Approximately one in five older people--even those with good health insurance--misuse their asthma drugs, and doctors fail an even greater proportion by not managing their care aggressively or giving them enough information to manage symptoms on their own, according to a report presented by Johns Hopkins researchers on May 22 at the American Thoracic Society's annual meeting.

"This is a wake-up call that doctors need to review medications that patients are using and improve other aspects of care," says Linda Wolfenden, a postdoctoral fellow in the Division of Pulmonary and Critical Care Medicine. "We are missing opportunities to control this disease. Doctors need to increase their efforts to implement all components of the asthma guidelines, and patients need to remind themselves that asthma care involves more than just taking medications." The shortcomings, she says, may explain why almost one in five older people studied ended up in the hospital.

To examine how older individuals are coping with asthma, the Hopkins team reviewed information from 237 insured men and women 70 or older. They found that their lackluster care fell significantly short of care described in the National Asthma and Education Prevention Program guidelines. Twenty percent did not use an inhaled corticosteroid. Taken once or twice daily to quiet lung inflammation, this drug reduces the likelihood of an asthma attack before it begins, helps change the course of the disease and is considered the first line of defense against the disease. Underuse of the drug increases the risk of an asthma attack triggered by allergens such as dust, cockroaches, pets, perfume or pollution.

The researchers also identified overuse of other drugs--beta agonists and theophylline--that provide short-term relief. "These drugs stimulate the nervous system, revving up heart rate and blood pressure," says Wolfenden, lead author of the study. "They can be dangerous, particularly for the older heart, and could lead to potentially fatal irregular heart rhythms."

In addition to misusing drugs, many patients did not receive guidance and information about how to manage their symptoms. Eighty percent of the patients, for example, did not have a peak-flow meter, a device that measures lung capacity and is used to adjust anti-asthma drugs and avoid severe episodes. Sixty percent of patients did not know which allergens triggered their attacks.

Wolfenden embarked on her investigation because asthmatics 70 and over are hospitalized at more than twice the rate of those 18 to 35, and their death rate is roughly 17-fold higher than that of their younger counterparts. She gathered data from the Managed Health Care Association Outcomes Management System Asthma Project. This project, launched by researchers at Hopkins and other institutions, has information from 6,612 sicker-than-average asthmatic individuals about their gender, race, education, symptoms, medication use, health care access and satisfaction, and physician specialists. All are employees and dependents of some of the largest U.S. companies and had health insurance coverage through managed care.

Other researchers involved in the study include Gregory Diette, Elizabeth Skinner, Donald Steinwachs and Albert Wu. The study was funded by the Managed Health Care Association and the National Institutes of Health.

For more information on asthma, go to www.hopkins-lungs.org and www.hopkins-allergy.org.