These are barriers to presentation and not to diagnosis, and should be dealt with in health education campaigns. 11 However, the proportions who dismiss their asthma symptoms as part of the normal ageing process, or deny that they have symptoms, or experience classical as opposed to non-classical symptoms of asthma, is unknown. Altered perceptions of dyspnoea have been described in older people, 10 and patients under-report symptoms to their doctor. Several complex and possible contributory factors need to be considered in understanding why asthma is underdiagnosed in older people, and an algorithm may not be able to address this problem. 9 Given the relative diagnostic uncertainty, the utility of an algorithm may be in providing a pathway for an approach to decision-making. 8 The UK National Institute for Clinical Excellence, in its recent guideline on chronic obstructive pulmonary disease (COPD), recommended a 400 mL increase in FEV 1 in response to bronchodilator as diagnostic of asthma. There is also controversy surrounding the diagnostic value of the response to bronchodilator. 6, 7 In addition, there is inconsistency between guidelines as to whether the post-bronchodilator response should be a percentage of baseline or of predicted FEV 1. However, the degree of reversibility of airflow restriction that is considered significant varies between guidelines, from 12% to 15% of the baseline value. International guidelines for the diagnosis and management of asthma suggest that a significant change in forced expiratory volume in 1 second (FEV 1) after use of a bronchodilator is indicative of asthma. However, this will be refined in future algorithms, and does not prevent us from using agreed best practice now. Another issue is the lack of a gold standard for diagnosing asthma, which has implications for the sensitivity and specificity of the algorithm. The definition of asthma by the Global Initiative for Asthma 6 includes inherent ambiguities (eg, “episodes are usually associated with widespread but variable airflow obstruction that is often reversible. It is difficult to define asthma accurately. 5 It is important to consider the issues associated with making an asthma diagnosis overall, and specifically in older people in whom other issues of ageing play a part, and whether these can be accommodated in an algorithm. For the purpose of this discussion, we define an algorithm according to Stedman’s medical dictionary as a “step-by-step protocol for management of a health care problem”. 3 Although there is no Level I evidence 4 to support the idea, an algorithm to aid the early diagnosis and treatment of asthma in older people may improve their respiratory outcomes. 2 Given that patients whose asthma is undertreated have worse outcomes, recognition of people with undiagnosed and untreated asthma is important. In conjunction with GPs, develop a pilot program to increase awareness of the current asthma problem.Ĭonduct focus-group research to identify why some people do not believe they can develop asthma for the first time in adult life.Ĭonduct focus-group research to identify why some adults do not attribute asthma symptoms to asthma.Ĭonduct focus groups with GPs to identify what support is needed to diagnose asthma more effectively.Ĭonsult with all stakeholders before an intervention is used.Īrecent study has estimated that the prevalence of undiagnosed asthma in the adult population is 2.3%, 1 and that this prevalence almost doubles in those aged over 65 years. Work on developing a gold standard for asthma diagnosis.ĭevelop prototype algorithms for general practice discussion.Ĭonduct a general practice study to assess the effectiveness of an algorithm. What systems or supports do GPs need to diagnose asthma more effectively? What proportion of the population believe asthma does not occur in the older population? What proportion of older people with undiagnosed asthma fail to recognise symptoms? How effective would an algorithm be in helping general practitioners diagnose asthma?
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