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Improving the management of asthma in older adults NS721 Carnegie E, Jones A (2013) Improving the management of asthma in older adults. Nursing Standard. 28, 13, 50-58. Date of submission: July 9 2013; date of acceptance: September 6 2013.
Abstract
Aims and intended learning outcomes
Older people with asthma are a discrete patient group that requires specialist nursing skills and knowledge. They have specific and sometimes hidden needs that will affect their quality of life unless these are addressed by caring and competent nurses who have an interest in asthma. It is necessary to focus on both asthma and ageing to help older people achieve good asthma outcomes. This article discusses the complex physical, social and psychological issues affecting people with asthma aged 64 or older, age-related risk factors for poor control, age-related barriers to assessment and treatment, the scope of pharmacological and non-pharmacological approaches, and principal treatment outcomes. Providing high quality services and information will equip older people to manage their asthma more effectively, attain physical and mental wellbeing, and lead to fewer hospitalisations and fatal episodes in this group.
Authors Elaine Carnegie Policy officer, Asthma UK, Edinburgh. Angela Jones Asthma nurse specialist, Asthma UK, London. Correspondence to: [email protected]
Keywords Ageing, asthma, asthma exacerbations, older people, self-management
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This article focuses on the physical and psychosocial needs of older adults (aged 64 or older) with asthma. After reading this article and completing the time out activities you should be able to: 4Describe age-related structural and functional changes that affect the respiratory system. 4Discuss asthma-related mortality and morbidity in later life. 4Understand barriers to the diagnosis and treatment of asthma in older adults. 4Explain the aims of treatment for older people with asthma. 4Discuss self-management of asthma in older adults.
Introduction Despite the high morbidity and mortality associated with asthma in older people, the evidence base and care of this group of patients remain neglected worldwide (Gibson et al 2010, British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) 2012, Gillman and Douglass 2012). Older people have low expectations of healthcare services, reporting higher rates of satisfaction while experiencing greater frequency of symptoms. There is also evidence that some healthcare professionals may have low expectations of the care this group of patients receive, attributing their symptoms to age-related diseases rather than asthma, and failing to ascertain how asthma limits their physical activity in comparison with younger individuals (Asthma UK 2005, Byles 2005).
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Inappropriately treated asthma can lead to poor lung function, impaired quality of life, disability and increased risk of life-threatening asthma attacks in all age groups (Global Initiative for Asthma (GINA) 2012). Owing to the specific and sometimes hidden needs of older people with asthma, it is essential that all patients in this group receive comprehensive asthma care, including those with complex needs such as learning disabilities, mental health problems or dementia (GINA 2012).
Asthma and ageing Ageing and health problems in later life can lead to loss of independence, identity and dignity (Lloyd et al 2011). Ageing can result in changes in social relationships, gender differences in coping with personal illness and stress, financial difficulties, isolation, loneliness, and difficulties in accessing transport and health care (Byles 2005). Some of these factors can affect how, and if, older people access asthma care. Asthma imposes more constraints on the lives of older people than younger people with the disease. Older people are more likely to say that their asthma ‘often’ prevents them from going out with friends to restaurants or from playing with grandchildren, and their asthma ‘often’ makes them avoid using stairs (Asthma UK 2005). Older people are also more likely to report fair or poor general health, have lower expectations of treatment and experience poorer healthcare services than younger people with asthma; however, older people require greater access to asthma information and are more likely to have other long-term conditions (Gibson et al 2010). These constraints demand a comprehensive response from healthcare services so that the physical, social and psychological issues of ageing and asthma are addressed and treatment is delivered by caring, competent healthcare professionals to preserve patients’ quality of life (Lloyd et al 2011). Complete time out activity 1
Physiology of ageing There is a progressive decline in lung function from the age of 20 in women and the age of 25 in men (Gibson et al 2010). Chest expansion may become constricted because of loss of vertebral height, osteoporosis and advancing kyphosis (Ennis 2013). Changes in the structure, physiology and function of the respiratory system can exacerbate existing narrowing of the airways and increase the risk
of pulmonary infections (Gibson et al 2010, King and Hanania 2010, Hwang et al 2012, McDonald et al 2013). In addition, patients are less aware that their airways are becoming narrower with age, and the sensitivity of the cough reflex is reduced, which can contribute to a delay in diagnosing asthma in older people (Berend 2005). Other physical changes to the lungs with ageing include (Berend 2005): 4Reconfiguration of the chest wall as a result of calcification of the rib cage and a decrease in respiratory muscle strength. 4Reduced ability of the diaphragm to generate force. 4Impairment of mucociliary clearance. 4Loss of elastin fibres, resulting in reduced vital capacity and increased air trapping. 4Reduced number of alveoli and increased size of the alveolar ducts. 4Decrease in function of beta2 adrenergic receptors. Pharmacokinetic changes in older people can also lead to increased incidence of adverse drug reactions, resulting in the development of asthma, persistence of asthma symptoms, and physical and mental distress from side effects of asthma treatments such as beta2 agonists (Downie et al 2008). Beta2 agonists stimulate beta2 adrenergic receptors to mimic the effects of adrenaline (epinephrine) or noradrenaline (norepinephrine), which leads to relaxation of the bronchial smooth muscle and increased mucociliary clearance. Beta blockers interfere with the binding of adrenaline and other stress hormones to adrenoceptors, leading to constriction of the bronchial smooth muscle (Kassianos et al 2005). Beta blockers that block beta2 receptors may cause shortness of breath for people with asthma, therefore they should not be prescribed, and people with asthma should be asked if they have had a past reaction to using them (BTS/SIGN 2012). Cognitive impairment, sensory impairment, decreased peak inspiratory flow, poor co-ordination, decreased manual dexterity resulting from arthritis, and decreased press and breathe co-ordination during inhaler use may lead to unintentional poor medication adherence in older people with asthma (Goeman and Douglass 2007, Gibson et al 2010).
Mortality and morbidity The prevalence of asthma in older adults aged 65 or older is estimated to be 6-10% in the developed world (Gibson et al 2010). In the UK, around four fifths of asthma-related deaths and
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1 Revise the characteristics of asthma before reflecting on the normal anatomy and physiology of the upper and lower respiratory tract. You may find chapters 1 and 2 of the GINA (2012) guideline useful. List the main aspects of anatomy involved in the pathophysiology of asthma and how these might affect asthma in older people as a result of the effect of ageing on the respiratory system.
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CPD respiratory nursing more than 10% of hospital admissions as a result of asthma are in the over 65 age group (Office for National Statistics 2011). In Australia and the United States, patients over 65 have increased asthma mortality rates, hospital admission rates and lengths of hospital stay in comparison with younger age groups with asthma (Baptist et al 2010, Jones et al 2011). Hospitalisation rates may be correlated with a high risk of respiratory tract infections in older people and are influenced by socioeconomic status (Olivenstein and Hamid 2011). Although mortality rates can be confounded by other causes of dyspnoea, there is evidence of seasonal variation; mortality rates in older people peak during December and January in contrast to those aged under 44 where mortality peaks in July and August (Marks and Poulos 2005, BTS/SIGN 2012). According to Baptist et al (2010), greater mortality and morbidity in older people with asthma are partly as a result of the increased frequency of cardiovascular comorbidities, which are a known risk factor for asthma death. Risk factors associated with deaths related to asthma include depression, smoking, suboptimal use of inhaled corticosteroid therapy, patients underestimating the severity of their symptoms, lack of education about what to do in an emergency and patients not wanting to make a fuss (Gibson et al 2010, Asthma UK 2012). Hoskins et al (2001) reported that, despite people aged over 65 with asthma being more likely to receive higher doses of inhaled corticosteroids and demonstrating greater compliance, they experienced more symptoms than younger people, with almost three quarters of the older patient group reporting symptoms. Persistent physical symptoms can lead to psychological distress and, ultimately, to a reduction in functional status. Ho and Jones (1999) found that there was increased psychological morbidity (depression and anxiety), a known risk for life-threatening exacerbations, and higher numbers of hospital visits by older people with self-reported asthma than those without asthma (BTS/SIGN 2012). It is important to remember that exclusion of older people with asthma in care homes from community health services may contribute to an underestimation of morbidity (Ho and Jones 1999, Gibson et al 2010).
Barriers to care Adult-onset asthma
Older people may have developed asthma in childhood, adolescence or adulthood. The risk
factors for developing asthma in adulthood include genetic susceptibility, hormonal changes in some women, exposure to indoor and outdoor pollutants, occupational exposures, excess body weight, rhinitis, medications such as beta blockers, and viral and bacterial infections (Jones et al 2011).
