Challenges In Managing Asthma In Elderly Population

Prevalence of Asthma in Elderly Population

Discuss About The Working Memory Design Of Health Materials.

Asthma is a long-term inflammatory condition associated with narrowing of the airways and high production of mucus. People affected by asthma experience symptoms of shortness of breath, wheeziness and breathing difficulty (Ozturk & Iliaz, 2016). According to the World Health Organization report released in 2016, 3, 83, 000 deaths have occurred due to asthma in 2015 (World Health Organization, 2017). It has become a public health concern for high-income countries as well as low and middle income countries. Asthma related death is highest in low and middle income countries. Though it is recognized as the disease of the younger adults however, mortality rate of asthma is mostly seen in people above 55 years (Gillman & Douglass, 2012). Asthma is common in older adults above 65 years of age and the risk factor is similar to those found in young age group. The diagnosis of asthma significantly reduces psychological and physical quality of life of elderly people. It has been noted that the burden of the disease is also found to increase with age and people between 75-79 years of age experience greatest burden of the disease (globalasthmareport.org, 2014). Paying attention to optimal management of asthma in elderly population gains much attention because of disproportionate burden of asthma in elderly and the presence of multi-faced risk factors unique to older age group.

With the increase in ageing population, paying attention to diseases most commonly found in older people is important to reduce the burden on the health care system. Elderly people are vulnerable to asthma because of pulmonary changes due to ageing, challenges in diagnosis of asthma in elderly people and adverse effect of medications due to presence of other co-morbidities at old age. All these factors further increased challenges for health care professionals while managing asthma symptoms in elderly people. Review of research literature suggests under-diagnosis as one of the treatment challenges in asthmatic older population. Pandya et al. (2016) reported that diagnosis is difficult because many cardiovascular diseases mimic asthma related symptoms which is more commonly found in elderly population compared to young population. Chronic airflow obstruction and asthma symptom in elderly is also misdiagnosed as chronic bronchitis. Inconsistent results in spirometry also increase the challenges for elderly population (Gillman & Douglass, 2012). However, the gaps found in the result was that it was not a population based study and conducting research in a single hospital gave limited information regarding challenges in diagnosing asthma. Diagnosis of asthma in elderly not only increases events of misdiagnosis but also challenges in management of the condition. Benfante and Scichilone (2016) investigated about management challenges in elderly people with asthma and it showed that very few studies have evaluated the effect of multiple co-morbidities on controlling asthma symptoms in elderly. Hence, many gaps remain in literature regarding asthma management in elderly.

Management Challenges in Elderly People with Asthma

As gaps in research data exist regarding appropriate intervention to overcome challenges in asthma management, conducting a systematic review on identifying the challenges in the management of asthma in the elderly population has been felt crucial. Systematic review and analysis of research articles reporting about interventions for elderly asthma management and the associated challenges may help to gain understanding regarding barrier to optimal recovery of elderly people. The main research problem identified from the above discussion is the prevalence of asthma in elderly population and increase in health burden due to poor management of asthma in health care setting. The research question that can provide guidance in conducting the systematic review is as follows:

‘How proper management of asthma can be done in elderly population for reducing the symptoms of this condition?

By conducting systematic review on challenges in the management of asthma in elderly population, the purpose is to develop understanding regarding range of interventions for elderly people and the factors increasing challenges for elderly people.

The main objectives of the systematic review are as follows:

• To gain insight about challenges faced in management of asthma in elderly population
• To link comorbidities in elderly patient with management of asthma symptoms
• To understand the effect of asthma interventions for elderly
• To evaluate intervention implemented for asthma management in elderly population grou

For the purpose of alignment of research outcomes at the end of the research with the outlined research objectives outlined at the initial stage of the research, it was advantageous to carry out a systematic literature review. According to LoBiondo-Wood and Haber (2014) systematic literature reviews are comprehensive yet informative literature reviews that are aimed at identification and subsequent synthesis of existing studies. Summarization of the main findings of existing studies is the main purpose of such studies. In the present case, a systematic literature review aimed at carrying out a planned research and consolidating the relevant and valuable research findings on the topic of management of asthma in elderly patients so that the concerned stakeholders can be informed about practice changes in healthcare settings in relation to asthma management. In systematic literature review, the integrative assessment relevant data was sorted from a vast pool of information so that appropriate conclusions can be drawn from it. As mentioned by Alligood (2017) a systematic literature review is to be considered as a protocol driven and comprehensive review that focuses on a particular question. A polished methodology is to be followed for enabling best outcomes of the review.

Inclusion and exclusion criteria considered in a systematic literature review are responsible for setting the boundaries of the study. The two sets of criteria are to be articulated after the research question is set, and prior to commencement of the research and the search for the articles is conducted. Varied factors can be determined as the inclusion or exclusion criteria ((LoBiondo-Wood & Haber, 2014).). As per the researchers, inclusion criteria are the set of characteristics that the selected studies must be possessing and the exclusion criteria are the set of characteristics that out rightly disqualify the articles from being included in the review. For the present review, the inclusion and exclusion criteria were pre-set. Inclusion criteria included Peer-reviewed journal research articles retrieved from different sources. Further, only those articles that had full-article access were selected for the study. Other inclusion criteria were year of publication after the year 2009, and those published in English language. Lastly, article with human participants were significant for the present review. Articles from only last ten years were selected for synthesizing key inferences from updated and recent studies against evolving healthcare services in relation to asthma (Alligood, 2017). Exclusion criteria therefore were non-full text articles, those not published in English language and before 2009, and absence of human participants in research. Articles from across the globe were considered for increasing the generalizability of the study findings.

