1. health and fitness
2. disease
3. asthma

Characteristics
of Asthma among Elderly
Adults in a Sample of the General
Population*
Burmw
M.D. , F. C. C.P; Robert
Martha G. CUrie, M.S.; ROnaLdJ
Knudson,
Michael D. Lebowitz,
Ph.D., EC.C.P
Barbee, M.D. , F. C. C.R;
M.D., FC.C.P; and
Benjamin
This
article
characteristics
and course
of
who were older than 65 years
at
the time of enrollment
in a longitudinal
study of a general
population
sample.
It was present
in 3.8 percent
of men
and 7.1 percent
of women.
An additional
4.1 percent
of
men reported
having
“asthma,”
but they also had seen a
physician
for “emphysema”
and had smoked significantly;
their “asthma”
diagnosis
is regarded
as highly
questionable.
They
did not show the elevated
rate of allergy
skin test
reactivity
of high serum IgE levels that were characteristic
of other asthmatics.
Many
of the elderly asthmatics
(mean
age, 72 years)
had severe
disease
with marked
ventilatory
impairment.
There
was a close relationship
between
the
severity
of wheezing
complaints
and impairment
of the
FEV,.
Of the 46 patients,
48 percent
reported
an onset
before
age 40 years.
There
was no relationship
between
severity
and age of onset or duration
of disease.
A second
diagnosis
of”chronic
bronchitis”
was reported
by 46 percent
of the asthmatics,
but this did not delineate
a distinctive
asthma
describes
A.
among
the
subjects
S ince
antiquity,
asthma
has been
described
as
disease
ofadults.
Indeed,
as noted in an historical
review
by Rosenblatt,’
its clear
recognition
as
childhood
century,
disease
with
appears
to date
the contributions
In recent
years,
generally
emphasized,
the
pediatric
and
has been
paid to asthma
though
the problem
has
only
ofJohn
onset
relatively
in elderly
been
noted
from
the
Millar
of the
a
18th
in 1760.
illness
little
a
years
and
in this age
prevalence
subjects,2
even
to be relatively
examination)
community
prevalence
than
in
because
pointed
out
the
difficulties
of diagnosis
group.
In 1979,
Burr et al6 noted
of active
asthma
(confirmed
by
in
subjects
study. In this
of the disease
women
(5.8
the overall
older
study
was
percent
sample
than
70
a high
clinical
years
in
percent),
primarily
there
were
a
but
of
#{149}Fmm
the Division of Respiratory
Sciences,
University
of Arizona
College of Medicine,
Tucson.
Supported
by a Specialized
Center ofResearch
Grant (HL 14136)
from the National Heart, Lung, and Blood Institute
Manuscript
received
February
7; accepted
February
14
Reprint
requests:
Ds Burmws
Respirctonj
Sciences,
University
of
Arizona Health Sciences
Center, Thcson 85724
no remissions
it rarely
a
severe,
goes
into
complete
disorder.
disabling
with
severe
remission
but tends to remain
(Chest
1991; 100:935-42)
ANOVA=analysis
ofvariance;
pack-years;
STpos
positive
gradewheezing
grade
women,
the
actual
CBchmnicbmnchilis;
plcyrs
to allergy
numbers
skin
of patients
tests;
WZ-
were
nearly
equal in the sexes.
In both of these
studies
of elderly
asthmatics,
persistent
airflow
obstruction
was present
in most
of the patients
and corticosteroids
were
generally
needed
for effective
therapy.
We have
been
impressed
by the
number
of elderly
subjects,
particularly
women,
who are being
seen in
our pulmonary
disease
clinic for what appears
to be a
persistent
form of asthma.
Despite
this, there are few
references
dealing
with the characteristics
and course
ofasthma
in older
adults.
scant
attention
medicine.
in
the
Indeed,
standard
nature
the disorder
textbooks
of asthma
is given
on
in the
geriatric
elderly,
we
have analyzed
findings
in subjects
reporting
“asthma”
among
the 804 subjects
who were
aged 65 or older
when
they were enrolled
in a longitudinal
study of a
general
age
years.
this
population
at the
time
The
initial
population
follow-up
sample
in Tucson,
of enrollment
was
characteristics
sample
as well
AZ.
Their
mean
approximately
of the
as their
73
asthmatics
course
in
during
are reported.
METhODS
The subjects
cluster
sample
are part ofalongitudinal
of
white,
study ofa stratified
non-Mexican-American
CHEST
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in subjects
at the time of entry. We concluded
that asthma
in
the elderly is not a rare disease and may be associated
with
severe
symptoms
and chronic airways obstruction.
If severe,
disease
To examine
from south Wales,
the
much
higher
in men
vs 1.8
consisted
symptoms;
is
attention
frequent
in general
population
studies.3’4
In 1973, Lee
and Stretton5
drew
attention
to 15 subjects
who
appeared
to have the onset of asthma
after the age of
60
group with late-onset,
smoking-related
disease.
Death rates
in the asthmatics
tended to be higher
than in nonasthmatics
(odds ratio, 1.9; CI, 0.998 to 3.70, after stratifying
by sex).