Underdiagnosis
Respiratory symptoms are common in people over 75 years and may be associated with lung disease, heart disease or cancer (Gibson et al 2010). It can, therefore, be difficult to diagnose asthma in older adults, which can be frustrating for people who feel they have been living with asthma-like symptoms for months or even years (Gibson et al 2010). Underdiagnosis may also occur as a result of a combination of under-reporting of symptoms by the patient, possibly because of social isolation or cognitive impairment, and underdiagnosis by the physician (Dow 1998). From a cross-sectional population-based survey of 6,000 adults, researchers estimated that 2.4% of men and 1.2% of women aged 65 or over had untreated asthma even though some participants had been diagnosed previously with the condition (Dow et al 2001). Dow et al (2001) suggested that 15-20% of older adults may have untreated asthma if they have been diagnosed in the past or experience wheeze or breathlessness at rest. Wilson et al (2005) found that people with undiagnosed asthma saw a GP as often as those diagnosed with asthma. Further research is required to discover whether patients with undiagnosed asthma had noticed, recognised or reported their symptoms to the GP or whether the GP was unable to diagnose asthma. Underdiagnosis of asthma may also occur as a result of underuse of objective tests, such as spirometry. Even though some older people will be unable to use a peak flowmeter or spirometer, spirometry can be adequately tested in more than 90% of older patients when staff are appropriately trained, the equipment is used correctly and there is rigorous quality control (Gibson et al 2010, Primary Care Commissioning 2013). Other factors that can contribute to underdiagnosis of asthma in older people are self-limitation of activities, depression, the misconception that adult-onset asthma is rare, and misdiagnosis of chronic obstructive pulmonary disease (COPD) (Gibson et al 2010). It is important, but difficult, to distinguish between asthma and COPD in clinical practice. Asthma is characterised by spontaneous
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variability of airway obstruction and patients are often symptomatic when lung function tests are normal, whereas most patients with COPD do not report their symptoms until lung function deteriorates to below 50% of its predicted value (Doherty 2003). Dyspnoea in patients with COPD is mainly triggered by exertion, whereas in asthma there are other triggers such as allergens, cold air and irritants (Jenkins et al 2005). Healthcare professionals should consider diagnosis and treatment of asthma when presented with several co-existing conditions. Congestive heart failure, obesity, anaemia, general unfitness and obstructive lung disease may individually or collectively cause breathlessness. It is also important to consider a person’s past or present occupation when considering a diagnosis of asthma – occupational exposures account for one in six cases of asthma in adults of working age (British Occupational Health Research Foundation 2010). Comprehensive asthma management for older people must begin with ensuring the diagnosis has been verified, preferably by objective testing using spirometry. Specific questions should be asked to identify respiratory symptoms suggestive of asthma, such as a full history of specific as well as vague unresolved symptoms, history of atopy, previous occupation, smoking history and response to previous treatment trials (Gibson et al 2010). By assessing and managing systemic problems and comorbidities related to asthma, healthcare professionals can address current problems and assess future risk of asthma in older people (Marks et al 2009). Medications used to treat comorbidities may exacerbate asthma symptoms; it is important to remember that beta blockers and non-steroidal anti-inflammatory drugs (NSAIDs), including acetylsalicylic acid-based medications, can trigger asthma symptoms in adults of all ages (Dow 1998). Comorbidities can be complicated by drug interactions, polypharmacy, inhaler device polypharmacy and impaired use of devices contributing to poor symptom control (Gibson et al 2010). Complete time out activity 2
Misperception of symptoms Older patients with asthma tend to under-report symptoms and present for medical care later in their disease course than younger patients. Older people may believe their symptoms are a natural part of the ageing process, or because symptoms of asthma are often non-specific they can be confused with symptoms of other respiratory
and cardiovascular diseases such as chest tightness or breathlessness (Jones et al 2011). For some, shortness of breath may be their only symptom. Other reasons for misperception of symptoms include (Jones et al 2011): 4Underestimating the severity of symptoms. 4Less awareness than younger adults of bronchoconstriction as a result of ageing processes in the respiratory system. 4Cognitive decline. 4Poor knowledge and understanding of asthma as an inflammatory condition. 4Low expectations regarding activity and mobility. In an exploratory qualitative study of 46 adults aged over 65 with asthma, Baptist et al (2010) reported that: 4Asthma was often described as feelings of fatigue and lethargy. 4Patterns of symptoms often changed over time. 4Participants were unable to distinguish between symptoms of asthma and those of cardiac problems such as shortness of breath and chest tightness. 4Participants tended not to discuss symptoms with other people, including family members. Evers et al (2013) called for greater provision of knowledge and understanding of asthma and its symptoms among older people to encourage them to consider asthma as a possible reason for their symptoms and to seek a diagnosis.
Changing symptom patterns and triggers Some people who have had asthma all their life may find it starts affecting them in different ways as they get older. For example, they may have coughed or wheezed previously, but may notice they become more breathless. Older people are less likely to have periods of remission, and changes in symptom patterns and triggers may add to confusion regarding the relevance and severity of symptoms. Many older people with asthma appear to be compliant with treatment, but in reality they may feel confused or anxious about their symptoms and treatment (Asthma UK 2012). Therefore, it is important, in discussion with the person, to identify personal asthma triggers as well as triggers experienced indoors and outdoors. Common triggers of asthma symptoms include: influenza, colds and other viral infections; exercise; laughing; anxiety; some medications, for example aspirin, beta blockers and NSAIDs; irritants, such as cigarette smoke, cold air, perfumes and chemical fumes; and allergens, for example house-dust mites, furry or feathered pets, pollen and mould spores.
2 Review the BTS/ SIGN (2012) guideline. List the investigations you would consider if a patient presents with atypical or additional signs and symptoms.
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CPD respiratory nursing It was previously thought that adult-onset asthma was likely to be triggered by non-allergic rather than allergic inflammation (atopy), such as sensitivity to house-dust mites. However, there is increasing evidence of older people with asthma being more likely to have underlying allergies – many of these allergies may be known, but may not have been investigated. Therefore, it is important to remember that adults can become sensitised to allergens at any age (Busse et al 2013). Testing for possible allergies and subsequent counselling regarding environmental allergy exposure needs to be considered in older people with asthma. Complete time out activity 3
Treating older people with asthma
3 Look up the Royal College of Physicians Three Questions in the BTS/SIGN (2012) guideline and the Asthma Control Test (tinyurl.com/ns8b4ag). Having read about these tools, consider how you might further explore and understand the experiences of older people with asthma. List the questions that would help you explore a patient’s quality of life, asthma control, activity, mobility and psychosocial needs. 4 Access the Guide to Good Asthma Care for Adults and Children with Asthma (Asthma UK 2010). Review the sections on diagnosis, self-management and regular structured review, and consider how this applies to older people. Compile a checklist for the care of a newly diagnosed older person with asthma.
The aims of asthma treatment in older people are to (Dow 1998, Smith et al 2012): 4Minimise symptoms and physical disability, and increase quality of life. 4Develop patient and carer understanding and skills necessary to manage asthma effectively. 4Remove or reduce complications of underlying disease. In one exploratory participatory study, older people with asthma were confused about their diagnosis, had poor understanding of asthma and their asthma medicines, and reported low, irregular provision of emergency advice, written personal asthma action plans and asthma reviews (Asthma UK 2012). Once the diagnosis has been clarified and discussed with the person, patient education must cover (Asthma UK 2010): 4Achievement of asthma control through pharmacological and non-pharmacological strategies. 4Short and long-term side effects of medicines. 4Risk of exacerbations. 4Identification of triggers in the indoor and outdoor environment. 4Discussion of a written asthma action plan, including recognition of worsening symptoms. 4How to deal with breathlessness during exercise. 4What to do when symptoms worsen. 4What to do in an emergency and who to contact – this is particularly important for patients who live alone, or in rural or remote areas. Emergency care information should include (SIGN 2011): 4What happens during an asthma exacerbation. 4How to recognise an asthma exacerbation.
4Actions to take during an asthma exacerbation. 4Treatment of an asthma exacerbation. In the presence of comorbidities or disability, it is essential to assess activities of daily living and mobility. This includes asking patients about their social networks and availability of community support. In addition to offering treatment, it is important for the healthcare professional to allow time for patients to ask questions and to explore their understanding of asthma and how they feel about managing their condition at home. Evaluating functional and psychological status is useful when assessing older people with asthma. This will involve the assessment of mood and cognitive function. It is important that healthcare professionals take time to assess patients, including how they are feeling not only during the consultation, but over the preceding weeks and months. Feelings of defeat and frustration may be present in patients who are juggling comorbidities, persistent symptoms and polypharmacy. Anxiety, depression and despair compounded with social isolation increase the risk of an asthma exacerbation (Ross et al 2013). It is, therefore, necessary to offer appropriate pharmacological, psychological and social support. Complete time out activity 4
Medication Following diagnosis, every person with asthma should be treated according to one of the five steps of treatment described in the BTS/SIGN (2012) guideline. Each step includes medicines that correspond to the severity of disease to improve and maintain control of symptoms. Healthcare professionals should ensure that every patient understands which treatment step they are currently on. Concerns about taking corticosteroids are widespread among people with asthma and can be a significant barrier to treatment adherence (Bellia et al 2009). These concerns are of particular importance for older people with asthma because of the physiological effects of ageing. For example, older people are more likely to experience adverse effects from high-dose inhaled corticosteroids, leading to the development of purpura and bruising as a result of increased skin fragility and reduced skin elasticity. Beta2 agonists may be less effective in relieving symptoms and the adverse effects associated with these drugs, such as increased heart rate and tremor, are more noticeable in older people
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(Goeman and Douglass 2005, Gupta and O’Mahony 2008). The adverse effects of beta2 agonists are a direct disincentive to their use. Unless using a dry powder device, high-dose inhaled corticosteroids should be administered with volumatic spacers and the mouth should be thoroughly rinsed afterwards to decrease systemic absorption and prevent side effects such as oral candida (Dow 1998). Systemic side effects of oral corticosteroids include confusion or psychosis and further bone damage in people who already have osteoporosis. It is important that the bone mineral density of patients on long-term oral corticosteroid treatment is monitored and, if there is a significant reduction, a long-acting bisphosphonate should also be given (BTS/SIGN 2012). If older people have swallowing difficulties they may require soluble oral corticosteroid tablets. Older people with asthma might fail to adhere to treatment advice because of reasons out of their control, such as impaired vision; musculoskeletal problems affecting their ability to use inhaler devices; ineffective communication between the patient and healthcare professional; and failing to remember how often to take their medication (Gibson et al 2010). Depression can also lead to non-adherence. Polypharmacy increases the risk of adverse outcomes and poor medication adherence, and in some cases the medications used to treat comorbidities may exacerbate asthma symptoms (Goeman and Douglass 2005). Complete time out activity 5
Inhalers and inhaler technique Difficulties relating to poor medication adherence in older people are compounded by difficulties in using pressurised metered-dose inhaler devices (PMDIs) (King and Hanania 2010). The use of spacers, particularly with preventive medication, can improve the delivery of asthma medications in older people (Goeman and Douglass 2005). Nurses and pharmacists should conduct a regular review of PMDI and dry powder devices in older patients with asthma. This review must include patients in private nursing and care homes, where governance arrangements and training may not include educating staff about correct inhaler technique (The Health Foundation and Age UK 2011).
