Asthma is a chronic lung disease that causes inflammation and narrowing of the airways, making breathing difficult. It is a common condition that affects people of all ages, but there has been some debate around whether asthma tends to worsen as a person gets older.
In the opening paragraphs, we’ll provide a quick overview answering whether asthma does in fact worsen with age, and what some of the factors are that contribute to this.
Does asthma get worse with age? Quick answer:
For many people, asthma symptoms do tend to worsen as they get older. Some key points:
– Lung function naturally declines with age, which can worsen asthma. The airways become more rigid and less elastic.
– Older people often have more persistent inflammation in their airways, which exacerbates asthma symptoms.
– Environmental exposures over a lifetime, like air pollution and allergens, may contribute to worsening asthma in older age.
– Obesity becomes more common as people age, and excess weight is linked to more severe asthma.
– Older people may be less able to properly use inhalers and monitor their condition.
However, it does depend on the individual – well controlled asthma in youth can stay stable into old age. But in general, most data shows asthma severity increases with age.
Age-related changes to lungs
One of the main reasons asthma often gets worse with age is because of natural age-related changes that occur in the respiratory system.
As we get older, our lung capacity and function declines. The airways and lung tissue become stiffer and less elastic. The chest wall also stiffens, which makes breathing more effortful.
Some key lung changes include:
- Reduced strength of respiratory muscles
- Less elastic recoil of lung tissue
- Stiffening of the chest wall
- Narrowing of airways
- Reduced gas exchange
All of these changes mean the lungs have a reduced ability to move air in and out. This exacerbates any breathing difficulties in people with asthma.
The natural aging process also leads to a reduction in mucociliary clearance from the airways. Mucus clearance helps remove debris and pathogens from the lungs. With less efficient clearance, people are prone to more mucus build up and inflammation.
Lung function decline with age
Lung function reaches its peak in early adulthood, then begins a slow decline with age. This decline is accelerated in people who smoke.
Two measures of lung function often used are:
– FEV1 – Forced expiratory volume in 1 second. This measures how much air you can forcefully exhale in one second.
– FVC – Forced vital capacity. This is the total volume of air forcefully exhaled.
Healthy aging sees a gradual decline in both measures. But with asthma, the decline in lung function is typically faster:
- FEV1 declines 30mL per year in healthy adults after age 30.
- In asthmatics, the decline may be 60-100 mL per year.
The rapid decline in FEV1 is linked to worsening asthma symptoms with age. FEV1 is closely tied to airway obstruction. As it drops off, breathing becomes much more difficult.
The airways of older people with asthma undergo some structural changes that make asthma worse.
Some of these age-related airway changes include:
- Thickening of airway smooth muscle
- Increased collagen deposition around airways
- Hyperplasia of mucus-producing goblet cells
- Vascular proliferation and dilation
Collectively, these changes make the airways more rigid and narrower. The walls become thicker and more obstructed with mucus. Older airways are often described as more “brittle”.
With such structural changes, even mild asthma triggers can provoke more severe bronchospasm and symptoms in older airways. The airways overreact and struggle to recover.
Alongside structural changes, older asthmatics typically have more persistent inflammation of their lower airways. This is due to:
- Increased activation of inflammatory cells like mast cells, eosinophils, and T-lymphocytes
- Higher levels of inflammatory mediators like histamine, cytokines, and leukotrienes
- Disruption of epithelial barriers
- Damage to normal tissue repair processes
This age-related airway inflammation makes people more susceptible to asthma triggers. The “brittle” inflamed airways are always primed and ready to provoke a flare-up.
The chronic inflammatory state is thought to be caused by lifetime exposures to environmental factors, like pollution, allergens, and infections. This creates cumulative damage and irritation to the respiratory tract.
Impact of lifetime exposures
A lifetime of exposures to environmental factors are believed to contribute to worsening asthma in the elderly.
Exposures that may play a role include:
- Cigarette smoke
- Outdoor/indoor air pollution
- Allergens and irritants
- Respiratory infections
- Occupational exposures like chemicals or dust
In young asthmatics, the airways may be able to recover from intermittent exposures. But after years or decades of repeated exposures, the cumulative damage leads to persistent inflammation and airway remodeling.
Research finds the number of years with active asthma symptoms correlates with poorer lung function and harder to control symptoms in later life. Chronic untreated inflammation eventually takes its toll.
Role of allergens
Allergies play a prominent role in asthma. Exposure over time to indoor allergens like dust mites, molds, and pet dander can continually trigger and worsen asthma.
Some studies have found sensitivity to indoor allergens increases with age. Older people may react to lower allergen exposures than the young.
Reasons for this increasing sensitivity include:
- Increased inflammation in aging airways
- Reduced immune regulation
- Higher total IgE levels
- Increased activity of mast cells and eosinophils
Controlling the home environment by minimizing dust and allergens can help improve asthma control in the elderly.
