washing of washable furnishings, and removal of older carpets can dramatically decrease daily allergen exposure. Adding a high efficiency particle arrestor (HEPA) filter and instituting daily nasal isotonic saline irrigations are additional nonmedication methods of decreasing allergy symptoms.
In the older patients, medications for allergies can have troublesome risks, side-effects, and unwanted interactions with other medications. Nasal steroid sprays, usually considered a benign initial allergy therapy, may have detrimental effects on intraocular pressure (IOP). Although the most recent studies suggest this fear may have been overestimated, it is prudent to bear it in mind [10,11]. It is probably not a good idea to start a patient with glaucoma on a nasal steroid spray, and to have a recent IOP measurement in patients over 50 starting on a nasal steroid. This way, if any ocular symptoms occur, there is an IOP baseline for comparison. Of the nonsedating oral antihistamines currently available in the United States, cetirazine, desloratadine, and loratadine need renal and hepatic dose adjustments, whereas fexofenadine and xyzal need only renal adjustments. Immunotherapy is frequently dismissed as inappropriate for allergy or asthma treatment in the elderly. Reasons given range from ‘too old to have enough time to benefit’ to ‘it doesn’t work in older folks’ to ‘it’s too dangerous with their other comorbidities’ [12]. In fact the scanty publications in this area support the well tolerated use of and benefit from immunotherapy in the elderly. Of the handful of studies over the past two decades using subcutaneous (injection) immunotherapy, most have shown marked improvements in symptom scores and medication use. One major benefit of immunotherapy as compared with medications is avoidance of medication side-effects that occur more frequently in the elderly, and avoidance of adding to polypharmacy [2 ,13,14]. One study showed impressive symptom improvement after sublingual immunotherapy (SLIT) for house dust mites in older patients. Perennial allergens like house dust mite, cockroach, and molds are particularly prevalent in the elderly, so this is very encouraging. It is especially encouraging in the use of SLIT, with its excellent safety record and convenience [13,14]. Many older patients take beta-adrenergic blocking medications for hypertension or other problems [15 ]. Traditional wisdom is that taking beta-blockers is a contraindication for receiving immunotherapy. This is because the patient who is betablockaded will respond differently to epinephrine should it be needed. Recent studies show, however, that being on a beta-blocker does not increase the frequency of reactions, although some of the rare anaphylactic reactions can have an unusual indolent or hard-to-treat course. SLIT, with its excellent safety profile, is a great choice for patients on betablockers. In our office, we will also administer subcutaneous immunotherapy to patients on beta-blockers after thorough discussion with the &&
&&
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Allergy
patient of the risks and benefits. Remember that although intuition might suggest that a cardioselective beta-blocker would be less of a risk, this is in fact incorrect, with all types of beta-blockers appearing to carrying similar risk-of-unusual-anaphylaxis profiles. Asthma in the elderly has a reputation as being more difficult to control, which may be because earlier clinical studies often did not include patients over age 60 or 65. Recent studies suggest this is not totally true, although asthma deaths, while declining in most age groups, are actually increasing in older patients. Ponte et al. showed that if proper treatment and follow-up are used in this age group, response to appropriate treatment is good. Starting treatment with inhaled corticosteroids, as is done in younger patients, appears to be the best approach [16]. Hand–eye and breathing coordination can be a challenge in the elderly patient with movement disorders or cognitive disturbances. Careful education and coaching, including using a spacer, can be helpful. A few of the current asthma inhalers are breath activated, which may also be helpful. Finally, considering oral medications such as leukotriene modifiers is also worthwhile in these patients. Although there are few past studies specifically addressing asthma treatment in the elderly, interest in this underdiagnosed disease is increasing, and clinical studies of the older age groups are underway.