Choice of inhaler
The choice of inhaler device is crucial. The nurse must remember to:
4Check the patient’s level of understanding, signs of neuromotor impairment, visual acuity and dexterity. 4Highlight aids for the chosen device, such as Turbogrip, raised dots, dose counter and Haleraid (an aid that fits on to a PMDI allowing it to be activated by a pincer movement). 4Discuss the importance of correct inspiratory flow rate for the device. 4Explain to the patient that he or she may be able to taste the medication from a dry powder inhaler. In rare cases, individuals may experience paradoxical bronchospasm when the aerosol gas reaches the pharynx and larynx (Nicklas 1990). Using a PMDI with a spacer or changing to a dry powder inhaler should resolve this problem.
Assessing inhaler technique
Inhalation airflow meter devices help healthcare professionals and patient to assess and correct inspiratory flow rate when selecting a suitable device. However, when assessing inhaler technique, the patient’s own inhaler or a placebo should be used to assess dexterity, visual acuity, and the steps of priming, shaking, position and dose counter (Pearce 2011). Instruction regarding inhaler use should include checking expiry dates, and cleaning and storing the spacer and inhalers. Co-ordinating deployment of manual aerosol inhalers with respiratory movements is difficult; therefore, a spacer can be used to promote good drug delivery into the lungs (Asthma UK 2013). A Haleraid can also be used with a spacer to help overcome manual dexterity problems. Breath-actuated inhalers can remove some of the problems associated with poor co-ordination; however, spacers cannot be used with breath-actuated inhalers. When selecting a suitable inhaler device, the healthcare professional should: 4Assess whether the patient requires a spacer, identify the most suitable spacer and discuss which method of delivery (single or multibreath technique) is most appropriate. 4Explain the role of spacers (to help more of the medicine get into the airways) and that they should ideally be used with reliever inhalers during an asthma attack. Complete time out activity 6
Self-management Ageing and its associated social, physical and economic limitations requires that older people
5 Examine the five treatment steps outlined in the BTS/SIGN (2012) guideline. Choose a corticosteroid inhaler and bronchodilator inhaler and look up their properties in the British National Formulary or the electronic Medicines Compendium. Compile the information that the healthcare professional should communicate to an older person prescribed these medicines. 6 Watch the inhaler technique demonstrations for inhalers and spacers on the Asthma UK website (www.asthma. org.uk/knowledgebank-treatment-andmedicines-using-yourinhalers). List the main points of a discussion you would have with an older person about his or her choice of inhaler device and technique.
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CPD respiratory nursing
7 If your organisation has developed a personal asthma action plan, consider its suitability and appropriateness for older people. Make a list of what might need to be revised to make it more appropriate for older people with asthma. Search for a range of other self-management tools, such as plans, peak-flow diaries or asthma attack cards, either from the NHS or other respiratory-specific organisations. Note if and how these tools address the specific needs of older people with asthma and their carers.
are equipped to manage their asthma at home or in a residential setting (The Health Foundation 2011). It is essential that older people are able to recognise when their asthma is worsening and not to delay their use of reliever medication (Allen and Khattab 2012). It is also important that older people know whether they are administering their medicine correctly, that they can assess whether it is relieving their symptoms and, if it is not, what to do about it. Self-management has been defined as ‘the successful outcome of the person and all appropriate individuals and services working together to support them to deal with the very real implications of living the rest of their life with one or more long-term condition’ (Long Term Conditions Alliance Scotland and the Scottish Government 2008). Self-management support can be viewed in two ways: ‘as a portfolio of techniques and tools that help patients choose healthy behaviours; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership’ (The Health Foundation 2011). Tools to increase patient confidence in self-management of asthma include personal asthma action plans, patient-held records and the provision of accessible information. Personal asthma action plans are designed to encourage people with asthma, and their carers, to take more responsibility for the management of asthma in partnership with healthcare professionals. These plans have been shown to improve symptom control and reduce use of healthcare services (Gibson and Powell 2004). The plan is a written record of what action to take when asthma symptoms worsen or peak flow measurements deteriorate, and includes information about when to seek medical help or access emergency services. Plans are aimed at people with regular symptoms who are at risk of having an exacerbation as well as those wishing to become more involved in self-managing their condition. The action plan involves an explanation by a doctor or nurse about signs of deterioration and information about prescribed medication to help prevent a severe asthma attack. The plan also indicates when to return for an asthma review (Gibson and Powell 2004). Misperception of symptoms may make it more difficult for older people with asthma to follow a symptom-based personal asthma action plan (Goeman and Douglass 2005). Some people prefer to use a symptom-based asthma action plan, whereas others prefer to use a peak-flow based management plan, or a combination of both (Goeman and Douglass 2007, Huang
et al 2009). The nurse should give patients and family members a written copy of their agreed asthma action plan, and should use follow-up telephone calls to address the concerns of patients and family members, monitor patients’ progress, review medicines use and adjust the asthma action plan (Akgün et al 2012). Attitudes to self-management and self-management plans need to be explored primarily with older people themselves (Goeman and Douglass 2007). Because of lower expectations, many older people will put up with symptoms and are reluctant to complain about them, even to their family. It is, therefore, important to make patients feel that they can question or challenge their treatment (Asthma UK 2012). Attention needs to be focused on strengthening the patient-nurse therapeutic relationship to improve asthma outcomes (Huang et al 2009). Each older person with asthma should have a named asthma nurse within primary care. Older people particularly appreciate being treated as intelligent people with a part to play in their own treatment and care, and as individuals with their own history, preferences, fears and beliefs. Demonstrating an awareness of the effect of asthma on patients, and treating these individuals with respect may also be helpful. Complete time out activity 7
Asthma education It is imperative to identify effective and efficient ways of providing detailed and personalised information in a way that meets the educational needs of older people with asthma. The aim of asthma education is to optimise patients’ asthma management and prevent them from experiencing unnecessary symptoms in the long term (SIGN 2011). Management of older people with asthma will improve if their specific needs are addressed with written asthma information and a written asthma action plan. Huang et al (2009) conducted a randomised controlled trial to examine the effectiveness of individualised self-care education programmes for older people with moderate to severe asthma. The researchers reported that, even though there was no difference in rates of emergency care, patients who received individualised education with peak-flow monitoring had significantly higher asthma self-care behaviours, including better medicines use, self-monitoring and environmental control, and self-confidence scores and asthma control indicators than those
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who received usual care and those who received education alone. Self-management and education topics should also include exposure to tobacco smoke, exercise, air pollution and vaccinations.
Tobacco smoke
Smoking accelerates deterioration of lung function in people with asthma, impairs corticosteroid response and increases mortality (Gibson et al 2010). Nicotine pharmacokinetics in older age do not appear to diminish the effect of nicotine replacement treatment. Innovative methods should be used to encourage older people to access nicotine replacement therapy and smoking cessation services (Gibson et al 2010). Older people who smoke are at greater risk than non-smokers of developing cardiovascular disease or cancer and of experiencing cognitive decline, including dementia (The Scottish Government 2011).
Exercise
It is important to discuss the older person’s mobility to determine whether any mobility problems are the result of poor fitness levels, asthma or other comorbidities. The healthcare professional should check whether the person with asthma needs to take his or her reliever medication during exercise and whether the medication is relieving symptoms. People with persistent breathlessness will need to be referred to respiratory specialists for assessment and pulmonary rehabilitation, if possible. It is important to encourage older people with asthma who are generally fit and do not have other health conditions that limit their mobility to be active daily.
Air pollution
Air pollution can trigger symptoms in people who already have asthma, leading
References Akgün KM, Crothers K, Pisani M (2012) Epidemiology and management of common pulmonary diseases in older persons. Journals of Gerontology: Series A Biological Sciences and Medical Sciences. 67A, 3, 276-291. Allen SC, Khattab A (2012) The airflow resistance sensing threshold during tidal breathing rises in old age in patients with asthma. Age and Ageing. 41, 4, 557-560. Andersen ZJ, Bønnelykke K, Hvidberg M et al (2012) Long-term exposure to air pollution and asthma hospitalisations in older adults: a cohort study. Thorax. 67, 1, 6-11. Asthma UK (2005) Out of Sight, Out of Mind. Asthma in Scotland Today. tinyurl.com/op7w8fl (Last accessed: November 15 2013.) Asthma UK (2010) Guide to Good Asthma Care for Adults and Children with Asthma. tinyurl.com/nmw5woe (Last accessed: November 15 2013.) Asthma UK (2012) ‘The Forgotten Generation?’ tinyurl.com/op7w8fl (Last accessed: November 15 2013.) Asthma UK (2013) Using your Inhalers. tinyurl.com/pnkxyeh (Last accessed: November 15 2013.) Baptist AP, Deol BK, Reddy RC, Nelson B, Clark NM (2010)
Age-specific factors influencing asthma management by older adults. Qualitative Health Research. 20, 1, 117-124.
