Asthma in Older Adults: What Changes After 60

What asthma is

In asthma, the airways are inflamed and unusually sensitive. When exposed to triggers, they narrow, swell and make mucus, causing wheeze, cough, chest tightness and shortness of breath. The narrowing is typically variable: worse at some times, better at others, and at least partly reversible with treatment. In older adults, long-standing asthma can lead to some permanent narrowing, so that the picture overlaps with COPD, and some people have features of both.

How it differs after 60

• Symptoms can be vague: a night-time cough, tiredness, reduced exercise tolerance, or breathlessness that the person attributes to ageing or being unfit.
• Perception is blunted: older people may not feel airway narrowing as clearly, and may under-report symptoms, which delays treatment.
• Overlap and mimics: COPD, heart failure, anaemia, reflux, vocal cord problems, lung scarring, infections and medicines can cause similar symptoms. A person can have more than one.
• Fixed airflow limitation: in long-standing asthma the airways may not return fully to normal.
• More triggers from other diseases and medicines.
• More complications from treatment: osteoporosis, cataracts, high sugar and thin skin can be influenced by some asthma medicines, particularly high-dose or oral steroids, so the doctor balances benefits and risks.
• Frailty and other conditions affect inhaler use, safety and exercise.

Telling asthma from COPD and heart failure

Doctors use history, examination and tests such as spirometry (a breathing test), peak flow readings, chest X-ray, blood tests and sometimes heart tests.

• Asthma: symptoms vary through the day and between days, often with night or early-morning cough or wheeze, a family or allergy history, a trigger pattern and good response to a reliever. Peak flow swings by more than about 20 per cent.
• COPD: usually linked to smoking or long exposure to smoke or dust, with steadily progressive breathlessness and daily cough and sputum; less variable.
• Heart failure: breathlessness lying flat or at night, ankle swelling, weight gain, tiredness. It can cause "cardiac asthma" with wheeze, and needs a different treatment.

Do not diagnose at home. A wheeze is not always asthma, and treating heart failure with asthma medicines alone can leave the real problem unaddressed. See COPD at home guide and heart failure at home: daily checks and warning signs.

Common triggers

• Infections: colds and flu are the most frequent cause of flare-ups. - Allergens: dust mites, mould, pollen, animal dander, cockroaches. - Smoke and fumes: tobacco, incense, mosquito coils, wood or dung smoke, cooking fumes, strong perfumes and cleaning products, paint and agarbatti. - Air pollution and dust, especially in winter and in the festive season. - Weather: cold air, humidity, sudden changes, thunderstorms. - Exercise, especially in cold or dry air. - Acid reflux and some foods. - Emotions and stress. - Medicines. Some can worsen asthma in susceptible people, and a doctor should check the list: - Beta-blockers, used for blood pressure, heart disease and also in some eye drops for glaucoma. - Aspirin and other anti-inflammatory painkillers. - Some other medicines; the doctor or pharmacist can review.

Do not stop any medicine yourself. If breathing worsens after a new tablet or eye drop, call the doctor and report it, and bring the medicine list. See medicine side effects families should watch for.

Treatment overview

Asthma treatment aims to keep symptoms away and prevent attacks.

• Reliever inhaler: a short-acting medicine taken when symptoms occur. Needing it more than a couple of times a week suggests poor control.
• Preventer inhaler: regular inhaled steroid, often with a long-acting medicine, taken daily even when well, as the doctor prescribes. Rinse the mouth after steroid inhalers.
• Add-on treatments for severe asthma, from a specialist.
• Courses of steroid tablets for attacks, only when the doctor prescribes.
• Avoiding triggers, vaccines (influenza, pneumococcal and COVID-19 as advised) and treating allergies and reflux.

Inhaler technique matters: many older people use inhalers incorrectly, and a spacer often fixes this. See inhaler technique and spacers for older adults and nebuliser or inhaler: understanding the difference. A nebuliser is used only when the doctor decides; see nebulisers: types, use and cleaning.

Never alter doses, add extra puffs or stop preventers because you feel well.

Monitoring at home

• Symptom diary: night waking, cough, wheeze, reliever use, activity limits.
• Peak flow: useful if the technique is good. See peak flow meters: tracking asthma and breathing at home.
• Oximeter: can help during a flare-up if advised; see pulse oximeters: how they work and how to use one.
• A written asthma action plan, with zones and steps, from the doctor. The idea is similar to a COPD plan; see building a COPD action plan with your doctor.

Making the home asthma-friendly

• Reduce dust mites: wash bedding weekly in hot water if the fabric allows, use dust-proof covers, avoid heavy curtains and soft toys, and damp-dust rather than dry-sweep.
• Control damp and mould: fix leaks, ventilate bathrooms and kitchens and dry clothes outside the bedroom; see indoor air quality for older lungs: dust, smoke and damp and pest, damp and mould at home.
• Keep out smoke: no smoking, no incense, mosquito coils or camphor in the bedroom; ventilate during cooking.
• Pollution days: keep windows closed during peak pollution; an air purifier may help some people; see air purifiers: choosing one for an older adult's room and a pollution season plan for older adults.
• Pets: if allergic, keep pets out of the bedroom.
• Cleaning products: use mild products with ventilation, and avoid strong sprays.

Exercise and daily life

Regular, gentle exercise, such as walking, improves fitness and breathing. Warm up first, and keep the reliever at hand if the doctor advises using it before exercise. Avoid exercising in heavy pollution, very cold air or during a flare-up. See pulmonary rehabilitation exercises at home. Maintain a healthy weight, as excess weight can worsen asthma.

Warning signs

Call the doctor the same day if:

• The reliever is needed more than usual, or does not last as long.
• Night waking from cough or wheeze increases.
• Peak flow falls into the yellow zone from the action plan.
• Cough or sputum changes, or there is fever.
• Breathlessness limits usual activities.

Call 112 if:

• Your parent is struggling to breathe, cannot speak in full sentences or is too breathless to walk.
• Lips or fingertips are blue or grey.
• Your parent is exhausted, confused or drowsy.
• The reliever has no effect, or relief lasts less than a few hours, as the action plan states.
• There is chest pain.

While waiting, sit your parent upright, keep them calm and use the reliever as the plan or doctor has instructed. Do not give other people's medicines.

When to ask a professional

Ask the doctor to confirm the diagnosis with breathing tests, to check whether any medicines could worsen asthma, to write an asthma action plan, and to check inhaler technique. Ask for vaccine advice. Ask whether allergy testing is useful. Ask a pharmacist to review all medicines and eye drops. Call the doctor if control slips. Call 112 for severe breathlessness.