Asthma in elderly patients: community assistance, depression, and cognitive dysfunction
National Heart, Lung and Blood Institute (NHLBI): Managing Asthma in Older Adults
Symposium presented Sunday, February 26, 2023
Moderator
James P. Kiley, PhD
Director, Division of Lung Diseases at the National Heart, Lung and Blood Institute, National Institutes of Health (NIH).
Presenters
Andrea J. Apter, MD, MA, MSc
Professor Emeritus of Medicine, University of Pennsylvania
Community Health Worker Intervention in Older Adults with Asthma
Paula J. Busse, MD
Professor, Icahn School of Medicine at Mount Sinai
Depression in Older Adults with Asthma
Nizar N. Jarjour, MD
Professor, Pulmonary and Critical Care Faculty, University of Wisconsin
Cognitive, Anatomic and Biomarker Changes in Older Adults with Asthma
Summary:
Concerns for elderly patients with asthma include the potential benefit of community assistance, the consequences of depression, and increased risk of cognitive dysfunction.
Asthma is not uncommon in the elderly population, but more attention is needed, considering that 4% to 8% of elderly people are affected. Three experts shared their concerns about this vulnerable population, with insights into the potential for community assistance, developing information about the relationship between depression and asthma, and findings that show a relationship between asthma and risk of cognitive dysfunction.
Improving asthma management with community involvement
“When we look at published guidelines for asthma,” observed Andrea J. Apter, MD, “we don’t see many pictures of older adults; we find them lumped in with teenagers, so that a person who is 13 and an adult who is 65 might have the same treatment recommendations.” But, she said, asthma patients with the highest morbidity and mortality are marginalized older adults with comorbidities, especially women.
A new concept, community health navigators (CHNs) can play a role in helping these patients. CHNs are trained health workers with close ties to patient neighborhoods who help connect patients to healthcare and social services.
Dr. Apter, who is professor emeritus of medicine, University of Pennsylvania, pointed out that CHNs can fill the gap created when physicians stopped making house calls and, in so doing, can see how patients live. She is leading a study that focuses on low-income, minority adults with asthma and engages CHNs to:
- Meet with patients and help them prepare for doctor visits
- Review issues from previous appointments
- Identify questions for the patient to ask during their visit
- Ensure that the patient’s medication list is up to date and brought to the visit
- Accompany the patient to the visit
- Take notes for the patient to refer to later
- Ensure that the patient understands the clinician’s recommendations
- Help schedule new appointments and fill out forms
The concept of social determinants of health (health behaviors, socioeconomic status, and physical environment) supports the CHN approach, said Dr. Apter, who noted that at least 80% of health outcomes can be explained by social determinants of health, and 10% to 20% by clinical care. For example, CHNs can provide transportation assistance and visit patients at home to assess for environmental problems, such as exposure to second-hand smoke. They can explain basic asthma issues to the patient and provide a report to the clinician. They can help patients obtain nebulizers and other asthma medication.
Dr. Apter encouraged clinicians to incorporate CHNs into their practice as well as consider social determinants of health.
Depression with asthma in older adults: a bidirectional relationship
“We often think of asthma as a pediatric disease, but that is not necessarily the case,” said Paula J. Busse, MD, echoing a theme voiced by others. “Of the older population, 4% to 8% have asthma, and that population is growing,” she said.
The most important factor contributing to severe asthma in older adults is nonadherence to medication, but other factors include altered perceptions of asthma symptoms, different patterns of airway inflammation, less responsiveness to asthma therapies, and, significantly, depression.
Citing her work with colleagues at the Icahn School of Medicine at Mount Sinai, where she is a professor, Dr. Busse said that she and coinvestigators have found that patients with depression are more likely to have impaired asthma control and quality of life along with increased asthma symptoms and exacerbation. Researchers have found that depression is associated with increased proinflammatory markers such as cytokines.