CONCLUSION Allergies and asthma occur often enough in elderly patients to earn a regular place on the differential diagnosis of patients presenting with oculonasal or respiratory symptoms. Their impact on quality of life is severe enough to make missing this treatable diagnosis unfortunate. In-vivo testing (SPT or IDT) is preferred to in-vitro testing if it is not medically contraindicated. Whether allergies revealed on IDT following negative SPT are clinically relevant remains unsettled. Geriatric patients with new-onset or worsening apparent COPD, bronchitis, and/or cough should have exhaled fractionated nitric oxide, spirometry (before and after albuterol), or both. Finding a reversible component to a respiratory problem alters the treatment approach, leading to potentially better outcomes for these patients. Avoidance measures, including nasal isotonic saline irrigation, are the safest treatment for allergy in all age groups and should be strongly recommended. Many geriatric patients have lived in the same home for decades. Often, the upholstered 238
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furnishings and mattresses are older and may harbor mold and dust mites. For smokers, the scent and residue of cigarette smoke may permeate soft furnishings. A thorough cleaning to decrease mold, dust mites, and animal danders is likely to be helpful, even for the nonallergic. Likewise, a HEPA filter, especially in the bedroom, will certainly not hurt, and the resulting improvement in indoor air quality could be helpful to allergic and nonallergic patients alike. The same medications useful in younger groups are useful in the elderly, with the exception of firstgeneration antihistamines and decongestants. For the available medications, physicians must be familiar with the contraindications, dose modifications, and interactions with other medications. Careful consideration of therapeutic choices is necessary in this age group in which comorbidities, polypharmacy, and frailty are common. Pending future age-specific studies, allergy immunotherapy appears to be effective in immune modification and symptom relief in elderly patients. Depending on the physician’s treatment philosophy, this means offering allergy immunotherapy early in the course of treatment (the author’s preference) or after all environmental changes, and possible medications have proven insufficient for reasonable disease control (traditional wisdom). Diagnosis and treatment of inhalant allergies and asthma in the geriatric population become increasingly relevant as the number of older adults in the United States increases. There are a multitude of questions and studies to be performed in this segment of the population, making this a fruitful area of potential research for today’s residents and fellows. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Cardona V1, Guilarte M, Luengo O, et al. Allergic diseases in the elderly. Clin Transl Allergy 2011; 1:11.
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Allergy in the geriatric population Calhoun 2. Klimek L. Old, wise and allergic: allergies are no longer solely disease of the grandchildren. Int Arch Allergy Immunol 2014; 163:75–76. This is a succinct and well written summary of allergies in the older patient. The author reviews prevalence, the immunology of allergies and asthma, and treatment options. 3. Campo P, Rondo´n C, Gould HJ, et al. Local IgE in non-allergic rhinitis. Clin Exp & Allergy. (in press). Excellent summary of what is currently know about local specific IgE in the absence of systemic evidence such as positive skin tests or in-vitro testing. 4. Karabulut H, Baysal S, Acar B, et al. Arch Gerontol Geriatr 2011; 53:270– 273. 5. Wu¨thrich B, Schmid-Grendelmeier P, Schindler C, et al. Prevalence of atopy and respiratory allergic disease in the elderly SAPALDIA population. Int Arch Allergy Immunol 2013; 162:143–148. 6. Madeo J, Li Z, Frieri M. Asthma in the geriatric population. Allergy Asthma Proc 2013; 34:427–433. 7. Scichilone N, Pedone C, Battaglia S, et al. Diagnosis and management of asthma in the elderly. Eur J Intern Med 2014; 25:336–342. 8. Porsbjerg C, Sverrild A, Stensen L, Backer V. The level of specialist assess& ment of adult asthma is influenced by patient age. Resp Med. (in press). This is a fascinating study demonstrating ‘ageism’ in medicine, older patients were less likely to be referred to a specialist for evaluation of their breathing symptoms.
