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Rhinitis in the geriatric population

Rhinitis in the geriatric population The current geriatric population in the United States accounts for approximately 12% of the total population and is projected to reach nearly 20% (71.5 million people) by 2030[1]. With this expansion of the number of older adults, physicians will face the common complaint of rhinitis with increasing frequency. Nasal symptoms pose a significant burden on the health of older people and require attention to improve quality of life. Several mechanisms likely underlie the pathogenesis of rhinitis in these patients, including inflammatory conditions and the influence of aging on nasal physiology, with the potential for interaction between the two. Various treatments have been proposed to manage this condition; however, more work is needed to enhance our understanding of the pathophysiology of the various forms of geriatric rhinitis and to develop more effective therapies for this important patient population. Classifications Nonallergic rhinitis is characterized by non-IgE-medi- Rhinitis is defined as inflammation of the nasal mucosa ated symptoms typical of rhinitis, such as congestion and and is characterized by symptoms of congestion, rhinor- clear rhinorrhea, with less prominence of sneezing and rhea, itching of the nose, postnasal drip, and sneezing[2]. ocular/nasal pruritis[6,7]. The associated symptoms may In the geriatric population, a broad interpretation of this be perennial or sporadic, lacking a clear seasonality, and symptom complex may also include crusting within the may be exacerbated by nonspecific triggers such as odors, nose, cough, excessive drainage, olfactory loss, and nasal food, emotion, or change in atmospheric condi- dryness[3,4]. tions[5,8,9]. Though no formal classification system Rhinitis can be divided broadly into two major catego- exists, nonallergic rhinitis can be further subcategorized; ries: allergic and nonallergic (Appendix 1). most commonly seen in older patients are the vasomotor, Allergic rhinitis is an IgE-mediated inflammation of the atrophic, gustatory, and medication-induced sub- nasal passageways triggered by various allergens such as types[10,11]. dust, pollens, or molds. Symptoms of allergic rhinitis may be classified as seasonal or perennial. An international Epidemiology working group modified this classification scheme due to Allergic rhinitis affects approximately 10-30% of Ameri- potential difficulties in differentiating between seasonal can adults[2,12]. The condition predominantly affects and perennial symptoms and created the Allergic Rhinitis males in their late teens or young adulthood and the and its Impact on Asthma (ARIA) Report[5]. The ARIA prevalence decreases with age[12,13]; yet, it is estimated guidelines temporally classify allergic rhinitis as 'intermit- that three per one thousand individuals over the age of 65 tent' if symptoms are present less than four days per week also suffer from allergic rhinitis with a shift to female pre- or less than four consecutive weeks, or as 'persistent' if dominance after adolescence[13,14]. Cross-sectional and symptoms are present more than four days per week and longitudinal studies have shown that both allergic rhinitis for more than four consecutive weeks. Severity of symp- symptoms and allergic skin test sensitivity become milder toms is graded as 'mild' if they are present but not trou- over time; however, these findings may not necessarily blesome, and as 'moderate/severe' if they lead to sleep correlate[15,16]. Such changes may be due to alterations disturbance, impairment of daily activities, or impair- in immune function with age[17,18]. For instance, total ment of school or work. IgE levels and eosinophil degranulation in response to cytokine stimulation decrease with age[19,20]. Further- * Correspondence: [email protected] more, repetitive exposure to allergens may induce toler- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, ance or anergy over time through mechanisms that are The University of Chicago, Chicago, IL, USA not completely clear[14]. Full list of author information is available at the end of the article © 2010 Pinto and Jeswani; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Com- mons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduc- BioMed Central tion in any medium, provided the original work is properly cited. Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 2 of 12 http://www.aacijournal.com/content/6/1/10 There is substantially less research regarding frequency year thereafter[37]. The decline in functional mass causes of nonallergic rhinitis in comparison to allergic rhinitis in depressed production of naïve T-cells leading to impaired older subjects. An estimated 19 million people in the cell-mediated immunity[37,38]. Despite thymic involu- United States suffer from nonallergic rhinitis[21]. The tion, the total T-cell pool remains constant due to an prevalence of nonallergic rhinitis is greater in females and increase in production of memory T-cells[38]. The cause the incidence of diagnosis increases with age[22-24]. of this heterogeneity in the lymphocyte pool remains Greater than 60% of rhinitis patients over the age of 50 unknown. With the aging process also comes decreased suffer from a nonallergic etiology[9]. T-cell responsiveness to growth factors, altered lympho- cyte response to specific antigens, and diminished IL-2 production and receptor expression[17]. An imbalance in Effects of Rhinitis on Quality of life Several studies have shown the deleterious effects of rhin- the Th1/Th2 ratio occurs during immunosenescence, itis on the quality of life in symptomatic patients. Ben- with a shift towards Th2, leading to further altered ninger et al found that allergic rhinitis can result in cytokine production[39]. This is somewhat of a paradox significant sleep disturbance and fatigue using the Rhi- since the incidence of allergic rhinitis declines with age. nosinusitis Disability Index (RSDI), a validated outcomes The diminished T-cell response may be associated with tool that assesses how allergic rhinitis affects quality of the increased incidence of malignancy and infections in life[25]. Complaints of poor sleep are already common the geriatric population[17,40], whereas the aberration in among older individuals due to various sleep disorders as cytokine production and inflammatory response may well as the normal aging process[26], thus allergic rhinitis explain chronic or late onset rhinitis. may exacerbate these problems. Lack of sleep can alter B-cell function changes with age as well. Although the physiological processes such as glucose metabolism, cog- peripheral B-cell population remains consistent, there is nition, appetite control, and endocrine function, all criti- less IgG isotype class switching, and the number of anti- cal physiologic processes in older people[27,28]. gen-specific antibodies decreases while the number of Longitudinal studies have demonstrated that sleep com- autoantibodies and circulating immune complexes plaints in the geriatric population are also associated with increase[17,18]. This may explain the fact that older indi- lower self-reported health status, depression, and viduals are prone to infection, have decreased immune increased mortality[29-32]. Other effects of allergic rhini- response to vaccines, and have increased prevalence of tis include headache, poor concentration, and general autoimmune diseases[17,38,40]. These changes might irritability. These symptoms may hinder an individual's also contribute to the milder symptoms as well as the ability to carry out physical and social responsibilities decreased incidence of allergic rhinitis in the geriatric effectively[2]. Both of these domains were found to be population. large factors that contribute to geriatric quality of Changes of the Aging Nose life[33,34]. Structural Little data are available that specifically address the As individuals age, several changes in nasal anatomy and effects of nonallergic rhinitis on quality of life, especially physiology occur which may affect the development and in geriatric subjects. Because allergic and nonallergic expression of rhinitis. A loss of nasal tip support develops rhinitis share similar symptoms, the two conditions are because of weakening of fibrous connective tissue at the perceived by patients similarly[35] and it would be plausi- upper and lower lateral cartilages[4]. Collagen and elastin ble to extrapolate data on allergic rhinitis to model the loss, maxillary alveolar hypoplasia, and decreased facial effects of nonallergic rhinitis. In fact, a recent study dem- musculature lead to a drooped tip[41]. Furthermore, onstrated a decrease in health-related quality of life in weakening and fragmentation of septal cartilage and both allergic and nonallergic rhinitis patients; indeed, retraction of the nasal columella leads to changes in the there was no significant difference in the degree of nasal cavity[42]. A combination of these structural impairment between the two patient populations[36]. changes may decrease nasal airflow leading to complaints of nasal obstruction commonly seen in geriatric rhinitis Physiological Changes with age that may affect patients. Rhinitis Mucus Immunosenescence Mucosal epithelium atrophies with age and older patients Rhinitis is an inflammatory disease, as such, mechanisms are frequently dehydrated[43,44]. These factors may and presentation of the condition are altered as immune account for the excessively thick mucus in older patients. function changes with age, a concept entitled immunose- Thickened mucus along with decreased mucociliary nescence. A critical component of the immune system is clearance (see below) is thought to lead to common rhi- the thymus, which rapidly involutes from adolescence to nitic complaints such as postnasal drip, cough, and glo- near middle age, followed by an approximate 1% loss per Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 3 of 12 http://www.aacijournal.com/content/6/1/10 bus. Edelstein was able to demonstrate that the the mucociliary transport time in patients classified with prevalence of postnasal drip, nasal drainage, coughing, moderate-severe allergic rhinitis[52]. This may be due to and sneezing increased with age[4]. poor clearance of allergen and irritants, as well as stasis of Nasal Humidification and Dryness thick, dehydrated mucus within the nasal cavities and It is well recognized clinically that older people are more nasopharynx, leading to rhinitis complaints among the susceptible to dryness in the nose. Lindemann et al illus- geriatric population of postnasal drip, cough, and globus. trated that temperature and humidity values in the nasal Olfaction cavities were significantly lower in geriatric patients when Olfactory function decreases with age, with more rapid compared to younger individuals[45]. Other reasons for decline after the seventh decade. Both the sense of smell decreased humidification include age-related changes in (detection) and the ability to discriminate between two nasal vasculature. For instance, submucosal vessels scents is decreased with the normal aging process[53]. become less patent and therefore are not able to moisten Olfactory dysfunction is also commonly associated with and warm inspired air in the older nose as compared to rhinitis. One study demonstrated that 71% of study sub- the younger nose[44]. These findings in geriatric patients jects complaining of dysosmia had positive allergy skin likely explain the typical symptoms of nasal irritation tests[54]. The mechanism for olfactory dysfunction in related to dryness and crusting. allergic rhinitis patients has been typically