Byles JE (2005) How do the psychosocial consequences of ageing affect asthma management? Medical Journal of Australia. 183, 1, S30-S32.
Bellia V, Scichilone N, Battaglia S (2009) Asthma in the elderly. European Respiratory Society Monograph. 43, 56-76.
Doherty DE (2003) Identification and assessment of chronic obstructive disease in the elderly. Journal of American Medical Directors Association. 4, 5, S116-S120.
Berend N (2005) Normal ageing of the lung: implications for diagnosis and monitoring of asthma in older people. Medical Journal of Australia. 183, 1, S28-S29. British Occupational Health Research Foundation (2010) Occupational Asthma. A Guide for Employers, Workers and their Representatives. tinyurl.com/psu2akh (Last accessed: November 15 2013.) British Thoracic Society, Scottish Intercollegiate Guidelines Network (2012) British Guideline on the Management of Asthma. tinyurl. com/9mfwb7 (Last accessed: November 15 2013.) Busse PJ, Cohn RD, Salo PM, Zeldin DC (2013) Characteristics of allergic sensitization among asthmatic adults older than 55 years: results from the National Health and Nutrition Examination Survey, 2005-2006. Annals of Allergy, Asthma & Immunology. 110, 4, 247-252.
Dow L (1998) Asthma in older people. Clinical and Experimental Allergy. 28, Suppl 5, 195-202. Dow L, Fowler L, Phelps L et al (2001) Prevalence of untreated asthma in a population sample of 6000 older adults in Bristol, UK. Thorax. 56, 6, 472-476. Downie G, Mackenzie J, Williams A (2008) Pharmacology and Medicines Management for Nurses. Fourth edition. Churchill Livingstone, Edinburgh. Ennis J (2013) The physiology of ageing. Practice Nurse. 43, 3, 38-42. Evers U, Jones SC, Caputi P, Iverson D (2013) The asthma knowledge and perceptions of older Australian adults: implications for social marketing campaigns. Patient Education and Counseling. 91, 3, 392-399. Gibson P, McDonald VM, Marks GB (2010) Asthma in older adults. The
Lancet. 376, 9743, 803-813. Gibson PG, Powell H (2004) Written action plans for asthma: an evidence-based review of the key components. Thorax. 59, 2, 94-99. Gillman A, Douglass JA (2012) Asthma in the elderly. Asia Pacific Allergy. 2, 2 101-108. Global Initiative for Asthma (2012) Global Strategy for Asthma Management and Prevention. www.ginasthma.org/ documents/4 (Last accessed: November 15 2013.) Goeman DP, Douglass JA (2005) Understanding asthma in older Australians: a qualitative approach. Medical Journal of Australia. 183, 1, S26-S27. Goeman DP, Douglass JA (2007) Optimal management of asthma in elderly patients. Strategies to improve adherence to recommended interventions. Drugs & Aging. 24, 5, 381-394. Gupta P, O’Mahony MS (2008) Potential adverse effects of bronchodilators in the treatment of airways obstruction in older people: recommendations for prescribing. Drugs & Aging. 25, 5, 415-443.
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CPD respiratory nursing to increased hospital admissions (Andersen et al 2012). Those most at risk include people with severe asthma and older people with heart problems or chronic respiratory problems (Met Office 2013). Those living in urban areas should be informed about the free, online, daily air quality index (Met Office 2013), which provides advice on exercising outdoors within current pollution levels.
Influenza and pneumococcal vaccinations
8 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
Influenza and pneumococcal vaccinations reduce the potential severity of infection, risk of hospitalisation and death in adults with asthma or COPD (Pesek and Lockey 2011). Older people with asthma should, therefore, be encouraged to attend vaccination clinics to keep up to date with influenza and pneumococcal vaccinations.
Ho SF, Jones D (1999) Morbidity in older people with self-reported asthma. Age and Ageing. 28, 5, 475-480. Hoskins G, McCowan C, Thomas G, Neville R, Clark R, Smith B (2001) Asthma or COPD? An investigation into the symptom patterns of asthma may highlight the need for more rigorous diagnostic procedures in elderly patients. Primary Care Respiratory Journal. 10, 4, 99-102. Huang T-T, Li Y-T, Wang C-H (2009) Individualized programme to promote self-care among older adults with asthma: randomized controlled trial. Journal of Advanced Nursing. 65, 2, 348-358. Hwang E-K, Jin HJ, Nam Y-H et al (2012) The predictors of poorly controlled asthma in elderly. Allergy, Asthma & Immunology Research. 4, 5, 270-276. Jenkins CR, Thompson PJ, Gibson PG, Wood-Baker R (2005) Distinguishing asthma and chronic obstructive pulmonary disease: why, why not and how? Medical Journal of Australia. 183, 1, S35-S37. Jones SC, Iverson D, Burns P, Evers U, Caputi P, Morgan S (2011) Asthma and ageing: an end user’s perspective – the perception and problems with the management of asthma in the elderly. Clinical and Experimental Allergy. 41, 4, 471-481.
Kassianos G, Chung F, Gruffydd-Jones K, Thomas M, Price D (2005) Best Medicine Asthma. CSF Medical Communications, Long Hanborough. King MJ, Hanania NA (2010) Asthma in the elderly; current knowledge and future directions. Current Opinion in Pulmonary Medicine. 16, 1, 55-59. Lloyd E, Calnan M, Cameron A, Seymour J, Smith R, White K (2011) Maintaining Dignity in Later Life: A Longitudinal Qualitative Study of Older People’s Experiences of Support and Care. tinyurl.com/oszucz2 (Last accessed: November 15 2013.) Long Term Conditions Alliance Scotland, The Scottish Government (2008) “Gaun Yersel!” The Self Management Strategy for Long Term Conditions in Scotland. tinyurl.com/ ngmq9me (Last accessed: November 15 2013.) Marks GB, Poulos LM (2005) A nationwide perspective on asthma in older Australians. Medical Journal of Australia. 183, 1, S14-S16.
Conclusion Older people need to understand that asthma is a widespread and serious condition, and that they need to be able to recognise asthma symptoms and seek a diagnosis. Principal treatment outcomes for older patients diagnosed with asthma are to maintain and increase quality of life. Nurses caring for older patients with asthma require specialist skills and knowledge. Care should include a holistic assessment, recognition of age-related barriers to treatment, the delivery of age-appropriate pharmacological treatment and devices, and non-pharmacological treatments that include individualised education and self-management tools. Offering high quality services and information will assist older people with asthma to attain both physical and mental wellbeing, and will lead to fewer hospitalisations and fatal asthma episodes in this age group NS Complete time out activity 8
coexistent asthma and chronic obstructive pulmonary disease: diagnostic and therapeutic challenges. Drugs & Aging. 30, 1, 1-17.
health care utilization, and control in older adults with asthma. Journal of Allergy and Clinical Immunology: In Practice. 1, 2, 157-162.
Met Office (2013) Daily Air Quality Index. tinyurl.com/nnn7mek (Last accessed: November 15 2013.)
Scottish Intercollegiate Guidelines Network (2011) Managing Asthma in Adults: A Booklet for Patients and their Families and Carers. tinyurl.com/nnkaxtr (Last accessed: November 15 2013.)
Nicklas RA (1990) Paradoxical bronchospasm associated with the use of inhaled beta agonists. Journal of Allergy and Clinical Immunology. 85, 5, 959-964. Office for National Statistics (2011) Mortality Statistics: Deaths Registered in England and Wales (Series DR), 2010. tinyurl.com/ONSmortstat2010 (Last accessed: November 18 2013.) Olivenstein R, Hamid Q (2011) Asthma in the elderly… Their time is right now. Clinical and Experimental Allergy. 41, 4, 457-458. Pearce L (2011) How to teach inhaler technique. Nursing Times. 107, 8, 16-17. Pesek R, Lockey R (2011) Vaccination of adults with asthma and COPD. Allergy. 66, 1, 25-31.
Marks GB, Poulos LM, Jenkins CR, Gibson PG (2009) Asthma in older adults: a holistic, person-centred and problem-oriented approach. Medical Journal of Australia. 191, 4, 197-199.
Primary Care Commissioning (2013) A Guide to Performing Quality Assured Diagnostic Spirometry. tinyurl.com/ovlnh2e (Last accessed: November 15 2013.)
McDonald VM, Higgins I, Gibson PG (2013) Managing older patients with
Ross JA, Y Yang, Song PXK, Clark NM, Baptist AP (2013) Quality of life,
Smith AM, Villareal M, Bernstein DI, Swikert DJ (2012) Asthma in the elderly: risk factors and impact on physical function. Annals of Allergy, Asthma and Immunology. 108, 5, 305-310. The Health Foundation (2011) Evidence: Helping People Help Themselves. tinyurl.com/85rxcux (Last accessed: November 15 2013.) The Health Foundation, Age UK (2011) Making Care Safer. Improving Medication Safety for People in Care Homes: Thoughts and Experiences from Carers and Relatives. tinyurl. com/q4ds73j (Last accessed: November 15 2013.) The Scottish Government (2011) The Scottish Health Survey. Older People’s Health. tinyurl.com/n9c4hkf (Last accessed: November 15 2013.) Wilson DHD, Appleton SL, Adams RJ, Ruffin RE (2005) Undiagnosed asthma in older people: an underestimated problem. Medical Journal of Australia. 183, 1, S20-S22.
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Asthma in older adults multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
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Improving the management of asthma in older adults NS721 Carnegie E, Jones A (2013) Improving the management of asthma in older adults. Nursing Standard. 28, 13, 50-58. Date of submission: July 9 2013; date of acceptance: September 6 2013.
