Among older individuals, women are significantly more likely than men to report having asthma and also have a 30% higher asthma-related mortality rate. In addition, women are nearly twice as likely to visit the emergency department for asthma when compared with men. Older women have been shown to have the highest hospitalization rates among all people with asthma (Figure). “However, little is known regarding why older women are more likely to suffer from the adverse events of asthma,” says Alan P. Baptist, MD, MPH. To better understand the specific issues that are unique to older women with asthma, Dr. Baptist and colleagues conducted a literature review and published their findings in Annals of Allergy, Asthma, & Immunology.
Menopause and hormone replacement are unique features among older women that may play a role in how asthma affects them differently from others. “Adult women experience the most asthma exacerbations around age 50, which is also the average age of menopause,” explains Dr. Baptist. “Studies also show that hormonal changes during the menstrual cycle often play a large role in asthma symptoms. Although we can’t say menopause and asthma symptoms are definitely related, we did find data suggesting this may be the case.”
Dr. Baptists and colleagues also found that women with no history of asthma who were started on hormone replacement therapy were more likely to develop asthma than women who did not. “Conversely, among women who had asthma, hormone replacement actually improved symptoms and decreased asthma exacerbations,” Dr. Baptist says. “Hormone replacement therapy has many side effects, but it may be worthwhile to consider it in some women with asthma after carefully considering the risks and benefits for each person.”
Addressing Common Features
Dr. Baptist and colleagues also reviewed what they felt may be certain aspects of asthma in older women that are not seen in other populations. “For example, it has been well known that oral steroids can affect bone mineral density,” he says. ”And now some data show that use of inhaled corticosteroids—the cornerstone of chronic asthma treatment—significantly lowers bone mineral density among post-menopausal women, when compared with age-matched controls. Bone mineral density screening is therefore important among older women.” Aspirin, β-blockers, and NSAIDs used to treat comorbidities that are commonly used by older women may also worsen asthma.
More than half of adults with asthma report at least one comorbidity, and rates are higher among women and increase with age. “Comorbidities may be related to some of the worst outcome among older adults with asthma,” says Dr. Baptist. “Comorbidities can lead to depression, a comorbidity itself that is strongly associated with poor asthma control, especially among the elderly.” Dr. Baptist points to a previous study in which he and colleagues found that depression was more strongly associated with poor asthma quality of life and poor asthma control than were asthma severity, number of exacerbations, lung function testing, or other comorbidities. He suggests that clinicians screen for depression among older women with asthma.
Older women often serve as primary caregivers for loved ones with other chronic illnesses. “These women may overlook their own health while caring for others,” Dr. Baptist says. “Caregivers often experience stress and depression, which can potentiate one another and cause asthma to worsen.” He recommends asking older women with asthma about any caregiver duties. He also recommends that those with caregiver duties undergo screening for depression or stress and connecting these patients to appropriate resources, such as mental health professionals, social work services, and support groups.
Research suggests that about 10% of older adults live below the poverty line, many of whom are unable to afford medication or office visit copays or other expenses relating to healthcare access. “We found that limited income and poverty can affect asthma care among older women,” says Dr. Baptist. “It is important for physicians to address finances with these patients.”
Several strategies can help physicians improve the care of older women with asthma (Table). Aside from understanding and addressing risk factors, Dr. Baptist recommends that physicians use peek flow meters to assess asthma control because older women may have a decreased perception of breathlessness. “We must also recognize that obesity plays a large role in asthma and that older women are frequently overweight or obese,” he says. “Furthermore, we need to understand that incorrect inhaler use is common in older adults but can be avoided with good teaching and keep in mind that certain medications may be less appropriate for older adults.”