attributed to Nasal Airflow nasal obstruction; however, newer data suggest that the The effects of age on nasal airflow still remain largely etiology may be due to inflammation in the olfactory cleft unclear. Calhoun et al did not find a relationship between itself[55]. This inflammation may be responsive to intra- age and nasal resistance[46], whereas Vig and Zajac nasal steroids. Of note, one trial has demonstrated that determined that there is a direct relationship between age the sense of smell in nonallergic rhinitis patients was and both nasal resistance and breathing mode[47]. Edel- worse than in allergic rhinitis patients[56]. Together, this stein found a significant correlation between aging and data illustrates that though olfactory dysfunction may be nasal airway resistance, before and after decongestant primarily due to the aging process, rhinitis may present as use[4]. Kalmovich et al studied endonasal architecture in a 'second hit' that aggravates the problem. geriatric patients using acoustic rhinometry and con- cluded that endonasal volumes and minimal cross-sec- Pathophysiology and Clinical Presentation of tional areas gradually increase with age[48]. The reason Rhinitis for the discrepancy between the latter two studies is Allergic unclear. Sahin-Yilmaz and Corey suggest this difference To briefly review, allergic rhinitis is the result of type I may be due to decreased functioning of the nasal hypersensitivity reactions whereby exposure to allergens mucosa[10]. The authors note that the estrogen content in susceptible individuals leads to sensitization by pro- in the nasal mucosa decreases with age and can subse- duction of specific IgE antibodies directed against these quently cause to loss of softness and elasticity, leading to extrinsic proteins. This antibody then binds to the surface increased airway resistance. Post-menopausal women of mast cells, and when the allergen is reintroduced, IgE may also suffer from olfactory loss, nasal congestion, and cross-binding to the antigen leads to mast cell degranula- an increase in mucociliary time secondary to hormonal tion[57]. Within seconds of contact, inflammatory medi- changes[49]. Estrogens modulate mucosal function by ators such as histamine, leukotrienes, and prostaglandin modifying the local concentration of neurotransmitters D2 are released causing vascular endothelial dilation, or their receptors, which regulate basal vasculature and which subsequently causes leakage and mucosal glandular secretions[49]. Recent evidence suggests that edema[58,59]. This leads to nasal obstruction and symp- the number of specific estrogen receptors (ERβ) within toms of congestion, redness, tearing, swelling, ear pres- the nasal mucosa positively correlates to rhinitic symp- sure, and postnasal drip. Irritant receptors are stimulated toms, yet the mechanism of the receptors' effects on nasal by the allergen causing itching and sneezing[60]. mucosa is yet to be elucidated[50]. It is plausible that Within four to eight hours of initial exposure, cytokines other airflow abnormalities could also underlie nasal attracted by previously released mediators lead to complaints in older subjects. recruitment of other inflammatory cells to the mucosa, Mucociliary Clearance such as neutrophils, eosinophils, lymphocytes, and mac- Studies show that the frequency at which cilia beat, as rophages[59]. The inflammation persists and this stage is well as time for mucociliary clearance within nasal epi- termed the late-phase response. The late-phase response thelium, slow with age[51]; however, the number of cili- presents similar to the early phase, however, sneezing and ated cells in the nasal epithelium does not change[4]. In itching are less prominent, whereas congestion and fact, Kirtsreesakul et al have recently shown that the mucus production are more severe. The late phase may severity of symptoms was significantly correlated with persist for hours or days[61]. Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 4 of 12 http://www.aacijournal.com/content/6/1/10 Though its peak incidence is during young adulthood, in the nose. Sensory nerves of the nasal mucosa respond allergic rhinitis is prevalent among older people. In fact, to chemical stimuli by initiating sneezing and nasal the 2005 National Center for Health Statistics report hypersecretion through reflex pathways. The sensory stated that 10.7% of individuals between 45-64 years of fibers that are unmyelinated and slow conducting belong age, 7.8% of patients 65-75 years of age, and 5.4% of to the C-fiber type and contain neuropeptides such as patients older than 75 are affected by allergic rhinitis[62]. substance P, calcitonin gene-related peptide, and vasoac- Along with the anatomic and physiologic changes of the tive intestinal peptide, which regulate glandular secre- nose, non-specific immune changes such as decreased tions and vascular tone[67,69]. Baraniuk and colleagues mucus production and ineffective cough mechanisms are have demonstrated that these neuropeptides communi- all thought to contribute to persistent or late-onset aller- cate with immune mediators, such as histamine. The gic disease in older people, as these processes are neces- interplay between these molecules may cause neural sary for clearance of allergens and irritants[17]. responses and vice versa, all leading to an integrated Interestingly, Jackola et al. illustrated that atopic individu- response to external stimuli[70]. These mechanisms may als with a positive family history did not have a change in be involved in the etiology of vasomotor rhinitis in older severity or sensitivity of atopy as they age. Also, there people. were no changes in the amount of IgE specific to ragweed Cardell et al recently studied nasal mucosa biopsies of extract, despite age-related decline of total serum IgE[63]. nonallergic rhinitis patients using microarray analy- Mediaty et al also demonstrated that immunosenescence sis[71]. The group noted at least ten genes to be involved does not affect increased IgE levels in atopic patients with in nonallergic rhinitis, relating to functions of cellular atopic dermatitis or high serum IgE levels[64]. In sum- movement, hematological system development, and mary, these findings suggest that the atopic predisposi- immune response. Two of these genes, c-fos and cell divi- tion remains present into advanced age in these sion cycle 42 (cdc42) were found to have pivotal roles in subgroups of patients. Therefore, allergic rhinitis should the possible mechanistic pathways of nonallergic rhinitis not be overlooked in the geriatric population if a patient's and the authors believe these genes could be potentially history and symptoms are consistent with this condition. useful as biomarkers for this condition and aid in diagno- sis. These data are preliminary and will require follow-up. Nonallergic Gustatory Vasomotor Gustatory rhinorrhea is characterized by profuse watery Vasomotor rhinitis is the most common form of nonaller- rhinorrhea following ingestion of certain foods. These gic rhinitis, and its prevalence is increased in the aging symptoms can be socially awkward and even lead to population[22]; however, due to the difficulties in classi- decreased nutrition. Commonly, alcohol and spicy or fying this condition, epidemiological data is scant. This cold foods are the culprits. With spicy food, the capsaicin condition does not have an obvious immunologic or content induces neuropeptide release from sensory nerve infectious etiology and is not associated with nasal fibers, leading to overstimulation of the parasympathetic eosinophilia[2]. Prominent symptoms of vasomotor rhin- nervous system[67]. Baraniuk and colleagues demon- itis include nasal obstruction, rhinorrhea, and conges- strated the significance of the TRP (transient receptor tion[6,65]. These symptoms are exacerbated by strong potential) receptor family in the regulation of sensory odors or fumes, bright lights, and changes in weather or neuron depolarization and repolarization, glandular exo- humidity[65,66]. cytosis, and many other functions. Substrates for these The mechanism of vasomotor rhinitis is unclear. One receptors include capsaicin, extremely high or low tem- theory is that autonomic instability may lead to both peratures, alcohol, mustard oil, and some garlic compo- hyperactive parasympathetic activity and an imbalance in nents[72]. One speculation is that TRP receptors may sympathetic to parasympathetic activity in vasomotor play a role in gustatory rhinorrhea. patients, which cause nasal congestion and rhinor- Medication-induced rhea[67]. The sympathetic pathway promotes nasal air- Several classes of medications are known to induce rhini- way patency by secretion of norepinephrine and tis (Appendix 2). The mechanisms causing this include neuropeptide Y[68], whereas the parasympathetic path- alteration of autonomic regulation on nasal mucosa and way releases substances that lead to congestion and vasculature, platelet activity, immune effects, and hor- mucus secretion such as acetylcholine. Thus, vasomotor monal effects. This condition is of particular importance rhinitis in older patients may represent a decline in con- in older patients, as polypharmacy has become a com- trol of neurological responses that affect nasal physiology. mon issue among the geriatric population with an Another possibility may be that neurogenic reflex increasing amount of comorbid conditions. Although the mechanisms triggered by environmental factors (e.g., number of individuals over 65 years of age represents less ozone, cigarette smoke) lead to inflammatory responses than 15% of the total population, this group accounts for Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 5 of 12 http://www.aacijournal.com/content/6/1/10 over one third of prescription drug use nationwide[73]. well as bothersome nasal crusting upon awaken- Furthermore, Kaufman et al discovered that 57% of ing[77,78,81]. Because this progressive condition pres- American women greater than 65 years of age use at least ents with symptoms similar to other types of rhinitis, it is five medications and 12% use at least ten medica- often improperly diagnosed and undertreated. More tions[74]. Common agents used in the geriatric popula- work needs to be done to recognize atrophic rhinitis as tion that can induce rhinitis are discussed below. well as to administer effective treatment. Medications with effects on the cardiovascular system For completeness, we mention that secondary atrophic carry side effects of rhinitis due to disruption of the nor- rhinitis is seen in patients with extensive nasal surgery, mal sympathetic tone that causes vasoconstriction of trauma, granulomatous diseases, and radiation ther- local vessels. Medications such as alpha and beta-block- apy[82] and will not be discussed here. ers, centrally acting anti-hypertensives, and angiotensin converting enzyme (ACE) inhibitors that inhibit sympa- Evaluation thetic tone lead to vasodilation and symptoms of nasal Diagnosis and treatment of rhinitis in the older popula- congestion. Antipsychotics also have well-known rhino- tion is complicated by comorbid conditions. Approxi- logic side effects due to their alpha and beta blocking mately 50% of people over the age of 75 have three or properties[75]. more diseases and take three or more medications[83]. Topical decongestants can cause rebound vasodilation Within this population, there are also concerns of compli- with overuse. The older population is at increased risk for ance due to physical or cognitive impairments and finan- this adverse effect due to thinning and dryness of their cial issues[83]. Furthermore, many older patients with nasal mucosa[76]. rhinitis complain of "sinus trouble" or "allergies", thus it is Aspirin-sensitive patients may suffer from rhinitis with difficult to assess the specific type of rhinitis involved or use as well as prolonged epistaxis due to its anti-platelet the appropriate treatment[77]. activity. Other systemic medications that cause rhinitis Evaluation of an older patient with rhinitis should begin are contraceptives, erectile dysfunction therapies, immu- with a complete history. Details regarding length and nosuppressants, antivirals, penicillamine, and oral retin- timing of symptoms, exacerbating factors, and response oids[75]. to medications should be elicited from the patient. Also Primary atrophic important for investigation are environmental exposures Geriatric rhinitis, or primary atrophic rhinitis, is an such as tobacco smoke, pets, pollution, housing type imprecise term used to signify rhinitis due to the age- which may be older and might contain formaldehyde for related changes in nasal physiology (nasal glandular atro- insulation or upholstery finishing, cockroaches and phy, vascular changes, decreased nasal humidification, rodents. Activities requiring use of latex gloves, certain decreased mucociliary clearance, and structural changes cleaning products, certain glues, wood dust, and acid of the nose)[77]. Histopathological changes associated anhydrides can trigger symptoms of rhinitis[84]. Interest- with primary atrophic rhinitis include mucosal atrophy, ingly, psyllium powder from Metamucil preparation squamous metaplasia, and chronic inflammatory cell (commonly used in the older patient for constipation) has infiltrate[78]. Garcia et al studied how these changes lead been reported to induce acute rhinitis[85]. to symptoms using techniques of computational fluid Past medical history consisting of trauma to the nose or dynamics of airflow and water and heat transport, finding face, asymmetry of nasal breathing due to structural that excessive evaporation of the mucus layer secondary causes, allergic conditions such as asthma and eczema, as to widened nasal cavities and decreased mucosal surface well as family history of atopy should be noted. Though area are integral components of atrophic rhinitis[79]. the typical age of onset of allergic rhinitis is under age 20 These changes lead to thickened and persistent mucus years, humans can be sensitized at any time [14], there- and altered nasal airflow. Recent studies have attempted fore an allergic cause should not be perfunctorily dis- to elucidate the role of apoptosis in rhinitis, finding that missed. nasal epithelium from patients suffering from atrophic Physical examination should begin with externally rhinitis display increased activity of caspase 3, a key pro- inspecting the tip of the nose for drooping and absence of tein in the apoptosis cascade[80]. This finding directs structural support. Internally, the physician should assess future studies to investigate therapeutic strategies that nasal patency, turbinates, straightness of the septum, may regulate apoptosis. presence of polyps, and signs of inflammation. Most of Patients suffering from primary atrophic rhinitis, a this endonasal examination can be accomplished with an diagnosis of exclusion, typically present with symptoms otoscope. Mucosal evaluation may be challenging to of postnasal drip, chronic cough, and nasal obstruction interpret as both allergic and nonallergic rhinitis can and dryness. Patients may also complain of a frequent present with mucosal pallor, edema, or hyperemia[2]. need to clear the throat, thick and dense secretions, as Overuse of topical medications may cause the nasal Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 6 of 12 http://www.aacijournal.com/content/6/1/10 mucosa to appear reddened. The quality of secretions troesophageal reflux disease or decreased nasal patency may aid in distinguishing the etiology of rhinitis. For in select settings[23,91,92]. instance, allergic rhinitis typically presents as watery mucus, whereas in mucociliary defects or severe obstruc- Management tion, thick mucus can be seen pooling on the nasal General measures floor[2]. Furthermore, mucopurulent drainage along with There are a variety of methods to treat rhinitis in older "cobblestoning" of the pharynx may be suggestive of subjects. In the case of both allergic and nonallergic rhin- chronic rhinitis complicated by acute sinusitis. In most itis, the simplest therapy is eliminating exposure to cases of rhinitis, findings should be bilateral. Unilateral known allergens and/or irritants. It should be noted that findings may reflect anatomic pathology or neoplasm some avoidance measures (mite dust covers, air purifiers, requiring further workup including nasal endoscopy or carpet removal) have not been shown to be effective in sinonasal imaging by computed tomography (CT) scan. reducing symptoms and pose barriers for some patients The remainder of the physical examination should be regarding cost. Humidification with saline nasal irriga- employed to eliminate other causes of rhinitis including tion has been demonstrated to be a safe and effective cerebrospinal fluid rhinorrhea and tumors. technique to reduce nasal dryness and help with the Allergy testing is useful both to determine atopy status clearing of thick, tenacious mucus[93,94]. Mucolytic with total serum IgE (usually > 100 U/mL)[86] as well as agents may also help clear thick mucus and provide to identify the specific offending allergens (specific IgE). symptom relief. Emollients have been shown to help with It should be noted, however, that response to skin testing nasal crusting[10]. For example, Johnsen et al demon- decreases with age and photo damage, requiring skin strated that in patients suffering from nasal dryness due tests in geriatric patients to be interpreted with care[87]. to low humidity, use of sesame oil significantly improved Other factors that may affect a skin test in the geriatric mucosal dryness, nasal stuffiness, and nasal crusting population are medications (most notably long-acting when compared to an isotonic sodium chloride solu- antihistamines and tricyclic antidepressants), blood pres- tion[95]. The measures are generally safe and can be used sure, temperature of the extremity, and change in the adjunctively with other treatments. allergen exposure over time[87]. When administering a Allergic Rhinitis skin test to an older individual, a sun-protected area of Treatment of allergic rhinitis has three main components: the skin should be used for testing, such as the lower avoidance of exposure to known allergens, pharmaco- back. If an acceptable area cannot be found, the physician therapy, and immunotherapy. should consider in vitro testing. Allergen avoidance By definition, patients with nonallergic rhinitis demon- Some forms of allergen avoidance can be effective in strate negative test results. Nonallergic rhinitis is a diag- management of allergic rhinitis; though proof in random- nosis of exclusion due to the absence of specific ized trials has been difficult to generate, this is still a stan- laboratory tests that confirm this diagnosis[67]. dard recommendation for patients. Staying indoors with Adjunct testing can also be useful in the evaluation of the windows closed while pollens and molds are in their rhinitis in older subjects. Upper airway endoscopy is seasonal and daytime peaks can decrease disease burden. valuable in identifying any anatomic abnormalities that Other measures include regular vacuuming of carpet, may not have been visualized on anterior rhinoscopy, removal of pets from home, and frequent washing of bed- such as septal deviation, nasal polyposis, or mucosal atro- ding. These factors are particularly relevant for the older phy. Moreover, the middle meatal sinus ostia can be patient since s/he may spend significantly more time assessed for signs of obstruction which could predispose indoors and therefore may be exposed to allergens such to sinusitis[84,88]. Sinus imaging by screening CT scan as dust mites and indoor molds more than outdoor aller- provides information on any obstruction of the gens such as pollens. As such, they may face a perennial osteomeatal complex, and can also aid in identifying pol- allergen challenge which is sometimes more difficult to yps, turbinate edema, or bony abnormalities such as con- control. Cost and practicality must govern recommenda- cha bullosae[84]. However, given cost and radiation tions in this area for costly and difficult measures (e.g., exposure, imaging is reserved for cases of lack of carpet removal, HEPA filters, etc.) given the lack of evi- response to therapy, high index of clinical suspicion, or dence for efficacy for these measures. pre-operative assessment for use during endoscopic sinus Pharmacotherapy surgery to delineate anatomy[89,90]. Additional special- Second generation antihistamines are standard in the ized testing (e.g. acid reflux testing by pH probe, assess- treatment of mild allergic diseases. These agents are ment of nasal volume by acoustic rhinometry) can be effective in reducing symptoms of nasal and ocular pruri- useful for evaluation of exacerbating factors, such as gas- tis, rhinorrhea, and sneezing, but do little in managing Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 7 of 12 http://www.aacijournal.com/content/6/1/10 nasal congestion[2,96]. Second generation agents are safe major side effect of topical decongestant overuse is in older rhinitis patients since they do not carry the risk rebound vasodilation and nasal dryness, as well as the of anticholinergic or alpha-adrenergic activity[57,76]. potential for rhinitis medicamentosa with prolonged First-generation antihistamines should not be prescribed use[105,112]. as they have numerous potential adverse effects on the Leukotriene receptor antagonists (e.g. montelukast, central nervous system and interactions with other medi- zileuton) decrease the inflammatory response in allergic cations, which are more pronounced in the geriatric pop- rhinitis and limit symptoms of congestion, sneezing, and ulation[10,57,76]. For example, these medications can rhinorrhea[113]. These agents are weak as a monother- affect driving performance more than alcohol, perturb apy and are commonly used as an adjunct to antihista- the normal sleep cycle, and markedly affect attention and mine or intranasal steroid treatment[96,114]. Long-term cognitive performance[97,98], all of these factors being data has not been reported to determine safety of leukot- germane to the older patient. riene inhibitors in the older patients, yet these medica- Topical antihistamines, such azelastine, are good alter- tions seem to be well tolerated in this population[10,115]. natives to the oral therapy and are approved for seasonal These agents primarily help with congestion and are par- allergic rhinitis in the United States. Studies have proven ticularly useful in asthmatics where they may have the equal efficacy to ebastine, cetirizine, loratadine, and ter- double benefit of improving lower airway disease. fenadine in terms of symptom reduction and may also Intranasal cromolyn sodium can be effective in mini- improve nasal congestion more so than oral antihista- mizing allergic rhinitis symptoms in refractory patients. mines[99]. Azelastine has been shown to be well tolerated This agent inhibits the degranulation of sensitized mast in geriatric patients[100]. Typical adverse events include cells thereby preventing the release of mediators of the bitter taste, sedation, headache, and application site irri- allergic response and inflammation[116]. Patients who tation[99,101]. Topical antihistamines have demonstrated are given nasal cromolyn sodium must be instructed to greater efficacy when combined with intranasal steroids use