Role of respiratory infections
Respiratory infections, like colds and flu, are a major trigger for asthma exacerbations. The elderly are more susceptible to these infections for several reasons:
- Decline in immune function with age
- Reduced mucociliary clearance
- Waning vaccine immunity
- Institutional living
Studies show respiratory infections are the most common cause of asthma attacks in the elderly requiring hospitalization. The airways have trouble recovering back to baseline after an infection.
Preventing infections through vaccination and hygiene practices are an important part of managing asthma in older populations.
Obesity worsens with age
Obesity becomes increasingly common as people age. Excess weight is linked to worsening asthma severity for several reasons:
- Excess fat on the chest and abdomen restricts breathing motion
- Obesity leads to increased systemic inflammation
- Leptin and other inflammatory mediators are increased
- Gastroesophageal reflux is worsened, which can trigger asthma
With the onset of osteoarthritis and reduced mobility, it can be hard for older people to exercise and lose weight. Maintaining a healthy BMI through diet and activity should be emphasized for asthma patients.
Difficulty using inhalers
Many elderly asthmatics have difficulty correctly using prescribed inhalers and devices. This leads to poorly controlled asthma.
- Reduced strength and coordination to properly actuate inhalers
- Cognitive or memory issues remembering complex regimens
- Vision problems reading small print on inhaler labels
- Poor hand-breath coordination
- Non-adherence due to cost of medications
Healthcare providers should take time to demonstrate and assess proper inhaler technique among elderly patients. Simplifying regimens, reminders, and spacers can help overcome some usage difficulties.
Reduced perception of symptoms
Some studies show older adults have a decreased perception of asthma symptoms like wheezing and shortness of breath. They seem to underestimate the severity of their condition.
Some potential reasons include:
- Neurological changes reduce respiratory sensations
- Accommodation to symptoms over time
- Distraction from other health conditions
- Reduced activity levels mask impairment
Regardless of perceived symptoms, lung function tests can objectively assess asthma control in older patients. Monitoring is important to assess risk of flare-ups.
Co-existing medical conditions
Older adults frequently have multiple chronic medical conditions along with their asthma. Some may interact and worsen asthma control, such as:
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure
- Chronic sinusitis
- Gastroesophageal reflux disease (GERD)
- Obstructive sleep apnea
- Arthritis limiting activity
The presence of co-morbidities should prompt comprehensive assessment and care from a multidisciplinary team. Optimal control of conditions like heart disease, reflux, and COPD can help improve asthma outcomes.
Socioeconomic disadvantages in older populations can negatively impact asthma outcomes, such as:
- Low health literacy
- Financial barriers accessing care
- Reduced social support
- Depression and anxiety
- Living in low quality housing conditions
- Inability to avoid asthma triggers
Proactive social support and asthma education can help overcome some of these barriers. Home visits by community health nurses may also improve outcomes among socially isolated elderly.
Managing worsening asthma in the elderly
Despite the various age-related factors that contribute to worsening asthma, the condition can still be managed to minimize symptoms and improve quality of life.
Key management strategies include:
- Annual influenza vaccinations
- Pneumococcal vaccines
- Regular monitoring by a healthcare professional
- Asthma education and action plans
- Emphasis on medication adherence
- Identifying and avoiding triggers
- Treatment of co-morbidities
- Smoking cessation support
- Pulmonary rehabilitation if indicated
In severe or difficult-to-control cases, referral to an asthma specialist may optimize therapies and outcomes.
Newer biologic medications, like anti-IgE, anti-IL5, anti-IL4, and anti-IL13 drugs, are also more effective for some difficult-to-control asthmatic patients who have an allergic or eosinophilic phenotype.
In summary, the key points on whether asthma tends to worsen with older age:
- Natural aging changes to the lungs worsen asthma control
- Airflow limitation and airway remodeling occurs
- Increased inflammation from lifetime exposures contribute
- Obesity and other conditions exacerbate asthma
- Impaired inhaler use and symptom monitoring occur
- Good control in youth may delay progression
- Management is key to minimize symptoms
For many asthmatics, their disease does worsen over time. But with proper education, monitoring, avoidance of triggers and tailored treatment, asthma can be controlled to prevent major exacerbations and disability into old age.
Asthma is a variable disease that manifests differently in each individual. While lung changes from aging itself play a role, disease progression is also determined by lifetime environmental exposures, co-morbidities, socioeconomic factors and management interventions.
With a patient-centered approach, regular assessment, and new therapeutic options, the outlook for well-controlled asthma is improving. Although barriers exist in the elderly, focus on education, adherence, and reducing risk factors can help minimize exacerbations and disability.
For some, asthma may remain stable without major progression. But for many elderly patients, asthma control does tend to decline compared to earlier in life. Worsening respiratory function over time requires ongoing adaptation of treatment and vigilance in avoiding triggers.
With informed self-management and healthcare support, the hope is elderly asthmatics can live full, active lives despite their diagnosis. More research is still needed into the mechanisms and risk factors that influence disease trajectory over a lifetime. As we understand more, we can better modify treatment and environment to benefit asthma patients into old age.