&&
9. Wardzyn´ska A, Kubsik B, Kowalski ML. Comorbidities in elderly patients with asthma: association with control of the disease and concomitant treatment. Geriatr Gerontol Int. (in press). 10. Seiberling KA, Chang DF, Nyirady J, et al. Effect of intranasal budesonide irrigations on intraocular pressure. Int Forum Allergy Rhinol 2013; 3:704–714. 11. Yuen D, Buys YM, Jin YP, Trope GE. Effect of beclomethasone nasal spray on intraocular pressure in ocular hypertension or controlled glaucoma. J Glaucoma 2013; 22:84–87. 12. Milani M. Allergen-specific immunotherapy for allergic rhinitis in the elderly: is it never too late? Immunotherapy 2013; 5:699–702. 13. Bozek A, Ignasiak B, Filipowska B, Jarzab J. Allergen-specific immunotherapy for allergic rhinitis in the elderly: is it never too late? Immunotherapy 2013; 5:699–702. 14. Bozek A, Ignasiak B, Filipowska B, Jarzab J. House dust mite sublingual immunotherapy: a double-blind placebo-controlled study in elderly patients with allergic rhinitis. Clin Exp Allergy 2013; 43:242–248. 15. Ridolo E, Montagni M, Bonzano L, et al. Arguing the misconceptions in && allergen-specific immunotherapy. Immunotherapy 2014; 6:587–595. This is another very well written article addressing the more common ‘myths’ about immunotherapy. It supplies solid evidence with quality references to back up its ‘myth-busting’. 16. Boulet LP. Is asthma control really more difficult to achieve in the elderly patient? Int Arch Allergy Immunol 2014; 165:149–151.
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239
Allergy in the geriatric population Karen H. Calhoun
Purpose of review Allergies and asthma have long been considered diseases of children and young adults. They are, however, prevalent among older patients also. This article summarizes findings on the diagnosis and treatment of allergies and asthma in the older population. Recent findings Allergies and asthma occur with fair frequency in older patients. Remembering to look and test for these problems enables better treatment and symptom control for these patients. Immunotherapy works well in this population. Summary Regardless of the patient’s age, the differential diagnosis for sinonasal and dyspnea complaints should include allergies and asthma. Diagnosis is straightforward, and appropriate treatment improves quality of life. Keywords allergies, asthma, elderly, geriatric, immunotherapy
INTRODUCTION Answer True or False: Q: People outgrow their inhalant allergies, so allergies rarely play a significant role in older patients. Q: Asthma is mainly a disease of kids and teens – it rarely persists or starts anew as people get older. A: (to both questions!): Mostly False. Bottom line: There is some evidence that allergic reactivity decreases after age 50, but, new onset allergies, worsening of existing allergies, and onset or worsening of asthma definitely do occur in this age range [1]. If you think allergies could not be a problem in the older patient, you are going to miss many opportunities to diagnose and treat these problems in this population.
allergy tests, significant bronchial hyperreactivity on spirometry (or both), treatment results in improved quality of life. Failing to consider these diagnoses based on the patient’s age means missing a chance for treating with a great risk/benefit ratio!
What happens to the allergy part of the immune system – especially Th1/Th2 balance part – as people age? Aging brings immunosenescence. All parts of the immune system function less robustly than they did when the patient was a teen. Age-related thymic atrophy results in decreased naive T-cell diversity. Immunosenescence, however, does not diminish total immunoglobulin E (IgE) levels in patients with atopic dermatitis. Similar studies have not been performed for allergic rhinitis and asthma [2 ]. &&
Why should I even think about atopic disease in the elderly? In my practice I see many older patients. My practice is currently limited to allergy and asthma, so of course all who come have allergy or asthma concerns – a bit different from the general ENT or ENT subspecialist’s office. Still, many of these patients will visit the rhinologist’s office, the otologist’s office, and others. And they may have allergies affecting their chronic sinusitis, eustachian tube dysfunction, and others. When there are positive
Department of Otolaryngology Head and Neck Surgery, Wexner School of Medicine, Ohio State University, Columbus, Ohio, USA Correspondence to Karen H. Calhoun, MD, FACS, FAAOA, Department of Otolaryngology Head and Neck Surgery, Ohio State University, Wexner Medical Center, 915 Olentangy River Rd, Suite 4A Columbus, OH 43212, USA. E-mail: [email protected] Curr Opin Otolaryngol Head Neck Surg 2015, 23:235–239 DOI:10.1097/MOO.0000000000000157
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Allergy
KEY POINTS Allergies and asthma occur much more commonly in the geriatric age group than is generally thought. Immunosenescence does occur, but it does not result in the absence of allergies and asthma in older patients. Diagnosis of allergies and asthma in geriatric patients is straightforward and very similar to approaches used in younger patients. When allergies are present, the use of nondrug avoidance measures is very useful. Immunotherapy [shots (subcutaneous immunotherapy) or drops (sublingual immunotherapy)] works well in older patients, and should be strongly considered for another method of nondrug symptom improvement in this age group.