Systematic Literature Review for Identifying the Challenges and Interventions

Databases- Electronic databases are powerful and reliable tools used by researchers across the globe for engaging in secondary research, including systematic literature review. Appropriate electronic databases are to be identified and used for making the systematic search successful (LoBiondo-Wood & Haber, 2014). A number of electronic databases are present that are beneficial in health science research. For the present review, the databases that were used are Medline, CINAHL, PubMed and EMBASE. It has been noted that the above mentioned databases are the ones that are commonly used for accessing a diverse range of research articles. It is easy to access full-text articles from these databases wherein access to different journals is possible, and since peer reviewed articles is found, the same are reliable and authentic. Updated articles make the databases beneficial as recent information can be retrieved.

Search terms-Search terms are a crucial elementin systematic literature review. These are the terms, words or short phrases used for searching the relevant articles in an electronic database. The terms mainly relate to the research objectives. The use of appropriate terms makes the research process faster and convenient (Peters et al., 2015). For the present review, the search terms used were asthma, elderly, elder, older, management, treatment, challenge, and difficulty.

Boolean operation-Usage of appropriate search terms is not alone sufficient for making the search an easy process. Application of Boolean operations comes into forefront in this regard. These operations are logical terms that researchers use together with the identified search terms for making the process of research more refined. An authentic and smooth search is therefore enabled. The utility is that inappropriate search hits can be suitably eliminated, making the end result more productive (LoBiondo-Wood & Haber, 2014). Boolean operations that were considered for use in the present review were AND and OR, as per the requirement of the respective database.

A meticulous search is necessary for appropriate study results. To ensure that the inference drawn from the research aligns with the research objectives, the researchers are to select the articles through proper screening (Parahoo, 2014). In case of systematic literature review, intensive activities are required from the researcher’s end as they are to evaluate a large pool of studies for identifying only those that are meeting the eligibility criteria appropriately. A bird’s eye view is needed for producing a full review, as readers gain in depth knowledge of the articles presented. An investment in valuable resources was entailed in the present review to highlight the challenges in managing asthma in elderly patients. Each of the databases was searched one at a time for the related articles. Total number of articles retrieved was 106. 35 articles were selected for the second round of screening. The title of the articles and the abstracts were scrutinized for understanding their validity. 28 articles subsequently screened in the next step. The suitability of the articles was adjudged after reading the full articles. 13 articles were finally included in the systematic literature review.

Methodology

The next step after retrieving articles is to read the full text of the articles to be included in the review so that pertinent data can be extracted. Extraction of data in a systematic literature review has to be precise for augmenting the research outcome. This also helps in reducing the amount of time taken for completing the review. Systematic literature reviews helps in the identification, synthesis and interpretation of published pool of evidence on the concerned topic for improving decision making process for stakeholders such as policy makers and clinicians (Jonnalagadda et al., 2015). For the present research on challenges of managing asthma patients in elderly, the key insights from the articles were drawn in. In the present review, a summary table was used for summarizing the key information from the eligible studies. The information that was focused on in the summary table was author details, country and year of publication, study aim, study setting, research sample, study design, results. The table provides an all-inclusive overview of the papers and the main findings of the paper. An idea can be made out of the summary table about the direction in which the results of the review is heading.

Quality assessment of the quantitative articles was done with the help of the PRISMA checklist. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) is an evidence based set of items that are referred to for reporting on reviews. The checklist offers precise outline about what is to be included in the systematic literature review. It covers varied aspects ranging from the methodology to the results. It is reported that it acts as an excellent template for reporting on the systematic review.

The content of the research articles selected for the review are to be analyzed in an appropriate manner and presented in a clear form. Systematic literature review aim at assessing the quality of the study and the efforts given into research. In the present review it was found considerable to carry out thematic analysis in place of meta-analysis. Meta-analysis is carried out when the aim of the research is identification of consistency is research studies and a certain treatment effect (Parahoo, 2014). In the preset case, the aim of the review was not to highlight any treatment or management effect on asthma. Thematic method was adopted for analyzing articles and categorizing them under different refrains. The focus was no pinpointing and recording patterns within data. As opined by LoBiondo-Wood and Haber (2014) thematic analysis is known to be an operative and efficient approach for linking selected studies with the research objective, thereby enabling drawing of conclusion. The categorization into different themes has been found to help researchers to process text after refining key findings. Each theme is a representation of the pattered meaning or response from the generated data in regards to the research question.

Criteria for Including the Studies

PRISMA Flow chart

Challenges in the use of inhalation therapy in elderly population

Inhalation therapy is one of the interventions used for treatment of people with asthma. The utility of inhalation therapy is that the same holds the potential to assist the delivery of medication to the right site for action. The effectiveness of the therapy is dependent on choice of device and correct use of inhalation technique. It has a major contribution in controlling asthma and preventing affected people from future exacerbation (Scichilone, 2015).  The review of research literature gave idea about unique challenges in providing instructions on inhaler use in elderly patients with asthma.

