ALLERGIC RHINITIS IN

ELDERLY
Suprihati
Faculty of Medicine Diponegoro University-Kariadi Hospital
Semarang

Medan, June 2013

Introduction
At

the end of 2030, people > 65 years =

20% in developed country

Allergic

conditions is a childhood
disorders, often persists into older age
and occasionally its initial appearance in
the elderly

Prevalence of allergic disease in elderly :

under estimated, under diagnosed and
under- treated
Cardona V at al Clinical & translational Allergy 2011: 1-11

Specific issues when investigating

allergies in elderly patients.

Elderly : older persons > 65 years

- chronologic aging
- retirement in many countries
Sub classification in this age :
increasing frailty, co-morbidities
&
dependence

Prevalence of AR

National Center for Health Statistics

( Chicago Medical Center 2005 ) :
Pinto J . Allergy , Asthma & Clin Immunol 2010:6(1):10

Allergic rhinitis :
45-64 years old : 10.7 %
65-75 years old : 7.8 %
> 75 years old : 5.4 %
Valeo T : ENT Today October 2010

Factors in older subjects to the risk for

developing allergic related conditions
Coexisting
Memory
Use

medical problems

issues

of multiple prescribed & non

prescribed medications

Underlying mechanism of allergic disease

in the elderly

1. Immunosensence
Complex

process are the aging of the

immune system

The

clinical consequences : increase

susceptibility to infections, decrease
response to vaccination, & impaired
wound healing

The

most severe impact : the lost of

diversity in T cell & B cell receptor
repertoire (accumulation of
dysfunctional cells)

Underlying mechanism of allergic disease

in the elderly

Specific organ changes

Typical

symptoms of AR may worsened by :

retraction of the nasal columella & loss of
nasal tip support nasal obstruction

Post nasal drip & cough are common in

AR,
be worsen by thickened mucus
along with
decrease muccociliary
clearance with age

Temperature

& humidity in the nasal cavity

significantly lower in geriatric population
(Kirtsreesakul V at al, Laryngoscope 2009, 119(8): 1458-62)

Underlying mechanism of allergic disease

in the elderly

3. Other factors
Physiological

changes : local immune

response contribute to development of food
allergy
IgA is the first line GI defense mechanism to
ingested antigen.
Intestinal permeability is increase with
aging in human
Extrinsic factor to increase permeability: alcohol,
substance induce hypoacidic conditions ( PPI or
antacid drugs) to increase food allergy
( Mullin JM at al. Aliment Pharmacol Ther 2008,28: 1317-1325).

Clinical features of AR in elderly

AR

affecting 5.4-10.7% > 65 years

patients
Patients present with sneezing, pruritus, &
nasal congestion
Isolated ocular symptoms in patient > 50
years
This populations at risk for other type of
rhinitis, with similar symptoms.
Reduction of blood flow to the nose to
progressive nasal atrophy with clinical
manifestation as atrophic rhinitis
elderly prone to rhinitis medicamentosa

Clinical features of AR in elderly

Diagnostic considerations

Patients with AR
> 65years
Number
Female

32
65.6%

Pos SPT
50 %
No of allergen
6,1%
Pos to pollen
12.5%
Fish
3.2%

40-45years

37
73%

ns

75.7%
7.4%
35.1%
2.6%

0.044
ns
0.048
0.033

Karabulut H at all, Gerontology and Geriatrics 2011: 270-273

Specific factors that affect

medical treatment in the elderly :
Polypharmacy
Cognitive

dysfunction
Change in body composition
Impairment of liver and renal function
Cost of medications in the face of
limited resources

Slavin RG : Treating rhinitis in the older populations Allergy Asthma &

Clinical Immunology 2009, 5:9

Pharmacotherapy in allergic
elderly patients

The potential drug interaction increases with age

Most important mechanism : inhibition or

induction of drug metabolism & pharmacodynamic
potentiation/ antagonism

The elderly have: reduced homeostatic

mechanisms, decreased renal function and
biotransformation in the liver
Prescribing treatment for AR in elderly :
possibility of drug-drug interaction, impact of
drug treatment on concomitant diseases
should be taken

General rule

Nasal steroids, topical AH, non sedating

AH are particularly suited for management
of AR in elderly

First generation AH should not be used for

AR in elderly due to risks of side effects
and interactions with other medications.

Topical and systemic decongestant should

be avoided

Non pharmacologic treatment should

include nasal lavage with isotonic sodium
chloride, reducing nasal dryness and
clearing thick mucus

Management of AR in elderly

To avoid drug-drug interaction :