it before an anticipated allergen exposure and to use than either agent alone[102]. A new formulation of it on a regular basis during the period of exposure[2]. azelastine was developed to reduce the bitter taste associ- Cromolyn may require two to three weeks of use before ated with the medication. This new product is as effective any benefit is experienced and should be used three to as the older version with similar frequency and constella- four times per day[105]. The medication is generally well tion of side effects[103,104]. tolerated and side effects are minimal[116]. Cromolyn Intranasal steroids have become first-line treatment for can be good option in older patients that cannot tolerate moderate to severe allergic rhinitis and effectively treat all antihistamines and decongestants, or with use of multiple symptoms of rhinitis[105]. A recent randomized con- medications due to its lack of drug interactions [102,116]. trolled trial studied the effects of mometasone furoate Immunotherapy nasal spray in patients older than 65 years of age suffering Immunotherapy is typically regarded as a last line therapy from perennial allergic rhinitis, showing it to be an effec- when patients continue to have moderate to severe aller- tive treatment in this cohort[106]. Intranasal steroids are gic rhinitis symptoms despite pharmacologic interven- generally well tolerated by older patients[10,107]; how- tion. Few studies have been conducted on the efficacy of ever, they can aggravate nasal dryness, epistaxis, and immunotherapy in the geriatric population; however, the mucosal crusting in geriatric patients[108]. Therefore, data thus far seems positive. Eidelman et al reported a careful instruction in use with patients is critical along favorable response to specific immunotherapy in patients with close follow-up to examine the presence of these greater than 60 years of age compared to controls aged problems in the nose. less than 60[117]. Asero conducted a study assessing Topical and systemic decongestants are alpha-adrener- patients older than 54 years of age with monosensitiza- gic agonists that significantly reduce nasal congestion, tion to birch pollen and ragweed[118]. The trial showed however they do not relieve symptoms sneezing, pruritis, immunotherapy to be an effective treatment in healthy and secretions[109]. Decongestants can be used with older individuals with short disease duration (<10 years) antihistamines if a patient presents with multiple rhinitis whose symptoms cannot be adequately controlled by symptoms including congestion. Oral agents are avoided drug therapy alone. Further studies need to be performed in those older patients with multiple comorbid conditions to address the safety profile of this treatment within the such as coronary artery disease, diabetes, hypertension, geriatric population. hyperthyroidism, narrow angle glaucoma, and symptoms Nonallergic rhinitis of bladder neck obstruction[96,110,111]. Side effects Vasomotor rhinitis from oral decongestants include palpitations, insomnia, Pharmacotherapy Azelastine has been approved by the nervousness, and irritability. Some patients may have Food and Drug Administration (FDA) for treatment of trouble with urination and a decreased appetite[2]. The Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 8 of 12 http://www.aacijournal.com/content/6/1/10 vasomotor rhinitis. This agent has demonstrated anti- Surgery inflammatory effects and thus can be given for nearly all Surgical treatment is also an option in the geriatric popu- symptoms of vasomotor rhinitis including rhinorrhea, lation. First, structural causes can be addressed. Nasal sneezing, postnasal drip, and congestion[119,120]. Intra- reconstruction can be performed to reverse the aging nasal steroids may be given for complaints of nasal effects on the nose, such as raising the nasal tip and sup- obstruction or congestion[121]; however, a recent study porting the lateral cartilage[10]. This should aid in air has shown that steroid use for symptoms of vasomotor flow and nasal function. Similarly, septoplasty with or rhinitis triggered by temperature or weather may not be without inferior turbinate reduction has been shown to effective[122]. The use of anticholinergics in this condi- be beneficial in patients 65 years of age and older[129]. tion is mainly for symptoms of rhinorrhea[6,123] but the Moreover, functional endoscopic sinus surgery can be applicability of this agent to geriatric patients has not used to address concomitant sinus disease. Sinus surgery been examined. Sneezing and congestion associated with has been shown to be a safe and efficacious procedure in vasomotor rhinitis may be relieved with cromolyn older patients[130,131] with improvement in quality of sodium, but is not as effective as a first-line treatment for life. Reh et al demonstrated that older individuals with these symptoms[6]. There is no evidence for use of topi- chronic rhinosinusitis had a similar degree of improve- cal or oral decongestants. Empiric use of decongestants is ment in endoscopic and quality of life measures after possible provided that the geriatric patient has no con- endoscopic sinus surgery when compared to matched traindications. In summary, pharmacotherapy for vaso- younger controls[132]. Surgery could be an effective motor rhinitis is symptom based, thus if one medication treatment for an older individual, but the functional sta- fails current practice is therapeutic trials with other listed tus of the geriatric patient must be assessed pre-opera- agents. tively to determine if surgery is a suitable option. Novel therapies for VMR A Chinese group demon- strated polysaccharide nucleic acid fraction of the Bacil- Conclusions lus Calmette-Guérin vaccine (BCG-PSN) to be a safe and Rhinitis is clearly an important burden in the older com- effective treatment of vasomotor rhinitis with no munity that needs to be further addressed as the geriatric reported adverse events[124]. This therapy requires mul- population rapidly expands in the United States. The tiple injections, which may be difficult and painful of structure and function of the aging nose may contribute older patients, and may also require adjunctive treatment to the manifestations and mechanisms of this condition. with a topical antihistamine. Follow up for this trial was This broad set of symptoms fall under a heterogeneous only six months and therefore more evidence is necessary group of disorders, and thus the focus of therapy must for long-term efficacy and safety of BCG-PSN. Further first be classification of the patient within the proper sub- study of these findings is needed before this can reach type, and then engagement of appropriate therapy that is clinical practice. both safe and efficacious in older individuals. Treatment Gustatory Rhinorrhea is challenging as little data exists on clearly beneficial Atropine decreases the parasympathetic response and treatments for several of these subtypes. Trial and error thus is useful in treatment of gustatory rhinorrhea[67]. may prove to be useful in instances where no validated Intranasal anticholinergic agents, such as intranasal iprat- data are available for geriatric patients. Furthermore, use ropium, are FDA approved for use in rhinorrhea in aller- of adjunct measures such as allergen/irritant avoidance gic and nonallergic perennial rhinitis and are thus very and nasal humidification are not only cost-effective, but effective for gustatory rhinorrhea if used before eat- can also limit the extent of polypharmacy in a population ing[125]. These medications have few local side effects with multiple comorbid conditions. More research is such as epistaxis and nasal dryness[105]. needed to develop effective treatment protocols for this Botulinum toxin is a newer therapy for gustatory rhin- group of rhinitis patients. orrhea, however optimal site of administration, optimal dose, long-term efficacy, and side effects have yet to be List of Abbreviations determined[126,127]. 1) ARIA: Allergic Rhinitis and its Impact on Asthma; 2) Atrophic Rhinitis RSDI: rhinosinusitis disability index; 3) cdc42: cell divi- The focus of treatment in atrophic rhinitis is to increase sion cycle 42; 4) TRP: transient receptor potential; 5) moisture content in the nose. This can be done with gen- ACE: angiotensin converting enzyme; 6) CT: computed tle hydration, nasal irrigation, improving mucus function tomography; 7) HEPA: high-efficiency particulate air; 8) with agents such as guaifenesin, or use of home humidifi- BCG-PSN: polysaccharide nucleic acid fraction of the ers[108]. Over-the-counter mucolytic agents such as Bacillus Calmette-Guérin vaccine; 9) FDA: Food and Alkalol can also provide some therapeutic benefit[128]. Drug Administration Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 9 of 12 http://www.aacijournal.com/content/6/1/10 tion of JMP. JMP edited and revised the manuscript. Both authors read and Author information approved the final manuscript. JMP is Assistant Professor of Surgery in the Section of Otolaryngology-Head and Neck Surgery at The Univer- Acknowledgements The authors gratefully thank Ms. Jamie Phillips, Gairta Bartos, RN, and Marcella sity of Chicago. He directs the Program in Transitional DeTineo, BSN, for logistical assistance. This work was supported in part by the Rhinology Research http://surgicalresearch.bsd.uchi- McHugh Otolaryngology Research Fund. JMP was also supported by a Dennis cago.edu/faculty/pinto/. W. Jahnigen Career Development Award from the American Geriatrics Society and the K12 Scholars Program from the Institute for Translational Medicine at the University of Chicago from the NIH (KL2RR025000). SJ was supported by an Appendix 1 - Types of Rhinitis American Academy of Allergy, Asthma, and Immunology summer research Allergic grant and by the Pritzker School of Medicine summer research program. Seasonal Perennial Author Details Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Intermittent The University of Chicago, Chicago, IL, USA Persistent Received: 20 November 2009 Accepted: 13 May 2010 Nonallergic Published: 13 May 2010 T © T Ah h l le 2010 P i is s rg i arti s y, an A cle i s O n th i tp o s ma e ava an n & C A dicce lable Je lin sw ss arti ic f a a rn lo Immu im ;cl li:e ce h d ttp:/ n no is st eri lo e /bu Bi w gy w o te 2010, M w d.aaci e u d n C d 6je e :10 on r th utrn ral L e al.co te td rm .m s/ c oo f th nte en C tr /e 6a /1 ti/ve 10 Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Idiopathic/Vasomotor Nonallergic rhinitis with eosinophilia syndrome References (NARES) 1. Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: Key indicators of well-being. 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Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 12 of 12 http://www.aacijournal.com/content/6/1/10 119. Ciprandi G: Treatment of nonallergic perennial rhinitis. Allergy 2004, 59(Suppl 76):16-22. 120. Banov C, Lieberman P, Vasomotor Rhinitis Study Groups: Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. Ann Allergy Asthma Immunol 2001, 86(1):28-35. 121. Settipane R, Lieberman P: Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 2001, 86(5):494-507. 122. Jacobs R, Lieberman P, Kent E, Silvey M, Locantore N, Philpot E: Weather/ temperature-sensitive vasomotor rhinitis may be refractory to intranasal corticosteroid treatment. Allergy Asthma Proc 2009, 30(2):120-7. 123. Managementof allergic and nonallergic rhinitis. Report/Technology assessment: Number 54 2002 [http://www.ncbi.nlm.nih.gov/bookshelf/ br.fcgi?book=hserta&part=A82200]. 124. 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Otolaryngol Head Neck Surg 2004, 131(6):946-9. 131. Ramadan H, VanMetre R: Endoscopic sinus surgery in geriatric population. Am J Rhinol 2004, 18(2):125-7. 132. Reh D, Mace J, Robinson J, Smith T: Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery. Am J Rhinol 2007, 21(2):207-13. doi: 10.1186/1710-1492-6-10 Cite this article as: Pinto and Jeswani, Rhinitis in the geriatric population Allergy, Asthma & Clinical Immunology 2010, 6:10 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Allergy, Asthma & Clinical Immunology Springer Journals