The article by Turan, Turan and Mirici (2017) also focussed on the problem associated with treatment of elderly patients with asthma and the main aim was to identify the factors that affect the success of using inhalers and the factors affecting treatment adherence rate. COPD or asthma patients above 65 years old were the main research participants. Assessment of cognitive impairment in participants was done by the Mini Mental state test and treatment adherence was measured by Morisky Medication Adherence Scale. Usage of inhaler and skills in using inhaler device technique was collected and a questionnaire was used. The analysis of research findings revealed that the breath out before and after inhalation as the most common mistake done by elderly patients. Various other forms of mistakes related to inhaler use was found. Association between cognitive impairment and lower inhalation device use was also found. The findings gives the implication that cognitive dysfunction in elderly people can be a major barrier to effective use of inhalation device technique. The study has small sample size limitation; the findings can gives implication to health care professionals to learn ways to teacher inhalation technique to elderly patients with cognitive impairment. The findings obtained by is is supported by Elliott et al. (2015) as the author explains that cognitive impairment in elderly people impairs functional status of elderly people such as self-administration of medication.   Hence, identify impaired capacity to manage medication is essential to prevent risk of medication errors and hospitalization in elderly patients.

Asthma is a common illness in people above 65 years of age however challenges in treatment and management process increase because of the presence of complex co-morbidities in patient. This is the reason for frequent hospitalizations, poor adherence to treatment, high mortality rate and poor quality of life (Song & Cho, 2015).

Identification of Studies

Wardzy?ska, Kubsik & Kowalski (2015) highlighted about the issue of comorbidties and its link with control of asthma and asthma management. Elderly people aged above 65 years and younger asthmatic patient were selected and participants were evaluated based on questionnaire, spirometry and prick testing. The questionnaires covered topics like smoking, respiratory symptoms, use of health services and history of concomitant chronic disease. On comparison of data obtained from young and old participant group, it was found that elderly patient had low forced expiratory volume and high number of co-morbidities compared to younger asthmatics. Older patients were found to use non-asthma drugs in large numbers. However, one significant outcome is that the study revealed no association between co-morbidities and asthma control. This is a contradictory finding and this could have occurred because diagnosis of co-morbidities was done based on answers in the questionnaire. Despite this limitation, the study showed effect of concomitant medication on asthma control. Milanese et al. (2014) also supports the argument as the author explained that co-morbidities is one of the hallmarks of elderly patient this may account for poor outcome in elderly patients compared to younger patients.

 While reviewing impact of co-morbidities on asthma management in elderly population, coexistence of COPD has also been found as a treatment challenge. This is because COPD deteriorates symptom of asthma as proved by the study by Milanese et al. (2014). The main purpose of the study by Milanese et al. (2014) was to carry out an exploration of the level of asthma control in elderly patients along with identifying barriers to asthma control. The multi-centre observational study was done with patients above 64 years old and information related to age, smoking status, age of asthma onset and chronic bronchitis was recorder by research participants. The level of co-morbidities in participants was analyzed by the use of concomitant drug prescription for other diseases. Airborne allergen and spirometry test was also performed. 29% of asthma patients were found to be suffering from COPD and those patients had high rate of dypnea and asthma control test score. Hence, patients with COPD were found to have worse asthma control and a high exacerbation rate. This established links between presence of COPD and treatment challenges due to COPD exacerbation. Despite this finding, transferability of the research is low as certain test were done in subjects only with smoking habits and airway obstructions. The study gives the implication to pay special attention to elderly asthma patients with COPD as comorbidity as this leads to worst outcome and clinical deterioration in patient.

Selection and Appraisal of Articles

Ross et al., (2013) stated that older adults suffering from asthma often experience poor quality of life, asthma control, and require increased health care utilization. However, thee factors that lead to such state remain unknown. The researchers carried out a study for identifying physiologic, psychological or demographic characteristics related to quality of life of asthma patients. A cross-sectional study design was considered for people aged more than 65 years. The individuals had a history of asthma. Psychological, physiological and demographic characteristics were identified. Correlation was obtained for the mentioned factors, and the mini Asthma Quality of Life Questionnaire, Asthma Control Questionnaire and health care utilization were under scrutiny. 70 participants enrolled in the study who had the mean age of 73.3 years. It was indicated that higher depression screening scores and self-reported depression had strong association with poor quality of life. Overall poor functional status also led to poor level of motivation among patients to bring improvement in their condition. Subjects who reported to be living alone were found to be having unscheduled visits to a physician’s office (P = .06). It was therefore concluded that comorbid depression led to poor management of asthma in elderly population and control over life. Screening for depression might lead to better healthcare outcomes.

From the review of research literature, another common themes identified related to treatment challenges include poor adherence to asthma medications in elderly patients. Various factors were identified to be contributing to poor adherence and treatment challenges in geriatric asthma management. For example, health literacy, cognitive skills and other factors were identified as factors that influence medication adherence rare in older adults with asthma.

Soones et al., (2016) pointed out that limitations in health literacy are significantly associated with lower level of adherence to controller medications of asthma in older adults. There are multi-varied factors that lead to inappropriate and inadequate use of asthma controller medications. The barriers range from those related to costly regimens, complex regimens, provider-patient level challenges, and perception regarding the time taken for completion of patient counseling. The researchers aimed at describing the causal pathway that links health literacy and adherence to medication through modeling of asthma illness and medication beliefs. Recruited of elder asthma patient was done above the age of 60 years from different community practices and hospitals in New York and Chicago. Measurement of health literacy was done along with medication adherence with the help of Short Test of Functional Health Literacy with the help of Short Test of Functional Health Literacy in Adults and the Medication Adherence Rating Scale. Validated instruments were used for assessment of asthma and medication beliefs. Cognition assessment was undertaken with the help of a cognitive battery. The results indicated that there was a direct relation between health literacy and adherence to medication (beta = 0.089; P < .001). It was further indicated that 36% of individuals with lower level of health literacy had more chances of developing misconceptions about asthma medications (P < .001) and asthma (P < .001). Illness beliefs did not demonstrate a meditational role between adherence and health literacy (beta= 0.007; P =.143). It was therefore inferred that improved asthma controller medication adherence can be achieved through adequate focus given on to communication strategies as deemed fit for cognitive impairments and lower level of health literacy.