Over a mean follow-up
of 7.44 years,
most symptoms
as
well as the FEV,
remained
relatively
stable.
Chrome
productive
cough did tend to remit
(p<O.Ol), but this was
noted
in the nonasthmatics
as well. We estimate
that no
more than 19 percent
of the asthmatics
went into complete
remission
during
follow-up.
Most of these had mild initial
I 100 I 4 I OCTOBER,
random
households
1991
in
935
Thcson, AZ, in 1971 to 1972. Details of selection
of the population
sample have been published.’
New members
of these households
have continued
to be enrolled throughout
the fullow-up
period.
Some ofthe new enrollees
were new spouses as well as some parents
who moved
in with their children.
Through
the eighth
survey
of
this population,
completed in 1984, a total of804 subjects aged 65
or more have been enrolled,
45(6.0 percent)ofwhom
were enrolled
after survey
1. The mean
age of the subjects
at the time of
enrollment
was
72.8±5.83
years
(range,
65 to 95 years) and 57.6
percent
were women.
Details of the methods of testing have been
provided
in previous
reports.’7
Percent
predicted
values
fur
spirometric
variables
were derived from reference equations fur
the population
sample.
The percent predicted
FEy, is abbreviated
as percent FEV,.
Asthma
on
and huliminary
Enrollment
have “exasthma.”
sidered
the
prick
test
Analyses
technIque.
Diagnoses
are based on subjects’ responses
to direct questions
concerning
the presence
ofthe diseases.
Subjects
are considered
to
have had “asthma”
if they answered
“yes” to “Have you ever had
stir
The disease is considered
active ifthe subject (1) claimed
to “still have it:’ (2) had more than rare “attacks
of shortness
of
breath
with
wheezing:’
(3) had only rare attacks but admifted
to
wheezing
“apart from colds’
or(4)was
taking antiasthmatic
therapy
at the time of enrollment.
Otherwise,
the subject is considered
to
Table
1-FEV,,
Allergy
(Total n in group)
Percentmen
Mean age±SD
% Predicted
FEy,
(N tested)
Mean±SD,
Serum
1gB,
%
Skin
That Reactivity,
answered
that
are conthey still have the disease
fur it.
Using the definitions
given above, there are 60 cases of apparent
active “asthma” representing
7.5 percent of the study population
aged 65 years and above. Of these, 27 are men (7.9 percent
of all
men) and 33 are women
(7. 1 percent
ofall women).
Pbssible diagnostic
confusion between
asthma and other furms of
chronic airways disease was evaluated
in these elderly subjects. In
men, 17 (63.0 percent)
of the patients
with “asthma”
reported
emphysema
as well as asthma
in women,
only fuur (12.1 percent)
reported
this combination.
Some of these combined
diagnoses
occurred
in subjects
with little if any smoking
history
but 14 of
them were in subjects
who had smoked
at least 20 pack-years
(pkyrs) ofclgarettes.
One can not be certain that such subjects were
truly asthmatic
rather
than having
typical
smoking-related
chronic
obstructive
pulmonary
disease (COPD) that showed some reversibility with bronchodilator
therapy,
leading
to a secondary
asthma
label. lhble 1 compares
subjects
with a diagnosis ofemphysema
as
well as asthma who had smoked atleast 20 pkyrs(called
“?Asthma”)
with other asthmatics
as well as with nonasthmatlcs
and with the
exasthmatics
in the series. All of the 14 “?Asthma”
patients
are
men. They have a significantly
lower mean percent FEy, than any
other group and do not show the immunologic characteristics
of
other asthmatics.
Their serum
1gB Z scores are not significantly
different
than nonasthmatics
in the population
and none of the 14
is STpos. In view of the uncertainty
about their diagnoses,
these
subjects
will not be included
as asthma in subsequent
analyses,
leaving
13 men (3.8 percent
ofall men) and 33 females (7.1 percent
of all women) who were considered
likely to be truly asthmatic
at
the time of entry to the study. The relationship
between
asthma
and chronic bronchitis
will be analyzed
separately.
There are 20 additional
subjects
in this age group who are
classified as exasthmatics
by our criteria. They tend to be slightly
more skin test positive than nonasthmatics
but have no elevation of
their serum 1gB level; their mean 1gB Z score Is significantly
lower
than in active asthmatics
(p<0.01).
The mean percent
FEy,
in
these exasthmatics
(95.9 percent)
is slightly higher than in the
overall group ofnonasthmatics.
To simplify presentation
ofthe data,
these exasthmatics
as well as the “?Asthma” group noted above have
been excluded
in the subsequent
analyses
that compare
our 46
current
asthmatics
with the 724 subjects who denied
ever having
asthma
have moved away from the Thcson
have continued
to return
fullow-up
self-completion
questionnaires,
including
intitial
furms
fur new
household
members,
we have been able to obtain spirometsic
tests
only by making periodic
visits to parts ofthe United States in which
there are clusters ofout-migrants
or by having such subjects come
to our research
dime in Tucson when they are visiting the area.
