Allergies in the Elderly

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Allergies in the Elderly

Allergy
Geriatrics
Author Credentials 

Alissa Kanaan, MD
Assistant Professor, Otolaryngology Head and Neck Surgery
University of Arkansas for Medical Sciences
Little Rock, AR

Module Summary

Allergies in the increasing elderly population remain an undervalued, common disease with a major impact on quality of life. Immunosenescence is a factor behind developing new allergies and inability to mount an immune response. Changes in sinonasal tissue, GI system and skin cause these patients to develop allergic rhinitis, allergic conjunctivitis, dermatitis, asthma and food allergies. Symptoms can range from nasal congestion, sneezing, nasal drainage, rash, food intolerance and itchy eyes to generalized fatigue and sleep disturbance. Multimorbidity and polypharmacy make treatment challenging in this unique population. Second generation antihistamines and nasal corticosteroids are generally well tolerated whereas first generation antihistamines and decongestants should be avoided. 

Module Learning Objectives 
  1. Recognize and treat allergies in the elderly 
  2. Explain the effects of age on the immune system and organ systems exacerbating allergies in the elderly
  3. Recognize the multimorbidity, polypharmacy and side effects of medications in the elderly 

Pathogenesis

Learning Objectives 
  1. Describe the effects of age on the immune system: immunosenescence
    1. Imbalance in lymphocyte subpopulation
    2. Involution of the thymus with decreased new T cell generation
    3. Dysfunction in hematopoietic stem cell
  1. Describe the effects of age on the sinonasal tissue leading to rhinitis
    1. Decrease mucociliary clearance due to slowing of ciliary beat frequency and microtubule disarrangement
    2. Thinning of nasal mucosa
    3. Decrease in percent water per body weight leading to thicker mucus secretion
    4. Decrease in the S100 protein in the sinonasal tissue which mediates inflammatory activity, defends against pathogens, and promotes epithelial repair
  1. Describe the effects of age on the GI system leading to food allergy
    1. Atrophic gastritis and effect of anti-reflux medications
    2. Weakened secretory antigen-specific IgA responses
    3. Increase in intestinal permeability with aging
  1. Describe the effects of age on the skin leading to dermatitis
    1. Loss of hydration causing dermis and epidermis atrophy and structural and functional integrity
    2. Altered skin barrier function and reduced immunological response
References 
  1. Hsu DW, Suh JD. Rhinitis and Sinusitis in the Geriatric Population. Otolaryngol Clin N Am 51(2018) 803-813
  2. Ho JC, Chan KN, Hu WH, et al. The effect of aging on nasal mucociliary clearance, beat frequency, and ultrastructure of respiratory cilia. Am J Respir Crit Care Med 2001;163:983–8. 
  3. DelGaudio JM, Panella NJ. Presbynasalis. Int Forum Allergy Rhinol 2016;6: 1083–7. 
  4. Tieu DD, Peters AT, Carter RT, et al. Evidence for diminished levels of epithelial psoriasin and calprotectin in chronic rhinosinusitis. J Allergy Clin Immunol 2010;125:667–75. 
  5. Cho SH, Hong SJ, Han B, et al. Age-related differences in the pathogenesis of chronic rhinosinusitis. J Allergy Clin Immunol 2012;129:858–60. 
  6. Denkinger MD, Leins H, Schirmbeck R, Florian MC, Geiger H (2015). HSC aging and senescent immune remodeling. Trends Immunol, 36(12): 815-24
  7. Mohrenschlager M, Ring J. Food allergy: an increasing problem for the elderly. Gerontology, (2011) 57: 33-36
  8. Klimek L. Old, Wise and Allergic: Allergies Are No Longer Solely Diseases of the Grandchildren. Int Arch Allergy Immunol, (2014) 163:75-76

Basic Science

Learning Objectives 
  1. Understand the effects of age on the molecular level:
    1. Zinc and Vitamin D deficiency
    2. Increase in oxidative stress leading to increase release of histamine
    3. Difficulty in mounting immune response to newly encountered antigens
  2. Understand that allergies in the elderly can be caused by:
    1. Inhalant allergens, mostly pollens and mold
    2. Medication related allergies
References 
  1. Cardona V, Guilarte M, Luengo O, Labrador-Horrillo M, Sala-Cunill A, Garriga T. Allergic diseases in the elderly. Clinical and Translational Allergy. 2011;1:11.
  2. Milgrom H, Huang H, Allergic Disorders at a Venerable Age: A Mini-Review. Gerontology 2014;60:99-107
  3. De Martinis M, Sirufo MM, Ginaldi L. Allergy and Aging: An Old/New Emerging Health Issue. Aging and Disease. 2017;8(2):162-175. 

Incidence

Learning Objectives 
  1. Incidence of allergic diseases in the elderly is estimated around 5-10%
  2. Allergic rhinitis (AR) affects 5.4 to 10.7% of patients above 65 years
  3. Prevalence of asthma in the elderly is around 6-10%
  4. Allergic conjunctivitis remains widely underdiagnosed in the elderly
References 
  1. Mathur SK. Allergy and asthma in the elderly. Semin Respir Crit Care Med. 2010;31(5):587–95. 
  2. Pinto JM, Jeswani S. Rhinitis in the geriatric population. Allergy Asthma Clin Immunol. 2010;6(1):10.
  3. Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010;376(9743):803–13. 
  4. Ventura MT, D’Amato A, Giannini M, Carretta A, Tummolo RA, Buquicchio R. Incidence of allergic diseases in an elderly population. Immunopharmacol Immunotoxicol.