Data Extraction and Synthesis

Asthma in elderly population is often linked with under-diagnosis and uncontrolled disease lead to poor quality of life, if not morality. Previous research indicates that in elderly patients functional and mental states, and depressive symptoms are influential in due course of adherence to therapy of asthma. In this regard it is to be mentioned that the contribution of medical staff as well as physician is primitive. Insufficient role delegation in terms of treatment monitoring leads to poor adherence to treatment (Bozek & Jarzab, 2010).The scholars estimated extent of anti-asthmatic therapy adherence prior to and after one year of treatment monitoring through an assessment carried out with anti-asthmatic drugs. Patients above the age of 65 years were recruited for the study, and retrospective analysis was done for evaluation of adherence with the help of the Modified Morisky (MM) scale and a visual analog scale (VAS). As a latter element of the study, monitoring of asthma was undertaken for one year on the basis of drug usage. The researchers considered assessment through VAS, MM scale and assessment of functional status, depressive symptoms and cognition prior to the observation and after completion of the observation. The results indicated that out of the 117 total numbers of participants, only 21% and 9% had adherence to therapy as per the VAS and MM scale respectively. Monitoring of adherence led to an increase in compliance, from 3.08 ± 0.97 to 3.85 ± 1.01 as assessed by the MM scale, and from 44% ± 7.8% to 90% ± 5.9% as assessed by VAS. Further it was assessed found that a statistical correlation was evident between adherence, cognition and depression symptoms, as compared to functional status. It was therefore concluded from the study that poor compliance with anti-asthmatic treatment can be due to poor degree of monitoring, and use of drug packages with cognitive status and depression symptoms estimation would be beneficial for ensuring patient outcomes.

The significance of the study by O’Conor et al. (2015) is that it aimed to investigate the extent to which asthma patient’s cognitive skills can be related to health literacy. The significance of this study is that it recognizes the fact that component of health literacy can limit the effectiveness of interventions and asthma management strategies and cognitive ability can be a significant factor that mediates the relationship between health literacy and health outcomes (Baker et al., 2008). O’Conor et al. (2015) conducted the study with patients aged 60 years at eight outpatient clinics and the main outcome of interest for the study included medication adherence, inhaler technique, health literacy and cognitive ability. Standard tools were used to measure each outcome variables. The statistical analysis of study findings revealed that very few participants (only 38.2%) adhere to asthma medication. The likelihood of adhering to medication differed based on level of health literacy and the indication was that because people with limited health literacy were less likely to comply with asthma medications. This provides the evidence that adequate health literacy acts as a significant predictor of medication adherence rate. Another important finding was that cognitive functions were independent predictor of medication behaviour. This finding is consistent with research hypothesis and other research evidence too. Wilson and Wolf (2009) justified that fluid abilities of people decline with age and because of cognitive decline, they require careful management process. The strength of the study is that it gives the implication to implement self-care behaviour interventions so that cognitive burden related to asthma and medication management can be reduced. However, the findings cannot be generalized because the findings focus only on asthma medication behaviour, but elderly people struggle in managing multiple medication routine for multiple co-morbidities (Wallace et al. 2015).

Results

Asthma in the elderly population is associated with higher mortality and morbidity. Skloot et al. (2016) identified that the poor outcomes of asthma in elderly population are a result of, to some extent, under-diagnosis followed by under-treatment. There are a number of factors in relation to aging that influences to a great extent asthma presentation in elderly population, thereby influencing management. The researchers carried out a study with noted researchers and clinicians from different clinical backgrounds such as allergy, immunology, pulmonary medicine and geriatrics, who had interest in the field of Asthma in elderly (AIE). An official American Thoracic Society Workshop was conducted. Participants were required to present the current knowledge present relevant to AIE. Each presentation by the participants was followed by discussions. Transcripts were prepared on the basis of information collected. The study concluded that confounding influences such as impaired motor skills, impaired cognitive skills, medication adverse effects due to age, psychosocial effects of aging guide treatment of asthma in the elderly. Further studies are necessary for understanding how patient specific asthma management can be promoted in clinical settings.

Pandya et al. (2016) identified that asthma affects older people in a universal manner. Instead of suspecting the condition in elder population, misdiagnosis is common as chronic obstructive pulmonary disease (COPD). Due to this, suboptimal treatment is evident. The researchers aimed at highlighting the extent of misdiagnosis of elderly asthma. A prospective study was carried out that involved 350 patients with clinically diagnosis of obstructive airway diseases (OADs). Out of the total number of patients, 292 individuals were found to be suffering from obstructive pattern in pulmonary function test. Out of these individuals, 100 had been diagnosed with asthma while 192 were suffering from COPD. Out of the 100 patients, 16 individuals were of more than 60 years and 5 individuals of them were previously given treatment for COPD. It was concluded that if misdiagnosis occurs, proper management of asthma in elderly is related to key challenges.