Also, some of these elderly
subjects
were unable
to perform
acceptable
spirometeric
tests.
For these
reasons,
the data
set is
incomplete in regard to spirometric
testing,
serum IgE levels, and
allergy
skin tests. Of the total group
of 804 subjects,
741 (92.2
percent)
had satisfactory
spirograms
close
to enrollment
that are
used to describe their initial characteristics,
749 (93.2 percent)
had
complete allergy skin tests, and 687 (85.5 percent) had serum 1gB
measurements.
In order to age and sex standardize
our serum
1gB levels, they
are expressed
as “Z scores” which represent
the number of standard
deviations
by which an individuafl
log 1gB value differs
from the
mean log 1gB fur their age-sex
specific
group.
Age was stratified
as
65 to 74 years and 75+years
as in a previous
report.’#{176}Subjects
are
considered positive to allergy skin tests (STpos)
if they
have any
reaction
greater
than
control
to a small battery
of aeroallergens
using
and “chronic bronchitis”
“Emphysema”
ifsubjects
and had seen a physician
Some ofthe enrolled subjects
area over the years. While most
applied
present
Follow-up
Studies
data
Follow-up
through
and
Serum
the
lgE
on the 804 subjects
tenth
in
survey
“?Asthma”
in the study
of the population
vs Other
that
was
were
analyzed
completed
in
Groups
No asthma
Exasthma
?Asthma
Asthma
(724)
42.0
72.9±5.90
(20)
50.0
73.1±5.14
(14)
100
73.3±6.54
(46)
28.3
71.5±4.74
(663)
(18)
(14)
(46)
91.5±24.4
95.9±25.7
48.1±23.7
67.5±23.9
IU
(N tested)
MeanloglgE±SD
[Geometric
mean]
Mean Z score±
Allergy skin tests
(N tested)
% positive
*?thmaemphysema
SD
as well as asthma
(614)
(18)
(13)
1.25±.703
1.34±.812
1.45±.598
[17.9]
- .064± .950
[22.0]
- .008± 1.106
(675)
21.0
(19)
36.8
diagnosis
and smoked
936
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20+
(42)
1.84±.718
[28.01
[68.61
.005±
.776
(14)
0
.794±
.988
(41)
36.6
pkyrs.
Asthma among ElderlyAdults
(Burmws
etaQ
30%
E
20%
0
I.-.
0
0
C,
10%
.
a-
0%
‘
-1.5
(32)
-1.5’-.5
(166)
-.5’.5
(301)
Serum
.51.5
(154)
1.5.
(34)
IgE Z Score
of current
asthma
prevalence
to 1gB Z score In the 687 subjects
with serum
The 14 subjects with “?Asthma” noted in the text are not considered
as asthmatics
in
these data, although their inclusion would not eliminate
the overall trend and none falls in the lowest 1gB
category. The tendency fur asthma prevalence
to increase
with 1gB level is highly significant (p<0.0001).
Ficutu
1. The
relationship
1gB measurements.
January
mortality
entire
1988.
of56.5
population
By that
there had been 454 deaths, an overall
The mean questionnaire
fullow-up
of the
time,
percent.
was
7.44±5.0
years,
and
fur survivors
It was
10.4±4.9
years. For those who died, follow-up
questionnaires
were
available an average
of5.1 ±3.7 years after enrollment.
There
were
no significant
differences
in the duration offollow-up
based on the
asthma category
at the time of entry.
Among survivors,
89.6 percent
had fullow-up
spirometry
cornpared with 76.1 percent of those who died. Follow-up
spirometry
wasobtained
in89.1 percentofallasthmaticsandin
14 (93 percent)
of 15 of asthmatic
survivors.
The mean duration
of spirometric
fullow-up
in all those fullowed was 7.2±4.7
years,
9.8±4.4
years
for survivors,
and 4.8±3.4
years for those who died. More than
four years ofspirornetry
fullow-up
was available
on 61 percent
of all
asthmatics
and 51 percent of all nonasthrnatics.
Thus, spirornetric
fullow-up tended to be more regular and slightly longer in asthrnatlea, but there were no statistically
significant
differences
in the
frequency
or duration
of spirornetric
fullow-up
between
them
and
the subjects who denied
ever having
asthma.
there
is a very
Analyses
were carried
out using
SPSS/PC + . Stated probabilities
are two tailed
and were determined
by analysis
of variance,
regression
analyses,
trend
or Mantel-Haenszel
analysis
of
stratified
data, as appropriate.
Except fur the FEy,,
for which least
squares regression
slopes are reported,
analyses
cornpare
the Initial
findings with those at the last fullow-up
on record.
