Tailoring asthma education and medication use instruction to the specific needs of older patients significantly improved asthma control and medication adherence among adults over age 60 with persistent, uncontrolled disease, a randomized trial found.
Half as many study participants in the individualized support arm of the study reported an asthma-related hospital emergency department visit compared to controls who did not receive the intervention support (6% vs 12%, respectively) over 12 months of follow-up, reported Alex Federman, MD, of the Icahn School of Medicine at Mount Sinai, New York City, and colleagues.
Statistically significant improvements were also seen for quality of life and inhaler technique in the intervention group, the authors wrote in JAMA Internal Medicine.
Roughly 7% of people in the U.S. over age 65 have asthma, and, as a group, elderly patients tend to have worse asthma control and outcomes than other adult patients.
This is due, in part, to issues related to disease self-management, such as improper use of inhalers or suboptimal use of daily asthma-control medications, Federman said.
“Studies regularly find that only about 30% to 40% of [older] patients regularly use medications designed to control disease,” he told MedPage Today.
The management of older patients with asthma is also complicated by a greater prevalence of co-morbidities such as cardiovascular disease, diabetes, and high blood pressure.
Federman added that asthma treatment is often neglected in older patients who are taking multiple medications for other chronic conditions.
Psychosocial, cognitive, physical, and mental health issues can also complicate asthma treatment in elderly patients.
Most interventions aimed at improving adherence with asthma medications “emphasize generalized asthma education and skills training, with limited tailoring to the specific needs of the individual patient,” the authors wrote. “Yet, a generalized asthma education approach can cognitively overload older patients, distracting them from the information they need most to improve self-care.”
They developed an asthma self-management support intervention for older patients that emphasized screening for psychosocial, physical, cognitive, and environmental barriers that could interfere with treatment.
To test the efficacy of the patient-tailored support intervention, the researchers conducted a three-arm randomized clinical trial called the Self-Management Behaviors in Older Adults (SAMBA) trial. It involved 406 patients ages 60 and older in New York City with persistent, uncontrolled asthma.
The patients were randomized to receive either home-based self-management intervention, clinic-based intervention or usual care without the self-management support intervention (control group).
During the initial visit, an asthma care coach conducted a screening assessment to identify three barriers to asthma care: poor inhaler technique, intermittent use of fluticasone propionate, and evidence of cockroach infestation in the home. Targeted actions provided by the asthma care coach included training patients on correct inhaler technique, asthma education focusing on the chronic nature of the disease, and the different roles and use of controller and rescue medications.
Patients who cited medication cost as a barrier to treatment were also advised to discuss cost issues with their physician, and patients with household pest issues were referred to New York City-sponsored pest control services available for residents of low-income households.
Over 12 months of follow-up, the coaches intermittently met with the patients and assessed inhaler technique, medication adherence, and addressed new problems as they arose.
The primary study outcomes included better asthma control, quality of life and drug adherence, measured by the Asthma Control Test, Mini Asthma Quality of Life Questionnaire, Medication Adherence Rating Scale, metered dose inhaler technique, and asthma-related emergency department visits.
There were 391 patients included in the final analysis. The mean age was about 68 and roughly 85% of the patients were women.
Among the main findings:
- Compared to baseline scores, scores on the asthma control test were better in the intervention groups versus the control group (difference-in-differences at 3 months, 1.2; 95% CI, 0.2-2.2; P=0.02 and 6 months, 1.0; 95% CI, 0.0-2.1; P=0.049).
- Asthma-related visits to emergency departments were lower at 12 months in the intervention groups versus the control group (6.2% vs 12.7%; P=0.03; adjusted odds ratio, 0.8; 95% CI, 0.6-0.99; P=0.03).
- Quality of life scores were also better in the intervention group (overall effect: χ2 = 10.5, with 4 degrees of freedom; P=0.03), as was medication adherence (overall effect: χ2 = 9.5, with 4 degrees of freedom; P=0.049), and inhaler technique (metered-dose inhaler technique, correctly completed steps at 12 months, median [range]: 75% [0%-100%] vs 58% [0%-100%]).
The home-based and clinic-based interventions did not have significantly different outcomes.
The researchers noted that while the study demonstrated the usefulness of patient centered support and coaching, the findings “also highlighted the challenges of engaging vulnerable populations in self-management support, including modest retention rates and reduced impact over time despite repeated encounters designed to sustain its effects.”
“Future iterations of the intervention will test strategies to improve long-term retention and impact, and may include repeated barrier screening, interventional matching of asthma care coaches (ACCs) with patients, and targeted skills development with ACCs to enhance their ability to engage patients and affect behaviors,” they wrote.
Funding for this research was provided by the Patient-Centered Outcomes Research Institute.
Principal researcher Juan Wisnivesky reported receiving personal fees from Sanofi, Quintiles, and Banook, as well as grants from Sanofi and Quorum not related to this study.