What is the evidence about allergies occurring in older patients? Allergies commonly present with nasal congestion, rhinorrhea, and postnasal drip. Asthma presents with dyspnea, cough, and chest tightness. In older patients, especially, there are many other causes of such symptoms. Vasomotor or gustatory rhinitis, chronic obstructive pulmonary disease (COPD), and bronchitis are often near the top of the differential diagnosis list. Recent studies suggest that allergies and asthma belong right near the top of this list for older patients presenting with such complaints. One study of patients over 60 found that about 14% had allergic rhinitis (self-reported) and about 7% had asthma (doctor-diagnosed) [2 ]. Some patients formerly diagnosed as having vasomotor rhinitis based on negative allergy skin or invitro testing may actually have an allergic origin for their nasal or lung symptoms. Local allergic rhinitis is a recently described entity wherein systemic allergy tests are negative, but nasal washings, brushings or biopsies demonstrate specific IgE. These patients also respond to classic allergy medications and avoidance measures. It is unknown whether immunotherapy will be helpful in these patients [3 ]. Numerous studies compare the rate of allergy test positivity (in vivo or in vitro) in younger groups to that in older groups. Most show a decrease in positivity in the older age groups. This ranges from 50 versus 75% in older versus younger patients with allergic rhinitis symptoms in 36 versus 26% in younger versus older men, and 31 versus 18% in younger versus older women [4,5]. There is a challenge, however, in interpreting these studies. Let us say a theoretical study shows 30% of men in a group aged 25–40-years old have allergies,and 12% ofmen inthe over75 age grouphave &&
&
236
www.co-otolaryngology.com
allergies. One might conclude that the incidence of allergies decreases with aging. But during the 40 years the older patients have lived from 35 to 75, many changes have taking place in our world, our environment and our exposure to toxins and industrial waste, some of which have been shown to facilitate the development of allergies. So, in the example above, does this mean that in the younger men there will be approximately 30% with objective evidence of allergies, and when this same cohort ages to, say, 80-years old, only 12% of them will have allergies with 18% changing from objective evidence of allergies to ‘no objective evidence’ of allergies? Or does it mean that in 2015, 30% of younger patients have allergies, but 50 years ago the prevalence of allergies was only 12% in this same age group, and has remained unchanged over time? Future studies that follow the same patients over decades are needed to define this.
