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*
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{at}aol.com
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionAppendix 1Appendix 2References |
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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.
Key Words: asthma • elderly • peak flow • quality of life • spirometry • wheezing
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1Appendix 2References |
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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.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1Appendix 2References |
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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.1 2 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.3
Additional asthma-specific questions were
taken from the European Respiratory Health Questionnaire
(IUATLD)4
5
and the Tucson Airways SCOR
questionnaire.6
Supplemental dyspnea questions were taken
from Guyatt and coworkers,7
and daytime sleepiness
questions from the Epworth sleepiness scale (ESS).8
The
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.11 12 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 8.5x11-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.
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).
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1Appendix 2References |
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2 test; Fig 1
).
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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.
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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.
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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).
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1Appendix 2References |
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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
22
23
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,23
who 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.26
One 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 ß-selective bronchodilators or inhaled
anti-inflammatory agents has been shown to reduce or eliminate
nocturnal awakenings due to asthma27
28
; 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,30 because 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.
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Appendix 1 |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1Appendix 2References |
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Appendix 2 |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1Appendix 2References |
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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 ß-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.
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Acknowledgements |
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Footnotes |
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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
Received for publication August 31, 1998. Accepted for publication March 30, 1999.
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