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Geriatr Gerontol Int 2015; 15: 902–909
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment Aleksandra Wardzyn´ska,1 Beata Kubsik2 and Marek Leszek Kowalski1 1
Department of Clinical Immunology, Rheumatology and Allergy, Healthy Aging Research Center, Medical University of Lodz, Lodz, and Public Health Care Center, Gostynin, Poland
2
Aim: The incidence of concomitant conditions increases with age. In elderly patients, the presence of comorbidities has been related to the course and severity of asthma. The aim of the present study was to assess the impact of comorbidities and concomitant treatment on asthma control and severity in older adults. Methods: A total of 93 elderly (age >65 years) and 78 younger (age 30–50 years) asthmatic patients were randomly selected from a database including 1755 asthmatics. Evaluation consisted of a questionnaire, spirometry and skin prick testing. Results: In elderly asthmatics, a higher incidence of chronic comorbidities (mean 8.4 vs 4.7; P < 0.001) and a higher number of prescribed medicines (7.4 vs 4.5, P < 0.001) were observed, but the severity of asthma and the intensity of anti-asthma treatment were similar to that seen in younger patients. Asthma control was not strikingly different between the groups. There was no correlation between the presence of comorbid conditions and asthma control, severity or frequency of exacerbations in older patients. Elderly patients treated with statins had a lower risk of asthma exacerbation (OR 0.39, 95% CI 0.18–0.84, P = 0.017), whereas treatment with proton pump inhibitors was associated with a higher risk of exacerbations in older adults (OR 1.84, 95% CI 1.07–3.18, P = 0.029) and higher disease severity in younger patients (OR 2.49, 95% CI 1.1–5.67, P = 0.029). Conclusion: The higher prevalence of comorbidities observed in elderly asthmatics under specialist care do not seem to be associated with worsened asthma control or severity. However, concomitant medications can significantly affect asthma control in both elderly and younger asthmatics. Geriatr Gerontol Int 2015; 15: 902–909. Keywords: bronchial asthma, comorbidity, drug polytherapy, elderly, exacerbation.
Introduction Asthma is a serious cause of illness and disability among patients aged 65 years and older. Aging is considered as one of the factors in worsened asthma control,1 increased rate of emergency interventions2 or hospitalizations3 as a result of asthma. Comorbidities in older adults are associated with higher mortality, more frequent hospitalizations, poor adherence to therapy and a significantly reduced quality of life.4 Concomitant diseases can have additional impacts on asthma.5,6 It is
Accepted for publication 9 July 2014. Correspondence: Professor Marek L Kowalski PhD MD, Department of Clinical Immunology, Rheumatology and Allergy, Healthy Ageing Research Centre, Medical University of Lodz, Pomorska 251 Street, 92-213 Lodz, Poland. Email: [email protected]
902 |
doi: 10.1111/ggi.12367
known that asthma is associated with a specific pattern of comorbid conditions whose profile depends on age.7,8 Within the elderly population, asthmatics have an increased incidence of respiratory diseases, such as chronic bronchitis,7,9 chronic obstructive pulmonary disease10 and chronic sinusitis,7 but also stomach ulcers,7,11 cardiovascular disease,7,11,12 osteoporosis,7 diabetes,7,12 depression11 and cancer7,11,12 than the rest of the population. Comorbidities have an impact on the course of asthma, and affect the quality of life of patients, especially among elderly asthmatics.13 Individuals with severe asthma have a higher incidence of sinusitis, gastroesophageal reflux disease (GERD), hypersensitivity to non-steroidal anti-inflammatory drugs, pneumonia, obstructive sleep apnea syndrome, recurrent respiratory infections and psychological problems8,11 compared with non-severe asthma patients. Elderly patients are particularly exposed to the negative effects of polypharmacy. The total number of used
© 2014 The Authors. Geriatrics & Gerontology International published by Wiley Publishing Asia Pty Ltd on behalf of Japanese Geriatrics Society.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Comorbidities in elderly asthmatics
medications increases with age,14 especially in those suffering from osteoarthritis, and circulatory and respiratory diseases.15 Polypharmacy in older adults has been associated with an increased risk of hospitalization, emergency visits and death.16 Although comorbidity and polypharmacy are considered to be the major reasons for worse control of asthma in older adults, no conclusive evidence exists to support these assumptions.5,17 The aim of the present study was to examine the association between concomitant diseases and medication load with disease severity and control in a group of elderly and non-elderly asthmatics under specialist care in a University Asthma Clinic.
