Although asthma is commonly associated with childhood illness, it affects 5% to 10% of tibe U.S. population - including high numbers of adults. A high risk, and often unrecognized adult asthmatic population is the elderly. This is due to the fact that asthma may not develop until middle age and may then be accompanied or camouflaged by other recurring complications (Reynolds & Maxwell, 1992). These two factors may well account for today's rising asthmatic mortality rate, with the highest incidence of death occurring in persons over 65 years of age (Janson-Bjerklies, Ferketich, Benner, & Becker, 1992).
For many years bronchospasm was considered the main characteristic of asthma. In fact, this smooth muscle constriction of the airway was the major focus of medical treatment. Today, however, we recognize that the underlying pathophysiologic process in asthma is airway inflammation, which occurs in a two-phase sequence. First, the initial response to allergen exposure is a release of sensitized mast cells that promote bronchial smooth muscle contraction. This is known as the early phase. Then, a few hours later, inflammatory cells, edema, mucous secretion, cellular infiltration, and vascular permeability may all occur simultaneously, and may last for weeks. This is considered the late phase and is responsible for the ongoing hyperresponsive state - the trademark of asthma (Barbee, 1993). This inflammatory disease process can be both acute and chronic, and falls under six different categories.
Intrinsic asthma is an airway irritation syndrome resulting from cigarette smoking. These individuals may also have chronic obstructive pulmonary disease. Symptoms associated with this form of asthma are dyspnea, coughing, sputum production, and wheezing. Intrinsic asthma may be accompanied by recurrent respiratory infections and bronchitis. The incidence of intrinsic asthma is highest in elderly adults.
Extrinsic asthma is caused by a reactivity of individuals to defined allergens through inhalation or ingestion of food. Individuals develop seasonal rhinitis and asthma syndrome from exposure to specific allergens. This type of asthma is not commonly found in the elderly.
Mixed asthma, a third type, develops when an individual experiences extrinsic asthma during infancy or childhood, and then apparently outgrows it. Later in adulthood, airway irritation from other factors such as smoking, for example, reveal intrinsic asthma. This asthmatic combination is difficult to treat because many of these individuals become dependent on steroid therapy and, over time, require large doses to control the symptoms. Sadly, mixed asthma is most often found in older adults. Symptoms include wheezing, sputum production, and coughing.
Drug-induced asthma is a hypersensitivity state caused by a reaction to specific drugs which include acetylsalicylic acid, nonsteroidal antiinflammatory drugs, angiotensin converting enzyme inhibitors, morphine, and codeine. Symptoms include angioedema and /or complex rhinitis, nasal polyposia, and asthma.
Exercise-induced asthma is an asthmatic syndrome of wheezing and coughing following increased activity or exertion. The stimulus is temporary exposure to cold air or warm, dry air.
Aerosol-induced asthma is a sensitization to certain chemicals after repeated inhalation. Two chemicals identified are toluene 2,4-dii socyonate, a solvent used in foam products, and trimellitic acid, an agent used in paints and epoxy resins. Symptoms include dyspnea, coughing, and wheezing (Nelson, Lockey, & Bukantz, 1993; Reynolds & Maxwell, 1992).
MAGNOSiS OF ASTHMA
Intrinsic, extrinsic, mixed, exercise-induced, and aerosol-induced asthma are chronic conditions that can become acute if not treated properly. Drug-induced asthma is always acute just by its very nature. These variations of asthma make it extremely difficult to assess the elderly patient, so it is important that a nurse obtain good baseline data for the asthmatic patient. A thorough medical history is the first step and should include such topics as smoking history, occupation and environmental exposure, how the disease presented, and what symptoms the patient is exhibiting now. Include factors or situations that appear to aggravate symptoms. Elderly patients should be encouraged to explain their exacerbation process and how they are affected by it. It is also important to find out how or if the disease affects the patient and family socially.