Abstract
Aims and intended learning outcomes
Older people with asthma are a discrete patient group that requires specialist nursing skills and knowledge. They have specific and sometimes hidden needs that will affect their quality of life unless these are addressed by caring and competent nurses who have an interest in asthma. It is necessary to focus on both asthma and ageing to help older people achieve good asthma outcomes. This article discusses the complex physical, social and psychological issues affecting people with asthma aged 64 or older, age-related risk factors for poor control, age-related barriers to assessment and treatment, the scope of pharmacological and non-pharmacological approaches, and principal treatment outcomes. Providing high quality services and information will equip older people to manage their asthma more effectively, attain physical and mental wellbeing, and lead to fewer hospitalisations and fatal episodes in this group.
Authors Elaine Carnegie Policy officer, Asthma UK, Edinburgh. Angela Jones Asthma nurse specialist, Asthma UK, London. Correspondence to: [email protected]
Keywords Ageing, asthma, asthma exacerbations, older people, self-management
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
This article focuses on the physical and psychosocial needs of older adults (aged 64 or older) with asthma. After reading this article and completing the time out activities you should be able to: 4Describe age-related structural and functional changes that affect the respiratory system. 4Discuss asthma-related mortality and morbidity in later life. 4Understand barriers to the diagnosis and treatment of asthma in older adults. 4Explain the aims of treatment for older people with asthma. 4Discuss self-management of asthma in older adults.
Introduction Despite the high morbidity and mortality associated with asthma in older people, the evidence base and care of this group of patients remain neglected worldwide (Gibson et al 2010, British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) 2012, Gillman and Douglass 2012). Older people have low expectations of healthcare services, reporting higher rates of satisfaction while experiencing greater frequency of symptoms. There is also evidence that some healthcare professionals may have low expectations of the care this group of patients receive, attributing their symptoms to age-related diseases rather than asthma, and failing to ascertain how asthma limits their physical activity in comparison with younger individuals (Asthma UK 2005, Byles 2005).
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Inappropriately treated asthma can lead to poor lung function, impaired quality of life, disability and increased risk of life-threatening asthma attacks in all age groups (Global Initiative for Asthma (GINA) 2012). Owing to the specific and sometimes hidden needs of older people with asthma, it is essential that all patients in this group receive comprehensive asthma care, including those with complex needs such as learning disabilities, mental health problems or dementia (GINA 2012).
Asthma and ageing Ageing and health problems in later life can lead to loss of independence, identity and dignity (Lloyd et al 2011). Ageing can result in changes in social relationships, gender differences in coping with personal illness and stress, financial difficulties, isolation, loneliness, and difficulties in accessing transport and health care (Byles 2005). Some of these factors can affect how, and if, older people access asthma care. Asthma imposes more constraints on the lives of older people than younger people with the disease. Older people are more likely to say that their asthma ‘often’ prevents them from going out with friends to restaurants or from playing with grandchildren, and their asthma ‘often’ makes them avoid using stairs (Asthma UK 2005). Older people are also more likely to report fair or poor general health, have lower expectations of treatment and experience poorer healthcare services than younger people with asthma; however, older people require greater access to asthma information and are more likely to have other long-term conditions (Gibson et al 2010). These constraints demand a comprehensive response from healthcare services so that the physical, social and psychological issues of ageing and asthma are addressed and treatment is delivered by caring, competent healthcare professionals to preserve patients’ quality of life (Lloyd et al 2011). Complete time out activity 1
Physiology of ageing There is a progressive decline in lung function from the age of 20 in women and the age of 25 in men (Gibson et al 2010). Chest expansion may become constricted because of loss of vertebral height, osteoporosis and advancing kyphosis (Ennis 2013). Changes in the structure, physiology and function of the respiratory system can exacerbate existing narrowing of the airways and increase the risk
of pulmonary infections (Gibson et al 2010, King and Hanania 2010, Hwang et al 2012, McDonald et al 2013). In addition, patients are less aware that their airways are becoming narrower with age, and the sensitivity of the cough reflex is reduced, which can contribute to a delay in diagnosing asthma in older people (Berend 2005). Other physical changes to the lungs with ageing include (Berend 2005): 4Reconfiguration of the chest wall as a result of calcification of the rib cage and a decrease in respiratory muscle strength. 4Reduced ability of the diaphragm to generate force. 4Impairment of mucociliary clearance. 4Loss of elastin fibres, resulting in reduced vital capacity and increased air trapping. 4Reduced number of alveoli and increased size of the alveolar ducts. 4Decrease in function of beta2 adrenergic receptors. Pharmacokinetic changes in older people can also lead to increased incidence of adverse drug reactions, resulting in the development of asthma, persistence of asthma symptoms, and physical and mental distress from side effects of asthma treatments such as beta2 agonists (Downie et al 2008). Beta2 agonists stimulate beta2 adrenergic receptors to mimic the effects of adrenaline (epinephrine) or noradrenaline (norepinephrine), which leads to relaxation of the bronchial smooth muscle and increased mucociliary clearance. Beta blockers interfere with the binding of adrenaline and other stress hormones to adrenoceptors, leading to constriction of the bronchial smooth muscle (Kassianos et al 2005). Beta blockers that block beta2 receptors may cause shortness of breath for people with asthma, therefore they should not be prescribed, and people with asthma should be asked if they have had a past reaction to using them (BTS/SIGN 2012). Cognitive impairment, sensory impairment, decreased peak inspiratory flow, poor co-ordination, decreased manual dexterity resulting from arthritis, and decreased press and breathe co-ordination during inhaler use may lead to unintentional poor medication adherence in older people with asthma (Goeman and Douglass 2007, Gibson et al 2010).
Mortality and morbidity The prevalence of asthma in older adults aged 65 or older is estimated to be 6-10% in the developed world (Gibson et al 2010). In the UK, around four fifths of asthma-related deaths and
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1 Revise the characteristics of asthma before reflecting on the normal anatomy and physiology of the upper and lower respiratory tract. You may find chapters 1 and 2 of the GINA (2012) guideline useful. List the main aspects of anatomy involved in the pathophysiology of asthma and how these might affect asthma in older people as a result of the effect of ageing on the respiratory system.
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CPD respiratory nursing more than 10% of hospital admissions as a result of asthma are in the over 65 age group (Office for National Statistics 2011). In Australia and the United States, patients over 65 have increased asthma mortality rates, hospital admission rates and lengths of hospital stay in comparison with younger age groups with asthma (Baptist et al 2010, Jones et al 2011). Hospitalisation rates may be correlated with a high risk of respiratory tract infections in older people and are influenced by socioeconomic status (Olivenstein and Hamid 2011). Although mortality rates can be confounded by other causes of dyspnoea, there is evidence of seasonal variation; mortality rates in older people peak during December and January in contrast to those aged under 44 where mortality peaks in July and August (Marks and Poulos 2005, BTS/SIGN 2012). According to Baptist et al (2010), greater mortality and morbidity in older people with asthma are partly as a result of the increased frequency of cardiovascular comorbidities, which are a known risk factor for asthma death. Risk factors associated with deaths related to asthma include depression, smoking, suboptimal use of inhaled corticosteroid therapy, patients underestimating the severity of their symptoms, lack of education about what to do in an emergency and patients not wanting to make a fuss (Gibson et al 2010, Asthma UK 2012). Hoskins et al (2001) reported that, despite people aged over 65 with asthma being more likely to receive higher doses of inhaled corticosteroids and demonstrating greater compliance, they experienced more symptoms than younger people, with almost three quarters of the older patient group reporting symptoms. Persistent physical symptoms can lead to psychological distress and, ultimately, to a reduction in functional status. Ho and Jones (1999) found that there was increased psychological morbidity (depression and anxiety), a known risk for life-threatening exacerbations, and higher numbers of hospital visits by older people with self-reported asthma than those without asthma (BTS/SIGN 2012). It is important to remember that exclusion of older people with asthma in care homes from community health services may contribute to an underestimation of morbidity (Ho and Jones 1999, Gibson et al 2010).
Barriers to care Adult-onset asthma
Older people may have developed asthma in childhood, adolescence or adulthood. The risk
factors for developing asthma in adulthood include genetic susceptibility, hormonal changes in some women, exposure to indoor and outdoor pollutants, occupational exposures, excess body weight, rhinitis, medications such as beta blockers, and viral and bacterial infections (Jones et al 2011).
