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Clinical Investigations: ASTHMA |

Underdiagnosis and Undertreatment of Asthma in the Elderly* FREE TO VIEW

Paul L. Enright, MD; Robyn L. McClelland, MS; Anne B. Newman, MD; Daniel J. Gottlieb, MD; Michael D. Lebowitz, PhD; for the Cardiovascular Health Study Research Group
Author and Funding Information

Affiliations: *From the University of Arizona (Drs. Enright and Lebowitz), Tucson, AZ; the University of Washington (Ms. McClelland), Seattle, WA; the University of Pittsburgh (Dr. Newman), Pittsburgh, PA; and Boston University (Dr. Gottlieb), Boston, MA.,  A complete list of participants is located in Appendix 1. Supported by National Heart, Lung, and Blood Institute contract N01–87079.

Correspondence to: Paul L. Enright, MD, The University of Arizona, HSC 2342, 1501 N Campbell Ave, Tucson, AZ 85724; e-mail: lungguy@aol.com


Affiliations: *From the University of Arizona (Drs. Enright and Lebowitz), Tucson, AZ; the University of Washington (Ms. McClelland), Seattle, WA; the University of Pittsburgh (Dr. Newman), Pittsburgh, PA; and Boston University (Dr. Gottlieb), Boston, MA.,  A complete list of participants is located in Appendix 1. Supported by National Heart, Lung, and Blood Institute contract N01–87079.


Chest. 1999;116(3):603-613. doi:10.1378/chest.116.3.603
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Objective: To describe the clinical correlates of asthma in a community-based sample of elderly persons.

Participants: A community sample of 4,581 persons ≥ 65 years old from the Cardiovascular Health Study.

Measurements: Standardized respiratory, sleep, and quality-of-life (QOL) questions, a medication inventory, spirometry, and ambulatory peak flow.

Results: Four percent of the participants reported a current diagnosis of asthma (definite asthma), while another 4% reported at least one attack of wheezing accompanied by chest tightness or dyspnea during the previous 12 months (probable asthma). Smokers and those with congestive heart failure were excluded from the subsequent analyses, leaving 2,527 participants. Of those who had definite asthma, 40% were taking a sympathomimetic bronchodilator, 30% inhaled corticosteroids, 21% theophylline, and 18% oral corticosteroids; 39% were taking no asthma medications. The participants with definite or probable asthma were much more likely than the others to have a family history of asthma, childhood respiratory problems, a history of workplace exposures, dyspnea on exertion, hay fever, chronic bronchitis, nocturnal symptoms, and daytime sleepiness. They were also more likely to report poor general health, symptoms of depression, and limitation of activities of daily living. There was little difference in the morbidity and QOL of participants with recent asthma-like symptoms who had received the diagnosis of asthma versus those who had not.

Conclusions: Asthma in elderly persons is associated with a lower QOL and considerable morbidity when compared with those who do not have asthma symptoms. Asthma is underdiagnosed in this group and is often associated with allergic triggers; inhaled corticosteroids are underutilized.

Figures in this Article

The Cardiovascular Health Study (CHS) is a prospective study of a general population sample designed to study the epidemiology and risk factors associated with cardiovascular disease in the elderly (coronary heart disease, congestive heart failure [CHF], and stroke). The CHS examination between May 1993 and June 1994 provided comprehensive measures of cardiovascular disease and risk factors from a representative sample of elderly persons from four United States communities; the study also involved spirometry and standardized questions regarding asthma symptoms and triggers. The goal of this report is to explore the associations of asthma in the elderly with quality of life (QOL), morbidity, and use of asthma medications.

Previous studies of QOL in persons with asthma included only children, young adults, or middle-aged adults, and did not study population samples (including healthy persons). This study extends those findings to population samples of black and white elderly persons from four large communities in the United States.

Recruitment

Participants in the CHS were selected using a Medicare eligibility list (United States citizens ≥ 65 years old) provided by the US Health Care Financing Administration for the four participating communities: Forsyth County, NC; Pittsburgh, PA; Sacramento County, CA; and Washington County, MD. These communities are diverse in proportion of minorities, education and income level, degree of urbanization, death rates, and availability of medical care. An age- and gender-stratified random sample of each community was targeted for recruitment. The initial study cohort of 5,201 participants was recruited and examined between May 1989 and June 1990. Because the original cohort included only 5% minority subjects, an additional cohort of 687 black participants was recruited and examined between May 1992 and June 1993 using the same methods as in the original cohort. Both cohorts underwent repeat examination between May 1993 and June 1994, which included a more extensive asthma and sleep questionnaire. All data in this report are derived from 1993 to 1994 examination.

The following were exclusion factors: institutionalization; terminal illness; inability to walk, communicate, or give informed consent; or potential of moving from the area during the next 3 years. Enrolled CHS participants were younger, more educated, and more likely to be married and white than those who refused or were ineligible. The CHS design and recruitment are described in detail elsewhere.12 The research protocol was reviewed and approved by the institutional review board for human studies of each clinical center, and informed consent was obtained.

Interview and Clinical Examination

Spirometry and other examination components were scheduled throughout the morning of the examination, which included seated BP, resting 12-lead ECG, and a physical examination. Anthropometric measurements included the following: standing height without shoes, sitting height, weight, and hip and waist circumference. Trained interviewers completed a subset of a standard respiratory questionnaire.3Additional asthma-specific questions were taken from the European Respiratory Health Questionnaire (IUATLD)45 and the Tucson Airways SCOR questionnaire.6Supplemental dyspnea questions were taken from Guyatt and coworkers,7and daytime sleepiness questions from the Epworth sleepiness scale (ESS).8The categorical variable “depression symptoms” was defined as a depression score ≥ 15 using a standardized set of questions.9

QOL: As recommended by a recent National Institutes of Health Workshop on asthma outcome measures,10 CHS participants answered both generic and asthma-specific QOL questions. The CHS questionnaire included most of the questions from the MOS 36-item short form health survey (SF-36), a widely-used, self-administered, generic health survey found to be valid and reliable in patients with asthma.1112 The use of these generic QOL questions allows comparisons with studies that include relatively healthy persons and persons with diseases other than asthma. Generic QOL questions represent three general components (health concepts): (1) functional status (physical, social, and role); (2) well-being (mental health, energy vs fatigue, and bodily pain); and (3) general health.