According to McDonald et al., (2011) COPD and asthma in elderly population are known to be complex conditions that have a distinct relationship with multiple clinical concerns. Asthma frequently has a coexistence with COPD, and research indicates that in elder population asthma is associated with comorbidities. The clinical problems that arise in elderly asthma patients relate to symptoms of pathophysiological changes, lifestyle, self-management skills and individual problems as brought into the limelight by the patient himself. The problems might not be elicited by the clinician unless adequate probing is done. The research carried out by the McDonald et al., (2011) aimed at assessing patient’sand physician’s perceived importance of understanding clinical problems and describing the extent of concordance between physicians and patients with regards to the problems. 52 participants aged above 55 years were selected for the problem prioritization study. A multidimensional assessment was carried out for characterizing the prevalence of clinical problems. The objective was to achieve rating for problem importance. The results indicated that the higher rated problems were activity limitation, dyspnoea, airway inflammation. Further, these areas demonstrated satisfactory patient-physician concordance. The result further indicated that poor concordance was evident in relation to airflow obstruction, and inhaler technique adequacy. Though good agreement was found in relation to written action plans, the importance to physicians and patients was limited. It was therefore concluded from the paper that patients and physicians agree on limited aspects of asthma care in elderly patients. It can be inferred that the problems faced by elderly asthma patients are not adequately elicited and thus not addressed for ensuring better health outcomes.

Discussion

Goeman et al., (2011) identified that asthma burden in expected to increase considerably in the coming few decades. The researchers considered undertaking a cross-sectional survey for identifying concerns of elderly asthma patients and the perceived symptom of asthma. 199 individuals above the age of 55 years and suffering from asthma were included in the study conducted in Australia. 120 individuals reported that they could well control their conditions while 78% individuals claimed that they adhered to asthma treatment. in spite of this, 105 individuals said that they experienced moderate to severe symptoms, Further, it was indicated that exacerbations were common in around one-third of the population would required emergency care in the past one year. Though 80% of the respondents said that they could manage their condition properly, only 10% reported that they could visit an emergency department when they had severe aggravation of symptoms.  Those with age above 65 years had the preference for less autonomy in decision making. It was therefore concluded that asthma educators are supposed to identify the individual needs of the elderly asthma patients for tailoring the delivery of comprehensive asthma care.

Asthma education delivered to a wide population of patients had been found to be promising. Asthma is considered as a major public health concern that affects individuals across the age spectrum. Research indicates that elderly asthma leads to almost half of the total number of deaths due to asthma on an annual basis. Further, asthma in elderly leads to significant hospitalizations. Baptist et al., (2011) highlighted that though the burden of medical costs and healthcare resource utilization for elderly asthma is high, little research has been done to understand the methods by which quality of life of elderly asthma patients can be improved. Patient education acts as a vital component for asthma management. Limited research has been done to understand the challenges faced in educating elderly asthma patients so that they can combat the symptoms experienced. The researchers brought into notice that previous trials to understand effectiveness of asthma education did not consider patient population above the age of 65 years. The researchers therefore conducted a study to carry out an evaluation of the effectiveness of asthma education of long terms and short term indicators of asthma management in the population above 65 years. The research considered using the Four-State National Asthma Survey (NAS) data. Asthma control was evaluated and compared between population of elder adults above the age of 65 years who received education and those who did not use. Elderly asthma patients were taught to use asthma action plan (AAP) and peak flow meter (PEM). Comparison was done among older patients who took part in asthma course and those who did not. The short term outcomes measured were (symptoms within last 1 week, day and night symptoms in last 30 days, and the use of steroid in last 3 months), while the long term outcomes studied were asthma attack, emergency department visit, hospitalizations, and activity limitations in the prior year. No differences were found in the short- and long-term asthma outcomes between older adults receiving and not receiving education. It was therefore concluded that instructions on asthma plan, asthma education course and instruction of using of PFM were not effective in changing asthma outcomes in elderly population. The inference drawn was that education programs are to be tailored specifically for older population for making the same effective.