The smoking
the relationship
characteristics
findings
in
excluding
pkyrs
Asthma
As
IgE
and
IgE:
noted under
of asthmatics
these elderly
the “Methods”
is significantly
subjects,
a minority
section,
elevated.
ofwhom
the mean
Even
are STpos,
in
histories
ofour
of their
habits
are summarized
nonasthmatics
in
the
14 subjects
who
and
Table
had
(see
“Methods”),
there are still
smokers
among
our asthmatic
eral,
the smoking
histories
of
relatively
little
from those
of
tend to be fewer
smokers
differences
asthmatics,
smokers
prevaserum
subjects
and
to some
other
compared
2. Even
with
after
smoked
at least 20
and asthma
labels
a moderate
number
of
subjects,
and, in genthese
asthmatics
differ
nonasthmatics.
There
of 20 +
in asthmatics
pkyrs
of both
and
sexes,
are not statistically
significant.
there
also tends to be a little
cigarette
consumption,
but these differences
criteria
the
asthmatic
smoking
fewer
but
In
less
the
male
overall
particularly
among exsmokers,
could
be a result
of exclusion
(see
“Methods”)
and are not significant.
FEy1
is much lower
in nonasthmatic
than
in other
nonasthmatics,
and in the
The percent
nonasthmatics
there is a highly
significant
correlation
between
percent
FEy1
and
pkyrs
(p<Z0.0001).
In
contrast,
the percent
FEY1 in asthmatics
(all of whom
had satisfactory
spirometry
on enrollment)
is no more
reduced
in those
who smoked
20 + pkyrs
than in
those
with
a lesser
smoking
CHEST
Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2014
between
sex-standardized
1.
and who had both emphysema
smokers
RESULTS
relationship
and Asthma
Smoking
current
Analyses
close
lence of asthma
and age- and
IgE level,
as shown
in Figure
history,
I 100
I 4 I
and
OCTOBER.
there
1991
is no
937
2-Smoking
Table
In Asthmatics
vs Nonaathmatics
No Asthma
(Total n at risk)
Smoking history
habits,
Smoking
Male
Female
Male
(304)
(420)
(13)
18.4
16.4
15.2
9.1
49.3
14.3
69.3
46.2
38.5
15.2
Nonsmoker
32.2
mean
29.4±31.5
smokers
50.1
In exsmokers
Smoked 20
or more
ofFEV,,
Mean
8.5±22.3
55.7±8.0
39.8±14.7
40.9±31.5
24.3±28.4
23.2±24.9
34.4±41.2
1gB, and allergy
53.6
17.4
skin tests
38.5
12.1
to smoking
FEy,
95.7±22.5
67.0±21.8
82.5±25.9
69.5±32.8
1gB Z scores
Smoked <20
Smoked 20+
- .134±
.082±
pkyrs
pkyrs
% positive
allergy skin test
Smoked<2Opkyrs
Smoked 20+ pkyrs
fur difference
*p<0.0001
tp<0.01
between
fur difference
between
between
is associated
percent
FEy1 in both
of smoking
(p<0.0001).
39.4
25.0
nonasthmatlcs.
and nonasthmatics.
asthmatics
correlation
sexes
FEy1
percent
with
a significantly
after controlling
The difference
FEy1 between
asthmatics
marked
in those
without
3-Findings
and
smoking
lower
level
is noted
nonasthmatics
of
in Asthmatic.
with
2).
the asthmatics,
relation
between
but statistically
is most
pkyrs
(Fable
Among
for pkyrs
in percent
and nonasthmatics
a history
of 20+
Table
smoking
significant
“Chronic
and without
attack,
%
Befureagel6yr
11
52
Age40yrormore
Repiratory
trouble
befure
Smoking history, %
Current
age
16 yr. %
24
smoker
Exsmoker
Receiving
therapy fur asthma on enrollment,
Chronic cough and/or sputum,
%
Overall grade ofwheezing
(WZgrade),
%
ofthe
overall
A slight
serum
IgE
of 20 + pkyrs
among
Regardless
of gender
Asthmatics
Without CB
Asthmatics
With CB
(25)
24
(21)
33
8
14
52
52
1.2
38
11
8
14
24
20
29
67
64
71
52
86t
2 (Moderate)
24
(4)
24
24
3(Severe)
46
(7)
44
48
59
(18)
64
67.5±23.9
37
70.4±20.4
1gB
Z score,
mean±SD
*nges
In
tp fur difference
*This
grade
%
between
ofdyspnea
indicate
those
indicates
prevalences
subjects
35
0.485±0.903
1.04±1.06
in nonasthmatics.
with and without
that
52
63.9±27.6
38
0.794±0.988
parentheses
the
or
(CB)
67 (23)
Grade 2+ exertions]
dyspnea,
% predicted
FEy,, mean±SD
Allergy skin test positive,
%
%
(8)
elevation
Bronchitis”
‘
(46)
28
there is no significant
and IgE Z score.
in smokers
(p<O.Ol).
All
Asthmatics
(ibtal n)
Frcentmale
Stated
age offlrst
.984
1.02
groups.
smoking
§p<O.O5
Asthma
.860±
.548±
17.0
:tp<0.0001
significant
.945
.945t
23.0
fur difference
between
smoking
groups.
fur differences
between
asthmatics
and
pkyrs.