Medication Inventory: Participants brought their prescription medication containers to the clinic, where interviewers transcribed the drug name, strength, and dosing instructions from the medication labels.13 The participants were then asked how many doses of each medication they actually took during the previous 2 weeks.

Spirometry Testing: A water-sealed spirometer was connected to a personal computer using software that assisted the pulmonary technician with quality control of maneuvers, calculated the pulmonary function variables, and compressed the results for transmission to the pulmonary function reading center. Details of the spirometry methods and predicted (reference) values used in this report have been previously published.14

Ambulatory Peak Flow: Immediately following spirometry testing, participants were asked to participate in an optional study of peak flow lability. If they agreed, they were instructed how to use the “Personal Best” peak expiratory flow (PEF) meter (HealthScan Products; Cedar Grove, NJ). This model was independently tested in Salt Lake City, UT, using 26 standard flow-time waveforms, and found to meet the 1994 American Thoracic Society (ATS) recommendations for PEF meter accuracy and repeatability.15

The trained technician coached participants to perform three maneuvers and recorded the highest value. Participants were given an 8.5×11-inch diary sheet with instructions on the reverse. The highest PEF from three maneuvers was recorded by filling in a circle corresponding to the reading on the PEF meter on the diary sheet, which was designed for automated optical mark reading. The participants were instructed to keep the PEF meter next to the bathroom sink and use it at soon as getting out of bed (between 6:00 am and 8:00 am and at dinner time (between 4:00 pm and 6:00 pm). After 7 days of use at home, the participants mailed the PEF meter and diary back to the clinic.

Asthma Definitions: For the purposes of this report,“ definite asthma” was defined as positive responses to all three of these questions (ATS questions 20A, 20B, and 20C3): (1)“ Have you ever had asthma?”; (2) “Do you still have it?”; and (3) “Was it confirmed by a doctor?” Participants with a diagnosis of CHF were excluded from the analyses for this manuscript, since the symptoms of CHF are similar to those of asthma.

“Probable asthma” was defined as positive responses to both of the following questions: (1) “Have you had wheezing or whistling in your chest at any time during the last 12 months?” (2) “Have you felt chest tightness or been breathless when the wheezing noise was present?” This category excludes those with a current asthma diagnosis, as defined above.

“Possible asthma” was defined as a positive response to the question, “Have you had wheezing or whistling in your chest at any time during the last 12 months?” and a positive response to one of the following three questions: (1) “These breathing symptoms were brought on or made worse by exposure to any one of the following: exercise or exertion; dust, smoke, or fumes; contact with animals, plants, or pollens; or worse during a particular season of the year?”; (2) “When you are near animals or near feather pillows, quilts, or comforters, do you ever start to wheeze, feel chest tightness, or start to feel short of breath?”; and (3) “Do you often wake up several times a night with trouble breathing or coughing?” This category of probable asthma excludes those with definite or possible asthma.

Asthma severity was classified according to recommendations made by the Global Initiative for Asthma (GIA),16 with modified percent predicted FEV1 thresholds (see Appendix 2). The presence of any one of the features of severity was sufficient to place a person in that category.

PEF Lability: The ambulatory PEF results were analyzed from subjects who completed at least 6 days of PEF data with both am and pm results. PEF data from the day of the clinic visit and the following day were excluded because of learning effects. The daily PEF lability (PEF max − PEF min/mean PEF) was determined from each of the remaining valid test days (minimum 4 days). The largest daily PEF lability was selected to represent PEF lability for the week. Of the 1,836 participants who returned PEF diaries, a valid PEF lability for the week could be calculated for 1,653 participants (90% of those who returned the diaries).

Reference Values: A very healthy subset of CHS participants examined during year 6 of the study was used to determine reference values for spirometry.14 These 435 healthy women and 158 healthy men were used to determine gender-specific reference values for PEF and PEF lability. The lower limit of the normal range for PEF was calculated at the fifth percentile of the age- and height-adjusted PEF (using the mean of all valid ambulatory PEF readings). The upper limit of the normal range for PEF lability was calculated as the 90th percentile of valid PEF lability for 1 week.

Statistical Analyses

All CHS participants who completed the year 6 asthma questionnaire, but did not have CHF, were included in the initial analysis. In the final analyses, those who were current smokers or had quit < 1 year prior to the year 6 visit, and former smokers who reported > 10 pack-years of smoking were also excluded.χ 2 tests were used to examine the bivariate associations of current asthma status (none, possible, probable, and definite) with a number of categorical variables. These included demographic characteristics, severity indicators, asthma risk factors, asthma symptoms, sleeping problems, QOL indicators, and medication use. Associations of asthma status with continuous variables were assessed using analysis of variance (ANOVA) models. All analyses were performed using the appropriate software (Statistical Package for the Social Sciences for Windows version 7.0; SPSS; Chicago, IL).

Asthma Prevalence

A total of 4,581 participants were seen in the CHS clinics during the year 6 follow-up examination from May 1993 to June 1994. Four percent of all CHS participants reported current (definite) asthma that had been confirmed by a physician (Table 1 ). An additional 4% reported at least one attack of wheezing with dyspnea or chest tightness during the previous year (probable asthma), and an additional 11% reported wheezing brought on by various exposures (possible asthma). Not included in the “definite asthma” category are 145 participants who reported a history of asthma but stated that they do not still have asthma. Some of these participants with “past asthma,” however, reported asthma symptoms during the previous 12 months, and are included in our possible or probable asthma categories (n = 32 and 16, respectively). Ninety-seven participants with past asthma (but no asthma symptoms) were included in the “no asthma” category.

About 8% of those with definite asthma and 8% of those with no asthma had CHF, and they were excluded from subsequent analyses. Those with asthma were somewhat more likely to be current or former smokers, and have more pack-years of smoking when compared with those without asthma. To eliminate the possibility that reported asthma symptoms and lung function abnormalities were due to smoking-related lung disease, we excluded current smokers as well as former smokers who reported> 10 pack-years of smoking from further analyses, leaving a total of 2,527 participants. See Table 2 for their demographics. Those with probable or definite asthma were more likely to be female, black, and older when compared with those who did not have asthma.