Rhinitis in the geriatric population

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Medicine & Public Health; Allergology; Immunology; Pneumology/Respiratory System
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Abstract

The current geriatric population in the United States accounts for approximately 12% of the total population and is projected to reach nearly 20% (71.5 million people) by 2030[1]. With this expansion of the number of older adults, physicians will face the common complaint of rhinitis with increasing frequency. Nasal symptoms pose a significant burden on the health of older people and require attention to improve quality of life. Several mechanisms likely underlie the pathogenesis of rhinitis in these patients, including inflammatory conditions and the influence of aging on nasal physiology, with the potential for interaction between the two. Various treatments have been proposed to manage this condition; however, more work is needed to enhance our understanding of the pathophysiology of the various forms of geriatric rhinitis and to develop more effective therapies for this important patient population. Classifications Nonallergic rhinitis is characterized by non-IgE-medi- Rhinitis is defined as inflammation of the nasal mucosa ated symptoms typical of rhinitis, such as congestion and and is characterized by symptoms of congestion, rhinor- clear rhinorrhea, with less prominence of sneezing and rhea, itching of the nose, postnasal drip, and sneezing[2]. ocular/nasal pruritis[6,7]. The associated symptoms may In the geriatric population, a broad interpretation of this be perennial or sporadic, lacking a clear seasonality, and symptom complex may also include crusting within the may be exacerbated by nonspecific triggers such as odors, nose, cough, excessive drainage, olfactory loss, and nasal food, emotion, or change in atmospheric condi- dryness[3,4]. tions[5,8,9]. Though no formal classification system Rhinitis can be divided broadly into two major catego- exists, nonallergic rhinitis can be further subcategorized; ries: allergic and nonallergic (Appendix 1). most commonly seen in older patients are the vasomotor, Allergic rhinitis is an IgE-mediated inflammation of the atrophic, gustatory, and medication-induced sub- nasal passageways triggered by various allergens such as types[10,11]. dust, pollens, or molds. Symptoms of allergic rhinitis may be classified as seasonal or perennial. An international Epidemiology working group modified this classification scheme due to Allergic rhinitis affects approximately 10-30% of Ameri- potential difficulties in differentiating between seasonal can adults[2,12]. The condition predominantly affects and perennial symptoms and created the Allergic Rhinitis males in their late teens or young adulthood and the and its Impact on Asthma (ARIA) Report[5]. The ARIA prevalence decreases with age[12,13]; yet, it is estimated guidelines temporally classify allergic rhinitis as 'intermit- that three per one thousand individuals over the age of 65 tent' if symptoms are present less than four days per week also suffer from allergic rhinitis with a shift to female pre- or less than four consecutive weeks, or as 'persistent' if dominance after adolescence[13,14]. Cross-sectional and symptoms are present more than four days per week and longitudinal studies have shown that both allergic rhinitis for more than four consecutive weeks. Severity of symp- symptoms and allergic skin test sensitivity become milder toms is graded as 'mild' if they are present but not trou- over time; however, these findings may not necessarily blesome, and as 'moderate/severe' if they lead to sleep correlate[15,16]. Such changes may be due to alterations disturbance, impairment of daily activities, or impair- in immune function with age[17,18]. For instance, total ment of school or work. IgE levels and eosinophil degranulation in response to cytokine stimulation decrease with age[19,20]. Further- * Correspondence: [email protected] more, repetitive exposure to allergens may induce toler- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, ance or anergy over time through mechanisms that are The University of Chicago, Chicago, IL, USA not completely clear[14]. Full list of author information is available at the end of the article © 2010 Pinto and Jeswani; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Com- mons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduc- BioMed Central tion in any medium, provided the original work is properly cited. Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 2 of 12 http://www.aacijournal.com/content/6/1/10 There is substantially less research regarding frequency year thereafter[37]. The decline in functional mass causes of nonallergic rhinitis in comparison to allergic rhinitis in depressed production of naïve T-cells leading to impaired older subjects. An estimated 19 million people in the cell-mediated immunity[37,38]. Despite thymic involu- United States suffer from nonallergic rhinitis[21]. The tion, the total T-cell pool remains constant due to an prevalence of nonallergic rhinitis is greater in females and increase in production of memory T-cells[38]. The cause the incidence of diagnosis increases with age[22-24]. of this heterogeneity in the lymphocyte pool remains Greater than 60% of rhinitis patients over the age of 50 unknown. With the aging process also comes decreased suffer from a nonallergic etiology[9]. T-cell responsiveness to growth factors, altered lympho- cyte response to specific antigens, and diminished IL-2 production and receptor expression[17]. An imbalance in Effects of Rhinitis on Quality of life Several studies have shown the deleterious effects of rhin- the Th1/Th2 ratio occurs during immunosenescence, itis on the quality of life in symptomatic patients. Ben- with a shift towards Th2, leading to further altered ninger et al found that allergic rhinitis can result in cytokine production[39]. This is somewhat of a paradox significant sleep disturbance and fatigue using the Rhi- since the incidence of allergic rhinitis declines with age. nosinusitis Disability Index (RSDI), a validated outcomes The diminished T-cell response may be associated with tool that assesses how allergic rhinitis affects quality of the increased incidence of malignancy and infections in life[25]. Complaints of poor sleep are already common the geriatric population[17,40], whereas the aberration in among older individuals due to various sleep disorders as cytokine production and inflammatory response may well as the normal aging process[26], thus allergic rhinitis explain chronic or late onset rhinitis. may exacerbate these problems. Lack of sleep can alter B-cell function changes with age as well. Although the physiological processes such as glucose metabolism, cog- peripheral B-cell population remains consistent, there is nition, appetite control, and endocrine function, all criti- less IgG isotype class switching, and the number of anti- cal physiologic processes in older people[27,28]. gen-specific antibodies decreases while the number of Longitudinal studies have demonstrated that sleep com- autoantibodies and circulating immune complexes plaints in the geriatric population are also associated with increase[17,18]. This may explain the fact that older indi- lower self-reported health status, depression, and viduals are prone to infection, have decreased immune increased mortality[29-32]. Other effects of allergic rhini- response to vaccines, and have increased prevalence of tis include headache, poor concentration, and general autoimmune diseases[17,38,40]. These changes might irritability. These symptoms may hinder an individual's also contribute to the milder symptoms as well as the ability to carry out physical and social responsibilities decreased incidence of allergic rhinitis in the geriatric effectively[2]. Both of these domains were found to be population. large factors that contribute to geriatric quality of Changes of the Aging Nose life[33,34]. Structural Little data are available that specifically address the As individuals age, several changes in nasal anatomy and effects of nonallergic rhinitis on quality of life, especially physiology occur which may affect the development and in geriatric subjects. Because allergic and nonallergic expression of rhinitis. A loss of nasal tip support develops rhinitis share similar symptoms, the two conditions are because of weakening of fibrous connective tissue at the perceived by patients similarly[35] and it would be plausi- upper and lower lateral cartilages[4]. Collagen and elastin ble to extrapolate data on allergic rhinitis to model the loss, maxillary alveolar hypoplasia, and decreased facial effects of nonallergic rhinitis. In fact, a recent study dem- musculature lead to a drooped tip[41]. Furthermore, onstrated a decrease in health-related quality of life in weakening and fragmentation of septal cartilage and both allergic and nonallergic rhinitis patients; indeed, retraction of the nasal columella leads to changes in the there was no significant difference in the degree of nasal cavity[42]. A combination of these structural impairment between the two patient populations[36]. changes may decrease nasal airflow leading to complaints of nasal obstruction commonly seen in geriatric rhinitis Physiological Changes with age that may affect patients. Rhinitis Mucus Immunosenescence Mucosal epithelium atrophies with age and older patients Rhinitis is an inflammatory disease, as such, mechanisms are frequently dehydrated[43,44]. These factors may and presentation of the condition are altered as immune account for the excessively thick mucus in older patients. function changes with age, a concept entitled immunose- Thickened mucus along with decreased mucociliary nescence. A critical component of the immune system is clearance (see below) is thought to lead to common rhi- the thymus, which rapidly involutes from adolescence to nitic complaints such as postnasal drip, cough, and glo- near middle age, followed by an approximate 1% loss per Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 3 of 12 http://www.aacijournal.com/content/6/1/10 bus. Edelstein was able to demonstrate that the the mucociliary transport time in patients classified with prevalence of postnasal drip, nasal drainage, coughing, moderate-severe allergic rhinitis[52]. This may be due to and sneezing increased with age[4]. poor clearance of allergen and irritants, as well as stasis of Nasal Humidification and Dryness thick, dehydrated mucus within the nasal cavities and It is well recognized clinically that older people are more nasopharynx, leading to rhinitis complaints among the susceptible to dryness in the nose. Lindemann et al illus- geriatric population of postnasal drip, cough, and globus. trated that temperature and humidity values in the nasal Olfaction cavities were significantly lower in geriatric patients when Olfactory function decreases with age, with more rapid compared to younger individuals[45]. Other reasons for decline after the seventh decade. Both the sense of smell decreased humidification include age-related changes in (detection) and the ability to discriminate between two nasal vasculature. For instance, submucosal vessels scents is decreased with the normal aging process[53]. become