A thorough physical examination is the second step in assisting the nurse to understand the important features of the elderly asthmatic. The physical examination should, naturally, focus on the upper respiratory tract. But in the older adult the exam should explore beyond typical findings such as decreased breath sounds, wheezing, and expiratory slowing. A more extensive examination should rule out congestive heart failure (CHF) since it can be easily mistaken for a chronic respiratory exacerbation (Barbee, 1993; Schaffer, 1991).
Although the physical examination may be suggestive of asthma, it is important to remember that some acute and chronic disease processes can also mimic asthma (e.g., chronic obstructive pulmonary disease, gastroesophageal reflux, tumors, beta blocker and ACE inhibitor druginduced cough, laryngeal dysfunction, viral or mycoplasma pneumonia, pulmonary embolism, and hypersensitivity pneumonia). Other chronic disorders could include vocal cord spasm and left ventricular failure (Barbee, 1993; Groth & Hurewitz, 1992).
In order to confirm the diagnosis of asthma, it is important that the elderly patient have a laboratory evaluation. The most commonly performed tests are the CBC and differential counts, which can indicate acute asthma, respiratory infection, or inflammatory disorders by measurement of the white cell count. Also, identifying the presence of eosinophilia may be useful in diagnosing asthma in the elderly patient. The AP and lateral chest x-ray may reveal evidence of hyperinflation of the lungs, an indicator of asthma, or the presence of other disorders such as CHF or pneumonia infiltrate. A pulmonary function test is very specific and confirms the presence or absence of airway obstruction (Groth & Hurewitz, 1992). Additionally, in the older adult a cardiac or gastrointestinal evaluation may be indicated when coronary insufficiency, CHF, hiatal hernia, or gastroesophageal reflux are considerations (Barbee, 1993).
The variability of asthma severity changes from one time to another, and is always individualized. The disease can be mild, moderate, or severe. Being able to identify the asthmatic's variability changes helps to simplify the medication regimen for the elderly patient. For the individual with mild, episodic asthma, an inhaled fy agent such as albuterol (Proventil, Ventolín), metaproterenol sulfate (Alupent, Metaprel), or terbutaline sulfate (Brethine) is recommended. For the individual with moderate and severe asthma, antiinflammatory agents such as cromolyn sodium (Intal) and inhaled corticosteroids such as beclomethasone dipropionate (Vanceril, Beclovent), triamcinolone acetonide (Azmacort), and flunisolide (AeroBid) are used, along with bronchodilators such as theophylline preparations (to control nocturnal symptoms). Oral B2-agonists are also used. Additionally, for severe asthma, oral corticosteroids such as prednisone, prednisolone, and methyl-prednisone are required on an ongoing basis (Barbee, 1993).
Aside from medication therapy, a family history of allergy could indicate the need for allergy evaluation. Referral to an allergist is a consideration, especially if an elderly patient has occupational asthma, asthma difficult to control, or whose lifestyle is affected. If the patient remains symptomatic with medication, immunotherapy may be an option.
OVERVIEW OF PATIENT TEACHING FOR THE ELDERLYASTHMATlC
IMPLEMENTING NEW SYSTEMS
Once the diagnosis of asthma is confirmed and a medication regimen established, a nursing treatment plan of care for the elderly patient can be developed. Aside from the complexity and acuteness of the disease process, there are additional major factors to consider.
Asthmatics, not unlike other patients with chronic illnesses, are often noncompliant with medication. In fact, this has been recognized as a major factor in the increased morbidity and mortality of asthmatics. Other problems identified include the complexity of the medication regimen and the adjustments required with exacerbations or infections. Moreover, asthmatics often have difficulty comprehending the medication's effect on their condition. This lack of understanding, compounded with a knowledge deficit of the disease process itself, often results in the elderly patient neglecting to act on red flag parameters that suggest when to seek medical attention.