The severity of asthma, as categorized by recent guidelines (see Appendix 2), was associated with our possible, probable, and definite asthma status categories (Table 3 ). About 10% of those with possible asthma and 16% of those with probable asthma were categorized as having “severe persistent asthma” although they did not have a diagnosis of asthma. The frequency of trouble breathing (IUATLD question 11)4 was strongly associated with asthma status (p < 0.001 based on aχ 2 test; Fig 1 ).

Asthma Risk Factors

More than half of those who had definite asthma reported that a relative (including children and grandchildren) was known to have asthma. As in previous studies,17 those with asthma were much more likely than others to recall childhood respiratory trouble before the age of 16 years (Table 4 ).

Respiratory comorbidity was present in some elderly persons with asthma. About 60% of those with definite asthma also reported a history of hay fever (allergic rhinitis); about one fourth of these participants were bothered by it “very much” during the previous 12 months, and two thirds took a medication for hay fever. About 28% of those who had definite asthma reported a physician diagnosis of chronic bronchitis (currently), while 36% reported a history of acute episodes of bronchitis. Even after those with > 10 pack-years of smoking were excluded, 12% of those with definite asthma had also been told that they had emphysema.

Asthma Symptoms

As expected by the categorization criteria, CHS participants with asthma reported a much higher prevalence of respiratory symptoms than those who did not have asthma or asthma-like symptoms. One fourth of those who had definite asthma repeatedly had trouble breathing,“ but it always gets completely better,” while an additional 10% reported continuous trouble with breathing, “so that your breathing is never quite right.”

Asthma-like symptoms were often brought on (or made worse) by exposure to the following factors: dust, smoke, or fumes; colds, sore throats, or flu; exercise or exertion; contact with animals, plants, or pollens; or lying down flat or sleeping (Fig 2 ). Of those who had definite or probable asthma, 72% reported that these symptoms were worse during a particular season of the year, and about one third of the participants reported that spring was the worst season. Many participants who had asthma also reported wheezing, chest tightness, coughing, itchy/watery eyes, runny nose, or sneezing when they were near animals (such as cats, dogs, or horses), or near feather pillows, quilts, or comforters.

Asthma was strongly associated with shortness of breath during physical activity. Two thirds of those with probable or definite asthma reported dyspnea while walking quickly (vs 39% of those who did not have asthma), and 16% reported getting short of breath walking on level ground at their own pace.

QOL Indicators

Participants who had any level of asthma were much more likely than others to rate their general health as fair or poor; and somewhat more likely to report their level of activity as less than in the previous year (Table 5 ). About half of them felt that in the previous 2 weeks “everything was an effort” and that they just “could not get going.” They were more likely to feel negative about life as a whole, and twice as likely as others to have symptoms of depression. Elderly asthmatics were also more likely than other elderly persons to report impairment of activities of daily living (IADLs) such as heavy housework, walking one half mile, or walking up 10 steps. The mean IADL score was higher for those with possible, probable, and definite asthma, when compared with others.

Participants with possible, probable, and definite asthma were much more likely than others to wake up in the middle of the night with coughing, chest tightness or pain, or trouble breathing. Participants with these symptoms were more likely than others to report usual daytime sleepiness (odds ratio, 2.61; 95% confidence interval, 1.9 to 3.6). Those who had asthma had mean ESS scores8 that were significantly higher than in other elderly persons.

Pulmonary Function

About 40% of the participants with definite asthma had airways obstruction (a low FEV1/FVC ratio), compared with only 10% of nonsmokers who had no evidence of asthma (Table 6 ). The mean percent predicted FEV1 values were much lower in those who had definite asthma (77%) when compared with those who did not have asthma (96%); those with probable and possible asthma had intermediate values. Peak flow, FEV1/FVC, and vital capacity were also lower in those with asthma. Peak flow lability was somewhat higher in those with asthma (16% vs 12%). Forty-five percent (15/33) of those with definite asthma of moderate severity had normal spirometry findings, but all of them were taking asthma medications. Only 5 of 20 participants with severe asthma had normal spirometry (and 3 were taking asthma medications).

Asthma Therapy

As seen in Table 7 , only 30% of those who had definite asthma were taking inhaled corticosteroids, while 40% were taking inhaled or oral sympathomimetic medications; 21% were taking oral theophylline; 19% were taking oral corticosteroids; and 39% were not taking any asthma medications (9/14 intermittent, 15/25 mild, 6/33 moderate, and 6/20 severe asthma). Only 20% of those taking oral corticosteroids were also using inhaled corticosteroids. About 8% of those who had definite asthma were taking beta-blockers for hypertension or coronary heart disease (vs 13% of others). Forty-four percent of those with definite asthma had ever had allergy shots (vs 7.5% of others).

Participants who had definite asthma and were taking sympathomimetic drugs (usually by inhaler) reported taking a mean of 13.6 doses during the previous 2 weeks; those taking inhaled corticosteroids reported taking an average of only 7.3 doses during the previous 2 weeks.

Asthma Prevalence

The CHS is one of the largest population-based examinations of heart and lung disease in elderly persons in the United States. The 6% prevalence of a history of asthma at the CHS baseline examination and 4% prevalence of current asthma during this follow-up examination are similar to the rates reported in subjects > 65 years of age during a postal survey in northern Sweden18and in Australia.19

The correlates of major respiratory symptoms and obstructive lung diseases in the CHS cohort at the time of their baseline examination were previously reported.20 Attacks of wheezing (ATS question 11A3) were then associated with chronic cough, chronic phlegm, and dyspnea on exertion; a diagnosis of asthma (ATS question 20C)3 was associated with chronic wheezing, airways obstruction, and fewer pack-years of cigarette smoking. In a separate analysis, asthma was also associated with higher plasma levels of high-density lipoprotein cholesterol and fibrinogen, but not with prevalent cardiovascular disease.21

Categorizing Asthma Severity

Prior to the recent publication and widespread acceptance of clinical guidelines for asthma diagnosis and therapy, there was no standardized method for categorizing the severity of asthma. We were fortunate to have measured in 1993 almost all of the factors used by the GIA guidelines for measuring asthma severity, which were published in 1995.16 These include daytime and nighttime symptom frequency, limitation of physical activities, percent predicted FEV1, peak flow lability, and use of asthma medications. The GIA guidelines did not specify the exact wording of questions to determine the presence of factors such as “frequent exacerbations” or “physical activities limited by asthma symptoms,” so we used standardized questions to define these factors, which seemed to match the intent of the guidelines. Although the GIA severity categories were designed for patients in whom the diagnosis of asthma has been established, we chose to also apply them to CHS participants who had symptoms suggesting asthma (our possible and probable asthma categories) in the belief that asthma is often underdiagnosed, and we wished to compare the symptom severity in these people and in those who had a diagnosis of asthma.