19.3±25.4
32.4±20.6
Smoked <20 pkyrs
Smoked 20+ pkyrs
Mean
75.8
pack-years
serum
% predicted
8.8±18.5
±21.1
% ofgroup
Relation
(33)
± SD
Overall
In current
Female
%
Current
smoker
Exsmoker
Pack-years,
Asthma
CB
report
<0.05;
becoming
938
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all other
short
differences
ofbreath
are not statistically
while
walldng
on
level
significant.
ground
with others
Asthma wiong
oftheir
age.
Elderly AduIIs(Burrows
eta!)
smoking,
cantly
the
higher
IgE
Z scores
than
in nonasthmatics
frequency
of allergy
skin
matics
and nonasthmatics
but the smoking-related
However,
the overall
tests
is significantly
in asthmatics
are
tion
signifi-
(p<0.0001).
The
test reactivity
in both asthis slightly
lower in smokers,
admit
differences
are not significant.
frequency
ofpositive
allergy
skin
higher
in asthmatics
than
in
(p<0.05).
nonasthmatics
Symptoms,
Age
These
The
“attacks
closely
are summarized
severity
in the
of wheezing
of shortness
interrelated.
first
and
of breath
To simplify
column
the
of Table
frequency
with wheezing”
presentation
to “respiratory
exertional
‘iuible
of
are
of the
data,
we have created
a wheezing
grade
(Wzgrade).
Those
with no more than rare attacks
of shortness
of
breath with wheeze
are given a WZgrade
ofl + (mild),
dyspnea,
in
3)
The
nonasthmatics
much higher
Sixty-seven
receiving
therapy
frequency
of3
Overall,
impaired
and
52 percent
date
attack”
it after
prior
40 years
to age
ofage.
16 years
There
73 percent,
(p for trend
percent
are
no significant
differences
between
those
claiming
an
onset
after
the age of 40 years
and those
with an
earlier
onset
in regard
to sex distribution,
symptom
severity,
rate of positive
skin tests, mean IgE Z score,
or percent
FEy1.
There
is also no significant
correla-
the
stated
16” than
date
average
in the
of
these
relationship
time
were
The
with the semoderate,
and
therapy
of the
in
enrollment.
43 percent,
time,
respectively
FEy1 values
are markedly
but within
the group,
are closely
especially
related
to the
to WZgrade
percent
FEy1
of smoking,
and
related
to percent
severity
(p<0.0005).
to
WZgrade
in Figure
2 in which
exasthmatics
to give an overall
perspective.
Sex,
status,
pkyrs
significantly
(No
all are very
asthmatics
of
current
percent
asthmatics,
of
group.
symptoms
therapy
increased
Those
with mild,
levels
and
wheezing
age
in parentheses;
the
reported
FEy1
depicted
shown
as severe
this
any of the findings
were
so they are combined
in
and 81 percent
<0.05).
of symptoms
The
in
sexes,
at
WZgrade
11 percent
age
in asthmatics
(p<0.0001).
percent
ofthese
elderly
severe
that only
in
prevalences
verity
indicates
as well
are shown
those
with
more
frequent
attacks
a grade
of 2 +
(moderate),
and those
with very frequent
attacks
or
with wheezing
on “most
days” are given
a WZgrade
+ (severe).
with
before
asthmatics
of current
of symptoms.
The stated age ofonset
had their “first asthma
FEy1
trouble
significant
differences
noted
between
the
Interrelationships
3.
or percent
or with the calculated
duration
of asthma.
larger fraction
of asthmatics
(24 percent)
complaints,
and Their
Spitvmetry,
Z score
their first asthma
attack to this age.
As also seen in the first column
ofTable
3, there are
high prevalence
rates ofchronic
cough
and/or
sputum
and
ofOnset,
of IgE
age ofonset
A somewhat
is
are also
smoking
serum
IgE level are not
FEy1 after accounting
>
w
Li.
60%
!
80%
40%
None
Mild
Moderate
Severe
(20)
(14)
(11)
(21)
Grade
percent
predicted
wheezing
and are given
asthmatics
(WZgrade)
is explained
Ficua
2. The relationship
have no significant
current
wheezing
FEy,
values
in current
for each
of Wheezing
of the
ofmean
groups
and
the
number
Complaints
FEy,
to wheeze
severity.
By definition,
exasthmatics
of “None:’
The calculation
of the grade of
in the text. Vertical
bars indicate
± 1 SEM percent
in each group is shown
in parentheses.
a grade
CHEST
Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2014
I 100 I 4 I OCTOBER,
1991
939
for severity
of wheeze.
significantly
A large
to WZgrade.
fraction
of
reported
“chronic
As seen
in the
Also,
none
these
subjects
bronchitis”
last
two
of these
(CB)
(46
as well
columns
significantly
more frequent
him in those
with a CB
is related
(20+
serum
percent)
as asthma.
of Table
chronic
diagnosis.
the time
3, there
is
cough and/or
spuThere
is only a
in whom
sputum,
end
onset
tendencies
trouble.”
in those
label.
a higher
The
with
The
than
of
“childhood
respiratory
mean percent
FEY1 is somewhat
GB than in those
without
the
IgE
Z score
in those
significantly
those
with
rate
without
tends
to be lower
a GB diagnosis,
lower
second
in those
but
higher
than in nonasthmatics
GB and <0.0001
for those
wheezing
smoking
of follow-up
it is
(p<0.02
without
for
the
smoking
chronic
percent
history
beginning
with
in
severity;
there
in those
in those
symptoms
and loss ofsymptoms
on enrollment.