Further, she said, depression and inflammation may have bidirectional relationships. Therefore, the increased inflammation associated with asthma can potentially cause or exacerbate depression, or the increased inflammation associated with depression can potentially increase the severity of asthma.
Since both asthma and depression are associated with systemic inflammation, crosstalk exists between the brain and the lungs. Depression is associated with elevated systemic levels of IL-6, TNFα, IL-1β, and IL-17. Research has identified cell sources of these cytokines in older patients with asthma and depression.
Dr. Busse proposes that treatment of depression can improve asthma control in older patients, and that, going forward, cytokines associated with depression may be a more precise and effective treatment target to improve both depression and asthma in older patients.
Considering the cognitive consequences of asthma
“Inflammation from asthma can contribute to cognitive dysfunction and dementia,” cautioned Nizar J. Jarjour, MD. He cited studies showing that patients with asthma may have as much as a 2-fold greater risk of developing dementia than people without asthma. Asthma also increases the incidence of dementia in patients with risk factors such as stroke or head injury, and inadequate asthma control increases the risk even further.
Dr. Jarjour, who is professor, pulmonary and critical care faculty, University of Wisconsin, said that a study of imaging and biomarkers by Rosenkranz et al showed more white matter disruption and disintegrity in patients with asthma compared to controls. He added that “the greater the severity of asthma, the greater the abnormality in white matter integrity, which is associated with cognitive deficits in severe and lifelong asthma.” He also noted that although cognition declines with cardiovascular disease, the decline is worse in the presence of asthma, which he said “acts as an amplifier of cognitive changes.”
Asthma and the brain have been shown to be interactive, and subsequently asthma has been shown to potentially cause cognitive dysfunction through structural brain changes. Asthma has also been shown to correlate with cardiovascular disease.
Selected references
Apter AJ, Bryant-Stephens T, Han X, et al. Clinic navigation and home visits to improve asthma care in low income adults with poorly controlled asthma: before and during the pandemic. Contemp Clin Trials 2022;118:106808. doi: 10.1016/j.cct.2022.106808
Baptist AP, Apter AJ, Gergen PJ, Jones BL. Reducing health disparities in asthma: how can progress be made. J Allergy Clin Immunol Pract 2023 Jan 21;S2213-2198(23)00073-9. doi: 10.1016/j.jaip.2022.12.044
Federman AD, O’Conor R, Mindlis I, et al. Effect of a self-management support intervention on asthma outcomes in older adults: the samba study randomized clinical trial. JAMA Intern Med 2019;179(8):1113-1121. doi: 10.1001/jamainternmed.2019.1201
Krieger J, Takaro TK, Song L, Beaudet N, Edwards K. A randomized controlled trial of asthma self-management support comparing clinic-based nurses and in-home community health workers: the Seattle-King County Healthy Homes II Project. Arch Pediatr Adolesc Med 2009;163(2):141-149. doi: 10.1001/archpediatrics.2008.532
Nanda A, Siles R, Park H, et al. Ensuring equitable access to guideline-based asthma care across the lifespan: tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a working group report of the AAAAI Asthma, Cough, Diagnosis and Treatment committee. J Allergy Clin Immunol 2023 Jan 28;S0091-6749(23)00121-5. Online ahead of print. doi: 10.1016/j.jaci.2023.01.017
Rosenkranz MA, Dean DC 3rd, Bendlin BB, et al. Neuroimaging and biomarker evidence of neurodegeneration in asthma. J Allergy Clin Immunol 2022 Feb;149(2):589-598.e6. Epub 2021 Sep 15. doi: 10.1016/j.jaci.2021.09.010
Udemgba C, Sarkaria SK, Gleeson P, et al. New considerations of health disparities within allergy and immunology. J Allergy Clin Immunol 2023;151(2):314-323. doi: 10.1016/j.jaci.2022.11.004
Disclosures
None of the faculty have relevant disclosures.