Review
The use of bronchodilators in the treatment of airway obstruction in elderly patients

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Abstract

Ageing is associated with important anatomical, physiological and psychosocial changes that may have an impact on the management of obstructive airway diseases (asthma and chronic obstructive pulmonary disease (COPD)) and on their optimal therapy. Ageing-related modifications might be responsible for a different effectiveness of bronchodilators in the elderly patients as compared to younger subjects. Furthermore, the physiological involution of organs and the frequent comorbidity, often interfere with pharmacokinetics of bronchodilator drugs used in asthma and COPD. This review will focus on the use of bronchodilators in the elderly, with particular attention to the achievable goals and to rationale, utility and pitfalls in using the inhalation therapy in this age group. β2-agonists, anticholinergics and methylxanthines will be discussed and their side effects in the elderly will be considered.

Introduction

Management of asthma [1] and chronic obstructive pulmonary disease (COPD) in the elderly is a topic of increasing interest since ageing is associated with important anatomical, physiological and psychosocial changes that may have an impact on obstructive diseases and on their optimal therapy. Stiffening of the chest wall, reduction of lung elastic recoil and diminished respiratory muscle strength are known to affect respiratory mechanics in this type of population [2]. The loss of the lung elastic recoil due to aging results in reduced maximal expiratory flow rates and in an increase of the resting functional residual capacity.

Ageing-related modifications in lung mechanics, in receptor populations, in nervous control, etc. are likely to interfere with clinical presentations. In comparison with younger subjects, these modifications might be responsible for a different effectiveness of bronchodilators in the elderly patients. In addition, changes in organs or systems other than lung (liver, kidney, heart), either due to physiological involution or to frequent comorbidity, often interfere with the pharmacokinetics of the bronchodilator drugs used in asthma and COPD.

Furthermore, older age is characterized by various aspects of disability (memory problems, loss of coordination and muscle strength, hearing and visual loss) that may often decrease the ability to regularly follow the treatment schedules or to handle complex devices, such as metered-dose inhalers (MDI) or powder dispensers, thus limiting the compliance to the prescribed therapy.

Adverse reactions related to polypharmacy and comorbidity are more frequent in the elderly: on one hand, bronchodilators might worsen coexisting diseases (such as cardiac arrhythmias); on the other, medications often used by elderly patients, like β-adrenergic blockers or non-steroidal anti-inflammatory drugs, might elicit or worsen bronchoconstriction.

Therefore, particular attention should be paid to the adaptation of treatment schedules for asthma and COPD in the elderly and above all to the specific issue of bronchodilators. The present review will be focused on this issue.

Section snippets

Adaptation of treatment strategy

Asthma control in the elderly cannot be achieved without an appropriate treatment strategy that takes into account the age-related peculiarities of this patients group. The international guidelines for treatment of asthma in the elderly [1] identify four “components”, which are of prominent importance in the management. Although these components are similar to those for adults, they have been adapted to the peculiar characteristics of the older age. The four identified components include:

Goals in the use of bronchodilators in the elderly

Asthma and COPD are chronic diseases in which therapeutic intervention aims at controlling symptoms and, if possible, at slowing down the loss of lung function over the time that characterizes these diseases to a various extent. The achievement of the desired therapeutic and clinical goals may be more difficult in the elderly rather than in the younger patients. Therefore, treatment should be individualized to each specific condition.

One of the most important goals of treatment is maintaining

Inhalation therapy

Inhalation therapy is the method of choice for asthma and COPD management. It is the most important and effective way to administer bronchodilators in all ages [6], [7]. In addition, inhalation route allows a more rapid achievement of therapeutic effect and reduction of side effects because of lesser systemic distribution of the drug [8].

MDI are the most common devices used for inhalation therapy. They are characterized by different shapes and complexity and some of them require more

Inhaled β2-agonists

Human aging is associated with an increase in the activity of the sympathetic nervous system. This is supported by the observations that plasma noradrenaline levels (that are often taken as an indirect index for sympathetic activity [27]) are higher in older subjects compared to younger persons [28] and subsequently it has been directly confirmed by microneurographic recordings of post-ganglionic sympathetic nerve activity to skeletal muscle [29]. This age-related increase in sympathetic

Conclusion

Progressive improvement in treatment has increased the life expectancy of patients with obstructive airway diseases, extending the interval between the onset of disability and death. Consequently, these patients can survive for a long time in spite of severe respiratory impairment and disability. This has an important impact since the number of elderly patients suffering from asthma or COPD is dramatically increasing.

Unfortunately, the implementation of a safe and effective treatment may be

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