Genetics

Learning Objectives 
  • Genetics play a role in the aging process and immunosenescence
  • Positive family history of allergies increases the risk
References 
  1. Ginaldi L, Mengoli LP, De Martinis M (2007). Review on Immunosenescence. Reviews in Clin Gerontol, 17: 161-9

Patient Evaluation

Learning Objectives 
  1. Recognize the symptoms of allergies in elderly
    1. Nasal congestion, rhinorrhea, sneezing and eye itching, sleep disturbance and apnea, fatigue, drowsiness, rash, cough
  2. Recognize the multimorbidity and polypharmacy in elderly patients
    1. Recognize possible side effects of medications causing allergic symptoms
    2. Recognize drug interactions
    3. Recognize medical morbidities that can affect drug metabolism (liver or kidney failure)
References 
  1. Hsu DW, Suh JD. Rhinitis and Sinusitis in the Geriatric Population. Otolaryngol Clin N Am 51(2018) 803-813
  2. Seymour R, Routledge A. Important Drug-Drug Interactions in the Elderly. Drug & Aging. 1998;12(6):485–496

Measurement of Functional Status

Learning Objectives 

1. Evaluation with nasal endoscopy to rule out evidence of sinusitis
2. Allergy testing to identify potential triggers
     a. Skin testing 
     b. IgE testing 

References 
  1. Hsu DW, Suh JD. Rhinitis and Sinusitis in the Geriatric Population. Otolaryngol Clin N Am 51(2018) 803-813
     

Imaging

Learning Objectives 
  • If suspected, a CT scan of sinuses is helpful to rule out sinusitis
References 
  1. Hsu DW, Suh JD. Rhinitis and Sinusitis in the Geriatric Population. Otolaryngol Clin N Am 51(2018) 803-813

Treatment

Learning Objectives 
  1. Environmental control: Allergen avoidance
  2. Immunotherapy:
    • Strongly recommended in patients who did not respond to medications
    • Not to be used with patients on Beta Blockers
    • Can offer Subcutaneous and Sublingual immunotherapy 
References 
  1. Jutel M, Agache I, Bonini S, et al. International consensus on allergen immunotherapy II: mechanisms, standardization, and pharmacoeconomics. J Allergy Clin Immunol 2016;137(2):358–68

Medical Therapies

Learning Objectives 
  1. Pharmacotherapy
    1. Intranasal corticosteroids
    2. Second generation oral antihistamines
    3. Intranasal antihistamine is an option
    4. Oral leukotriene receptor receptor antagonists not recommended as primary treatment
References 
  1. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg 2015;152(1 suppl):S1–43. 
  2. Hsu DW, Suh JD. Rhinitis and Sinusitis in the Geriatric Population. Otolaryngol Clin N Am 51(2018) 803-813

Pharmacology

Learning Objectives 
  1. Avoid use of first generation antihistamines in elderly: may cause confusion, loss of coordination, arrhythmias and sedation
  2. Oral decongestants drugs: may cause arterial hypertension, headache, and exacerbation of glaucoma. 
  3. Second generation antihistamines: use with caution in patients with liver or kidney disease
  4. Identify any possible drug allergies from the patient’s current medications
References 
  1. Bozek A. Pharmacological management of allergic rhinitis in the elderly. Drugs Aging 2017;34(1):21–8. 
  2. Yilmaz AAS, Corey JP. Rhinitis in the elderly. Curr Allergy Asthma Rep. 2006;61:125–131.

Surgical Therapies

Learning Objectives 
  • Possible inferior turbinate surgery for patients with allergic rhinitis:
    • Possible techniques: out fracture of turbinates, reduction using radiofrequency, submucosal resection, and partial/complete resection
    • Consider local anesthesia and/or in office procedure for patients who can’t tolerate general anesthesia 
References 
  1. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg 2015;152(1 suppl):S1–43.
  2. Hsu DW, Suh JD. Rhinitis and Sinusitis in the Geriatric Population. Otolaryngol Clin N Am 51(2018) 803-813.

Case Studies

  1. A 74-year-old lady presents with nasal obstruction, sneezing and runny nose that has been going on for the past couple of years. She is having to breathe through her mouth and this is affecting her sleep and causing her to have dry mouth. She had a history of allergies growing up but has not been tested for a while. She denies any recurrent sinus infections requiring antibiotics. What additional history would be pertinent to know in this patient? What could be possible exam findings? What tests would you order at this point, if any? What treatment would you recommend?
  2. An 80-year-old man presents with post nasal drip and cough that have been going on for 3 months now. He denies any recent colds or sinus infections. He had a recent chest X-ray that was clear. He denies any reflux symptoms. His past medical history is positive for diabetes mellitus type 2 and hypertension. What additional history would be pertinent to know in this patient? What could be possible exam findings? What tests would you order at this point, if any? What treatment would you recommend?

Complications

Learning Objectives 
  1. Allergy in the elderly can have a significant impact on quality of life if left untreated.
  2. Medical treatment should be selected carefully to avoid drug interactions/reactions
References 
  1. Hsu DW, Suh JD. Rhinitis and Sinusitis in the Geriatric Population. Otolaryngol Clin N Am 51(2018) 803-813.

Review

Review Questions 
  1. What are the effects of age on the allergic response in elderly?
  2. What are possible symptoms of allergic disease in the elderly?
  3. What is important to note in the history of these patients?
  4. What is a safe treatment for these patients?
Resources 

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