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ALLERGIC RHINITIS IN ELDERLY
LITERATURE READING
Lina Marlina
Supervisor :
Dr. Melati Sudiro, Mkes.,SpTHT-KL(K)
Dept of Otorhinolaryngology – HNS
Hasan Sadikin General Hospital
Bandung
2015
1
Introduction
Rhinitis : inflamation of the nose and is
characterizized by nasal symptoms
including anterior or posterior rhinorrhoea,
sneezing, itching, and nasal congestion
Allergic rhinitis (AR)  as symptomatic
disorder of the nose induced after allergen
exposure by an IgE-mediated inflammation
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
2
Introduction
• Allergic rhinitis
represent a global health
problem
• Geriatric patients often have multiple medical
problems and take multiple medications
• Undertaking evaluation and treatment of
allergies
Coordination of care with the patient’s primary
care of other specialists will ensureThe best
possible treatment outcome.
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
3
Epidemiology(2)
• The incidence of allergic rhinitis
decreases with age
• According to the 2005 report of the
National Center for Health Statistics
• 7.8% of adults 18 - 44 years
• 10.7% of those 45 - 64 years
• 7.8% of those 65 - 74 years, and
• 5.4% of those 75 years and older are
affected in the United States.
2008
Massoud Mahmoudi, Prevalence of Allergic Diseasw in .Children,
Adults, and the
Elderly.2008
4
Epidemiology(3)
• People 65 years old or more are the fastest
growing segmen of the population in the
developed countries
• 2030, it is estimated that this group will
comprise about 20% of the total population,
and among elderly persons, the percentage
of patients aged above 80 years will increase
disproportionately
• The prevalence of allergic diseases, in the
elderly is estimated around 5-10%
Victoria Cardona, et allAllergic disease in the elderyly.. 2011
. 2008
5
Rhinitis in Aging
Rhinitis is an inflammatory disease, mechanisms and
presentation of condition are altered as immune
function changes with age
A critical componen of the immune system is the
thymus, which involutes from adolescence to near
middle age
The decline in functional mass  depressed
production of T-cells impaired cell-mediated
immunity.
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
6
Pathophysiology Of Rhinitis
Powerpoint
Templates
Pathophysiology of Allergic and
Nonallergic
Rhinitis, Betul Sin and Alkis
Page7 7
Pathophysiology Of Rhinitis
Pathophysiology of Allergic and NonallergicPowerpoint
Rhinitis, Betul Sin and Alkis Togias
Templates
Page8 8
• Aging process  altered lymphocyte response to
specific antigen and diminished IL-2
• Imbalance in Th1/Th2 with a shift toward Th2
• This is somewhat of a paradox since the incidence of
allergic rhinitis declines with age
• The diminished T-cell response may be associated
with the increased incidence of malignancy and
infections in the geriatric population
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
9
Alteration in Nonspecific host defense
• Age-related effectiveness in chemotaxis may
be reduced in less vascular tissues in vivo,
such as in the skin, which also has a number
of other changes that may impair the ability
of cells in the vascular compartment to reach
a site of infection
Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010
10
Number and phagocytic capacity are preserved
but in vitro neutrophil functions is reduced
Endothelial
adherence
migration
Granule
secretion
Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010
apoptosis
11
• Alterations in signal transduction of TLR and
GM-CSF receptors → defective function of
neutrophils with decreased response to
stimuli such as infection with gram positive
bacteria
• With aging Defective production of cytokines
Diminished expression of MHC class II
molecules
Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010
12
Alteration in Specific Host
• Most studies show no significant changes with
human aging in the total number of peripheral
blood cells, including total lymphocytes,
monocytes, NK cells, or PMN leukocytes
• No changes in the percentages of B- and Tlymphocyte populations in the peripheral
blood
Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010
13
Qualitative changes in T-cell
function
Aged → Decreased thymic function
Changes in thymic dependent immunityadaptive T-cell immunity
Increase in inert memory lymphocytes
A relative expansion of the memory T-cell pool
14
Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010
Naive CD4+ T cells isolated from aged humans
Decreased in vitro responsiveness and altered
profiles of cytokine secretion to mitogen
stimulation
Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010
15
Decreased
Increased
Thymic output
Naive peripheral T-cells
Diversity of T- and B-cell
Co-stimulatory stimuli to T-cells
CD28+ T cells
CD45+ T cells
IL-2, INF-γ, IL-12, IL-10, IL-13
Proliferation with mitogens
Delayed type hypersensitivity
Response to vaccination
Memory T and B cells
Oligoclonal expansion of memory
lymphocytes
CMV specific CD8+/CD4+ T cells
CD45 RO+ T cells
CD28- T cells
IL-6, SCF+, LIF
Anergic T cells
Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010
16
Histology of Nasal Mucosa
Probst R. Grevers G, Iro H. Basic Otorhinolaryngology: A
Step–By-Step Learning Guide. New York :Thieme. 2006:8-13.