Author	Country and year of publication	Study aim	Study setting	Research sample	Study design	Results
Bozek & Jarbaz	Poland, 2010	Assessment of adherence to antiasthmatic therapy among elderly asthmatic spatient	Hospital setting	One hundred and seventeen participants from outpatient allergological and geriatric clinics, 63 women and 54 men, age 65 and older (mean age: 72 ± 3.9, range: 65–102),	Retrospective study design	Low adherence to anti-asthmatic treatment is common in elderly people as a result of poor monitoring course
McDonald et al.	Australia, 2011	Assessment of patients’ and physicians’ perceived importance of clinical problems in asthma	Respiratory ambulatory care clinics at the John Hunter Hospital, Newcastle, NSW, Australia	100 participants aged 55 years and above	Multidimensional assessment	Higher rated patient problems are airway inflammation, activity limitation and dyspnoea
Soones et al.	USA, 2016	Description of describe the causal pathway linking health literacy to medication adherence by modeling asthma illness and medication beliefs as mediators	Community and hospital practices	Adult asthma patients 60 years and above age	Structural equation modeling	Lower level of health literacy increase the chances of non adherence to asthma medication
Ross et al.	USA, 2013	To identify demographic, psychological or physiologic characteristics associated with asthma quality of life, control and health care utilization in older adults	Data taken from the university of Michigan asthma registry	Elderly asthma patients with mean age of 73.3 years	Cross sectional study	Comorbid depression leads to poor management of asthma in elderly patients
Skloot et al.	USA, 2016	To assess the challenges faced in managing asthma in elderly	American Thoracic Society	Experts and clinicians	Workshop with focus group discussions	Confounding influences, such as comorbidities impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, have an impact on treatment of asthma in the elderly
Pandya et al.	India  2016	To understand the mismanagement of asthma in elderly population	Patients at SBKS Medical Institute and Research Center	350 clinically diagnosed with obstructive airway diseases (OADs)	Prospective study	Misdiagnosis of asthma leads to suboptimal treatment in elderly
Wardzynska et al.	Japan, 2015	To carry out an assessment of the impact of comorbidities on asthma severity and management in older adults	Patients selected through database	93 elderly asthma patients aged 65 years and above	Evaluation through questionnaire	Higher prevalence of comorbidities have no significant relation with asthma control
O’conor et al.	USA, 2015	To investigate the extent to which cognitive skills is related to health literacy and medication adherence in asthma	8 outpatient clinics	Patients aged 60 years and above	In person interview	Limited literacy leads to poor medication adherence
Turan et al.	Turkey, 2015	To assess the parameters affecting inhaler using success and treatment adherence.	Hospital setting	Asthma  outpatients over age of 65	Assessment scale and questionnaire	Cognitive dysfunction, Cognitive dysfunction, socio-economical status, pulmonary symptoms, smoking, have effects on the adherence to inhalation therapy
Buranello et al.	Brazil, 2016	To evaluate knowledge possession among older asthma patients	Medical clinic department of private hospital	52 elderly asthma patients with mean age 75 years	Observational, descriptive cross-sectional study	Low level of standardized information, prescriptions and monitoring leads to poor outcome of oxygen inhalation therapy
Milanese et al.	Italy 2014	To explore extent of asthma control in elderly subjects	Hospital setting	350 patients aged 64 years and above	Observational study	Coexistence of COPD negatively influences asthma control
Baptist et al.	USA, 2011	To assess the effectiveness of asthma education in improving asthma condition in elderly	Survey conducted by National Center for Environmental Health	Older adults above age of 65 years	Cross sectional study	Engagement in asthma education course, instruction on action plans, and instruction on PFM use are not effective in  controlling poor asthma outcomes in elderly patients
Goeman et al.	Australia, 2011	To identify the unmet needs of older people with asthma	Community pharmacies in Victoria, Australia	120 asthma patients aged above 55 years	Cross sectional survey	Asthma educators are to provide tailored education program after identification of individual needs of patients

Conclusion

Asthma is a form of respiratory disease due to which patients suffer variable respiratory symptoms along with obstruction of the airway in relation with airway hyper-responsiveness (AHR). The feature mentioned are cause due to an inflammatory process that is marked by progressive bronchial remodeling (Iwanaga et al., 2017). The prevalence of asthma among the elderly population is reported to be equal or in some cases even higher than the general population suffering from asthma. It has been estimated that around 7-15% of people living in Australia aged above 65 years suffer from asthma. This implies that near about one out of seven people in the country are asthmatic. This statistics includes individuals who are diagnosed with asthma in the later stages of life, and those who are diagnosed with the condition in early stages (Braman, 2017). Asthma in older population of Australia is found to be distinct in a number of ways. The disease is known to be highly persistent and severe in elders, making the management of the same highly challenging. As per the data of 2006, around 92% of asthma deaths in the country were among those aged 45 years and above. It has been reported that asthma is more prevalent among females as comparison to males (10.8% compared to 7.4%) (Inoue et al., 2014).  

Management of asthma in elderly has been pointed out to be highly challenging due to different causes. The present review aimed at understanding the challenges faced by healthcare professionals to address asthma presentations in the elderly population. It had the objective of identifying the underlying factors related to poor management of asthma in the elderly population. The focus was to highlight the different aspects that hinder optimal care delivery to the patient population and the factors that diminish the effectiveness of self-management. By undertaking the systematic review on challenges in the management of asthma in elderly population, the purpose was to develop a thorough understanding of different interventions that can be applied to elderly asthma population for addressing their concerns and enabling better patient outcomes. The objectives of the review were multifold. The focus was on gaining insight into main challenges faced by healthcare professionals and the effect of asthma interventions on the elderly. Several issues particular to asthma management in elder people and their subsequent clinical implications have come into limelight through the present systematic review.

The review indicates that severity of asthma in the elderly population is significant and disrupts the course of care given. The severity of the condition leads to comorbid conditions in the chosen population, which in turn results in complications of management of the condition. Comorbidities hold the potential to affect the metabolism and excretion of respiratory drugs, and can negatively impact adherence to and persistence with chronic treatment. The impact of comorbidities on asthma management is of high significance and the common comorbidities that influence effective outcomes of treatment are coexistence of COPD, impaired cognition and motor skills, and psychosocial effects of aging. As opined by Ban et al., (2016) comorbidities such as COPD, cognition and motor skills, psychosocial impact of aging are common in elderly asthma patients and can effectively lead to alteration in the natural history of asthma, further complicating the management process and increasing the risk of suffering adverse drug reactions. Yanez et al., (2014) had further commented that patients suffering from multiple comorbidities also are subjected to complicated medication regimen adherence, leading to risks of treatment failure. There has been a lack of studies that focused on recruiting older patients in drug efficacy trials. In this regard Lombardi et al., (2016) had stated that overlapping symptoms of different lung diseases and other chronic diseases further lead to a confusion regarding the discourse of asthma self-management. For instance, considerable overlap of asthma and COPD in elder population is distinct. A key concern that has come into limelight through the systematic review is misdiagnosis and under-diagnosis of asthma in the elderly population. Diagnosis of asthma in the elderly population is usually based on the variable airflow limitation, variable respiratory symptoms, diurnal PFT, and peak expiratory flow rate variability. These might be difficult to be diagnosed in elderly population. Speaking on a general basis, asthma might be misdiagnosed in the elderly population for those with a history of smoking. It has been noted that asthma is characterized by reversible airway obstruction. In case of the elderly population, it is common to find incomplete reversibility, since asthma is persistent or severe in aged population. The diagnosis is therefore more difficult in the elderly population (Battaglia et al., 2016). 

