Asthma Control: Unique Concerns in Older Womenby James Thompson, M.D. Health Professional, Medical Reviewer
I've recently discussed how asthma phenotypes define different subcategories of asthma. Did you know that asthma is more severe in women over 50 years of age compared to men of the same age? Interestingly, young females have milder asthma compared to young males, but adult females surpass their male counterparts in asthma severity.
A new study published in the Annals of Allergy, Asthma and Immunology reported on some unique challenges facing older woman with asthma. Researchers at University of Michigan along with state public health experts collaborated to analyze published studies on asthma in this particular gender and age group. Several topic areas were addressed.
Why is it worse in older women? Female hormones, or lack of them, may play a key role in the onset and severity of asthma later in life. Researchers found that asthma was more severe in women at and beyond menopause. In fact, they reported that peak age for asthma flare-ups was 50 years. Those who had a history of asthma earlier in life had milder asthma when placed on hormone replacement therapy (HRT). Furthermore, women who had not been diagnosed to have asthma before menopause but began HRT at menopause had more than double the risk of becoming asthmatic.
Yes, female hormones must have some role in asthma, possibly protective, but more research is needed to define how this occurs.
Negative Impact of Certain Medications
Older women are often on multiple prescriptions and over-the-counter medications for asthma and other ailments. Certain asthma meds may contribute to other ailments.
Postmenopausal women are at higher risk for developing osteoporosis (OP) from steroids used to treat asthma. Inhaled steroids are associated with much lower risk of OP compared to infused, injected or oral steroids, but the risk is not eliminated.
The article summarized the results of a large study on 1,600 elderly (mean age 81) women taking inhaled steroids. Women on high dose inhaled steroidad greater than four times increased risk of fracture compared to elderly women who had never taken inhaled steroids.
Decreased Awareness of Breathlessness
Studies over the last 30 years have drawn attention to a subset of asthma patients who appear to have a decreased perception of feeling short of breath. The Annals article reported on a higher incidence of poor perception of breathlessness among elderly women. What does this mean?
Those with decreased ability to recognize when they are short of breath tend to get sicker from asthma, requiring more medications and hospital admissions. In fact, risk of dying from asthma is higher in this subgroup (phenotype) of asthma.
Several other points of interest unique to older people with asthma were reviewed. They included:
Multiple Medical Problems. People over 65 years of age often have multiple medical problems requiring several medications. Women exceed men in this area of concern; although, in my opinion, they are better at multi-tasking to manage their diseases. Having other problems and medications to understand, purchase, and schedule can complicate good asthma control.
Depression. Several studies have noted increased risks of depression with moderate to severe asthma. This is more evident in elderly women and may go unrecognized by family and health care providers. Depression in the elderly has been associated with lower adherence to medicine schedules and poor quality of life.
Obesity. The elderly have a higher incidence of obesity, especially women over 60 years of age. The overall prevalence of obesity for adults in the U.S. is 36 percent but for older women, 42 percent. Numerous research articles have associated poor asthma control with obesity.
Primary Caregivers. Older women are often caring for other family members (in some cases their spouses) and may neglect their own health which may complicate good care of asthma and other disorders.
Limited income and poverty. Needless to say the expense of health care, including doctor visits and medications, can be overwhelming for elderly men and women, but the rate of poverty is higher in the female subset.
What can be done about all this?
The authors recommended 10 strategies to improve the care of elderly women with asthma:
Further analyze the risks vs. benefits of hormone replacement therapy.
Schedule periodic bone mineral screening and eye exams.
Provide peak flow meters in order to manage decreased sense of breathlessness.
Discuss other medical problems and emphasize the importance of good asthma control.
Screen for depression and treat or refer for counseling.
Encourage weight loss if overweight or obese.
Determine if there is a caregiver role and refer to appropriate resources for assistance.
Determine financial constraints that may limit adherence to the asthma treatment plan.
Educate on proper use of inhalers.
Consider other alternatives to current reliever inhalers if resistance is suspected.
As you can see, many obstacles to good asthma control may surface in older women (and men), but they may be overcome if directly addressed. This article has given me a better understanding of asthma in this subgroup. I hope this summary was helpful.
Special challenges in treatment and self-management of older women with asthma, Alan P. Baptist, MD, MPH et al Annals of Allergy Asthma and Immunology 113 (2014) 125-130