17
• The normal respiratory
epithelium is described
as pseudostratified
ciliated columnar with
patchy areas of
squamous metaplasia
and goblet cell
hyperplasia covered by
blanket of mucus
• Ciliated epithelium
decrease with age
• Thin atrophic
epithelium with
conspicuously
thickened basement
membranes is only seen
above the age of 40
years and is frequently
found in older subjects
S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle
turbinate, 2003
18
In the middle aged group (26 to 50 years) we
found a remarkably high amount of squamous
metaplasia, resulting in overall thicker epithelium
becoming thinner in older subjects
S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle
turbinate, 2003
19
Age related decrease ephitelium
S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle
turbinate, 2003
20
Reduced epitheleal differentiation
Lead to reduction ciliary mucus clearence
21
Maria Teresa Ventura, MD et all, Clinical and cytologic charateristics of allergic rhinitis in eldery patients. 2012
• These include atrophy of the collagen fibers
and mucosal glands, loss of dermal elastic
fibers, and reduced blood flow to nasal tissues
• These changes can result  dehydrated,
drying, increased nasal congestion, and nasal
crusting in elderly patients.
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
22
Stratified ciliated epithelium in a
24-year-old subject
Disintegrating epithelium in healthy
37-year-old subject
S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle
turbinate, 2003
23
An atrophic epithelium in a 55-year-old
subject
S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle
turbinate, 2003
24
AGING
Body
water
content
Nasal
glandular
atropy
Nasal
mucociliary
dysfunction
Thick tenacious mucus
in nose and nasopharynx
Post nasal drip
Chronic
cough
Nasal
obstruction
Nasal
crusting
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
25
Trigger of Allergic Rhinitis
Allergens
Aeroallergens
mites, pollens, animal
danders, insects, plant origin,
moulds
Food allergens: milk, egg,
wheat, soya
Occupational rhinitis  rare
Aspirin allergy
Pollutants
Indoor air pollution
domestic allergens,
indoor gas pollutants
(tobacco smoke)
Outdoors air pollution
Automobile pollution
26
Effects of rhinitis on Quality of life
• Allergic rhinitis can result in significant sleep
disturbance and fatigue
• Complaints of poor sleep are already common
• Lack of sleep can alter physiologic processes
such as glucose metabolism, cognition,
appetite control
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
27
Quality of Life
Maria Teresa Ventura, MD et all, Clinical and cytologic charateristics of allergic rhinitis in eldery patients. 2012
28
Diagnostics
History
Allergy history
 vital
Family history
of atopic
disease
Environmental
history
Any treatment
given
Krouse J., Derebery J., Chadwick S., Managing the allergic patient, Elsevier, 2008
Updated ARIA Recomendation 2008
29
Physical Examination
Rhinoscopy
Anterior
Ear
• Concha hypertophy
• Mucosa livid
• Mucous serous
• Otitis media
• Otitis media
effusion
30
Nasoendoscopy
 Rigid / Flexible fiber optic endoscope.
3rd Step
1st Step
2nd Step
Inferior Concha –
Nasopharynx
Middle Concha and
Middle meatus
Superior concha,
resesus
sphenoethmoida
lis, resessus
frontalis
Allergen Testing: IgE, Skin Prick Test
31
MANAGEMENT
32
Therapeutic considerations
Allergen
avoidance
indicated when
posibble
Pharmacotherapy
Surgery
Jayant M Pinto and Seema
Jeswani, Allergic Rhinitis in the
Clin Immunology. 2008
geriatric population
,Allergy Asthma Clin Immunol.
2010; 6(1): 10.
Immunotherapy
33
Antihistamines
• First-generation H1 receptor antagonists liphophilic
and can easily penetrate the blood brain barrier
• Produce adverse effect in the CNS dyskinesia,
anxiety, confusion, sedation, and reduced mental
allertness
• AH first generation lack of specifity for the H1
receptor, have additional dopaminergic,
serotonergic, muscarinic and cholinergic adverse
effect
Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral
Antihistamine, 2005 the allergic patient, Elsevier, 2008
34
Muscarinic/
cholinergic
effect
α-adrenergic
effects
• Urinary retention & hesistancy,
constipation, sedation, impaired
coordination and memory
dysfunction
• Arrythmia, peripheral vasodilation,
postural hypotension, tachycardia,
dizziness
AH second generation low potential to cross the
blood brain barrier and have antiinflamatory effect
Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral
Antihistamine, 2005 the allergic patient, Elsevier, 2008
35
Antihistamine
Drug
Special Adverse Effect
Contraindications
Cetirizine
Cephalalgia, vertigo, agitation,
sleepiness,
xerostomia, urinary retention
Severe renal dysfunction
Loratadine
Alopecia, liver dysfunction
Other medication inhibiting
loratadine liver metabolism
Terfenadine
Tachyarrhytmia, cardiac arrest, GI
complaints, elevated transaminase,
cholestasis, hepatitis, alopecia
Decreased liver function
Ebastine
Cephalgia, xerostomia,
Severe hepatic or renal
dysfunction
Fexofenadine
Cephalgia, dizzines and nausea
Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral
Antihistamine, 2005 the allergic patient, Elsevier, 2008
36
Drug
Special Adverse Effect
Contraindications
Azelastine
Xerostomia, sleepiness
Severe hepatic or renal
dysfunction
Levocetirizine
Cephalgia, sleepiness,
xerostomia
Lactose intoleralnce,
Desloratadine
Sedation, xerostomia,
cephalgia
Severe renal dysfunction
Newer second-generation antihistamines such as
fexofenadine, levocetirizine, ebastine and desloratadine
have the least adverse effects and are therefore preferred in
the elderly patient.
Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral
37
Antihistamine, 2005 the allergic patient, Elsevier, 2008
Decongestant
Oral decongestant
• Activate  adrenergic receptors  reduce nasal swelling 
reducing nasal congestion
• commonly used agent is pseudoepherine. Central nervous system
stimulation by these agents may result in anxiety, irritability,
insomnia, and palpitations
• These drugs may aggravate urinary with bladder neck obstruction
cautiously in the elderly and should be avoided in patients with
poorly controlled hypertension, coronary artery disease,
cerebralvascular disease, and bladder neck obstruction
• Combined with antihistamine  more effective than alone
Topical decongestant
• Rebound effect (Rhinitis medicamentosa)
Raymond G Slavin, Treating rhinitis in the older population : special consideration. 2011, Managing the allergic
patient, Elsevier, 2008
38
Corticosteroid
• Intranasal steroids have become first-line
treatment for moderate to severe allergic
rhinitis and effectively treat all symptoms of
rhinitis
• Intranasal steroids are generally well tolerated
by older patients however, they can aggravate
nasal dryness, epistaxis, and mucosal crusting
in geriatric patients  careful instruction in
use
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
39
Anticholinergik & Leukotriens
• Leukotriene receptor antagonists (e.g. montelukast,
zileuton)decrease the inflammatory response in
allergic rhinitis and limit symptoms of congestion
sneezing, and rhinorrhea
• Long-term data has not been reported to determine
safety of leukotriene inhibitors in the older patients,
yet these medications seem to be well tolerated in
this population
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
40
Anticholinergik & Leukotriens
• Intranasal cromolyn sodium can be effective in
minimizing allergic rhinitis symptoms
• This agent inhibits the degranulation of
sensitized mast cells thereby preventing the
release of mediators of the allergic response
and inflammation
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
41
Immunotherapy
Immunotherapy can be considered in the treatment of
patients of all ages, and the risk/benefit assessment must be
evaluated in every situation
Some patients might be taking medications that
could make treatment of anaphylaxis with
epinephrine more difficult or have significant
comorbid medical conditions
β-blockers
Hypertension, coronary
arter disease,
cerebrovascular
disease, and/or cardiac
arrhythmias
42
Calabria C, et all. Allergen Immunotheraphy : A practise parameter third update. 2004
Background
• The role of specific immunotherapy (SIT) in elderly allergic patients is still
debated
Objection
• To assess whether SIT is associated with a better control of symptoms
and a better quality of life also in older allergic patients
Method
• The effect of injection SIT was assessed in patient >54 yo and <54 yo →
SIT → measure of SIT outcome
Result
• Patients submitted to SIT reported a much better quality of life and an
improved symptom control by standard therapy, as shown by the reduced
use of standard therapy
Conclusion
• Injection SIT can be considered an effective therapeutic option in
otherwise healthy elderly patients with a short disease duration whose
symptoms cannot be adequately controlled by drug therapies alone
43
Asero R, Efficacy of injection Imunotheraphy with Ragweed and Birch Pollen in Elderly Patients, 2004
Surgery
.
Surgical treatment is also an option in the
geriatric population
septoplasty with or without inferior
turbinate reduction has been shown to
be beneficial in older patients
Functional endoscopic sinus surgery can
be used to address concomitant sinus
disease.
Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population
,Allergy Asthma Clin Immunol. 2010; 6(1): 10.
44
• ESS in elderly population have complication was
higher than in younger population despite it is
relatively safe procedure even in the elderly
population with a low incidence of complication
45
Ramadan H, Hasan, VanMetre Ray, Endoscopic Sinus Surgery In Geriatric Population. 2003
• Both elderly and younger patients showed
improvement and Quality of Life after ESS did
not differ by age group
Douglas D. Reh, et all, Impact of age on presentation of Chronic rhinosinusitis and outcomes of
endoscopic sinus surgery.2006
46
Conclusion
• Aging rhinitis is common disorder in the elderly
and result from natural aging process in the nose.
• Prevalence rhinitis allergic decrease with aging
proces, increased malignancy and infection
• The structure and function of the aging nos emay
contribute to the manifestation and mechanism
of this condition
• Allergic rhinitis in elderly population have a
higher effect on quality of life than young adult
47
• Management allergic of rhinitis in elderly such
as avoidance allergen, pharmacotherapy,
immunotheraphy and surgery
• the management is different with young
people, need special management, due to
changes in physiologic
48
Thank you
49
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