Underdiagnosis
Respiratory symptoms are common in people over 75 years and may be associated with lung disease, heart disease or cancer (Gibson et al 2010). It can, therefore, be difficult to diagnose asthma in older adults, which can be frustrating for people who feel they have been living with asthma-like symptoms for months or even years (Gibson et al 2010). Underdiagnosis may also occur as a result of a combination of under-reporting of symptoms by the patient, possibly because of social isolation or cognitive impairment, and underdiagnosis by the physician (Dow 1998). From a cross-sectional population-based survey of 6,000 adults, researchers estimated that 2.4% of men and 1.2% of women aged 65 or over had untreated asthma even though some participants had been diagnosed previously with the condition (Dow et al 2001). Dow et al (2001) suggested that 15-20% of older adults may have untreated asthma if they have been diagnosed in the past or experience wheeze or breathlessness at rest. Wilson et al (2005) found that people with undiagnosed asthma saw a GP as often as those diagnosed with asthma. Further research is required to discover whether patients with undiagnosed asthma had noticed, recognised or reported their symptoms to the GP or whether the GP was unable to diagnose asthma. Underdiagnosis of asthma may also occur as a result of underuse of objective tests, such as spirometry. Even though some older people will be unable to use a peak flowmeter or spirometer, spirometry can be adequately tested in more than 90% of older patients when staff are appropriately trained, the equipment is used correctly and there is rigorous quality control (Gibson et al 2010, Primary Care Commissioning 2013). Other factors that can contribute to underdiagnosis of asthma in older people are self-limitation of activities, depression, the misconception that adult-onset asthma is rare, and misdiagnosis of chronic obstructive pulmonary disease (COPD) (Gibson et al 2010). It is important, but difficult, to distinguish between asthma and COPD in clinical practice. Asthma is characterised by spontaneous
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variability of airway obstruction and patients are often symptomatic when lung function tests are normal, whereas most patients with COPD do not report their symptoms until lung function deteriorates to below 50% of its predicted value (Doherty 2003). Dyspnoea in patients with COPD is mainly triggered by exertion, whereas in asthma there are other triggers such as allergens, cold air and irritants (Jenkins et al 2005). Healthcare professionals should consider diagnosis and treatment of asthma when presented with several co-existing conditions. Congestive heart failure, obesity, anaemia, general unfitness and obstructive lung disease may individually or collectively cause breathlessness. It is also important to consider a person’s past or present occupation when considering a diagnosis of asthma – occupational exposures account for one in six cases of asthma in adults of working age (British Occupational Health Research Foundation 2010). Comprehensive asthma management for older people must begin with ensuring the diagnosis has been verified, preferably by objective testing using spirometry. Specific questions should be asked to identify respiratory symptoms suggestive of asthma, such as a full history of specific as well as vague unresolved symptoms, history of atopy, previous occupation, smoking history and response to previous treatment trials (Gibson et al 2010). By assessing and managing systemic problems and comorbidities related to asthma, healthcare professionals can address current problems and assess future risk of asthma in older people (Marks et al 2009). Medications used to treat comorbidities may exacerbate asthma symptoms; it is important to remember that beta blockers and non-steroidal anti-inflammatory drugs (NSAIDs), including acetylsalicylic acid-based medications, can trigger asthma symptoms in adults of all ages (Dow 1998). Comorbidities can be complicated by drug interactions, polypharmacy, inhaler device polypharmacy and impaired use of devices contributing to poor symptom control (Gibson et al 2010). Complete time out activity 2
Misperception of symptoms Older patients with asthma tend to under-report symptoms and present for medical care later in their disease course than younger patients. Older people may believe their symptoms are a natural part of the ageing process, or because symptoms of asthma are often non-specific they can be confused with symptoms of other respiratory
and cardiovascular diseases such as chest tightness or breathlessness (Jones et al 2011). For some, shortness of breath may be their only symptom. Other reasons for misperception of symptoms include (Jones et al 2011): 4Underestimating the severity of symptoms. 4Less awareness than younger adults of bronchoconstriction as a result of ageing processes in the respiratory system. 4Cognitive decline. 4Poor knowledge and understanding of asthma as an inflammatory condition. 4Low expectations regarding activity and mobility. In an exploratory qualitative study of 46 adults aged over 65 with asthma, Baptist et al (2010) reported that: 4Asthma was often described as feelings of fatigue and lethargy. 4Patterns of symptoms often changed over time. 4Participants were unable to distinguish between symptoms of asthma and those of cardiac problems such as shortness of breath and chest tightness. 4Participants tended not to discuss symptoms with other people, including family members. Evers et al (2013) called for greater provision of knowledge and understanding of asthma and its symptoms among older people to encourage them to consider asthma as a possible reason for their symptoms and to seek a diagnosis.
Changing symptom patterns and triggers Some people who have had asthma all their life may find it starts affecting them in different ways as they get older. For example, they may have coughed or wheezed previously, but may notice they become more breathless. Older people are less likely to have periods of remission, and changes in symptom patterns and triggers may add to confusion regarding the relevance and severity of symptoms. Many older people with asthma appear to be compliant with treatment, but in reality they may feel confused or anxious about their symptoms and treatment (Asthma UK 2012). Therefore, it is important, in discussion with the person, to identify personal asthma triggers as well as triggers experienced indoors and outdoors. Common triggers of asthma symptoms include: influenza, colds and other viral infections; exercise; laughing; anxiety; some medications, for example aspirin, beta blockers and NSAIDs; irritants, such as cigarette smoke, cold air, perfumes and chemical fumes; and allergens, for example house-dust mites, furry or feathered pets, pollen and mould spores.
2 Review the BTS/ SIGN (2012) guideline. List the investigations you would consider if a patient presents with atypical or additional signs and symptoms.
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CPD respiratory nursing It was previously thought that adult-onset asthma was likely to be triggered by non-allergic rather than allergic inflammation (atopy), such as sensitivity to house-dust mites. However, there is increasing evidence of older people with asthma being more likely to have underlying allergies – many of these allergies may be known, but may not have been investigated. Therefore, it is important to remember that adults can become sensitised to allergens at any age (Busse et al 2013). Testing for possible allergies and subsequent counselling regarding environmental allergy exposure needs to be considered in older people with asthma. Complete time out activity 3
Treating older people with asthma
3 Look up the Royal College of Physicians Three Questions in the BTS/SIGN (2012) guideline and the Asthma Control Test (tinyurl.com/ns8b4ag). Having read about these tools, consider how you might further explore and understand the experiences of older people with asthma. List the questions that would help you explore a patient’s quality of life, asthma control, activity, mobility and psychosocial needs. 4 Access the Guide to Good Asthma Care for Adults and Children with Asthma (Asthma UK 2010). Review the sections on diagnosis, self-management and regular structured review, and consider how this applies to older people. Compile a checklist for the care of a newly diagnosed older person with asthma.
The aims of asthma treatment in older people are to (Dow 1998, Smith et al 2012): 4Minimise symptoms and physical disability, and increase quality of life. 4Develop patient and carer understanding and skills necessary to manage asthma effectively. 4Remove or reduce complications of underlying disease. In one exploratory participatory study, older people with asthma were confused about their diagnosis, had poor understanding of asthma and their asthma medicines, and reported low, irregular provision of emergency advice, written personal asthma action plans and asthma reviews (Asthma UK 2012). Once the diagnosis has been clarified and discussed with the person, patient education must cover (Asthma UK 2010): 4Achievement of asthma control through pharmacological and non-pharmacological strategies. 4Short and long-term side effects of medicines. 4Risk of exacerbations. 4Identification of triggers in the indoor and outdoor environment. 4Discussion of a written asthma action plan, including recognition of worsening symptoms. 4How to deal with breathlessness during exercise. 4What to do when symptoms worsen. 4What to do in an emergency and who to contact – this is particularly important for patients who live alone, or in rural or remote areas. Emergency care information should include (SIGN 2011): 4What happens during an asthma exacerbation. 4How to recognise an asthma exacerbation.
4Actions to take during an asthma exacerbation. 4Treatment of an asthma exacerbation. In the presence of comorbidities or disability, it is essential to assess activities of daily living and mobility. This includes asking patients about their social networks and availability of community support. In addition to offering treatment, it is important for the healthcare professional to allow time for patients to ask questions and to explore their understanding of asthma and how they feel about managing their condition at home. Evaluating functional and psychological status is useful when assessing older people with asthma. This will involve the assessment of mood and cognitive function. It is important that healthcare professionals take time to assess patients, including how they are feeling not only during the consultation, but over the preceding weeks and months. Feelings of defeat and frustration may be present in patients who are juggling comorbidities, persistent symptoms and polypharmacy. Anxiety, depression and despair compounded with social isolation increase the risk of an asthma exacerbation (Ross et al 2013). It is, therefore, necessary to offer appropriate pharmacological, psychological and social support. Complete time out activity 4
Medication Following diagnosis, every person with asthma should be treated according to one of the five steps of treatment described in the BTS/SIGN (2012) guideline. Each step includes medicines that correspond to the severity of disease to improve and maintain control of symptoms. Healthcare professionals should ensure that every patient understands which treatment step they are currently on. Concerns about taking corticosteroids are widespread among people with asthma and can be a significant barrier to treatment adherence (Bellia et al 2009). These concerns are of particular importance for older people with asthma because of the physiological effects of ageing. For example, older people are more likely to experience adverse effects from high-dose inhaled corticosteroids, leading to the development of purpura and bruising as a result of increased skin fragility and reduced skin elasticity. Beta2 agonists may be less effective in relieving symptoms and the adverse effects associated with these drugs, such as increased heart rate and tremor, are more noticeable in older people
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(Goeman and Douglass 2005, Gupta and O’Mahony 2008). The adverse effects of beta2 agonists are a direct disincentive to their use. Unless using a dry powder device, high-dose inhaled corticosteroids should be administered with volumatic spacers and the mouth should be thoroughly rinsed afterwards to decrease systemic absorption and prevent side effects such as oral candida (Dow 1998). Systemic side effects of oral corticosteroids include confusion or psychosis and further bone damage in people who already have osteoporosis. It is important that the bone mineral density of patients on long-term oral corticosteroid treatment is monitored and, if there is a significant reduction, a long-acting bisphosphonate should also be given (BTS/SIGN 2012). If older people have swallowing difficulties they may require soluble oral corticosteroid tablets. Older people with asthma might fail to adhere to treatment advice because of reasons out of their control, such as impaired vision; musculoskeletal problems affecting their ability to use inhaler devices; ineffective communication between the patient and healthcare professional; and failing to remember how often to take their medication (Gibson et al 2010). Depression can also lead to non-adherence. Polypharmacy increases the risk of adverse outcomes and poor medication adherence, and in some cases the medications used to treat comorbidities may exacerbate asthma symptoms (Goeman and Douglass 2005). Complete time out activity 5
Inhalers and inhaler technique Difficulties relating to poor medication adherence in older people are compounded by difficulties in using pressurised metered-dose inhaler devices (PMDIs) (King and Hanania 2010). The use of spacers, particularly with preventive medication, can improve the delivery of asthma medications in older people (Goeman and Douglass 2005). Nurses and pharmacists should conduct a regular review of PMDI and dry powder devices in older patients with asthma. This review must include patients in private nursing and care homes, where governance arrangements and training may not include educating staff about correct inhaler technique (The Health Foundation and Age UK 2011).