less patent and therefore are not able to moisten Olfactory dysfunction is also commonly associated with and warm inspired air in the older nose as compared to rhinitis. One study demonstrated that 71% of study sub- the younger nose[44]. These findings in geriatric patients jects complaining of dysosmia had positive allergy skin likely explain the typical symptoms of nasal irritation tests[54]. The mechanism for olfactory dysfunction in related to dryness and crusting. allergic rhinitis patients has been typically attributed to Nasal Airflow nasal obstruction; however, newer data suggest that the The effects of age on nasal airflow still remain largely etiology may be due to inflammation in the olfactory cleft unclear. Calhoun et al did not find a relationship between itself[55]. This inflammation may be responsive to intra- age and nasal resistance[46], whereas Vig and Zajac nasal steroids. Of note, one trial has demonstrated that determined that there is a direct relationship between age the sense of smell in nonallergic rhinitis patients was and both nasal resistance and breathing mode[47]. Edel- worse than in allergic rhinitis patients[56]. Together, this stein found a significant correlation between aging and data illustrates that though olfactory dysfunction may be nasal airway resistance, before and after decongestant primarily due to the aging process, rhinitis may present as use[4]. Kalmovich et al studied endonasal architecture in a 'second hit' that aggravates the problem. geriatric patients using acoustic rhinometry and con- cluded that endonasal volumes and minimal cross-sec- Pathophysiology and Clinical Presentation of tional areas gradually increase with age[48]. The reason Rhinitis for the discrepancy between the latter two studies is Allergic unclear. Sahin-Yilmaz and Corey suggest this difference To briefly review, allergic rhinitis is the result of type I may be due to decreased functioning of the nasal hypersensitivity reactions whereby exposure to allergens mucosa[10]. The authors note that the estrogen content in susceptible individuals leads to sensitization by pro- in the nasal mucosa decreases with age and can subse- duction of specific IgE antibodies directed against these quently cause to loss of softness and elasticity, leading to extrinsic proteins. This antibody then binds to the surface increased airway resistance. Post-menopausal women of mast cells, and when the allergen is reintroduced, IgE may also suffer from olfactory loss, nasal congestion, and cross-binding to the antigen leads to mast cell degranula- an increase in mucociliary time secondary to hormonal tion[57]. Within seconds of contact, inflammatory medi- changes[49]. Estrogens modulate mucosal function by ators such as histamine, leukotrienes, and prostaglandin modifying the local concentration of neurotransmitters D2 are released causing vascular endothelial dilation, or their receptors, which regulate basal vasculature and which subsequently causes leakage and mucosal glandular secretions[49]. Recent evidence suggests that edema[58,59]. This leads to nasal obstruction and symp- the number of specific estrogen receptors (ERβ) within toms of congestion, redness, tearing, swelling, ear pres- the nasal mucosa positively correlates to rhinitic symp- sure, and postnasal drip. Irritant receptors are stimulated toms, yet the mechanism of the receptors' effects on nasal by the allergen causing itching and sneezing[60]. mucosa is yet to be elucidated[50]. It is plausible that Within four to eight hours of initial exposure, cytokines other airflow abnormalities could also underlie nasal attracted by previously released mediators lead to complaints in older subjects. recruitment of other inflammatory cells to the mucosa, Mucociliary Clearance such as neutrophils, eosinophils, lymphocytes, and mac- Studies show that the frequency at which cilia beat, as rophages[59]. The inflammation persists and this stage is well as time for mucociliary clearance within nasal epi- termed the late-phase response. The late-phase response thelium, slow with age[51]; however, the number of cili- presents similar to the early phase, however, sneezing and ated cells in the nasal epithelium does not change[4]. In itching are less prominent, whereas congestion and fact, Kirtsreesakul et al have recently shown that the mucus production are more severe. The late phase may severity of symptoms was significantly correlated with persist for hours or days[61]. Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 4 of 12 http://www.aacijournal.com/content/6/1/10 Though its peak incidence is during young adulthood, in the nose. Sensory nerves of the nasal mucosa respond allergic rhinitis is prevalent among older people. In fact, to chemical stimuli by initiating sneezing and nasal the 2005 National Center for Health Statistics report hypersecretion through reflex pathways. The sensory stated that 10.7% of individuals between 45-64 years of fibers that are unmyelinated and slow conducting belong age, 7.8% of patients 65-75 years of age, and 5.4% of to the C-fiber type and contain neuropeptides such as patients older than 75 are affected by allergic rhinitis[62]. substance P, calcitonin gene-related peptide, and vasoac- Along with the anatomic and physiologic changes of the tive intestinal peptide, which regulate glandular secre- nose, non-specific immune changes such as decreased tions and vascular tone[67,69]. Baraniuk and colleagues mucus production and ineffective cough mechanisms are have demonstrated that these neuropeptides communi- all thought to contribute to persistent or late-onset aller- cate with immune mediators, such as histamine. The gic disease in older people, as these processes are neces- interplay between these molecules may cause neural sary for clearance of allergens and irritants[17]. responses and vice versa, all leading to an integrated Interestingly, Jackola et al. illustrated that atopic individu- response to external stimuli[70]. These mechanisms may als with a positive family history did not have a change in be involved in the etiology of vasomotor rhinitis in older severity or sensitivity of atopy as they age. Also, there people. were no changes in the amount of IgE specific to ragweed Cardell et al recently studied nasal mucosa biopsies of extract, despite age-related decline of total serum IgE[63]. nonallergic rhinitis patients using microarray analy- Mediaty et al also demonstrated that immunosenescence sis[71]. The group noted at least ten genes to be involved does not affect increased IgE levels in atopic patients with in nonallergic rhinitis, relating to functions of cellular atopic dermatitis or high serum IgE levels[64]. In sum- movement, hematological system development, and mary, these findings suggest that the atopic predisposi- immune response. Two of these genes, c-fos and cell divi- tion remains present into advanced age in these sion cycle 42 (cdc42) were found to have pivotal roles in subgroups of patients. Therefore, allergic rhinitis should the possible mechanistic pathways of nonallergic rhinitis not be overlooked in the geriatric population if a patient's and the authors believe these genes could be potentially history and symptoms are consistent with this condition. useful as biomarkers for this condition and aid in diagno- sis. These data are preliminary and will require follow-up. Nonallergic Gustatory Vasomotor Gustatory rhinorrhea is characterized by profuse watery Vasomotor rhinitis is the most common form of nonaller- rhinorrhea following ingestion of certain foods. These gic rhinitis, and its prevalence is increased in the aging symptoms can be socially awkward and even lead to population[22]; however, due to the difficulties in classi- decreased nutrition. Commonly, alcohol and spicy or fying this condition, epidemiological data is scant. This cold foods are the culprits. With spicy food, the capsaicin condition does not have an obvious immunologic or content induces neuropeptide release from sensory nerve infectious etiology and is not associated with nasal fibers, leading to overstimulation of the parasympathetic eosinophilia[2]. Prominent symptoms of vasomotor rhin- nervous system[67]. Baraniuk and colleagues demon- itis include nasal obstruction, rhinorrhea, and conges- strated the significance of the TRP (transient receptor tion[6,65]. These symptoms are exacerbated by strong potential) receptor family in the regulation of sensory odors or fumes, bright lights, and changes in weather or neuron depolarization and repolarization, glandular exo- humidity[65,66]. cytosis, and many other functions. Substrates for these The mechanism of vasomotor rhinitis is unclear. One receptors include capsaicin, extremely high or low tem- theory is that autonomic instability may lead to both peratures, alcohol, mustard oil, and some garlic compo- hyperactive parasympathetic activity and an imbalance in nents[72]. One speculation is that TRP receptors may sympathetic to parasympathetic activity in vasomotor play a role in gustatory rhinorrhea. patients, which cause nasal congestion and rhinor- Medication-induced rhea[67]. The sympathetic pathway promotes nasal air- Several classes of medications are known to induce rhini- way patency by secretion of norepinephrine and tis (Appendix 2). The mechanisms causing this include neuropeptide Y[68], whereas the parasympathetic path- alteration of autonomic regulation on nasal mucosa and way releases substances that lead to congestion and vasculature, platelet activity, immune effects, and hor- mucus secretion such as acetylcholine. Thus, vasomotor monal effects. This condition is of particular importance rhinitis in older patients may represent a decline in con- in older patients, as polypharmacy has become a com- trol of neurological responses that affect nasal physiology. mon issue among the geriatric population with an Another possibility may be that neurogenic reflex increasing amount of comorbid conditions. Although the mechanisms triggered by environmental factors (e.g., number of individuals over 65 years of age represents less ozone, cigarette smoke) lead to inflammatory responses than 15% of the total population, this group accounts for Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 5 of 12 http://www.aacijournal.com/content/6/1/10 over one third of prescription drug use nationwide[73]. well as bothersome nasal crusting upon awaken- Furthermore, Kaufman et al discovered that 57% of ing[77,78,81]. Because this progressive condition pres- American women greater than 65 years of age use at least ents with symptoms similar to other types of rhinitis, it is five medications and 12% use at least ten medica- often improperly diagnosed and undertreated. More tions[74]. Common agents used in the geriatric popula- work needs to be done to recognize atrophic rhinitis as tion that can induce rhinitis are discussed below. well as to administer effective treatment. Medications with effects on the cardiovascular system For completeness, we mention that secondary atrophic carry side effects of rhinitis due to disruption of the nor- rhinitis is seen in patients with extensive nasal surgery, mal sympathetic tone that causes vasoconstriction of trauma, granulomatous diseases, and radiation ther- local vessels. Medications such as alpha and beta-block- apy[82] and will not be discussed here. ers, centrally acting anti-hypertensives, and angiotensin converting enzyme (ACE) inhibitors that inhibit sympa- Evaluation thetic tone lead to vasodilation and symptoms of nasal Diagnosis and treatment of rhinitis in the older popula- congestion. Antipsychotics also have well-known rhino- tion is complicated by comorbid conditions. Approxi- logic side effects due to their alpha and beta