Asthma Risk Factors

Many elderly persons with asthma recalled that their respiratory problems started in childhood (before the age of 16 years), as previously noted by other investigators.17,2223 However, the first episode of asthma was distributed thoughout life, in many cases after the age of 60 years, suggesting an environmental or infectious etiology. Skin testing or serum IgE measurements were not available in this study to determine sensitivity to specific allergens, but about half of those who had definite asthma reported that wheezing was recently triggered by contact with animals, plants, or pollens, and was seasonal, and that asthma was strongly associated with hay fever symptoms. These findings are in agreement with those of Burrows and coworkers,23who found that higher IgE levels were associated with asthma, even in elderly persons. Objective measurements of specific IgE levels or eosinophil counts would be needed to dispel the widespread impression that asthma in the elderly is primarily intrinsic, and not triggered by allergens.24

Asthma and Spirometry

The degree of baseline pulmonary function abnormality (percent predicted FEV1) was the factor which most commonly determined whether the participant was placed in the mild, moderate, or severe asthma category (see Table 3 and Appendix 2). When an FEV1 of < 60% predicted (per the guidelines) was used as a criteria for the severe asthma category, unreasonably high proportions of participants with possible, probable, and definite asthma from the entire cohort were categorized as having severe asthma (29%, 40%, and 44% respectively within each category). Therefore, we empirically chose alternate FEV1 thresholds of < 50% predicted for severe, 50 to 69% predicted for moderate, and 70 to 79% predicted for mild asthma categories in order to obtain more reasonable severity distributions for these elderly persons with asthma. Based on these results, future asthma guidelines should consider age when using lung function to define asthma severity.

Many of the 92 participants who reported definite asthma had normal spirometry results (59%). This is not surprising because 27% of them had mild asthma and another 15% had intermittent asthma, and in such patients, a single clinical examination not scheduled to coincide with recent asthma symptoms is likely to show normal spirometry. We did not ask participants to withhold asthma medications, so their asthma therapy may have resulted in normal spirometry. Others may have been mistakenly given the diagnosis.

QOL

Elderly persons with asthma (or asthma symptoms) had significantly lower scores for all three general components of QOL, when compared with others their age. They were more likely to report IADLs and a reduction in functional status (level of activity) in comparison with the previous year. Their degree of well-being was lower, as measured by a more negative feeling about life as a whole and symptoms of depression. They were also more likely to report fair or poor general health. A French study of 83 elderly patients with asthma also reported reductions in QOL when compared with a control group.25 The investigators concluded that dyspnea (not depression) was a major cause of this lower QOL.

Problems with Sleep

Daytime sleepiness is associated with reduced QOL and may be related to frequent nocturnal awakenings in elderly persons.26One fourth of CHS participants with definite or probable asthma reported awakening with coughing, chest tightness, or trouble breathing. These sleep problems were associated with feeling groggy or unrefreshed in the morning and usually sleepy in the daytime. A standardized, more quantitative, and well-validated index of daytime sleepiness, the ESS, was also significantly higher in participants who had asthma or asthma symptoms than in those who did not. These findings have clinical significance because safe and effective treatments for the nocturnal symptoms of asthma are now available. The bedtime use of long-acting inhaled β-selective bronchodilators or inhaled anti-inflammatory agents has been shown to reduce or eliminate nocturnal awakenings due to asthma2728; thus, such medications are likely to improve daytime functioning.

Underdiagnosis of Asthma

As we have demonstrated above, asthma is associated with a substantial reduction in QOL in elderly persons. Advances in the safe and effective therapy of asthma during the last decade have caused expert panels to conclude that a reasonable goal of asthma treatment is to eliminate asthma morbidity. The large number of elderly persons who have asthma symptoms identified by this study but have not received a diagnosis of asthma is disturbing because they are experiencing reduced QOL and considerable morbidity associated with their asthma, which may be largely preventable. If the diagnosis were made, 23% of those with possible asthma and 27% of those with probable asthma would be categorized as having moderate or severe persistent asthma, for which daily inhaled corticosteroid medications are indicated.

Symptoms suggesting asthma are relatively straightforward and easy to identify. Office spirometers to confirm the presence of airways obstruction in patients with these symptoms are now inexpensive and easy to use in a primary care setting.29 About 90% of the elderly CHS participants were able to perform good-quality spirometry tests within 10 min. About 25% of those who had symptoms suggesting possible or probable asthma (including former and current smokers; 10% after excluding smokers) had airways obstruction on spirometry testing, which would have provided their primary care physician with further evidence suggesting asthma, as well as a baseline FEV1 that allows the physician to assess the lung function response to therapy.

In the absence of an office spirometer, peak flow lability may be measured in a patient’s home for 2 weeks using a $20 mechanical peak flowmeter or one of the new hand-held spirometers that store, transmit, and then graph daily PEF and FEV1 readings, eliminating the need to keep a written diary. About 20 to 30% of our participants who had symptoms suggesting probable or possible asthma had abnormally high PEF lability, as demonstrated by ambulatory home monitoring. If their primary care physicians had performed this test in response to the respiratory symptoms, this evidence probably would have prompted a diagnosis of asthma, followed by effective treatment to reduce the morbidity of this disease. PEF lability was probably lowered by asthma medications in some of those with definite asthma, thereby reducing the difference in PEF lability between those who had definite asthma and those who had asthma symptoms but no diagnosis of or treatment for asthma.

Our initial analyses included former and current smokers. The correlates of asthma in that larger group were very similar to those reported here from the final analyses that excluded former and current smokers. Some of those former and current smokers probably had airways disease caused by cigarette smoking and may have been misclassified as having asthma. However, even in smokers with asthma-like symptoms and airways obstruction, a 2-week clinical trial of corticosteroids and bronchodilators is indicated,30because about 10% of current or former smokers believed to have COPD will respond with a substantial increase in lung function.31 They have been called “hidden asthmatics.”

