1. Attaran D, Mashhad university of medical sciences

2. Introduction Asthma is common in adults over age 65 y 4-8 % ( F > M ) Two categories The first is early onset of asthma The second is late onset ( less common )

3. Risk Factors & Triggers Similar to other age groups Atopy is a important despite the decline in atopic symptoms Smoking is the major cause of COPD but can contribute to poor control Irritant exposure ( biomass fules, dust, gas ) Comorbid conditions ( IHD, CHF, HTN,GERD ) Medications ( B blockers,NSAID,HRT )

4. Clinical Manifestations Asthma in older patients is often underdiagnosed Cough, dyspnea, chest tightness Older patients less likely to report dyspnea Older patients usually have less physical signs Overlap syndrom ( Asthma & COPD )

6. Evaluation Spirometry should be performed ( few signs ) Air flow obstruction traditionally defiened as a FEV1/FVC < 0.7 Assess bronchodilator reversibility FEV1 change > 200ml & > 12% Imaging mostly to exclude alternative diseases

7. Measuring Airway Responsiveness © Global Initiative for Asthma

8. Differential Diagnosis More difficult than in younger adults COPD ( spirometry & clinical ) Heart failure ( clinical & BNP level ) Large airway obstruction ( PFT & imaging ) Cough induced by ACE inhibitors

9. General treatment principles Monitoring Education ( inhaler technique, prevention ) Vaccination ( influenza & pneumococcal ) Pharmacologic Therapy

12. Shaded green - preferred controller options TO STEP 3 TREATMENT, SELECT ONE OR MORE: TO STEP 4 TREATMENT, ADD EITHER © Global Initiative for Asthma

13. Pharmacologic Therapy Stepwise approach to asthma therapy Quick relief & long term controller medication SABA, Inhaled GC, LABA, Anti-leukotriene Starting with inhaled GC Adding LABA in poor controlled cases In patients with known CVD high dose GC and anti-leukotrene Methylxantine & anti cholinergic

16. Asthma inhaler

17. Prognosis Compared to younger adults,old patients have More hospitalizations More comorbidities Poor lung function More mortality

19. Conclusion Asthma is common in adults over age 65 Asthma is less likely to resolve spontaneously in older Older patients are less likely to report dyspnea spirometry is an important part of diagnosis & management The preferred initial controller therapy is inhaled GC In patients with CVD a higher dose of GC may be preferable to LABA