Choice of inhaler
The choice of inhaler device is crucial. The nurse must remember to:
4Check the patient’s level of understanding, signs of neuromotor impairment, visual acuity and dexterity. 4Highlight aids for the chosen device, such as Turbogrip, raised dots, dose counter and Haleraid (an aid that fits on to a PMDI allowing it to be activated by a pincer movement). 4Discuss the importance of correct inspiratory flow rate for the device. 4Explain to the patient that he or she may be able to taste the medication from a dry powder inhaler. In rare cases, individuals may experience paradoxical bronchospasm when the aerosol gas reaches the pharynx and larynx (Nicklas 1990). Using a PMDI with a spacer or changing to a dry powder inhaler should resolve this problem.
Assessing inhaler technique
Inhalation airflow meter devices help healthcare professionals and patient to assess and correct inspiratory flow rate when selecting a suitable device. However, when assessing inhaler technique, the patient’s own inhaler or a placebo should be used to assess dexterity, visual acuity, and the steps of priming, shaking, position and dose counter (Pearce 2011). Instruction regarding inhaler use should include checking expiry dates, and cleaning and storing the spacer and inhalers. Co-ordinating deployment of manual aerosol inhalers with respiratory movements is difficult; therefore, a spacer can be used to promote good drug delivery into the lungs (Asthma UK 2013). A Haleraid can also be used with a spacer to help overcome manual dexterity problems. Breath-actuated inhalers can remove some of the problems associated with poor co-ordination; however, spacers cannot be used with breath-actuated inhalers. When selecting a suitable inhaler device, the healthcare professional should: 4Assess whether the patient requires a spacer, identify the most suitable spacer and discuss which method of delivery (single or multibreath technique) is most appropriate. 4Explain the role of spacers (to help more of the medicine get into the airways) and that they should ideally be used with reliever inhalers during an asthma attack. Complete time out activity 6
Self-management Ageing and its associated social, physical and economic limitations requires that older people
5 Examine the five treatment steps outlined in the BTS/SIGN (2012) guideline. Choose a corticosteroid inhaler and bronchodilator inhaler and look up their properties in the British National Formulary or the electronic Medicines Compendium. Compile the information that the healthcare professional should communicate to an older person prescribed these medicines. 6 Watch the inhaler technique demonstrations for inhalers and spacers on the Asthma UK website (www.asthma. org.uk/knowledgebank-treatment-andmedicines-using-yourinhalers). List the main points of a discussion you would have with an older person about his or her choice of inhaler device and technique.
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CPD respiratory nursing
7 If your organisation has developed a personal asthma action plan, consider its suitability and appropriateness for older people. Make a list of what might need to be revised to make it more appropriate for older people with asthma. Search for a range of other self-management tools, such as plans, peak-flow diaries or asthma attack cards, either from the NHS or other respiratory-specific organisations. Note if and how these tools address the specific needs of older people with asthma and their carers.
are equipped to manage their asthma at home or in a residential setting (The Health Foundation 2011). It is essential that older people are able to recognise when their asthma is worsening and not to delay their use of reliever medication (Allen and Khattab 2012). It is also important that older people know whether they are administering their medicine correctly, that they can assess whether it is relieving their symptoms and, if it is not, what to do about it. Self-management has been defined as ‘the successful outcome of the person and all appropriate individuals and services working together to support them to deal with the very real implications of living the rest of their life with one or more long-term condition’ (Long Term Conditions Alliance Scotland and the Scottish Government 2008). Self-management support can be viewed in two ways: ‘as a portfolio of techniques and tools that help patients choose healthy behaviours; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership’ (The Health Foundation 2011). Tools to increase patient confidence in self-management of asthma include personal asthma action plans, patient-held records and the provision of accessible information. Personal asthma action plans are designed to encourage people with asthma, and their carers, to take more responsibility for the management of asthma in partnership with healthcare professionals. These plans have been shown to improve symptom control and reduce use of healthcare services (Gibson and Powell 2004). The plan is a written record of what action to take when asthma symptoms worsen or peak flow measurements deteriorate, and includes information about when to seek medical help or access emergency services. Plans are aimed at people with regular symptoms who are at risk of having an exacerbation as well as those wishing to become more involved in self-managing their condition. The action plan involves an explanation by a doctor or nurse about signs of deterioration and information about prescribed medication to help prevent a severe asthma attack. The plan also indicates when to return for an asthma review (Gibson and Powell 2004). Misperception of symptoms may make it more difficult for older people with asthma to follow a symptom-based personal asthma action plan (Goeman and Douglass 2005). Some people prefer to use a symptom-based asthma action plan, whereas others prefer to use a peak-flow based management plan, or a combination of both (Goeman and Douglass 2007, Huang
et al 2009). The nurse should give patients and family members a written copy of their agreed asthma action plan, and should use follow-up telephone calls to address the concerns of patients and family members, monitor patients’ progress, review medicines use and adjust the asthma action plan (Akgün et al 2012). Attitudes to self-management and self-management plans need to be explored primarily with older people themselves (Goeman and Douglass 2007). Because of lower expectations, many older people will put up with symptoms and are reluctant to complain about them, even to their family. It is, therefore, important to make patients feel that they can question or challenge their treatment (Asthma UK 2012). Attention needs to be focused on strengthening the patient-nurse therapeutic relationship to improve asthma outcomes (Huang et al 2009). Each older person with asthma should have a named asthma nurse within primary care. Older people particularly appreciate being treated as intelligent people with a part to play in their own treatment and care, and as individuals with their own history, preferences, fears and beliefs. Demonstrating an awareness of the effect of asthma on patients, and treating these individuals with respect may also be helpful. Complete time out activity 7
Asthma education It is imperative to identify effective and efficient ways of providing detailed and personalised information in a way that meets the educational needs of older people with asthma. The aim of asthma education is to optimise patients’ asthma management and prevent them from experiencing unnecessary symptoms in the long term (SIGN 2011). Management of older people with asthma will improve if their specific needs are addressed with written asthma information and a written asthma action plan. Huang et al (2009) conducted a randomised controlled trial to examine the effectiveness of individualised self-care education programmes for older people with moderate to severe asthma. The researchers reported that, even though there was no difference in rates of emergency care, patients who received individualised education with peak-flow monitoring had significantly higher asthma self-care behaviours, including better medicines use, self-monitoring and environmental control, and self-confidence scores and asthma control indicators than those
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who received usual care and those who received education alone. Self-management and education topics should also include exposure to tobacco smoke, exercise, air pollution and vaccinations.
Tobacco smoke
Smoking accelerates deterioration of lung function in people with asthma, impairs corticosteroid response and increases mortality (Gibson et al 2010). Nicotine pharmacokinetics in older age do not appear to diminish the effect of nicotine replacement treatment. Innovative methods should be used to encourage older people to access nicotine replacement therapy and smoking cessation services (Gibson et al 2010). Older people who smoke are at greater risk than non-smokers of developing cardiovascular disease or cancer and of experiencing cognitive decline, including dementia (The Scottish Government 2011).
Exercise
It is important to discuss the older person’s mobility to determine whether any mobility problems are the result of poor fitness levels, asthma or other comorbidities. The healthcare professional should check whether the person with asthma needs to take his or her reliever medication during exercise and whether the medication is relieving symptoms. People with persistent breathlessness will need to be referred to respiratory specialists for assessment and pulmonary rehabilitation, if possible. It is important to encourage older people with asthma who are generally fit and do not have other health conditions that limit their mobility to be active daily.
Air pollution
Air pollution can trigger symptoms in people who already have asthma, leading
References Akgün KM, Crothers K, Pisani M (2012) Epidemiology and management of common pulmonary diseases in older persons. Journals of Gerontology: Series A Biological Sciences and Medical Sciences. 67A, 3, 276-291. Allen SC, Khattab A (2012) The airflow resistance sensing threshold during tidal breathing rises in old age in patients with asthma. Age and Ageing. 41, 4, 557-560. Andersen ZJ, Bønnelykke K, Hvidberg M et al (2012) Long-term exposure to air pollution and asthma hospitalisations in older adults: a cohort study. Thorax. 67, 1, 6-11. Asthma UK (2005) Out of Sight, Out of Mind. Asthma in Scotland Today. tinyurl.com/op7w8fl (Last accessed: November 15 2013.) Asthma UK (2010) Guide to Good Asthma Care for Adults and Children with Asthma. tinyurl.com/nmw5woe (Last accessed: November 15 2013.) Asthma UK (2012) ‘The Forgotten Generation?’ tinyurl.com/op7w8fl (Last accessed: November 15 2013.) Asthma UK (2013) Using your Inhalers. tinyurl.com/pnkxyeh (Last accessed: November 15 2013.) Baptist AP, Deol BK, Reddy RC, Nelson B, Clark NM (2010)
Age-specific factors influencing asthma management by older adults. Qualitative Health Research. 20, 1, 117-124.
Byles JE (2005) How do the psychosocial consequences of ageing affect asthma management? Medical Journal of Australia. 183, 1, S30-S32.