Asthma Therapy

Clinical practice guidelines for asthma have been widely accepted since they were first published in the United States in 1991.32 They recommend the daily use of controller (anti-inflammatory) medications, such as inhaled corticosteroids, in addition to long-acting bronchodilators for all patients with moderate or severe persistent asthma. The optimal use of inhaled controller medications, which rarely cause side effects, minimizes the need for chronic oral corticosteroids (such as prednisone), which have many untoward side effects, especially in elderly persons. It is worrisome that a relatively high proportion (18%) of our elderly participants with definite asthma (regardless of their smoking history) were taking oral corticosteroids.

A large 1992 population survey in northern England reported the prescribing prevalence of inhaled corticosteroids and bronchodilators for all age groups of patients with asthma, bronchitis, or COPD.33 The investigators reported two distinct peaks in the 5- to 14-year and 65- to 74-year age groups in the use of these inhaled medications. Their elderly patients were twice as likely as children (who were usually treated intermittently) to be taking inhaled medications regularly (mean, six to seven prescriptions refilled per year for inhaled steroids and bronchodilator medications respectively). Only 20% of their elderly patients with asthma were not taking at least one inhaled asthma medication. In contrast, our study showed that only 30% of those who had been given a diagnosis of asthma by their physician were taking inhaled corticosteroids (with a mean of only seven doses during the previous 2 weeks), while 40% were taking sympathomimetics (with a mean of one dose per day).

In summary, our results suggest that not only is asthma underdiagnosed in elderly persons in the United States and associated with considerable morbidity, but most of those who have an asthma diagnosis and current symptoms are not being treated optimally.

Participating Institutions and Principal Staff

Forsyth County, NC—Bowman Gray School of Medicine of Wake Forest University: Gregory L. Burke, Alan Elster, Walter H. Ettinger, Curt D. Furberg, Edward Haponik, Gerardo Heiss, Dalane Kitzman, H. Sidney Klopfenstein, Margie Lamb, David S. Lefkowitz, Mary F. Lyles, Maurice B. Mittelmark, Cathy Nunn, Ward Riley, Grethe S. Tell, James F. Toole, and Beverly Tucker; ECG Reading Center—Forsyth County, NC—Bowman Gray School of Medicine: Kris Calhoun, Harry Calhoun, Farida Rautaharju, Pentti Rautaharju, and Loralee Robertson; Sacramento County, CA—University of California, Davis: William Bommer, Charles Bernick, Andrew Duxbury, Mary Haan, Calvin Hirsch, Paul Kellerman, Lawrence Laslett, Marshall Lee, Virginia Poirier, John Robbins, Marc Schenker, and Nemat Borhani; Washington County, MD—The Johns Hopkins University: M. Jan Busby-Whitehead, Joyce Chabot, George W. Comstock, Linda P. Fried, Joel G. Hill, Steven J. Kittner, Shiriki Kumanyika, David Levine, Joao A. Lima, Neil R. Powe, Thomas R. Price, Moyses Szklo, Melvyn Tockman, and Jeff Williamson; Washington County, MD—The Johns Hopkins University, MRI Reading Center: R. Nick Bryan, Carolyn C. Meltzer, Douglas Fellows, Melanie Hawkins, Patrice Holtz, Michael Kraut, Grace Lee, Larry Schertz, Earl P. Steinberg, Scott Wells, Linda Wilkins, and Nancy C. Yue; Allegheny County, PA—University of Pittsburgh: Diane G. Ives, Charles A. Jungreis, Laurie Knepper, Lewis H. Kuller, Elaine Meilahn, Peg Meyer, Roberta Moyer, Anne Newman, Richard Schulz, Vivienne E. Smith, and Sidney K. Wolfson; Echocardiography Reading Center (Baseline)—University of California, Irvine: Hoda Anton-Culver, Julius M. Gardin, Margaret Knoll, Tom Kurosaki, and Nathan Wong; Echocardiography Reading Center (Follow-Up)—Georgetown Medical Center: John Gottdiener, Eva Hausner, Stephen Kraus, Judy Gay, Sue Livengood, Mary Ann Yohe, and Retha Webb; Ultrasound Reading Center—Geisinger Medical Center: Daniel H. O’Leary, Joseph F. Polak, and Laurie Funk; Central Blood Analysis Laboratory—University of Vermont: Edwin Bovill, Elaine Cornell, Mary Cushman, and Russell P. Tracy; Pulmonary Reading Center—University of Arizona, Tucson: Paul Enright and Pam Boyer-Pfersdorf; Coordinating Center—University of Washington, Seattle: Alice M. Arnold, Annette L. Fitzpatrick, Bonnie K. Lind, Richard A. Kronmal, Bruce M. Psaty, David S. Siscovick, Lynn Shemanski, Will Longstreth, Patricia W. Wahl, David Yanez, Paula Diehr, and Maryann McBurnie; National Heart, Lung and Blood Institute Project Office: Diane E. Bild, Teri A. Manolio, Peter J. Savage, and Patricia Smith.

Classification of Asthma Severity†

Severe Persistent Asthma (GIA Step 4)

1. Continuous symptoms: “Do you have trouble with your breathing continuously?” = yes

2. Frequent nighttime symptoms: “How frequently have you had these symptoms (chest tightness or breathlessness with wheezing)?” = at least every day or night

3. Light physical activities limited by asthma symptoms: “Do you get short of breath with light physical activity, such as… ?” = yes, and “How short of breath do you feel during this activity?” = very or extremely

4. FEV1 < 50% predicted, or PEF lability > 30% (if ambulatory PEF done)

Moderate Persistent Asthma (GIA Step 3)

1. Daily symptoms: “How frequently have you had these symptoms?” = at least every day or night

2. Exacerbations affect moderate activity: “Do you get short of breath with moderate physical activity, such as… ?” = yes, and “How short of breath do you feel during this activity?” = very or extremely

3. Daily use of inhaled β-agonist: sympathomimetic medication taken at least once per day

4. FEV1 59 to 69% predicted

Mild Persistent Asthma (GIA Step 2)

1. Symptoms more than weekly but less than daily: “How frequently have you had these symptoms?” = only a few times a week, or only a few times a month

2. Exacerbations may affect activity and sleep

3. Nighttime symptoms more than twice per month: “Were these breathing symptoms brought on or made worse by lying down flat or sleeping?” = yes

4. FEV1 69 to 79% predicted

Intermittent Asthma (GIA Step 1)

1. All others

† We attempted to closely follow the guidelines of the Global Initiative for Asthma,15 except for modification of the thresholds for percent predicted FEV1 (see“ Discussion” in the text). A positive response to only one of the items within each category places a participant in that category.