Is not dyspnea in the older population almost always from chronic obstructive pulmonary disease or cardiac issues? Dyspnea can certainly be caused by COPD, or disease in cardiac or other systems. Asthma is not near the top of most clinicians’ differential diagnoses in, say, the 80-year old with dyspnea. Yet evidence suggests that asthma in the elderly may be about as common as it is in younger patients, with studies showing it is often misdiagnosed as COPD [6]. As the treatments are substantially different, this leads to suboptimal or incorrect treatment [7]. Even in this age group, many with asthma have allergic triggers, so failure to diagnose and treat the underlying allergies means the patient will not be as well as they could be. Older patients with dyspnea symptoms are less likely to be referred for specialist evaluation and less likely to have objective tests that could diagnose asthma, such as spirometry [8 ]. &
Which older patients should be tested, and how should we test? Any patient of any age with a history of chronic or recurrent rhinitis, nasal congestion, nasal obstruction, rhinorrhea, postnasal drip, or sinusitis should have allergy testing as a part of their workup. It is important to remember that there may be two or more causes contributing to a symptom complex, for example, allergic rhinitis along with gustatory rhinitis or asthma along with COPD. Excellent treatment requires addressing the allergic component. Photoaging and immunosenesence may conspire to make allergy skin testing less sensitive. In our office, skin prick testing (SPT; epicutaneous testing) is our usual starting point. The older the patient, the more Volume 23 Number 3 June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Allergy in the geriatric population Calhoun
likely he/she is to require intradermal testing (IDT) to fully define his/her allergic profile. In-vitro testing such as radioallergosorbent test or ImmunoCap testing can be useful, for example, in patients who cannot pause their use of medications that interfere with skin testing such as antihistamine. In my experience, however, in-vitro allergy testing is less sensitive than invivo testing, so reliance on blood testing alone may result in missing the allergic evidence. On the contrary, enthusiasm for the sensitivity of skin testing must be tempered by the consideration of comorbidities, and the likelihood of less cardiopulmonary reserve and a poorer outcome should a systemic reaction or anaphylaxis occur. For older patients presenting with dyspnea, especially new-onset dyspnea, asthma should definitely be considered. Fractional exhaled nitric oxide requires only a gentle breath, and an abnormally high score on this can suggest asthma. Spirometry, although requiring a little more focused effort from the patient, can be successfully performed by most of the elderly. When spirometry is performed before and after administration of albuterol, the asthmatic patient shows a marked increase in breathing capacity. This reversibility is the hallmark of asthma. Both of these tests, fractional exhaled nitric oxide and spirometry, require minimal investment in equipment and can be easily performed in an office setting.
Are best treatments for older patients with asthma and allergies different from the way we treat younger patients with similar problems? Treatment of allergies and asthma in the elderly is often complicated by comorbidities [9]. One study found that older patients with asthma more often than not also had heart disease and/or hypertension, and were unable to discern whether their dyspnea symptoms were from asthma or another cause. Education and a close working relationship between patient and physician will obviously result in better disease control. Allergen avoidance strategies are the front line of allergy control in the elderly population. Often these patients live in older homes with older furnishing that have accumulated dust mites, cockroach and rodent droppings, and mold over the course of a lifetime. A deep cleaning of the house and upholstered furniture and drapes, frequent washing of washable furnishings, and removal of older carpets can dramatically decrease daily allergen exposure. Adding a high efficiency particle arrestor (HEPA) filter and instituting daily nasal isotonic saline irrigations are additional nonmedication methods of decreasing allergy symptoms.