Further, it had been highlighted from the present systematic literature review that age related adverse effects of medications of asthma also pose problems for patient condition management. The primary method of asthma treatment might be similar across age groups as the goal of therapy is same for both elderly and young population. However, the drugs might be under-used in case of elderly patients due to the adverse effects brought about by the same (Adams & Urban,, 2015). In a study of Ray et al., (2016) it has been reported that the patho-physiologic mechanism of asthma is different in elder and younger population, influencing clinical outcomes to a great extent. The symptoms that the elderly population faces are not easy to be addressed through drug therapy since the patients might be resistant to steroids. Rance and O’Laughlen (2014) highlighted that a key medication for chronic and acute asthma is beta-adrenergic agents; however, elderly patients might be not responding adequately to such bronchodilator due to aging. In such case anti-cholinergic and beta agonist agents might be used which are not influenced by the patient’s age.

The elderly population also might face concerns about poor inhalation techniques and insufficient inspiratory flows, as pointed out by the present study. Difficulties in relation to poor medication have been attributed to inappropriate use of inhaler devices. The choice of inhaler has been reported to be crucial in treatment outcome achievement. The visual acuity, neuromotor impairment and dexterity might be affecting the level of understanding of the patient regarding the use of inhaler (Carnegie & Jones, 2013).  Nurses often do not discuss the required inspiratory flow rate with the patient, leading to difficulties. In absence of inhalation airflow meter devices, patients cannot assess the needed inspiratory flow rate as per the device to be used (Boulet, 2016). Further, professionals might not be considerate of the requirement of a patient to use a spacer and the corresponding mode of delivery. In addition, lack of proper review by nurses of the devices used contributes to challenges (Guilbert et al., 2017).

It is also know as a result of the systematic review that poor monitoring by care professionals, communication gap with professionals, and perception of professionals regarding clinical problems to be less important also add to difficulties in managing asthma in elderly population. Poor quality physician-patient relationship has a negative impact on treatment adherence among elderly asthma patient population. Due to unavailability of support from care professionals, patients are deterred from estimating the vitality of adhering to the self-management plan or medication regime (Webb, 2011). When the physicians and nurses adequately recognize the clinical problems faced by the patient, the patient’s confidence to carry out the self-management behavior is stronger. Riley (2015) in this regard said that higher level of support from professionals and effective communication are in support of increased self-efficacy and better quality of life. Based on a review of the factors contributing to challenges in managing asthma in elderly, the researcher pointed out that one category of factors perceived to be influential in asthma management is patients’ beliefs and attitudes regarding the treatment course as a result of education provided by professionals. Patients might not be satisfied with the quality of care provided to them from the clinician’s end, contributing to poor adherence to regimen (Roberts et al., 2016).

The present systematic literature review further points out that non-adherence to treatment regimen are due to poor socio-economic status, and lower level of literacy. As mentioned by Gemicioglu et al., (2018) treatment and medication regimen non-adherence might be intentional or unintentional among elderly asthma patients. Intentional under-use as a result of cost considerations has been linked with economic vulnerability. Other factors that influence adherence include dependency development, perception regarding necessity of medication and their effectiveness (Iwanaga et al., 2017). Concerns regarding certain side effects such as voice changes, osteoporosis, cataract, glaucoma and infections are reported by elderly asthma patient. These concerns also contribute to lower level of committeemen regarding adherence of treatment regimen (Abreu et al., 2018).  As found in the research of Boulet (2016) literacy level of the patients is a crucial factor in adherence to treatment regimen. A rich pool of evidence suggests that demographic and social factors have a key association with unintentional non-adherence to regimen. Education level is inked with the ability of the patient to understand the implications of self-management and the outcomes in the long run. Patients often fail to perceive the symptom severity that lead to delay in accessing appropriate medical help and implementing required self-management protocols. In addition, social relationship disruptions suffered by those with low literacy level also has an impact on management of disease. Those entailed to care for others, and those who act as primary care giver to other patients within the social context might often remain silent regarding their needs of asthma management. Access to pharmacies might also be challenging for those with lower socio-economic background.

The effectiveness of asthma education course and instructions on asthma care plan are also to be reviewed at the end of the discussion. From the literature review it can be concluded that patient education needs to be of optimal level and much specific for reaching to the desired outcomes. Tailored patient education programs are required for reaching out to the target population. Patient education holds the potential to be a crucial component of asthma management in the elderly population. Patients can be helped to gain confidence, motivation and skills for controlling their condition (O’Conor et al., 2015). Therefore much importance is to be given to this area of asthma management. Asthma education programs have different components in them, such as information about inhalation techniques, need of follow-up, and need of proper communication, and criteria for using control measures. When an individualized approach is demonstrated, elderly patients can be educated in a better way, and empowered to take care of the disease. Tailored programs as per the age of the patient, education level, desire for autonomy and psychological status might be more beneficial for managing asthma in the elderly population.