Methods Patients From 2009 to 2011, a total of 343 records of elderly asthmatics aged over 65 years and 1412 records of younger patients with asthma aged 30–50 years were selected from the electronic database of the Asthma and Allergy Clinic, Medical University of Lodz. After this, 100 older adults and an equal number of younger asthmatics were chosen using random numbers generated by Microsoft Office Excel 2007 (Microsoft, New York, NY, USA). From the selected sample we acquired data from 93 elderly and 78 younger patients. Selected patients were invited for an extra visit, and interviewed and examined by the same trained physician. All procedures (questionnaire, spirometry, skin prick tests) were carried out at the same time. The study was approved by the local bioethics committee, and all study participants provided their informed consent.
Definitions Asthma was diagnosed according to the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma 2011 criteria,18 chronic obstructive pulmonary disease according to the Global Initiative for Chronic Obstructive Lung Disease 2010 guidelines,19 diagnosis of rhinitis was based on the Allergic Rhinitis and its Impact on Asthma 2008,20 and chronic rhinosinusitis was diagnosed with European Position Paper on Rhinosinusitis and Nasal Polyps 2007 criteria.21 Other allergic diseases (food allergy, urticaria, contact dermatitis, atopic dermatitis, Hymenoptera venom allergy, drug hypersensitivity) were diagnosed by an allergist based on the medical history, which included results of additional tests (e.g. specific immunoglobulin E or food/drug provocation test if justified). The questionnaire included questions about family history and environmental factors including smoking, concomitant chronic diseases, allergic diseases, respiratory symptoms, medication load and use of health ser-
vices. The diagnosis of concomitant diseases was made based on data from the questionnaire, and was verified according to available medical records. Asthma exacerbation was defined as the presence of at least one of the following events during the past 12 months: an unscheduled visit to the doctor’s office, a course of oral corticosteroids, or hospitalization or emergency service intervention due to worsening of asthma related symptoms. The level of asthma control was established according to Global Initiative for Asthma 2011 guidelines,18 and assessed by the Asthma Control Test.22 Severe asthma was defined according to the American Thoracic Society (ATS) Workshop 2000 criteria.23
Spirometry Spirometry was carried out according to European Respiratory Society standards using a PNEUMO RS spirometer (Abcmed Artmed, Kraków, Poland) in 91 participants in the study group, two patients had contraindications to carry out the test, and in all patients in the control group.24 Before carrying out spirometry, the participants were asked to discontinue long-acting β-agonists, teophylline, leukotriene receptor antagonist for 24 h, short-β-agonist and ipratropium bromide for 6 h.
Skin prick tests Skin prick tests (Allergopharma, Reinbek, Germany) were carried out in 72 elderly and in 72 younger patients. The panel included the following allergens: Dermatophagoides pteronyssinus, Dermatophagoides farinae, cat, dog, rabbit, hamster, guinea pig, rat, swine, birch, grass mix, mugwort, plantain, Alternaria tenuis and Cladosporium herbarum. A positive result was defined as a wheal of 3 mm in diameter. Atopy was diagnosed in the presence of at least one positive skin test.