blocking mately 50% of people over the age of 75 have three or properties[75]. more diseases and take three or more medications[83]. Topical decongestants can cause rebound vasodilation Within this population, there are also concerns of compli- with overuse. The older population is at increased risk for ance due to physical or cognitive impairments and finan- this adverse effect due to thinning and dryness of their cial issues[83]. Furthermore, many older patients with nasal mucosa[76]. rhinitis complain of "sinus trouble" or "allergies", thus it is Aspirin-sensitive patients may suffer from rhinitis with difficult to assess the specific type of rhinitis involved or use as well as prolonged epistaxis due to its anti-platelet the appropriate treatment[77]. activity. Other systemic medications that cause rhinitis Evaluation of an older patient with rhinitis should begin are contraceptives, erectile dysfunction therapies, immu- with a complete history. Details regarding length and nosuppressants, antivirals, penicillamine, and oral retin- timing of symptoms, exacerbating factors, and response oids[75]. to medications should be elicited from the patient. Also Primary atrophic important for investigation are environmental exposures Geriatric rhinitis, or primary atrophic rhinitis, is an such as tobacco smoke, pets, pollution, housing type imprecise term used to signify rhinitis due to the age- which may be older and might contain formaldehyde for related changes in nasal physiology (nasal glandular atro- insulation or upholstery finishing, cockroaches and phy, vascular changes, decreased nasal humidification, rodents. Activities requiring use of latex gloves, certain decreased mucociliary clearance, and structural changes cleaning products, certain glues, wood dust, and acid of the nose)[77]. Histopathological changes associated anhydrides can trigger symptoms of rhinitis[84]. Interest- with primary atrophic rhinitis include mucosal atrophy, ingly, psyllium powder from Metamucil preparation squamous metaplasia, and chronic inflammatory cell (commonly used in the older patient for constipation) has infiltrate[78]. Garcia et al studied how these changes lead been reported to induce acute rhinitis[85]. to symptoms using techniques of computational fluid Past medical history consisting of trauma to the nose or dynamics of airflow and water and heat transport, finding face, asymmetry of nasal breathing due to structural that excessive evaporation of the mucus layer secondary causes, allergic conditions such as asthma and eczema, as to widened nasal cavities and decreased mucosal surface well as family history of atopy should be noted. Though area are integral components of atrophic rhinitis[79]. the typical age of onset of allergic rhinitis is under age 20 These changes lead to thickened and persistent mucus years, humans can be sensitized at any time [14], there- and altered nasal airflow. Recent studies have attempted fore an allergic cause should not be perfunctorily dis- to elucidate the role of apoptosis in rhinitis, finding that missed. nasal epithelium from patients suffering from atrophic Physical examination should begin with externally rhinitis display increased activity of caspase 3, a key pro- inspecting the tip of the nose for drooping and absence of tein in the apoptosis cascade[80]. This finding directs structural support. Internally, the physician should assess future studies to investigate therapeutic strategies that nasal patency, turbinates, straightness of the septum, may regulate apoptosis. presence of polyps, and signs of inflammation. Most of Patients suffering from primary atrophic rhinitis, a this endonasal examination can be accomplished with an diagnosis of exclusion, typically present with symptoms otoscope. Mucosal evaluation may be challenging to of postnasal drip, chronic cough, and nasal obstruction interpret as both allergic and nonallergic rhinitis can and dryness. Patients may also complain of a frequent present with mucosal pallor, edema, or hyperemia[2]. need to clear the throat, thick and dense secretions, as Overuse of topical medications may cause the nasal Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 6 of 12 http://www.aacijournal.com/content/6/1/10 mucosa to appear reddened. The quality of secretions troesophageal reflux disease or decreased nasal patency may aid in distinguishing the etiology of rhinitis. For in select settings[23,91,92]. instance, allergic rhinitis typically presents as watery mucus, whereas in mucociliary defects or severe obstruc- Management tion, thick mucus can be seen pooling on the nasal General measures floor[2]. Furthermore, mucopurulent drainage along with There are a variety of methods to treat rhinitis in older "cobblestoning" of the pharynx may be suggestive of subjects. In the case of both allergic and nonallergic rhin- chronic rhinitis complicated by acute sinusitis. In most itis, the simplest therapy is eliminating exposure to cases of rhinitis, findings should be bilateral. Unilateral known allergens and/or irritants. It should be noted that findings may reflect anatomic pathology or neoplasm some avoidance measures (mite dust covers, air purifiers, requiring further workup including nasal endoscopy or carpet removal) have not been shown to be effective in sinonasal imaging by computed tomography (CT) scan. reducing symptoms and pose barriers for some patients The remainder of the physical examination should be regarding cost. Humidification with saline nasal irriga- employed to eliminate other causes of rhinitis including tion has been demonstrated to be a safe and effective cerebrospinal fluid rhinorrhea and tumors. technique to reduce nasal dryness and help with the Allergy testing is useful both to determine atopy status clearing of thick, tenacious mucus[93,94]. Mucolytic with total serum IgE (usually > 100 U/mL)[86] as well as agents may also help clear thick mucus and provide to identify the specific offending allergens (specific IgE). symptom relief. Emollients have been shown to help with It should be noted, however, that response to skin testing nasal crusting[10]. For example, Johnsen et al demon- decreases with age and photo damage, requiring skin strated that in patients suffering from nasal dryness due tests in geriatric patients to be interpreted with care[87]. to low humidity, use of sesame oil significantly improved Other factors that may affect a skin test in the geriatric mucosal dryness, nasal stuffiness, and nasal crusting population are medications (most notably long-acting when compared to an isotonic sodium chloride solu- antihistamines and tricyclic antidepressants), blood pres- tion[95]. The measures are generally safe and can be used sure, temperature of the extremity, and change in the adjunctively with other treatments. allergen exposure over time[87]. When administering a Allergic Rhinitis skin test to an older individual, a sun-protected area of Treatment of allergic rhinitis has three main components: the skin should be used for testing, such as the lower avoidance of exposure to known allergens, pharmaco- back. If an acceptable area cannot be found, the physician therapy, and immunotherapy. should consider in vitro testing. Allergen avoidance By definition, patients with nonallergic rhinitis demon- Some forms of allergen avoidance can be effective in strate negative test results. Nonallergic rhinitis is a diag- management of allergic rhinitis; though proof in random- nosis of exclusion due to the absence of specific ized trials has been difficult to generate, this is still a stan- laboratory tests that confirm this diagnosis[67]. dard recommendation for patients. Staying indoors with Adjunct testing can also be useful in the evaluation of the windows closed while pollens and molds are in their rhinitis in older subjects. Upper airway endoscopy is seasonal and daytime peaks can decrease disease burden. valuable in identifying any anatomic abnormalities that Other measures include regular vacuuming of carpet, may not have been visualized on anterior rhinoscopy, removal of pets from home, and frequent washing of bed- such as septal deviation, nasal polyposis, or mucosal atro- ding. These factors are particularly relevant for the older phy. Moreover, the middle meatal sinus ostia can be patient since s/he may spend significantly more time assessed for signs of obstruction which could predispose indoors and therefore may be exposed to allergens such to sinusitis[84,88]. Sinus imaging by screening CT scan as dust mites and indoor molds more than outdoor aller- provides information on any obstruction of the gens such as pollens. As such, they may face a perennial osteomeatal complex, and can also aid in identifying pol- allergen challenge which is sometimes more difficult to yps, turbinate edema, or bony abnormalities such as con- control. Cost and practicality must govern recommenda- cha bullosae[84]. However, given cost and radiation tions in this area for costly and difficult measures (e.g., exposure, imaging is reserved for cases of lack of carpet removal, HEPA filters, etc.) given the lack of evi- response to therapy, high index of clinical suspicion, or dence for efficacy for these measures. pre-operative assessment for use during endoscopic sinus Pharmacotherapy surgery to delineate anatomy[89,90]. Additional special- Second generation antihistamines are standard in the ized testing (e.g. acid reflux testing by pH probe, assess- treatment of mild allergic diseases. These agents are ment of nasal volume by acoustic rhinometry) can be effective in reducing symptoms of nasal and ocular pruri- useful for evaluation of exacerbating factors, such as gas- tis, rhinorrhea, and sneezing, but do little in managing Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 7 of 12 http://www.aacijournal.com/content/6/1/10 nasal congestion[2,96]. Second generation agents are safe major side effect of topical decongestant overuse is in older rhinitis patients since they do not carry the risk rebound vasodilation and nasal dryness, as well as the of anticholinergic or alpha-adrenergic activity[57,76]. potential for rhinitis medicamentosa with prolonged First-generation antihistamines should not be prescribed use[105,112]. as they have numerous potential adverse effects on the Leukotriene receptor antagonists (e.g. montelukast, central nervous system and interactions with other medi- zileuton) decrease the inflammatory response in allergic cations, which are more pronounced in the geriatric pop- rhinitis and limit symptoms of congestion, sneezing, and ulation[10,57,76]. For example, these medications can rhinorrhea[113]. These agents are weak as a monother- affect driving performance more than alcohol, perturb apy and are commonly used as an adjunct to antihista- the normal sleep cycle, and markedly affect attention and mine or intranasal steroid treatment[96,114]. Long-term cognitive performance[97,98], all of these factors being data has not been reported to determine safety of leukot- germane to the older patient. riene inhibitors in the older patients, yet these medica- Topical antihistamines, such azelastine, are good alter- tions seem to be well tolerated in this population[10,115]. natives to the oral therapy and are approved for seasonal These agents primarily help with congestion and are par- allergic rhinitis in the United States. Studies have proven ticularly useful in asthmatics where they may have the equal efficacy to ebastine, cetirizine, loratadine, and ter- double benefit of improving lower airway disease. fenadine in terms of symptom reduction and may also Intranasal cromolyn sodium can be effective in mini- improve nasal congestion more so than oral antihista- mizing allergic rhinitis symptoms in refractory