The only complaint
that diminished
systematically
was chronic
cough
and/or
chronic
spuhim. Among
those with follow-up,
this was present
in
67 percent
of asthmatics
at the time of entry
but in
significant,
largely
group.
There
is
the last evaluation
by 55 percent
ofthose
who
to have it at the time of enrollment.
However,
Course
skin tests in those
vs 38 percent).
ofthe
The
since
the
mortality
onset
by the
of the
study)
not significantly
for nonasthmatics.
percent)
ofthe
in male
19 (57.6
tenth
13 asthmatics
died
while
Wheeze
also
in survival
approached
complaints,
Severe
from
attacks
subjects
matics;
percent
follow-up
among
significance
symptoms
including
presence
GB,
the
in Symptomsfrom
=
of remission
of chronic
Entry
to Last Follow-up
ofbreath
with
rate
at follow-up
no longer
at the
end
significant
of follow-up
the other comin the nonasth-
used for classifying
subjects
as “current”
on entry
to the
survey,
making our estimates
There
was
of wheezing
but of those
also
some
complaints
with followstill qualified
of their
last
This was closely
related
to the initial
severity.
None
of the 19 who had a severe
(3 +), two (20 percent)
of the ten with a
(exasthma)
+), and six (46
(1 + ) at entry
at the end
percent)
of the
were apparently
offollow-up
(p<0.001).
Although
asthmatics
had lower lung function
than
nonasthmatics,
the rates of decline
in FEy1 tended
to
be lower in asthmatics
than in those without
asthma.
When
analyses
were limited
to the 28 asthmatics
and
in 43 AsthmatIc
Subjects
with Follow-up
Questionnaires
% at Last
Follow-up
85
71
7
22
40
33
17
24
45
36
14
24
67
33
2
37
62
71
12
3
wheeze
was statistically
ambulant
claimed
chronic
% at
Entry
“colds”
short
at
(unlike
to remit
imprecise.
WZgrade
(2
a mild WZgrade
inactive
cough
status
this problem
at entry
while it was denied
on
up, we estimate
that at least 81 percent
as having
active
disease
at the time
13 with
0.06),
rates
(p<0.01).
questionnaire
in the severity
survey
to the next,
symptom
WZgrade
or other findings
the severity
of
smoking
last
complaint
was present
in 22.8
in only 16.0 percent
at the last
(p<0.01).
Not all ofthe
questions
with any asthma
history
study were asked at every
questionnaire.
asthmatics
(p
the
in them,
this
at entry, but
questionnaire
fluctuation
from one
1.92
(confidence
statistical
signifin these
elderly
cough and/or chronic
sputum
2 + exertional
dyspneat
‘The lower
tSIx
rate
In women,
47.4 percent
WZgrade
Chronic
Grade
the
reported
4-Changes
apart
Frequent
the death
on
and/or
chronic
sputum
in Table 4) also tended
moderate
sputum,
Table
69.6
was
had died by the end of followby sex, the odds ratio for death in
but there were no initial
that related
to survival,
and/or
cough
plaints
than
the 64.1
in men, 12(92.3
was 67. 1 percent.
33 asthmatics
and
difference
above)
wheezing
without
(16 years
for asthmatics
asthmatics
vs nonasthmatics
was
interval,
0.998
to 3.70),
approaching
icance
for an increase
in mortality
asthmatics.
The
sex
survey
different
However,
nonasthmatics
percent)
ofthe
of the nonasthmatics
up. After stratifying
(noted
and
33 percent
Only 1 of 14 asthmatics
without
developed
it during
follow-up,
Disease
overall
percent,
percent
with
some
not having them
with complaints
only
positive
allergy
GB (35 percent
ques-
was
second
label).
Except
for cough
and sputum
prevalences,
none
of the differences
between
asthmatics
with and without
chronic
bronchitis
are statistically
owing to the small numbers
in each
an almost
identical
frequency
of
and
follow-up
in Table 4. Wheezing
sympand statistically
insignificant
lessen
ofsuch
or
cough
and/or
FEY1 were
all
at the
for asthmatics
to
on entry
with
overall
complaints,
status,
and
tionnaires
is summarized
toms showed
only slight
acquisition
in both
a significant
significantly
related
to mortality.
A comparison
of symptoms
slight relationship
of a second
label of CB to smoking
history
in asthmatics.
Those
with a CB label as well
as asthma
tend to report
a somewhat
earlier
age of
and
ofentry,
pkyrs), allergy
skin test status, percent
FEy1,
IgE levels.
This contrasts
with nonasthmatics
% Developing
% Losing
Symptom
Symptom
(p’(O.Ol).
and unable to answer the exertlonal
940
Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2014
dyspnea questions
are excluded.