In the older patients, medications for allergies can have troublesome risks, side-effects, and unwanted interactions with other medications. Nasal steroid sprays, usually considered a benign initial allergy therapy, may have detrimental effects on intraocular pressure (IOP). Although the most recent studies suggest this fear may have been overestimated, it is prudent to bear it in mind [10,11]. It is probably not a good idea to start a patient with glaucoma on a nasal steroid spray, and to have a recent IOP measurement in patients over 50 starting on a nasal steroid. This way, if any ocular symptoms occur, there is an IOP baseline for comparison. Of the nonsedating oral antihistamines currently available in the United States, cetirazine, desloratadine, and loratadine need renal and hepatic dose adjustments, whereas fexofenadine and xyzal need only renal adjustments. Immunotherapy is frequently dismissed as inappropriate for allergy or asthma treatment in the elderly. Reasons given range from ‘too old to have enough time to benefit’ to ‘it doesn’t work in older folks’ to ‘it’s too dangerous with their other comorbidities’ [12]. In fact the scanty publications in this area support the well tolerated use of and benefit from immunotherapy in the elderly. Of the handful of studies over the past two decades using subcutaneous (injection) immunotherapy, most have shown marked improvements in symptom scores and medication use. One major benefit of immunotherapy as compared with medications is avoidance of medication side-effects that occur more frequently in the elderly, and avoidance of adding to polypharmacy [2 ,13,14]. One study showed impressive symptom improvement after sublingual immunotherapy (SLIT) for house dust mites in older patients. Perennial allergens like house dust mite, cockroach, and molds are particularly prevalent in the elderly, so this is very encouraging. It is especially encouraging in the use of SLIT, with its excellent safety record and convenience [13,14]. Many older patients take beta-adrenergic blocking medications for hypertension or other problems [15 ]. Traditional wisdom is that taking beta-blockers is a contraindication for receiving immunotherapy. This is because the patient who is betablockaded will respond differently to epinephrine should it be needed. Recent studies show, however, that being on a beta-blocker does not increase the frequency of reactions, although some of the rare anaphylactic reactions can have an unusual indolent or hard-to-treat course. SLIT, with its excellent safety profile, is a great choice for patients on betablockers. In our office, we will also administer subcutaneous immunotherapy to patients on beta-blockers after thorough discussion with the &&
&&
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237
Allergy
patient of the risks and benefits. Remember that although intuition might suggest that a cardioselective beta-blocker would be less of a risk, this is in fact incorrect, with all types of beta-blockers appearing to carrying similar risk-of-unusual-anaphylaxis profiles. Asthma in the elderly has a reputation as being more difficult to control, which may be because earlier clinical studies often did not include patients over age 60 or 65. Recent studies suggest this is not totally true, although asthma deaths, while declining in most age groups, are actually increasing in older patients. Ponte et al. showed that if proper treatment and follow-up are used in this age group, response to appropriate treatment is good. Starting treatment with inhaled corticosteroids, as is done in younger patients, appears to be the best approach [16]. Hand–eye and breathing coordination can be a challenge in the elderly patient with movement disorders or cognitive disturbances. Careful education and coaching, including using a spacer, can be helpful. A few of the current asthma inhalers are breath activated, which may also be helpful. Finally, considering oral medications such as leukotriene modifiers is also worthwhile in these patients. Although there are few past studies specifically addressing asthma treatment in the elderly, interest in this underdiagnosed disease is increasing, and clinical studies of the older age groups are underway.
CONCLUSION Allergies and asthma occur often enough in elderly patients to earn a regular place on the differential diagnosis of patients presenting with oculonasal or respiratory symptoms. Their impact on quality of life is severe enough to make missing this treatable diagnosis unfortunate. In-vivo testing (SPT or IDT) is preferred to in-vitro testing if it is not medically contraindicated. Whether allergies revealed on IDT following negative SPT are clinically relevant remains unsettled. Geriatric patients with new-onset or worsening apparent COPD, bronchitis, and/or cough should have exhaled fractionated nitric oxide, spirometry (before and after albuterol), or both. Finding a reversible component to a respiratory problem alters the treatment approach, leading to potentially better outcomes for these patients. Avoidance measures, including nasal isotonic saline irrigation, are the safest treatment for allergy in all age groups and should be strongly recommended. Many geriatric patients have lived in the same home for decades. Often, the upholstered 238
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furnishings and mattresses are older and may harbor mold and dust mites. For smokers, the scent and residue of cigarette smoke may permeate soft furnishings. A thorough cleaning to decrease mold, dust mites, and animal danders is likely to be helpful, even for the nonallergic. Likewise, a HEPA filter, especially in the bedroom, will certainly not hurt, and the resulting improvement in indoor air quality could be helpful to allergic and nonallergic patients alike. The same medications useful in younger groups are useful in the elderly, with the exception of firstgeneration antihistamines and decongestants. For the available medications, physicians must be familiar with the contraindications, dose modifications, and interactions with other medications. Careful consideration of therapeutic choices is necessary in this age group in which comorbidities, polypharmacy, and frailty are common. Pending future age-specific studies, allergy immunotherapy appears to be effective in immune modification and symptom relief in elderly patients. Depending on the physician’s treatment philosophy, this means offering allergy immunotherapy early in the course of treatment (the author’s preference) or after all environmental changes, and possible medications have proven insufficient for reasonable disease control (traditional wisdom). Diagnosis and treatment of inhalant allergies and asthma in the geriatric population become increasingly relevant as the number of older adults in the United States increases. There are a multitude of questions and studies to be performed in this segment of the population, making this a fruitful area of potential research for today’s residents and fellows. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Cardona V1, Guilarte M, Luengo O, et al. Allergic diseases in the elderly. Clin Transl Allergy 2011; 1:11.