The key inference drawn from the above discussion is that better understanding of asthma in elderly population is recommended for addressing the key challenges faced by professionals in managing the condition. Healthcare professionals, especially nurses, are to improve their level of knowledge regarding the development and impact of the condition in the elderly. The knowledge of nurses might be limited regarding the pathophysiology of aging and asthma (Song & Cho, 2015). Improvement of asthma management in elderly patients is of much significance in the present era, owing to the increasing prevalence of elderly asthma cases. Healthcare organizations and responsible for developing intervention strategies that are directed at care providers for encouraging them to treat asthma as a condition distinctly presented by elderly. There is also a need of increasing the adherence level of professionals to the set clinical guidelines for acknowledgement of barriers to management (Scichilone et al., 2015).

Further, increased awareness and understanding of elderly asthma is required. Healthcare professionals must be engaging in research to find out the optimal strategies through which there can be an increase in the community awareness level of elderly asthma. The elderly often demonstrate underestimation of significance of asthma prevalence. Both non-government and government public health organizations are in urgent need of evidence-based guidance for effectively facilitating communication of health messages to asthma patients. The nature of primitive challenge regarding asthma management is evident when population considers asthma to be a health condition occurring in childhood and not adulthood. Professionals are also to research on interventions that can augment acceptance of elderly asthma among the elderly population (Jones et al., 2011).

Healthcare providers must have a proactive approach in identifying efficient and effective methods of providing personalized and detailed information to the target population  regarding asthma management so that their needs are met adequately (Newcomb et al., 2010). Medication management is elementary for successfully managing symptoms of asthma. Elderly population suffering from asthma, often lack clear idea about self-management aspects. They however do not seek help in the correct and in adequate manner. Patient receiving information regarding management would likely demonstrate higher self-care behaviors, encompassing medication regimen adherence, self-confidence and self-monitoring. Education topics might include topics such as exposure to smoke and irritants, air pollution, exercise and vaccinations (Tousman et al., 2010). In this regard, it is recommended that older people with asthma are to be given increased attention and provided with information so that they are in a position to identify the emergence need of accessing medical help, or use reliever medicines. Tools for increasing patient confidence and imparting education include personalized action plans, provision of available health information and patient-held records. The plans have shown to be designed in such a manner that care givers are encouraged to take up additional accountability in managing asthma (Goeman et al., 2009).

 Tailored self-management protocols are to be developed that can enhance proper management of asthma. All attempts of improving asthma management in the elderly are to consider literacy level, cognitive ability and confidence level. Thus, care providers, especially nurses must utilize optimal resources for influencing the perspectives and attitudes of elderly patients towards asthma care and management (Gemicioglu et al., 2018).

Conclusion 

The present integrated literature review has led to the suitable identification of the status of present research on asthma management in elderly population. The prevalence of asthma among the elderly population has been noted to be high across different regions of the country, including Australia. Asthma is often found to be coexisting with other conditions such as COPD and cardiac complications. The explanation of poor outcomes of elderly asthma discourse can be attributed to changes in the asthma phenotype with increasing age. It has been reported that the severity of asthma increases with age, and women are more likely to suffer from the condition. Increased airway inflammation, activity limitation and dyspnoea are all related to asthma suffered by the older individuals. These medical aspects are to be considered as the prime focus for successful managing the condition among the chosen population.

The present literature review highlights that many challenges emerge in due course of managing elderly asthma condition. The challenges are highly unique in nature, and are partially due to under-diagnosis and under-treatment. Comorbidities and physiological changes are related to the process of management. Along with low level of literacy and psychosocial effects of aging, comorbidities and physiological changes contribute to major care burden on nurses across health care settings. Despite the acknowledgement of the challenges faced by care providers and patients alike, much is still needed to be done for enabling better outcomes. Several other issues regarding practice of nurses also come into limelight at this juncture that are responsible for poor management. In absence of role delegation of professionals, management is challenging. This is further aggravated if the communication between the patient and the care provider is not effective. Limited patient education is also a contributory factor.

It can therefore be concluded that management of elderly asthma should be multifaceted. It is expected that evidence-based strategies when applied in the future would address multiple, challenges at a single time. Older people are to be made to understand that seriousness of the condition that they suffer from so that they can seek assistance when in need. Increased patient education is entailed in this regard. The primary objective of nursing care for asthma patients is to enhance the quality of life and regain functionality. Nurses accountable for caring for older patients must therefore demonstrate high level of knowledge and skills for breaking treatment barriers. They are to put in their best efforts for delivering pharmacological treatment that are age-appropriate and non-pharmacological treatments including self-management tools and individualized education.  In short, care is to be provided in a holistic manner. When offered with adequate information and high quality services, older people would be better assisted in the whole process of obtaining better mental and physical wellbeing. This would directly lead to less incidents of hospitalization over a considerable period of time due to fatal asthma cases.

Further, management of asthma in elderly must focus on frequent monitoring of symptoms as well as adverse medications. More attention to the possible chances of suffering complications is warranted. A suitable and effective health care model focusing on better quality service provision clubbed with ongoing research would ensure development of best practices for further improvement of health outcomes of the target population.

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