Old Problem, New Focus: Otolaryngologists tailor allergy treatments to geriatric patients

Allergic rhinitis among the elderly poses a particularly difficult diagnostic challenge for the otolaryngologist. As people age, they undergo immunosenescence. The thymus, which produces T cells against new invaders, atrophies markedly after adolescence, and this decline results in a less robust immune response to bacteria, viruses and presumably allergens (J Pathol. 2007;211(2):144-156). Consequently, physicians have assumed that allergies should decline as people age.

But this may be an oversimplification, according to Karen Calhoun, MD, professor of otolaryngology at Ohio State University and president of the American Society of Geriatric Otolaryngology. One problem is that testing for allergies among older patients becomes less reliable due to immunosenescence.

“The skin becomes less reactive,” said Dr. Calhoun, co-editor of Expert Guide to Otolaryngology (American College of Physicians, 2001). “The typical prick test is done on the very outer level of the epidermis, and as people age, they have fewer and fewer reactive cells in that layer, but you can detect allergies with intradermal testing, which is done at a deeper layer where there are more reactive cells in everyone. The big message is: Allergies do happen in older adults.”

A Common Issue

Undertreating such allergies can impair quality of life, reduce work productivity and invite secondary complications such as sinusitis and sleep disturbances, especially in those patients with asthma, according to David M. Lang, MD, head of allergy and immunology and co-director of the Asthma Center in the Respiratory Institute at the Cleveland Clinic. He added that older people with asthma or chronic obstructive pulmonary disease (COPD) may find their symptoms aggravated by allergies.

In an article he wrote for the Geriatric Times (ìManagement of Allergic Rhinitis,î March/April 2002), Dr. Lang pointed out that by the year 2020, one in six people in the U.S. will be 65 or older, which means that proper recognition and management of allergic rhinitis in older adults will become increasingly important.

“For older adults with allergic rhinitis, avoidance measures combined with medication use [are] frequently effective,” he said. “If that’s not effective, then allergy shots can be considered, and, in select cases, you put patients on allergy immunotherapy if they don’t have an optimal or desired response to avoidance measures with medication.”

Bruce R. Gordon, MD, an otolaryngologist with a practice on Cape Cod, has noticed more and more cases of allergic rhinitis among his older patients.”ìI have a lot of people in their 70s and 80s who are on a lot of meds and often need immunotherapy because they have such bad allergy symptoms,” said Dr. Gordon, who has been practicing for 30 years. “We used to think that as people aged their allergies disappeared, but many more older people have allergies now, and their allergies are extending into very old age. In fact, people over 60 who never had trouble in their life are developing allergies.”