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Allergy in the geriatric population Calhoun 2. Klimek L. Old, wise and allergic: allergies are no longer solely disease of the grandchildren. Int Arch Allergy Immunol 2014; 163:75–76. This is a succinct and well written summary of allergies in the older patient. The author reviews prevalence, the immunology of allergies and asthma, and treatment options. 3. Campo P, Rondo´n C, Gould HJ, et al. Local IgE in non-allergic rhinitis. Clin Exp & Allergy. (in press). Excellent summary of what is currently know about local specific IgE in the absence of systemic evidence such as positive skin tests or in-vitro testing. 4. Karabulut H, Baysal S, Acar B, et al. Arch Gerontol Geriatr 2011; 53:270– 273. 5. Wu¨thrich B, Schmid-Grendelmeier P, Schindler C, et al. Prevalence of atopy and respiratory allergic disease in the elderly SAPALDIA population. Int Arch Allergy Immunol 2013; 162:143–148. 6. Madeo J, Li Z, Frieri M. Asthma in the geriatric population. Allergy Asthma Proc 2013; 34:427–433. 7. Scichilone N, Pedone C, Battaglia S, et al. Diagnosis and management of asthma in the elderly. Eur J Intern Med 2014; 25:336–342. 8. Porsbjerg C, Sverrild A, Stensen L, Backer V. The level of specialist assess& ment of adult asthma is influenced by patient age. Resp Med. (in press). This is a fascinating study demonstrating ‘ageism’ in medicine, older patients were less likely to be referred to a specialist for evaluation of their breathing symptoms.
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9. Wardzyn´ska A, Kubsik B, Kowalski ML. Comorbidities in elderly patients with asthma: association with control of the disease and concomitant treatment. Geriatr Gerontol Int. (in press). 10. Seiberling KA, Chang DF, Nyirady J, et al. Effect of intranasal budesonide irrigations on intraocular pressure. Int Forum Allergy Rhinol 2013; 3:704–714. 11. Yuen D, Buys YM, Jin YP, Trope GE. Effect of beclomethasone nasal spray on intraocular pressure in ocular hypertension or controlled glaucoma. J Glaucoma 2013; 22:84–87. 12. Milani M. Allergen-specific immunotherapy for allergic rhinitis in the elderly: is it never too late? Immunotherapy 2013; 5:699–702. 13. Bozek A, Ignasiak B, Filipowska B, Jarzab J. Allergen-specific immunotherapy for allergic rhinitis in the elderly: is it never too late? Immunotherapy 2013; 5:699–702. 14. Bozek A, Ignasiak B, Filipowska B, Jarzab J. House dust mite sublingual immunotherapy: a double-blind placebo-controlled study in elderly patients with allergic rhinitis. Clin Exp Allergy 2013; 43:242–248. 15. Ridolo E, Montagni M, Bonzano L, et al. Arguing the misconceptions in && allergen-specific immunotherapy. Immunotherapy 2014; 6:587–595. This is another very well written article addressing the more common ‘myths’ about immunotherapy. It supplies solid evidence with quality references to back up its ‘myth-busting’. 16. Boulet LP. Is asthma control really more difficult to achieve in the elderly patient? Int Arch Allergy Immunol 2014; 165:149–151.
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