For editorial comment see page 591.

Abbreviations: ANOVA = analysis of variance; ATS = American Thoracic Society; CHF = congestive heart failure; CHS = Cardiovascular Health Study; ESS = Epworth sleepiness scale; GIA = Global Initiative for Asthma; IADL = impairment of activities of daily living; IUATLD = European Respiratory Health Questionnaire; PEF = peak expiratory flow; QOL = quality of life; SF-36 = MOS 36-item short form health survey

Table Graphic Jump Location
Table 1. CHF and Smoking History by Asthma Status (Entire Cohort)*
* 

Data are expressed as No. (%), unless otherwise stated; smoking status and history of CHF were ascertained at the year-6 examination, and average pack-years of smoking was reported at study entry.

 

p < 0.001 based on a χ2 test for independence between the characteristic and asthma status.

Table Graphic Jump Location
Table 2. Participant Demographics (n = 2,527 After Excluding Smokers and Those With CHF)*
* 

Data are expressed as No. (%); p values are based on aχ 2 test for independence between the characteristic and asthma status.

 

p < 0.05

 

p < 0.001

§ 

p < 0.01

Table Graphic Jump Location
Table 3. Prevalence of Factors Used To Define Asthma Severity*
* 

Data are expressed as No. (%).

Figure Jump LinkFigure 1. The frequency of trouble breathing (dyspnea) by asthma status. This is question 11 from the IUATLD questionnaire.4 Continuously = trouble breathing continuously so that breathing is never quite right; repeatedly = trouble breathing repeatedly, but it always gets completely better; rarely = trouble breathing only rarely.Grahic Jump Location
Table Graphic Jump Location
Table 4. Association of Asthma Status With Other Respiratory Disorders*
* 

Data are expressed as No. (%); Hx = history; Dx = diagnosis; p < 0.001 based on a χ2 test for independence between the respiratory disorder and asthma status.

Figure Jump LinkFigure 2. Prevalence of factors that were reported to cause wheezing in elderly persons with definite or probable asthma (n = 185).Grahic Jump Location
Table Graphic Jump Location
Table 5. Association of Asthma Status With QOL Indicators*
* 

Data are expressed as No. (%), unless otherwise indicated; p values are based on a χ2 test for independence between the characteristic and asthma status for the categorical variables, and a one-way ANOVA for the continuous variables.

 

p < 0.01

 

p < 0.001

Table Graphic Jump Location
Table 6. Association of Asthma Status With Pulmonary Function*
* 

Data are expressed as mean (SD), unless otherwise stated; p values based on models adjusting for asthma medications, age, gender, and race (ANOVA models for the continuous variables, logistic regression models for the categorical variables). The means and rates presented are unadjusted, in order to enable comparisons with other studies.

 

p < 0.05

 

p < 0.01

§ 

p < 0.001

Table Graphic Jump Location
Table 7. Association of Asthma Status and Medication Use*
* 

Data are expressed as No. (%), unless otherwise indicated; p values are based on χ2 test for independence between the medication and asthma status; mean doses of medication reported as taken during the previous 2 weeks are based only on those participants who were using the medication (and data from a prescription inhaler or pill bottle brought to the clinic were recorded).

 

p < 0.001.

We wish to thank the elderly CHS participants for blowing into the spirometer and peak flowmeters again, the clinic staff for encouraging them to do so, and Pam Boyer-Pfersdorf for reviewing and reporting the quality of their pulmonary function data. Robyn McClelland is the biostatistician who performed all of the statistical analyses. They were verified by another biostatistician at the University of Washington, under the supervision of Dr. Richard Kronmal.

Fried, LP, Borhani, NO, Enright, PL, et al (1991) The Cardiovascular Health Study: design and rationale.Ann Epidemiol1,263-276. [PubMed] [CrossRef]
 
Tell, GS, Fried, LP, Hermanson, B, et al Recruitment of adults 65 years and older as participants in the Cardiovascular Health Study.Ann Epidemiol1993;3,358-366. [PubMed]
 
Ferris, BG Epidemiology Standardization Project: II. Recommended respiratory disease questionnaires for use with adults and children in epidemiological research.Am Rev Respir Dis1978;118(6,part 2),7-52
 
Burney, PG, Chinn, S, Britton, JR, et al What symptoms predict the bronchial response to histamine? Evaluation in a community survey of the bronchial symptoms questionnaire (1984) of the International Union Against Tuberculosis and Lung Disease.Int J Epidemiol1989;18,165-173. [PubMed]
 
Minette, A Questionnaire of the European Community for Coal and Steel (CSC) on respiratory symptoms (1987): updating of the 1962 and 1967 questionnaires for studying chronic bronchitis and emphysema.Eur Respir J1989;2,165-177. [PubMed]
 
Lebowitz, MD, Burrows, B Comparison of questionnaires: the BMRC and NHLI respiratory questionnaires and a new self-completion questionnaire.Am Rev Respir Dis1976;113,627-635. [PubMed]
 
Guyatt, GH, Berman, LB, Townsend, M, et al A measure of quality of life for clinical trials in chronic lung disease.Thorax1987;42,773-778. [PubMed]
 
Johns, MW A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.Sleep1991;14,540-545. [PubMed]
 
Orme, J, Reis, J, Herz, E Factorial and discriminate validity of the CES-D scale.J Clin Psychol1986;42,28-33. [PubMed]
 
Richards, JM, Hemstreet, MP Measures of life quality, role performance, and functional status in asthma research.Am J Respir Crit Care Med1994;149(suppl),S31-S39
 
Ware, JE, Sherbourne, CD The MOS 36-item short form health survey (SF-36).Med Care1992;30,473-483. [PubMed]
 
Bousquet, J, Knani, J, Dhivert, H, et al Quality of life in asthma: internal consistency and validity of the SF-36 questionnaire.Am J Respir Crit Care Med1994;149,371-375. [PubMed]
 
Psaty, BM, Lee, M, Savage, PJ, et al Assessing the use of medications in the elderly: methods and initial experience in the Cardiovascular Health Study.J Clin Epidemiol1992;45,683-692. [PubMed]
 
Enright, PL, Arnold, A, Manolio, TA, et al Spirometry reference values for healthy elderly blacks.Chest1996;110,1416-1424. [PubMed]
 
American Thoracic Society.. Standardization of Spirometry and PEF: 1994 update.Am J Respir Crit Care Med1995;152,1107-1136. [PubMed]
 
Global Initiative for Asthma Panel. Global strategy for asthma management and prevention: NHLBI/WHO workshop report of March 1993. Bethesda, MD: National Institutes of Health, January 1995; Publication No. 95–3659.
 
