Chest
Volume 123, Issue 4, April 2003, Pages 1066-1072
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Clinical Investigations
COPD
Aging and Disability Affect Misdiagnosis of COPD in Elderly Asthmatics: The SARA Study

https://doi.org/10.1378/chest.123.4.1066Get rights and content

Study objectives:

This study investigated to what extent a diagnosis of COPD is erroneously made or the disease remains unrecognized in elderly asthmatic patients, and identified factors leading to misdiagnosis and underdiagnosis of asthma in such patients.

Design:

A multicenter study involving 24 Italian pulmonary or geriatric institutions.

Patients:

One hundred twenty-eight asthmatic patients (98 women, 76.6%) aged 73 ± 6.4 years (mean ± SD) were selected from the cohort of the Salute Respiratoria nell'Anziano (respiratory health in the elderly) study.

Methods:

All patients underwent a clinical evaluation that included clinical history and spirometry with a bronchodilator test. A diagnosis of asthma was based on criteria proposed by international guidelines adapted to the elderly population. A multidimensional geriatric assessment was performed to estimate physical and cognitive impairments and mood state. Finally, the diagnosis of respiratory disease previously made by a doctor, if any, was recorded.

Results:

Of asthmatic patients, COPD had been improperly diagnosed in 19.5%, whereas 27.3% of asthmatic patients did not report any previous diagnosis of asthma. The main correlates of misdiagnosis were older age and disability. Conversely, underdiagnosis was associated with better functional conditions, expressed by spirometry, even when wheezing or a significant response to the bronchodilator test occurred.

Conclusions:

Asthma in the elderly is frequently confused with COPD. Misdiagnosis can be related to older age and to greater degree of disability. Asthma in patients with mild functional impairment may be underdiagnosed in spite of overt respiratory symptoms suggestive of asthma.

Section snippets

Subjects

We studied a subgroup of 128 asthmatic subjects (98 women, 76.6%) aged 73 ± 6.4 years (mean ± SD) enrolled in the Salute Respiratoria nell'Anziano (SARA) [respiratory health in the elderly] study. This is a multicenter Italian project aimed at investigating various aspects of chronic airway diseases in the elderly population. Twenty-four pulmonary or geriatric institutions, distributed throughout Italy, took part in the investigation (see Appendix). All eligible subjects ≥ 65 years old and

Results

Mean FEV1 percentage of predicted (FEV1%) in the entire sample was 70.7 ± 25.7%, and mean FEV1/FVC was 65.6 ± 13.3% (mean ± SD). Airway obstruction (FEV1/FVC < 70%) was detected in 60% of participants. The mean percentage increase in FEV1 after reversibility test was 14.4 ± 15.7%, with 50% showing an increase > 12%.

Discussion

The present study shows that in our population, one of five elderly asthmatic patients receives an improper diagnosis of COPD, and at least one of four asthmatic patients does not receive any diagnosis of respiratory disease. Older age and disability, together with a less typical clinical pattern, have been shown to significantly affect misdiagnosis, whereas a milder functional impairment appears to be a risk factor for underdiagnosis of asthma in the elderly. Male sex did not qualify as a risk

Conclusion

In summary, our results suggest that asthma in the elderly is frequently confused with COPD or not diagnosed. Older age and the greater degree of disability, together with a less typical clinical pattern, appear to be the main causes of misdiagnosis, even when smoking history and chronic sputum are not present. In addition, respiratory symptoms suggestive of asthma, such as wheezing, may be underestimated, especially in patients with mild disease.

Appendix

Study coordinators were V. Bellia (Palermo) and F. Rengo (Napoli). Scientific Committee members were R. Antonelli Incalzi (Rome), V. Grassi (Brescia), S. Maggi (Padua), G. Masotti (Florence), G. Melillo (Naples), D. Olivieri (Parma), M. Palleschi (Rome), R. Pistelli (Rome), M. Trabucchi (Rome), and S. Zuccaro (Rome).

Participating centers, principal investigators (in parentheses), and associated investigators (in brackets) were as follows: Divisione di Medicina 1°, Osp. Geriatrico INRCA, Ancona

ACKNOWLEDGMENT

All of the participants thank G. Torresin and the staff of Biomedin (Padua, Italy) for technical assistance.

References (20)

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This study was supported by a research grant from Boehringer Ingelheim Italia.

The work was performed at the Istituto di Medicina Generale e Pneumologia, University of Palermo, Italy.

A list of participants and participating institutions is given in the Appendix.

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