Delayed asthma in the elderly has little to do with allergic reactions. The main symptoms are chronic cough, intermittent wheezing, dyspnea or coughing at night. The pathogenesis of asthma has not been fully elucidated and may be related to age, heart disease, or chronic obstructive pulmonary disease. The use of methacholine to measure nonspecific bronchial reactivity in asthma in older adults is safe, effective, and reproducible, but the peak daily variation used to estimate expiratory flow rate is poor. Asthma mortality in the elderly increases with age. Aspirin or other nonsteroidal anti-inflammatory drugs often taken by older patients, as well as beta-blockers used to treat heart disease or glaucoma, can worsen bronchospasm.
The treatment of elderly patients with asthma is the same as that of patients with the same disease in other age groups, using bronchodilators and adrenocortical hormones. But asthma in older adults is often complicated by heart disease, making treatment complicated. Bronchodilators such as sympathomimetics and theophylline can increase myocardial oxygen consumption and worsen atrial and ventricular tachycardia. Elderly patients should use inhalation administration and avoid oral and parenteral administration of sympathomimetics to avoid greater cardiac adverse reactions (arrhythmia and angina).
1. Bronchodilator
(1) Inhaled β2-receptor agonist: β-receptor agonist has a selective effect on bronchial smooth muscle than myocardium, but the drug is inhaled in large doses It also has a myocardial stimulating effect. Airway β1 receptor response decreases with age, but most patients are effective at commonly used doses. For patients who are particularly intolerant to the drug, the dose can be adjusted by measuring lung function. Systemic adverse effects of this class of drugs include tremor, tachycardia, and hypokalemia. Medications commonly used for bronchospasm in the elderly include albuterol, ocsinaline, terbutaline, fenoterol, and rimitrol.
(2) Ipratropium bromide: a cholinergic receptor blocking drug, its bronchorelaxant effect on asthma patients is not affected by age, and it is more suitable for elderly asthma patients. The best rule of thumb when using bronchodilators to treat asthma is to use them when needed. Elderly patients can use drug delivery devices such as automatic breathing inhalers, isolation inhalers, and portable electronic nebulizers.
(3) Theophylline: The oral absorption of this drug does not change with age, and its elimination is reduced by 30% in the elderly. It can be combined with other drugs such as cimetidine, erythromycin, ditroleandomycin, and ciprofloxacin. , allopurinol and influenza vaccine, can increase the blood concentration of theophylline. Cimetidine and ciprofloxacin inhibit theophylline metabolism. Smoking or phenytoin can induce liver drug enzyme activity and accelerate theophylline metabolism, thereby increasing theophylline maintenance dose in elderly patients. The bronchodilatory effects of theophylline are not additive with beta2-agonists or corticosteroids, so intravenous administration is rarely used. Theophylline and other methylxanthine drugs can stimulate the central nervous system, have diuretic and cardiac effects, and when the blood concentration exceeds 20mg/L, they can produce adverse reactions such as nausea, arrhythmia and convulsions. Therefore, the blood concentration is best controlled at 5 to 15 mg/L. Long-term use of theophylline in elderly and frail patients is more likely to cause severe or fatal toxic reactions. Therefore, theophylline should be strictly limited to long-term use in the treatment of asthma in the elderly and should only be used to control nighttime asthma symptoms.
2. Adrenocortical hormones
Corticosteroid aerosols such as clomethasone dipropionate or budesonide are better than oral preparations for asthma treatment. Long-term routine use of corticosteroid aerosols can improve airway hypersensitivity, reduce the dose of bronchodilators and improve severe symptoms with almost no adverse reactions. However, long-term use should pay attention to Candida albicans infection in the mouth and throat. If such infection occurs, the mouth can be rinsed to control the infection. If acute attack symptoms worsen, high-dose corticosteroid aerosols (clomethasone dipropionate 1500-2000 μg/d) are ineffective, and systemic administration is recommended. Although systemic administration of corticosteroids can effectively treat obstructive airway diseases, long-term use can cause many adverse reactions, such as inhibiting calcium absorption and osteoblast activity, and aggravating osteoporosis. The combined use of calcium and calcitriol can reduce bone loss caused by corticosteroids in patients, and alendronate can also be used to reduce bone loss. For patients whose tuberculin test is positive and whose tuberculosis has not yet been treated, after starting the use of corticosteroids, they should also pay close attention to the treatment of tuberculosis.
3. Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease and asthma often coexist in the elderly, especially in smokers. It is very necessary for patients with chronic obstructive pulmonary disease to quit smoking. Nicotine skin patches can help quit smoking, and the smoking cessation rate can reach 20 to 40% with long-term use. The inhaled bronchodilator ipratropium bromide is more effective in treating chronic obstructive pulmonary disease than asthma, and high-dose beta-agonists have similar efficacy. The combined use of the two combines the rapid effects of ipratropium bromide with the long-acting effects of β2 receptor agonists, which can increase the efficacy and reduce adverse reactions.
The efficacy of inhaled corticosteroids in chronic obstructive pulmonary disease is controversial. Recent studies have found that long-term use of inhaled corticosteroids in patients with an average age of 52 years can significantly improve the patient's expiratory flow rate, reduce symptoms and slow down the progression of the disease. Long-term oral use of corticosteroids in elderly and frail patients increases the risk and has uncertain effects, and should only be used as a last resort.
It is best for elderly patients with chronic lung disease to use influenza vaccine and pneumonia vaccine. The efficacy of pneumonia vaccine is still controversial, but influenza vaccine can reduce the morbidity and mortality of influenza-related diseases such as pneumonia, bronchitis and heart disease.