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Australian Journal of Pharmacy : February 2005
Is it asthma? A recent meeting of health professionals focused on the fact that asthma in the elderly may be a different sort of disease and as you get older it is more difficult to give a particular diagnostic label to people. For example, it can be quite difficult to differentiate between the smoking asthmatic and the non-smoking COPD patient who may have had a history of asthma. One of the participants of the Macquarie Bank Asthma Australia Research Colloquium—Asthma and the older Australian—Professor Norbert Berend explained in asthmatics there is a progressive decline in lung function which is faster than the normal decline of age alone. ‘So by the time asthmatic patients reach those elderly years—and elderly is defined at older than 55—many of them can really look much like COPD and they can really be difficult to distinguish,’ said Professor Berend. ‘We finally decided that it is actually very difficult to differentiate between the two because many of them seem to have a mixed pattern airway inflammation. ‘One of the things we thought would be quite useful was to do some studies on whether it might be better to define such patients in terms of their therapy rather than putting a traditional label on them. ‘In other words, if we can define a population in the elderly that has a steroid responsive disease, then that would be a population that we would be giving inhaled steroids, and that might be more important than saying they are relatively unresponsive asthmatics or relatively poor responsive patients with COPD. ‘So one of the outcomes was we really need to know a little bit more about defining sub-populations in the elderly with airflow obstruction that might respond to particular forms of therapy, because that really does make a practical difference,’ Professor Berend said. Conclusions drawn from the colloquium will be published in the Medical Journal of Australiathis year. Home medicines reviews Dr Yates suggested that structuring three key elements into a home medicines review (HMR) would help to make it more useful. He said a pharmacist should know: • if the client has any impairments—so check vision, hearing and cognition; • what their physical strength is like; and • have some understanding about their mood. None of those were irretrievable and there were ways that they could be mea- sured quite readily, Dr Yates said. ‘If someone has got poor vision then obviously you can manage that with ver- bal instruction,’ he said. ‘You can measure cognition with sim- ple screening tools, for instance the abbre- viated mental test score. ‘Mood is important because we know that depression is associated with poor concordance ... you can pick that up quite easily usually but if you want to measure. There are very simple 15 point scales the patient can answer themselves before you come in for the HMR.’ It was also vital to determine the per- son’s strength and power. ‘We know that if you can’t generate more than six pounds of pressure, you can’t use a metered dose inhaler; we know that people with severe arthritis have some difficulties with some types of inhalers, for instance turning a turbo inhaler,’ he said. Dr Yates said hand function could be easily measured against the metered dose inhaler. He suggested that if a pharmacist was going to see a frail, elderly person for a HMR it was always useful to get the key family carer there as well. ‘The fact that someone has got cogni- tive impairment doesn’t stop proper com- pliance because you can usually engage a family member or carer,’ he said. ‘And if someone is having difficulty hearing, you can use printed material— but make sure the font is nice and big so they can read it,’ he said. Once a pharmacist knew these things about a person with asthma, then they should go through the actual medication review. ‘It’s not rocket science—it’s basic logic—but if you put it into a framework then you have then got some sense of where things are going,’ Dr Yates said. ‘If you take that structure, go in with the view that you are looking at mood, power and impairment—vision, hearing, and cognition—you know how you are going to deliver your education. ‘And if you have got limitations to the delivery of that education because of impairments you have found along the way, get a carer involved,’ Dr Yates said. Medication issues According to the NAC a medications review should help to uncover ACE inhibitor-induced cough, possible med- ication allergies or allergies to beta- blocker eye drops. The possibility also exists that treating other diseases, or the development of other diseases, may have unmasked asthma. Conditions that the older person may have could make their asthma more apparent. Treatment of conditions such as: • emphysema, bronchitis; • hypertension, heart failure, cerebro- vascular disease, myocardial infarction; • arthritis, osteoporosis; • glaucoma, cataracts; and • tremor, ecchymoses; can influence asthma management or can make the asthma itself worse. As Dr Yates pointed out, medication THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 FEBRUARY 2005 ? 91