Traver, GA, Cline, MG, Burrows, B Asthma in the elderly.J Asthma1993;30,81-91. [PubMed]
 
Lundback, B, Nystrom, L, Rosenhall, L, et al Obstructive lung disease in northern Sweden: respiratory symptoms assessed in a postal survey.Eur Respir J1991;4,257-266. [PubMed]
 
Marks, GB, Mellis, CM, Peat, JK, et al A profile of asthma and its management in a New South Wales provincial center.Med J Aust1994;160,260-264. [PubMed]
 
Enright, PL, Kronmal, RA, Higgins, MW, et al Prevalence and correlates of respiratory symptoms and disease in the elderly.Chest1994;106,827-834. [PubMed]
 
Enright, PL, Ward, BJ, Tracy, RP, et al Asthma and its association with cardiovascular disease in the elderly.J Asthma1996;33,45-53. [PubMed]
 
Burrows, B, Barbee, RA, Cline, MG, et al Characteristics of asthma among elderly adults in a sample of the general population.Chest1991;100,935-942. [PubMed]
 
Burrows, B, Lebowitz, MD, Barbee, RA, et al Findings before a diagnosis of asthma among the elderly in a longitudinal study of a general population study.J Allergy Clin Immunol1991;88,870-877. [PubMed]
 
Jack, CIA, Lye, M Asthma in the elderly patient.Gerontology1996;42,61-68. [PubMed]
 
Nejjari, C, Tessier, JF, Gateau, BP, et al Functional status of elderly people treated for asthma-related symptoms: a population based case-control study.Eur Respir J1994;7,1077-1083. [PubMed]
 
Whitney, CW, Enright, PL, Newman, AB, et al Correlates of daytime sleepiness in 4,578 elderly persons: the Cardiovascular Health Study.Sleep1998;21,27-36. [PubMed]
 
Okamoto, LJ, Noonan, M, DeBoisblanc, BP, et al Fluticasone propionate improves quality of life in patients with asthma requiring oral corticosteroids.Ann Allergy Asthma Immunol1996;76,455-461. [PubMed]
 
Greening, AP, Wind, P, Northfield, M, et al Added salmeterol versus higher dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid.Lancet1994;344,219-224. [PubMed]
 
Enright, PL, Lebowitz, MD, Cockroft, DW Asthma Outcome Measures Workshop: pulmonary function tests.Am Rev Respir Dis1994;149(part 2),S9-S18
 
Ferguson, GT, Cherniack, RM Management of COPD.N Engl J Med1993;328,1017-1022. [PubMed]
 
Callahan, CM, Dittus, RS, Katz, BP Oral corticosteroid therapy for patients with stable COPD.Ann Intern Med1991;114,216-223. [PubMed]
 
National Asthma Education Program. Expert panel report: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, 1991; Publication No. 91–3042.
 
Roberts, SJ, Bateman, DN Which patients are prescribed inhaled anti-asthma drugs?Thorax1994;49,1090-1095. [PubMed]
 

Figures

Figure Jump LinkFigure 1. The frequency of trouble breathing (dyspnea) by asthma status. This is question 11 from the IUATLD questionnaire.4 Continuously = trouble breathing continuously so that breathing is never quite right; repeatedly = trouble breathing repeatedly, but it always gets completely better; rarely = trouble breathing only rarely.Grahic Jump Location
Figure Jump LinkFigure 2. Prevalence of factors that were reported to cause wheezing in elderly persons with definite or probable asthma (n = 185).Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. CHF and Smoking History by Asthma Status (Entire Cohort)*
* 

Data are expressed as No. (%), unless otherwise stated; smoking status and history of CHF were ascertained at the year-6 examination, and average pack-years of smoking was reported at study entry.

 

p < 0.001 based on a χ2 test for independence between the characteristic and asthma status.

Table Graphic Jump Location
Table 2. Participant Demographics (n = 2,527 After Excluding Smokers and Those With CHF)*
* 

Data are expressed as No. (%); p values are based on aχ 2 test for independence between the characteristic and asthma status.

 

p < 0.05

 

p < 0.001

§ 

p < 0.01

Table Graphic Jump Location
Table 3. Prevalence of Factors Used To Define Asthma Severity*
* 

Data are expressed as No. (%).

Table Graphic Jump Location
Table 4. Association of Asthma Status With Other Respiratory Disorders*
* 

Data are expressed as No. (%); Hx = history; Dx = diagnosis; p < 0.001 based on a χ2 test for independence between the respiratory disorder and asthma status.

Table Graphic Jump Location
Table 5. Association of Asthma Status With QOL Indicators*
* 

Data are expressed as No. (%), unless otherwise indicated; p values are based on a χ2 test for independence between the characteristic and asthma status for the categorical variables, and a one-way ANOVA for the continuous variables.

 

p < 0.01

 

p < 0.001

Table Graphic Jump Location
Table 6. Association of Asthma Status With Pulmonary Function*
* 

Data are expressed as mean (SD), unless otherwise stated; p values based on models adjusting for asthma medications, age, gender, and race (ANOVA models for the continuous variables, logistic regression models for the categorical variables). The means and rates presented are unadjusted, in order to enable comparisons with other studies.

 

p < 0.05

 

p < 0.01

§ 

p < 0.001

Table Graphic Jump Location
Table 7. Association of Asthma Status and Medication Use*
* 

Data are expressed as No. (%), unless otherwise indicated; p values are based on χ2 test for independence between the medication and asthma status; mean doses of medication reported as taken during the previous 2 weeks are based only on those participants who were using the medication (and data from a prescription inhaler or pill bottle brought to the clinic were recorded).

