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

Treating rhinitis in older patients involves a fundamental paradox of the aging immune system. “With age, autoimmune disorders can increase,” Dr. Pinto said. “The mechanism for that is not known, but one possibility is that there might be less tight regulation of immune responses leading to autoimmunity, a loss of tolerance to self.”

Intranasal steroids have become the first-line treatment for moderate to severe geriatric allergic rhinitis, in part because they are generally well tolerated by older patients, although they can aggravate nasal dryness and mucosal crusting. Dr. Pinto also advises radioallergosorbent (RAS) testing to confirm allergic rhinitis.

A Worldwide Increase

While no one knows what is causing the apparently worldwide increase in allergies, “there are a bunch of theories,” Dr. Gordon said. “For example, we’re too clean and we don’t get enough bacterial exposure. That’s the hygiene hypothesis. Chemical pollutants in our food, water and air are altering our immune response. Aromatic polycyclic hydrocarbons, for example, have been strongly linked to eczema, allergic rhinitis and asthma. Living indoors means we’re exposed to house dust allergens almost all the time. Diesel particles in the air are synergistic with allergens in triggering asthma. And modern food processing means we are constantly exposed to wheat, corn, soy and yeast.”

One of the more recent theories involves inadequate levels of vitamin D, leading to more asthma and respiratory allergies. Swiss scientists recently reported in Gerontology that low levels of calcitrol, a form of vitamin D, may play a role in geriatric allergic disorders (Mohrenschlager M, Ring J. [Published online ahead of print June 11, 2010]). Also, in an animal model, calcitrol was found to prevent allergic asthma.

“I recommend that my patients get their vitamin D checked, and it’s very rare I find an older adult with a normal level,” Dr. Gordon said. “A value of about 25 nanograms per milliliter is normal. A good level is between 50 and 80. It’s very rare to find an older patient over 50, and most are 20 or lower.”

While vitamin D is the “sunshine vitamin,” Dr. Gordon does not encourage older people to spend more time in the sun, however. “You need significant sun exposure to reach that level, and people can’t tolerate that much sun exposure for their entire lives because of the danger of skin cancer,” he said. “Take (vitamin) pills.”

While approximately 12 percent of the population in the U.S. is defined as geriatric according to the Federal Interagency Forum on Aging-Related Statistics, that number will increase to about 20 percent by 2030. “I think all otolaryngologists should begin to think about how otolaryngic diseases manifest in older patients, and how older patients differ from younger, because that’s going to be a growing part of our practice,” Dr. Pinto said.