patients. mines[99]. Azelastine has been shown to be well tolerated This agent inhibits the degranulation of sensitized mast in geriatric patients[100]. Typical adverse events include cells thereby preventing the release of mediators of the bitter taste, sedation, headache, and application site irri- allergic response and inflammation[116]. Patients who tation[99,101]. Topical antihistamines have demonstrated are given nasal cromolyn sodium must be instructed to greater efficacy when combined with intranasal steroids use it before an anticipated allergen exposure and to use than either agent alone[102]. A new formulation of it on a regular basis during the period of exposure[2]. azelastine was developed to reduce the bitter taste associ- Cromolyn may require two to three weeks of use before ated with the medication. This new product is as effective any benefit is experienced and should be used three to as the older version with similar frequency and constella- four times per day[105]. The medication is generally well tion of side effects[103,104]. tolerated and side effects are minimal[116]. Cromolyn Intranasal steroids have become first-line treatment for can be good option in older patients that cannot tolerate moderate to severe allergic rhinitis and effectively treat all antihistamines and decongestants, or with use of multiple symptoms of rhinitis[105]. A recent randomized con- medications due to its lack of drug interactions [102,116]. trolled trial studied the effects of mometasone furoate Immunotherapy nasal spray in patients older than 65 years of age suffering Immunotherapy is typically regarded as a last line therapy from perennial allergic rhinitis, showing it to be an effec- when patients continue to have moderate to severe aller- tive treatment in this cohort[106]. Intranasal steroids are gic rhinitis symptoms despite pharmacologic interven- generally well tolerated by older patients[10,107]; how- tion. Few studies have been conducted on the efficacy of ever, they can aggravate nasal dryness, epistaxis, and immunotherapy in the geriatric population; however, the mucosal crusting in geriatric patients[108]. Therefore, data thus far seems positive. Eidelman et al reported a careful instruction in use with patients is critical along favorable response to specific immunotherapy in patients with close follow-up to examine the presence of these greater than 60 years of age compared to controls aged problems in the nose. less than 60[117]. Asero conducted a study assessing Topical and systemic decongestants are alpha-adrener- patients older than 54 years of age with monosensitiza- gic agonists that significantly reduce nasal congestion, tion to birch pollen and ragweed[118]. The trial showed however they do not relieve symptoms sneezing, pruritis, immunotherapy to be an effective treatment in healthy and secretions[109]. Decongestants can be used with older individuals with short disease duration (<10 years) antihistamines if a patient presents with multiple rhinitis whose symptoms cannot be adequately controlled by symptoms including congestion. Oral agents are avoided drug therapy alone. Further studies need to be performed in those older patients with multiple comorbid conditions to address the safety profile of this treatment within the such as coronary artery disease, diabetes, hypertension, geriatric population. hyperthyroidism, narrow angle glaucoma, and symptoms Nonallergic rhinitis of bladder neck obstruction[96,110,111]. Side effects Vasomotor rhinitis from oral decongestants include palpitations, insomnia, Pharmacotherapy Azelastine has been approved by the nervousness, and irritability. Some patients may have Food and Drug Administration (FDA) for treatment of trouble with urination and a decreased appetite[2]. The Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 8 of 12 http://www.aacijournal.com/content/6/1/10 vasomotor rhinitis. This agent has demonstrated anti- Surgery inflammatory effects and thus can be given for nearly all Surgical treatment is also an option in the geriatric popu- symptoms of vasomotor rhinitis including rhinorrhea, lation. First, structural causes can be addressed. Nasal sneezing, postnasal drip, and congestion[119,120]. Intra- reconstruction can be performed to reverse the aging nasal steroids may be given for complaints of nasal effects on the nose, such as raising the nasal tip and sup- obstruction or congestion[121]; however, a recent study porting the lateral cartilage[10]. This should aid in air has shown that steroid use for symptoms of vasomotor flow and nasal function. Similarly, septoplasty with or rhinitis triggered by temperature or weather may not be without inferior turbinate reduction has been shown to effective[122]. The use of anticholinergics in this condi- be beneficial in patients 65 years of age and older[129]. tion is mainly for symptoms of rhinorrhea[6,123] but the Moreover, functional endoscopic sinus surgery can be applicability of this agent to geriatric patients has not used to address concomitant sinus disease. Sinus surgery been examined. Sneezing and congestion associated with has been shown to be a safe and efficacious procedure in vasomotor rhinitis may be relieved with cromolyn older patients[130,131] with improvement in quality of sodium, but is not as effective as a first-line treatment for life. Reh et al demonstrated that older individuals with these symptoms[6]. There is no evidence for use of topi- chronic rhinosinusitis had a similar degree of improve- cal or oral decongestants. Empiric use of decongestants is ment in endoscopic and quality of life measures after possible provided that the geriatric patient has no con- endoscopic sinus surgery when compared to matched traindications. In summary, pharmacotherapy for vaso- younger controls[132]. Surgery could be an effective motor rhinitis is symptom based, thus if one medication treatment for an older individual, but the functional sta- fails current practice is therapeutic trials with other listed tus of the geriatric patient must be assessed pre-opera- agents. tively to determine if surgery is a suitable option. Novel therapies for VMR A Chinese group demon- strated polysaccharide nucleic acid fraction of the Bacil- Conclusions lus Calmette-Guérin vaccine (BCG-PSN) to be a safe and Rhinitis is clearly an important burden in the older com- effective treatment of vasomotor rhinitis with no munity that needs to be further addressed as the geriatric reported adverse events[124]. This therapy requires mul- population rapidly expands in the United States. The tiple injections, which may be difficult and painful of structure and function of the aging nose may contribute older patients, and may also require adjunctive treatment to the manifestations and mechanisms of this condition. with a topical antihistamine. Follow up for this trial was This broad set of symptoms fall under a heterogeneous only six months and therefore more evidence is necessary group of disorders, and thus the focus of therapy must for long-term efficacy and safety of BCG-PSN. Further first be classification of the patient within the proper sub- study of these findings is needed before this can reach type, and then engagement of appropriate therapy that is clinical practice. both safe and efficacious in older individuals. Treatment Gustatory Rhinorrhea is challenging as little data exists on clearly beneficial Atropine decreases the parasympathetic response and treatments for several of these subtypes. Trial and error thus is useful in treatment of gustatory rhinorrhea[67]. may prove to be useful in instances where no validated Intranasal anticholinergic agents, such as intranasal iprat- data are available for geriatric patients. Furthermore, use ropium, are FDA approved for use in rhinorrhea in aller- of adjunct measures such as allergen/irritant avoidance gic and nonallergic perennial rhinitis and are thus very and nasal humidification are not only cost-effective, but effective for gustatory rhinorrhea if used before eat- can also limit the extent of polypharmacy in a population ing[125]. These medications have few local side effects with multiple comorbid conditions. More research is such as epistaxis and nasal dryness[105]. needed to develop effective treatment protocols for this Botulinum toxin is a newer therapy for gustatory rhin- group of rhinitis patients. orrhea, however optimal site of administration, optimal dose, long-term efficacy, and side effects have yet to be List of Abbreviations determined[126,127]. 1) ARIA: Allergic Rhinitis and its Impact on Asthma; 2) Atrophic Rhinitis RSDI: rhinosinusitis disability index; 3) cdc42: cell divi- The focus of treatment in atrophic rhinitis is to increase sion cycle 42; 4) TRP: transient receptor potential; 5) moisture content in the nose. This can be done with gen- ACE: angiotensin converting enzyme; 6) CT: computed tle hydration, nasal irrigation, improving mucus function tomography; 7) HEPA: high-efficiency particulate air; 8) with agents such as guaifenesin, or use of home humidifi- BCG-PSN: polysaccharide nucleic acid fraction of the ers[108]. Over-the-counter mucolytic agents such as Bacillus Calmette-Guérin vaccine; 9) FDA: Food and Alkalol can also provide some therapeutic benefit[128]. Drug Administration Pinto and Jeswani Allergy, Asthma & Clinical Immunology 2010, 6:10 Page 9 of 12 http://www.aacijournal.com/content/6/1/10 tion of JMP. JMP edited and revised the manuscript. Both authors read and Author information approved the final manuscript. JMP is Assistant Professor of Surgery in the Section of Otolaryngology-Head and Neck Surgery at The Univer- Acknowledgements The authors gratefully thank Ms. Jamie Phillips, Gairta Bartos, RN, and Marcella sity of Chicago. He directs the Program in Transitional DeTineo, BSN, for logistical assistance. This work was supported in part by the Rhinology Research http://surgicalresearch.bsd.uchi- McHugh Otolaryngology Research Fund. JMP was also supported by a Dennis cago.edu/faculty/pinto/. W. Jahnigen Career Development Award from the American Geriatrics Society and the K12 Scholars Program from the Institute for Translational Medicine at the University of Chicago from the NIH (KL2RR025000). SJ was supported by an Appendix 1 - Types of Rhinitis American Academy of Allergy, Asthma, and Immunology summer research Allergic grant and by the Pritzker School of Medicine summer research program. Seasonal Perennial Author Details Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Intermittent The University of Chicago, Chicago, IL, USA Persistent Received: 20 November 2009 Accepted: 13 May 2010 Nonallergic Published: 13 May 2010 T © T Ah h l le 2010 P i is s rg i arti s y, an A cle i s O n th i tp o s ma e ava an n & C A dicce lable Je lin sw ss arti ic f a a rn lo Immu im ;cl li:e ce h d ttp:/ n no is st eri lo e /bu Bi w gy w o te 2010, M w d.aaci e u d n C d 6je e :10 on r th utrn ral L e al.co te td rm .m s/ c oo f th nte en C tr /e 6a /1 ti/ve 10 Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Idiopathic/Vasomotor Nonallergic rhinitis with eosinophilia syndrome References (NARES) 1. Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: Key indicators of well-being. 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Otolaryngol Head Neck Surg 2004, 131(6):946-9. 131. Ramadan H, VanMetre R: Endoscopic sinus surgery in geriatric population. Am J Rhinol 2004, 18(2):125-7. 132. Reh D, Mace J, Robinson J, Smith T: Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery. Am J Rhinol 2007, 21(2):207-13. doi: 10.1186/1710-1492-6-10 Cite this article as: Pinto and Jeswani, Rhinitis in the geriatric population Allergy, Asthma & Clinical Immunology 2010, 6:10

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