 

p < 0.001.

References

Fried, LP, Borhani, NO, Enright, PL, et al (1991) The Cardiovascular Health Study: design and rationale.Ann Epidemiol1,263-276. [PubMed] [CrossRef]
 
Tell, GS, Fried, LP, Hermanson, B, et al Recruitment of adults 65 years and older as participants in the Cardiovascular Health Study.Ann Epidemiol1993;3,358-366. [PubMed]
 
Ferris, BG Epidemiology Standardization Project: II. Recommended respiratory disease questionnaires for use with adults and children in epidemiological research.Am Rev Respir Dis1978;118(6,part 2),7-52
 
Burney, PG, Chinn, S, Britton, JR, et al What symptoms predict the bronchial response to histamine? Evaluation in a community survey of the bronchial symptoms questionnaire (1984) of the International Union Against Tuberculosis and Lung Disease.Int J Epidemiol1989;18,165-173. [PubMed]
 
Minette, A Questionnaire of the European Community for Coal and Steel (CSC) on respiratory symptoms (1987): updating of the 1962 and 1967 questionnaires for studying chronic bronchitis and emphysema.Eur Respir J1989;2,165-177. [PubMed]
 
Lebowitz, MD, Burrows, B Comparison of questionnaires: the BMRC and NHLI respiratory questionnaires and a new self-completion questionnaire.Am Rev Respir Dis1976;113,627-635. [PubMed]
 
Guyatt, GH, Berman, LB, Townsend, M, et al A measure of quality of life for clinical trials in chronic lung disease.Thorax1987;42,773-778. [PubMed]
 
Johns, MW A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.Sleep1991;14,540-545. [PubMed]
 
Orme, J, Reis, J, Herz, E Factorial and discriminate validity of the CES-D scale.J Clin Psychol1986;42,28-33. [PubMed]
 
Richards, JM, Hemstreet, MP Measures of life quality, role performance, and functional status in asthma research.Am J Respir Crit Care Med1994;149(suppl),S31-S39
 
Ware, JE, Sherbourne, CD The MOS 36-item short form health survey (SF-36).Med Care1992;30,473-483. [PubMed]
 
Bousquet, J, Knani, J, Dhivert, H, et al Quality of life in asthma: internal consistency and validity of the SF-36 questionnaire.Am J Respir Crit Care Med1994;149,371-375. [PubMed]
 
Psaty, BM, Lee, M, Savage, PJ, et al Assessing the use of medications in the elderly: methods and initial experience in the Cardiovascular Health Study.J Clin Epidemiol1992;45,683-692. [PubMed]
 
Enright, PL, Arnold, A, Manolio, TA, et al Spirometry reference values for healthy elderly blacks.Chest1996;110,1416-1424. [PubMed]
 
American Thoracic Society.. Standardization of Spirometry and PEF: 1994 update.Am J Respir Crit Care Med1995;152,1107-1136. [PubMed]
 
Global Initiative for Asthma Panel. Global strategy for asthma management and prevention: NHLBI/WHO workshop report of March 1993. Bethesda, MD: National Institutes of Health, January 1995; Publication No. 95–3659.
 
Traver, GA, Cline, MG, Burrows, B Asthma in the elderly.J Asthma1993;30,81-91. [PubMed]
 
Lundback, B, Nystrom, L, Rosenhall, L, et al Obstructive lung disease in northern Sweden: respiratory symptoms assessed in a postal survey.Eur Respir J1991;4,257-266. [PubMed]
 
Marks, GB, Mellis, CM, Peat, JK, et al A profile of asthma and its management in a New South Wales provincial center.Med J Aust1994;160,260-264. [PubMed]
 
Enright, PL, Kronmal, RA, Higgins, MW, et al Prevalence and correlates of respiratory symptoms and disease in the elderly.Chest1994;106,827-834. [PubMed]
 
Enright, PL, Ward, BJ, Tracy, RP, et al Asthma and its association with cardiovascular disease in the elderly.J Asthma1996;33,45-53. [PubMed]
 
Burrows, B, Barbee, RA, Cline, MG, et al Characteristics of asthma among elderly adults in a sample of the general population.Chest1991;100,935-942. [PubMed]
 
Burrows, B, Lebowitz, MD, Barbee, RA, et al Findings before a diagnosis of asthma among the elderly in a longitudinal study of a general population study.J Allergy Clin Immunol1991;88,870-877. [PubMed]
 
Jack, CIA, Lye, M Asthma in the elderly patient.Gerontology1996;42,61-68. [PubMed]
 
Nejjari, C, Tessier, JF, Gateau, BP, et al Functional status of elderly people treated for asthma-related symptoms: a population based case-control study.Eur Respir J1994;7,1077-1083. [PubMed]
 
Whitney, CW, Enright, PL, Newman, AB, et al Correlates of daytime sleepiness in 4,578 elderly persons: the Cardiovascular Health Study.Sleep1998;21,27-36. [PubMed]
 
Okamoto, LJ, Noonan, M, DeBoisblanc, BP, et al Fluticasone propionate improves quality of life in patients with asthma requiring oral corticosteroids.Ann Allergy Asthma Immunol1996;76,455-461. [PubMed]
 
Greening, AP, Wind, P, Northfield, M, et al Added salmeterol versus higher dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid.Lancet1994;344,219-224. [PubMed]
 
Enright, PL, Lebowitz, MD, Cockroft, DW Asthma Outcome Measures Workshop: pulmonary function tests.Am Rev Respir Dis1994;149(part 2),S9-S18
 
Ferguson, GT, Cherniack, RM Management of COPD.N Engl J Med1993;328,1017-1022. [PubMed]
 
Callahan, CM, Dittus, RS, Katz, BP Oral corticosteroid therapy for patients with stable COPD.Ann Intern Med1991;114,216-223. [PubMed]
 
National Asthma Education Program. Expert panel report: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, 1991; Publication No. 91–3042.
 
Roberts, SJ, Bateman, DN Which patients are prescribed inhaled anti-asthma drugs?Thorax1994;49,1090-1095. [PubMed]
 
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