Bellia V, Scichilone N, Battaglia S (2009) Asthma in the elderly. European Respiratory Society Monograph. 43, 56-76.
Doherty DE (2003) Identification and assessment of chronic obstructive disease in the elderly. Journal of American Medical Directors Association. 4, 5, S116-S120.
Berend N (2005) Normal ageing of the lung: implications for diagnosis and monitoring of asthma in older people. Medical Journal of Australia. 183, 1, S28-S29. British Occupational Health Research Foundation (2010) Occupational Asthma. A Guide for Employers, Workers and their Representatives. tinyurl.com/psu2akh (Last accessed: November 15 2013.) British Thoracic Society, Scottish Intercollegiate Guidelines Network (2012) British Guideline on the Management of Asthma. tinyurl. com/9mfwb7 (Last accessed: November 15 2013.) Busse PJ, Cohn RD, Salo PM, Zeldin DC (2013) Characteristics of allergic sensitization among asthmatic adults older than 55 years: results from the National Health and Nutrition Examination Survey, 2005-2006. Annals of Allergy, Asthma & Immunology. 110, 4, 247-252.
Dow L (1998) Asthma in older people. Clinical and Experimental Allergy. 28, Suppl 5, 195-202. Dow L, Fowler L, Phelps L et al (2001) Prevalence of untreated asthma in a population sample of 6000 older adults in Bristol, UK. Thorax. 56, 6, 472-476. Downie G, Mackenzie J, Williams A (2008) Pharmacology and Medicines Management for Nurses. Fourth edition. Churchill Livingstone, Edinburgh. Ennis J (2013) The physiology of ageing. Practice Nurse. 43, 3, 38-42. Evers U, Jones SC, Caputi P, Iverson D (2013) The asthma knowledge and perceptions of older Australian adults: implications for social marketing campaigns. Patient Education and Counseling. 91, 3, 392-399. Gibson P, McDonald VM, Marks GB (2010) Asthma in older adults. The
Lancet. 376, 9743, 803-813. Gibson PG, Powell H (2004) Written action plans for asthma: an evidence-based review of the key components. Thorax. 59, 2, 94-99. Gillman A, Douglass JA (2012) Asthma in the elderly. Asia Pacific Allergy. 2, 2 101-108. Global Initiative for Asthma (2012) Global Strategy for Asthma Management and Prevention. www.ginasthma.org/ documents/4 (Last accessed: November 15 2013.) Goeman DP, Douglass JA (2005) Understanding asthma in older Australians: a qualitative approach. Medical Journal of Australia. 183, 1, S26-S27. Goeman DP, Douglass JA (2007) Optimal management of asthma in elderly patients. Strategies to improve adherence to recommended interventions. Drugs & Aging. 24, 5, 381-394. Gupta P, O’Mahony MS (2008) Potential adverse effects of bronchodilators in the treatment of airways obstruction in older people: recommendations for prescribing. Drugs & Aging. 25, 5, 415-443.
© NURSING / RCNbyPUBLISHING november 27 :: vol 28 no 13 :: 2013 57 Downloaded fromSTANDARD rcnpublishing.com ${individualUser.displayName} on Oct 15, 2014. For personal use only. No other uses without permission. Copyright © 2014 RCN Publishing Ltd. All rights reserved.
CPD respiratory nursing to increased hospital admissions (Andersen et al 2012). Those most at risk include people with severe asthma and older people with heart problems or chronic respiratory problems (Met Office 2013). Those living in urban areas should be informed about the free, online, daily air quality index (Met Office 2013), which provides advice on exercising outdoors within current pollution levels.
Influenza and pneumococcal vaccinations
8 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
Influenza and pneumococcal vaccinations reduce the potential severity of infection, risk of hospitalisation and death in adults with asthma or COPD (Pesek and Lockey 2011). Older people with asthma should, therefore, be encouraged to attend vaccination clinics to keep up to date with influenza and pneumococcal vaccinations.
Ho SF, Jones D (1999) Morbidity in older people with self-reported asthma. Age and Ageing. 28, 5, 475-480. Hoskins G, McCowan C, Thomas G, Neville R, Clark R, Smith B (2001) Asthma or COPD? An investigation into the symptom patterns of asthma may highlight the need for more rigorous diagnostic procedures in elderly patients. Primary Care Respiratory Journal. 10, 4, 99-102. Huang T-T, Li Y-T, Wang C-H (2009) Individualized programme to promote self-care among older adults with asthma: randomized controlled trial. Journal of Advanced Nursing. 65, 2, 348-358. Hwang E-K, Jin HJ, Nam Y-H et al (2012) The predictors of poorly controlled asthma in elderly. Allergy, Asthma & Immunology Research. 4, 5, 270-276. Jenkins CR, Thompson PJ, Gibson PG, Wood-Baker R (2005) Distinguishing asthma and chronic obstructive pulmonary disease: why, why not and how? Medical Journal of Australia. 183, 1, S35-S37. Jones SC, Iverson D, Burns P, Evers U, Caputi P, Morgan S (2011) Asthma and ageing: an end user’s perspective – the perception and problems with the management of asthma in the elderly. Clinical and Experimental Allergy. 41, 4, 471-481.
Kassianos G, Chung F, Gruffydd-Jones K, Thomas M, Price D (2005) Best Medicine Asthma. CSF Medical Communications, Long Hanborough. King MJ, Hanania NA (2010) Asthma in the elderly; current knowledge and future directions. Current Opinion in Pulmonary Medicine. 16, 1, 55-59. Lloyd E, Calnan M, Cameron A, Seymour J, Smith R, White K (2011) Maintaining Dignity in Later Life: A Longitudinal Qualitative Study of Older People’s Experiences of Support and Care. tinyurl.com/oszucz2 (Last accessed: November 15 2013.) Long Term Conditions Alliance Scotland, The Scottish Government (2008) “Gaun Yersel!” The Self Management Strategy for Long Term Conditions in Scotland. tinyurl.com/ ngmq9me (Last accessed: November 15 2013.) Marks GB, Poulos LM (2005) A nationwide perspective on asthma in older Australians. Medical Journal of Australia. 183, 1, S14-S16.
Conclusion Older people need to understand that asthma is a widespread and serious condition, and that they need to be able to recognise asthma symptoms and seek a diagnosis. Principal treatment outcomes for older patients diagnosed with asthma are to maintain and increase quality of life. Nurses caring for older patients with asthma require specialist skills and knowledge. Care should include a holistic assessment, recognition of age-related barriers to treatment, the delivery of age-appropriate pharmacological treatment and devices, and non-pharmacological treatments that include individualised education and self-management tools. Offering high quality services and information will assist older people with asthma to attain both physical and mental wellbeing, and will lead to fewer hospitalisations and fatal asthma episodes in this age group NS Complete time out activity 8
coexistent asthma and chronic obstructive pulmonary disease: diagnostic and therapeutic challenges. Drugs & Aging. 30, 1, 1-17.
health care utilization, and control in older adults with asthma. Journal of Allergy and Clinical Immunology: In Practice. 1, 2, 157-162.
Met Office (2013) Daily Air Quality Index. tinyurl.com/nnn7mek (Last accessed: November 15 2013.)
Scottish Intercollegiate Guidelines Network (2011) Managing Asthma in Adults: A Booklet for Patients and their Families and Carers. tinyurl.com/nnkaxtr (Last accessed: November 15 2013.)
Nicklas RA (1990) Paradoxical bronchospasm associated with the use of inhaled beta agonists. Journal of Allergy and Clinical Immunology. 85, 5, 959-964. Office for National Statistics (2011) Mortality Statistics: Deaths Registered in England and Wales (Series DR), 2010. tinyurl.com/ONSmortstat2010 (Last accessed: November 18 2013.) Olivenstein R, Hamid Q (2011) Asthma in the elderly… Their time is right now. Clinical and Experimental Allergy. 41, 4, 457-458. Pearce L (2011) How to teach inhaler technique. Nursing Times. 107, 8, 16-17. Pesek R, Lockey R (2011) Vaccination of adults with asthma and COPD. Allergy. 66, 1, 25-31.
Marks GB, Poulos LM, Jenkins CR, Gibson PG (2009) Asthma in older adults: a holistic, person-centred and problem-oriented approach. Medical Journal of Australia. 191, 4, 197-199.
Primary Care Commissioning (2013) A Guide to Performing Quality Assured Diagnostic Spirometry. tinyurl.com/ovlnh2e (Last accessed: November 15 2013.)
McDonald VM, Higgins I, Gibson PG (2013) Managing older patients with
Ross JA, Y Yang, Song PXK, Clark NM, Baptist AP (2013) Quality of life,
Smith AM, Villareal M, Bernstein DI, Swikert DJ (2012) Asthma in the elderly: risk factors and impact on physical function. Annals of Allergy, Asthma and Immunology. 108, 5, 305-310. The Health Foundation (2011) Evidence: Helping People Help Themselves. tinyurl.com/85rxcux (Last accessed: November 15 2013.) The Health Foundation, Age UK (2011) Making Care Safer. Improving Medication Safety for People in Care Homes: Thoughts and Experiences from Carers and Relatives. tinyurl. com/q4ds73j (Last accessed: November 15 2013.) The Scottish Government (2011) The Scottish Health Survey. Older People’s Health. tinyurl.com/n9c4hkf (Last accessed: November 15 2013.) Wilson DHD, Appleton SL, Adams RJ, Ruffin RE (2005) Undiagnosed asthma in older people: an underestimated problem. Medical Journal of Australia. 183, 1, S20-S22.
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