Asthma among Elderty Adults(Buriowa
.ta)
372 nonasthmatics
metric
follow-up,
with at least
the minimal
considered
adequate
FEY1
slope,”
this
- 26. 1 ± 36.0
(p<0.01).
for reliable
difference
mI/year)
was
It remained
proved
measurement
(-8.0±24.2
statistically
significant
sex, current
smoking,
analysis
of variance
factors
four years
of spiroduration
previously
of
vs
significant
after
controlling
for
and initial
percent
FEy,
(ANOVA).
None
of these
independently
“emphysema”
a significant
predictive
in an
other
of FEy,
de-
clime, and there were no significant
interactions.
were too few asthmatics
with adequate
follow-up
There
who
were
at the
smoking
effect
at the
time
ofcontinuing
of enrollment
smoking
to look
on decline
as well
smoking
20 or more
with
pkyrs)
in our
sample.
ofapopulation
in Tucson.
by
sample
Since our
all men),
common
selective
in-migration
tients
with
this
brief
other
questionnaire
parts ofthe
they
are
completed
declined
practice
type
and in men
than “typical
to
United
patients.
questionnaire
with persistent
maintain
the
FEy,
was
than
more
men,
to be evenly
of
those
at a normal
often
more
than
It
was
One
completing
levels)
The majority
rarely if ever
level.
Although
common
the reverse,
between
the
the
in women
it was
sexes
by ten
of
Most believed
that the syndrome
to smoking
and only two related
it
The majority
reported
that a marked
dated
back
to childhood
the age of4O years.
by others,5
the diagnosis
and usually
of asthma
the lung
vigorous
with
function
therapy.
certainty
in young
can be restored
The distinction
subjects
among
or when
to near normal
by
is especially
difficult
in epidemiologic
studies
in which
the database
limited
and long-term
responses
to therapy
cannot
positive
skin
related
IgE
level.
reactions
The
is
be
evaluated.
In an attempt
to avoid including
subjects
with ordinary
GOPD,
we decided
a priori that those
who
reported
that they
had seen
a physician
for
to our small
battery
tests, the frequency
ofthe
disease
to the age- and sex-standardized
This
relationship
was
similar
in this
to that
population
46 asthmatics
were
primarily
women
Only
part
of this
preponderance
women
in the
is explained
total sample.
similar
a small
to that
reported
by Burr et al,6 the sex
very different.
However,
similar
(72 perof
by the larger
number
of women
While
our overall
asthma
rate is
diseases,
diagnosed
as having
an asthma
identified
label
in
as asthmatics
in elderly
subjects
in Wales
distribution
it is quite
of our
possible
patients
is
that even
more
GB
men
and/or
than
women
emphysema
our population
in this study.
were
without
and
thus
not
The possibility
of this type of diagnostic
bias cannot
be excluded.
Only about half of these elderly
asthmatics
with an
average
age of72 years dated the onset oftheir
disease
16 years.
Although
we
their
disease
onset
many
may
years
for
many
24 percent
recalled
problem
before
age
consider
histories
as relatively
unreliable,
large proportion
of these elderly
years.
these
retrospective
it seems
asthmatics
Those
clear that a
have had
claiming
a late
well have had subclinical
symptoms
prior to the time they recall as the
disease.
We were
unable
for
onset
to demonstrate
the stated age ofonset
or calculated
duration
had a significant
relationship
to its severity
immunologic
characteristics.
As a group,
these elderly
asthmatics
quite severe
disease,
and those with
that
of disease
or to its
tended
to have
the most severe
symptoms
showed
a marked
reduction
in their ventilatory
function
(Fig 2) which
was always
measured
between
acute
exacerbations
of their
disease.
development
of persistent
airflow
obstruction
vere asthmatics
has also been noted by
The
in se12
The death rate for asthmatics
tended
to be slightly
higher than that ofnonasthmatics,
but otherwise,
there
was little
evidence
of systematic
worsening
of the
disease
over an average
follow-up
of more than seven
CHEST I
Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2014
46 subjects
cent).
of their
the elderly
can be difficult.
It may be unclear
whether
one is dealing
with
ordinary
GOPD,
which
shows
some
degree
of response
to therapy,
rather
than a
persistent
form of asthma,
a disease
which
is easiest
to diagnose
had
the remaining
after
the age of 40 years,
and
having
some
type of respiratory
thought
to steroids
as well as steroid
dependat least “often;”
they also reported
that
seldom
that typified
not
or
were considered
likely to have a true asthmatic
of disease.