Statistical analysis Categorical variables were compared using the χ2-test. Quantitative variables were presented as means and standard deviation, and compared using unpaired t-tests. Significant factors found in univariate analysis were included in multivariate logistic regression analysis to identify variables associated with the occurrence of severe and uncontrolled asthma or the presence of exacerbation. Odds ratios and 95% confidence intervals were calculated to show the strength of influence. The statistical analysis was carried out using Statistica (StatSoft, Tulsa, OK, USA). P-values
Geriatr Gerontol Int 2015; 15: 902–909
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment Aleksandra Wardzyn´ska,1 Beata Kubsik2 and Marek Leszek Kowalski1 1
Department of Clinical Immunology, Rheumatology and Allergy, Healthy Aging Research Center, Medical University of Lodz, Lodz, and Public Health Care Center, Gostynin, Poland
2
Aim: The incidence of concomitant conditions increases with age. In elderly patients, the presence of comorbidities has been related to the course and severity of asthma. The aim of the present study was to assess the impact of comorbidities and concomitant treatment on asthma control and severity in older adults. Methods: A total of 93 elderly (age >65 years) and 78 younger (age 30–50 years) asthmatic patients were randomly selected from a database including 1755 asthmatics. Evaluation consisted of a questionnaire, spirometry and skin prick testing. Results: In elderly asthmatics, a higher incidence of chronic comorbidities (mean 8.4 vs 4.7; P < 0.001) and a higher number of prescribed medicines (7.4 vs 4.5, P < 0.001) were observed, but the severity of asthma and the intensity of anti-asthma treatment were similar to that seen in younger patients. Asthma control was not strikingly different between the groups. There was no correlation between the presence of comorbid conditions and asthma control, severity or frequency of exacerbations in older patients. Elderly patients treated with statins had a lower risk of asthma exacerbation (OR 0.39, 95% CI 0.18–0.84, P = 0.017), whereas treatment with proton pump inhibitors was associated with a higher risk of exacerbations in older adults (OR 1.84, 95% CI 1.07–3.18, P = 0.029) and higher disease severity in younger patients (OR 2.49, 95% CI 1.1–5.67, P = 0.029). Conclusion: The higher prevalence of comorbidities observed in elderly asthmatics under specialist care do not seem to be associated with worsened asthma control or severity. However, concomitant medications can significantly affect asthma control in both elderly and younger asthmatics. Geriatr Gerontol Int 2015; 15: 902–909. Keywords: bronchial asthma, comorbidity, drug polytherapy, elderly, exacerbation.
Introduction Asthma is a serious cause of illness and disability among patients aged 65 years and older. Aging is considered as one of the factors in worsened asthma control,1 increased rate of emergency interventions2 or hospitalizations3 as a result of asthma. Comorbidities in older adults are associated with higher mortality, more frequent hospitalizations, poor adherence to therapy and a significantly reduced quality of life.4 Concomitant diseases can have additional impacts on asthma.5,6 It is
Accepted for publication 9 July 2014. Correspondence: Professor Marek L Kowalski PhD MD, Department of Clinical Immunology, Rheumatology and Allergy, Healthy Ageing Research Centre, Medical University of Lodz, Pomorska 251 Street, 92-213 Lodz, Poland. Email: [email protected]
902 |
doi: 10.1111/ggi.12367
known that asthma is associated with a specific pattern of comorbid conditions whose profile depends on age.7,8 Within the elderly population, asthmatics have an increased incidence of respiratory diseases, such as chronic bronchitis,7,9 chronic obstructive pulmonary disease10 and chronic sinusitis,7 but also stomach ulcers,7,11 cardiovascular disease,7,11,12 osteoporosis,7 diabetes,7,12 depression11 and cancer7,11,12 than the rest of the population. Comorbidities have an impact on the course of asthma, and affect the quality of life of patients, especially among elderly asthmatics.13 Individuals with severe asthma have a higher incidence of sinusitis, gastroesophageal reflux disease (GERD), hypersensitivity to non-steroidal anti-inflammatory drugs, pneumonia, obstructive sleep apnea syndrome, recurrent respiratory infections and psychological problems8,11 compared with non-severe asthma patients. Elderly patients are particularly exposed to the negative effects of polypharmacy. The total number of used
© 2014 The Authors. Geriatrics & Gerontology International published by Wiley Publishing Asia Pty Ltd on behalf of Japanese Geriatrics Society.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Comorbidities in elderly asthmatics
medications increases with age,14 especially in those suffering from osteoarthritis, and circulatory and respiratory diseases.15 Polypharmacy in older adults has been associated with an increased risk of hospitalization, emergency visits and death.16 Although comorbidity and polypharmacy are considered to be the major reasons for worse control of asthma in older adults, no conclusive evidence exists to support these assumptions.5,17 The aim of the present study was to examine the association between concomitant diseases and medication load with disease severity and control in a group of elderly and non-elderly asthmatics under specialist care in a University Asthma Clinic.