When developing a treatment plan, patient education should focus on the asthmatic controlling his or her environment, understanding the importance of medication dosage instructions as prescribed for both chronic and acute episodes, and measuring lung functions on a daily basis (Barbee, 1993).
The elderly asthmatic also needs to stop smoking. These patients must recognize that they are at a significantly increased risk, and referral to a smoking cessation program would be beneficial. Take time to explain the importance of avoiding cigarettes, cigars, or pipes.
House dust and concomitant dust mites are regarded as the allergen most associated with asthma. There are many methods to control this allergen, including placing covers on mattresses, box springs, and pillows. It is a necessity to keep the home dust free by vacuuming (preferably with one of the newer low-dust models) and, whenever possible, removing carpeting and other dust collectors from bedrooms and frequently used areas. Maintaining a low humidity in the home and keeping pets out of bedrooms also helps. For seasonal allergens, outside work activity should be conducted early in the day because allergen concentrations tend to increase as the day progresses.
All elderly asthmatics should know that some of the most common symptoms of asthma they may experience include chronic cough, wheezing, dyspnea, and chest tightness. Changes in sputum color and consistency, though, are more advanced symptoms and can indicate a pending asthmatic exacerbation. These patients need to recognize and react to such changes, as well as to a decrease in their peak expiratory flow rate (PEFR).
The Metered Dose Inhaler
Any of the aforementioned symptoms can also occur if the patient forgets to take his or her medication. A written schedule incorporated into the treatment plan helps both the patient and nurse to keep track of the regimen. Most importantly, it helps track progress of medication efficacy and/or the necessity for increasing doses to control symptoms, thus indicating a possible worsening of the disease process.
One of the most crucial aspects of self-care is the proper use of the metered dose inhaler (MDI). Many patients simply do not understand how to use the MDI and have difficulty coordinating the inhalation process with its use. Since this is the main therapy route for elderly asthmatics, the understanding and use of the MDI is a high priority. Patients also need to understand why and how tu use the MDI spacer. Explaining that the spacer increases the concentration of the inhaled medication throughout the lungs may be the only explanation patients need. Patients with arthritis and paralysis due to CVA may need extra assistance in learning to use the MDI, while those with visual disabilities may need additional teaching in selfcare use of the MDI and spacer.
The Peak Flow Meter
An increased awareness of the asthmatic's response to the course of the disease can be monitored with a peak flow meter. This is especially useful for the patient with a more severe asthmatic disease. After being shown how to use the device, elderly patients can monitor themselves on a day-to-day basis and identify their own personal response to allergens or triggers. The elderly patient should recognize that the peak flow measurement varies in different patients as does the experience of asthma.
To assist the patient in monitoring peak flow measurement, it is important to establish a baseline value; this helps track the disease progress. The patient may determine their baseline PEFR by recording the highest measurement during a two or three week time frame. Later, any PEFR value 50% to 70% of baseline requires a medication adjustment. A PEFR less than 50% requires immediate notification of medical personnel. Further, the patient should recognize that changes in early morning PEER or increased nocturnal symptoms may be a grim indicator of asthma progression (Rumbak, 1991; Schaffer, 1991). Patients with visual, auditory, range of motion, or memory impairments may need additional patient teaching to manage their asthma.
DEVELOPING PRODUCTS AND SERVICE
Patient education in regard to the elderly asthmatic is aimed at providing the knowledge and skills they need to cope with and adapt to the disease process. The role of the nurse educator is to teach the elderly asthmatic self-care skills. In order to accomplish this, patients must be motivated. If patients lack interest or do not fully understand their plight, patient education will be ineffective.
With all the dramatic changes in the recognition and treatment of asthma, problems still remain with patients' apparent inability in effectively managing their own symptoms or understanding the severity of their own disease. Good patient and family education can correct these problems. As nurses, we can help our elderly patients "take care of business" by providing them with supportive health education. We can achieve our goals and their goals by assisting them in the maintenance of as normal a lifestyle as possible.
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