Although
less than 40 percent
of the
with
the
elderly
patients
but impressions
to some degree.
that they could
distributed
response
was seen
the disease
23
considered
the 23 respondents.
had no relationship
to heavy smoking.
began
after
As noted
All
differed
reported
syndrome
a
longer
in active
clinical
because
of his selected
did acknowledge
that
asthma
were not rare,
ofthe syndrome
of respondents
of pa-
patients.
contacted.
patients
the syndrome
was slightly
more
asthma:’
These
subjects
proved
reported
for asthmatics
of all ages
sample,’#{176} as seen in Figure
1.
to send
14 such
IgE
serum
25 pulmonary
physicians
in
States to determine
whether
seeing
similar
types
of
by 23 of the 25 physicians
of
Arizona
we decided
since
he was no
and another
declined
group
FEy,
ence
to southern
as “asthma”
only
who
ofaeroallergen
was closely
up longitudinally
could well be biased
ofdisorder,
were
high
type
in FEy1.
to be a relatively
common
than 65 years who are part
beingfollowed
population
not be classified
There
series,
representing
1.7 percent
of the total
However,
they were all men (4.1 percent
of
asthmatics
asthma
appears
in subjects
older
could
confidence.
any
and who had
considered
to have very severe
airways
obstruction
and did
show the allergic
characteristics
(frequent
STpos
DISCUSSION
Active
problem
as having
asthma
history
(arbitrarily
100
I 4
I OCTOBER,
1991
941
years,
either
in terms
of symptoms
or lung
function.
Indeed,
the decline
in FEy,
was remarkably
slow and
significantly
less
than
in nonasthmatics.
The
only
symptom
that appeared
to change
systematically
was
chronic
cough
common
and/or
at the
enrollment,
chronic
end
sputum,
of follow-up
a tendency
which
that was
was
at the
than
also
less
time
observed
of
somewhat
broader
rapidly
progressive
age
form
ease. In subjects
with severe
disease,
complete
remission did not occur.
Such subjects
continued
to have a
severe
and
probably
and ventilatory
disabling
impairment
of follow-up.
Such
not seen at all in those
at the time of enrollment
half
of the asthmatics
impossible
apparent
with
with
to determine
19 percent
disease
by
remissions
from
initial
our
symptoms.
data
how
observed,
but
matics
tended
a bias
smoking
it is likely
that the most
not to smoke
or to quit
that
would
obscure
on the disease.
Except
of
frequency
with
those
actually
lems
asthma
tended
more
alone.
to recall
Those
childhood
than
frequently
subjects
those
with
respiratory
without
prob-
jects
done
the
with asthma
in some
most
gory.
matic
disease
The
asthma
it may
latory
severe
plus
As we have
bronchitis”
than
typical
major point
among
the
be associated
impairment,
reported
appears
from
this
diagnostic
cate-
previously,
“chronic
asthto be a quite
different
smoking-related
942
Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2014
asthma.
3rd ed.
In:
Weiss
Little
Boston:
EB,
Brown
PP, Horton
in
a total
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In: Weiss
2nd
ed.
RJM.
The
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Little
MS,
& Co,
of asthma
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Stein
Brown
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community,
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Br
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ML,
Charles
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RJ, Lebowitz
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CJ, Burrows
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Burrows
B, Martinez
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13
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in forced
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HW,
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WP,
Camilli
Polis
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1989; 320:271-77
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Finucane
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B. Changes
with
IgE
considerations
Brown
McWhorter
M,
expiratory
methodologic
nonsmokers.
12
Halonen
with
serum
N Engl J Med
B, Lebowitz
Burrows
dinal
FD,
of asthma
to allergens.
reactivity
11
Immunol
68:106-11
9 Knudson
“COPD.”4
of the article
is to emphasize
that
elderly
is not a rare disorder,
that
with severe
and persistent
ventibut,
as noted
previously
in a
asthma,
fever
4 Lebowitz
CB as “COPD,”
as has been
To do so may remove
some of
asthmatics
hay
description
label
and a minority
had never
smoked.
Thus, contrary
to
our expectations,
a label of GB plus asthma
did not
distinguish
clearly
those with an apparent
late-onset,
smoking-related
disease.
We question
labeling
sub-
asthma,
in the eldery.
Bronchial
1985:854-56
I, Barlow
GB
this
A. Asthma
7 Barbee
of chronic
productive
cough,
a tendency
to more
severe
disease,
and a slightly
higher
frequency
of
smoking,
there
was little
difference
between
those
who had been told they had CB as well as asthma
and
of bronchial
Bronchial
3 Broder
and
severe
asthearly if they
History
eds.
1976:5-17
M, eds.
It is
effect
MB.
MS,
& Co.
the course
any adverse
for a higher
Segal
2 Seaton
the most severe
disease
but were
noted
in almost
mild
1 Rosenblatt
were
ofthe
disease
was affected
by therapy,
especially
since
the sickest
asthmatics
were
the most
likely
to be
receiving
therapy
at the time of entry to the study.
No significant
effect of current
or past smoking
was
began,
of symptoms
follow-up.
REFERENCES
Overall,
we estimate
that no more than
of our asthmatics
lost all evidence
of active
end
degree
throughout
in our
nonasthmatics.
the
4 it tends
not to be a
of airways
obstructive
dis-
Chine
MG.
airways
N
and
The
follow-up
course
obstruction
Engl
J Med
and
in a
1987;
317:1309-14
Asthma among Elderly Mufts
(Burrows et a!)