Methods Patients From 2009 to 2011, a total of 343 records of elderly asthmatics aged over 65 years and 1412 records of younger patients with asthma aged 30–50 years were selected from the electronic database of the Asthma and Allergy Clinic, Medical University of Lodz. After this, 100 older adults and an equal number of younger asthmatics were chosen using random numbers generated by Microsoft Office Excel 2007 (Microsoft, New York, NY, USA). From the selected sample we acquired data from 93 elderly and 78 younger patients. Selected patients were invited for an extra visit, and interviewed and examined by the same trained physician. All procedures (questionnaire, spirometry, skin prick tests) were carried out at the same time. The study was approved by the local bioethics committee, and all study participants provided their informed consent.
Definitions Asthma was diagnosed according to the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma 2011 criteria,18 chronic obstructive pulmonary disease according to the Global Initiative for Chronic Obstructive Lung Disease 2010 guidelines,19 diagnosis of rhinitis was based on the Allergic Rhinitis and its Impact on Asthma 2008,20 and chronic rhinosinusitis was diagnosed with European Position Paper on Rhinosinusitis and Nasal Polyps 2007 criteria.21 Other allergic diseases (food allergy, urticaria, contact dermatitis, atopic dermatitis, Hymenoptera venom allergy, drug hypersensitivity) were diagnosed by an allergist based on the medical history, which included results of additional tests (e.g. specific immunoglobulin E or food/drug provocation test if justified). The questionnaire included questions about family history and environmental factors including smoking, concomitant chronic diseases, allergic diseases, respiratory symptoms, medication load and use of health ser-
vices. The diagnosis of concomitant diseases was made based on data from the questionnaire, and was verified according to available medical records. Asthma exacerbation was defined as the presence of at least one of the following events during the past 12 months: an unscheduled visit to the doctor’s office, a course of oral corticosteroids, or hospitalization or emergency service intervention due to worsening of asthma related symptoms. The level of asthma control was established according to Global Initiative for Asthma 2011 guidelines,18 and assessed by the Asthma Control Test.22 Severe asthma was defined according to the American Thoracic Society (ATS) Workshop 2000 criteria.23
Spirometry Spirometry was carried out according to European Respiratory Society standards using a PNEUMO RS spirometer (Abcmed Artmed, Kraków, Poland) in 91 participants in the study group, two patients had contraindications to carry out the test, and in all patients in the control group.24 Before carrying out spirometry, the participants were asked to discontinue long-acting β-agonists, teophylline, leukotriene receptor antagonist for 24 h, short-β-agonist and ipratropium bromide for 6 h.
Skin prick tests Skin prick tests (Allergopharma, Reinbek, Germany) were carried out in 72 elderly and in 72 younger patients. The panel included the following allergens: Dermatophagoides pteronyssinus, Dermatophagoides farinae, cat, dog, rabbit, hamster, guinea pig, rat, swine, birch, grass mix, mugwort, plantain, Alternaria tenuis and Cladosporium herbarum. A positive result was defined as a wheal of 3 mm in diameter. Atopy was diagnosed in the presence of at least one positive skin test.
Statistical analysis Categorical variables were compared using the χ2-test. Quantitative variables were presented as means and standard deviation, and compared using unpaired t-tests. Significant factors found in univariate analysis were included in multivariate logistic regression analysis to identify variables associated with the occurrence of severe and uncontrolled asthma or the presence of exacerbation. Odds ratios and 95% confidence intervals were calculated to show the strength of influence. The statistical analysis was carried out using Statistica (StatSoft, Tulsa, OK, USA). P-values
