While patient autonomy is important to consider when managing patients with any chronic condition at any age, healthcare professionals tend to assume that older adults desire more of a paternalistic approach, explains Keerthi R. Karamched, MD. The prevalence of asthma in older adults is similar to that of other age groups, but previous studies using the Autonomy Preference Index (API) to better understand asthma patient preferences and desire for involvement in making medical decisions have focused on younger patients. “Hence, I felt that it was important to look preferences for autonomy in managing asthma among older adults,” says Dr. Karamched. “I also wanted to see if these autonomy preferences seemed to make an effect on asthma-related outcomes.”


Questioning Older Asthmatics

For a study published in Annals of Allergy, Asthma & Immunology, Dr. Karamched and colleagues collected data through baseline questionnaires of nearly 200 older adults with persistent asthma. Patients were asked about age, education level, gender, and comorbidities among other demographic factors, as well as asthma control and quality of life, which was measured using the Mini Asthma Quality of Life Questionnaire (AQLQ).  Information on each patient’s lung function was also collected. Preferences for autonomy were assessed using the API, with a higher score indicating higher desire for autonomy.

Scores were separated into 2 domains of information-seeking and decision-making preferences, with the decision making section assessing how much a patient wants to take an active role in making medical decisions. “All the data was collected in one sitting,” explains Dr. Karamched. “We initially looked for a correlation among demographic factors and autonomy scores, and then we looked for a correlation between asthma outcomes and autonomy scores.  Based on these initial correlations, we then did a linear regression analysis.”


Observed Correlations

The researchers found that higher decision making scores were correlated with higher AQLQ scores (Table 1), meaning “that the higher the decision making scores are, the higher that patient’s quality of life is,” explains Dr. Karamched. Even when accounting for other variables that may affect quality of life—such as gender, age, duration of asthma, race, comorbidities, education level, and depression scores—decision making scores remain statistically significantly associated with AQLQ scores (Table 2).

“The most striking finding in this study is that a higher degree of autonomy in older adults with asthma is associated with a higher asthma related quality of life,” says Dr. Karamched. “However, in younger patients with asthma, autonomy preferences did not impact outcomes. We also found that higher autonomy levels are associated with female gender, higher educational levels, and lower levels of depression.” The study investigators observed no association with asthma control test scores, spirometry values, and healthcare use. And while information-seeking preference scores were found to correlate with education level, there was no correlation with asthma outcomes.


Important Implications

While previous studies indicate that increasing patient involvement in asthma care through education and use of asthma action plans has helped improve asthma-related outcomes, patient involvement and autonomy are not universally the same among patients, note the study authors. Coupling this data with the current study’s finding that higher levels of autonomy can impact quality of life (an important outcome to consider in patients with asthma), Dr. Karamched suggests that clinicians may need to consider utilizing the API to understand patient autonomy when managing patients with asthma who are older than 55 years. She notes, however, that future longitudinal studies are needed to help identify any causation between autonomy and quality of life, as this study can only imply correlation and not causation.



Keerthi R. Karamched, MD, has indicated to Physician’s Weekly that she has no financial interests to disclose.