Allergy reactions are the most common immunological diseases and represent one of the most widespread and fast growing chronic human health problems among people over 15 years of age in developed countries. As populations get older worldwide, allergy manifestations in aged persons will occur more often in the future. To date, there has been much more studies on allergies in children than in adults. As the population ages, clinicians must be prepared to meet all the elderly's health care needs, including these new and emerging health issue. Allergic diseases represent an old/new emerging health issue. Because many common illnesses masquerade as atopic disease, the differential diagnosis of suspected allergic diseases becomes more expanded in an aging population. Research in the field needs to focus on both human and animal model systems to investigate the impact of the aging process on the immunologic pathways underpinning allergy and its different facets.
• The elderly population is steadily increasing and issues related to his state of health will become a topic of increasing relevance. • With increasing age, numerous underlying physiological changes occur, and the risk of chronic diseases rises. At the same time allergy is increasing worldwide, and 5-10% of allergies is affecting elderly people. • Taking into consideration the dramatic increase of all forms of allergies during the last decades also in the elderly, they are considered a real "epidemic" of the XXIst century, being classified by the WHO as the fourth most frequent chronic diseases. • Despite the great importance of the problem, allergic diseases, compared to all other chronic diseases, are neglected and undervalued. • In old people a number of factors may contribute to trigger allergy and/or to disguise it, making it longer and difficult to achieve the right diagnosis and relief suffering persons often already affected by several other diseases and in presence of many other causes of frailty. • The multifaceted dynamics among multimorbidity, disease, and underlying physiological change, can result in health states in older age that are not captured by traditional disease classifications and not easily diagnosed. • Many epidemiological surveys have shown that the number of allergic patients in Europe and other developed and developing countries is increasing dramatically. A notable proportion of individuals with respiratory allergy in Europe are underdiagnosed, undertreated and dissatisfied with their treatment and among these most are elderly people. • Recently there has been a large increase in knowledge about the immunological processes that play a role in allergic diseases and about environmental exposure (irritants and allergens), a tendency that will continue, and this gain in knowledge has led to changes in diagnostic and therapeutic possibilities (component-resolved diagnosis, new forms of immunotherapy), and to a better understanding of the role and the possibilities of primary and secondary prevention (benefits and risks of allergen avoidance, infant feeding, application of pro-/prebiotics, risk of tobacco smoke, role of epigenetics).
Table 1 Allergy in the elderly: a panoramic view
• The issue of the health of the elderly has become a topic in modern medicine as older people represent the most rapidly expanding part of the population and reached the highest levels in the history • Immediate hypersensitivity (type I) is the most common immunological disease. It represents the most widespread and fast growing chronic human health condition in people aged 15th years and older in industrialized countries. About 25% of the population is affected, with manifestations which range from only irritating to severe life-threatening conditions • Allergic diseases are mostly caused by inhalant allergens, in particular mold and pollens and climate changes modify their deployment and amount • The onset of allergic diseases in older people is driven by immunosenescence, the changes of immune function observed with aging and tissue structure modifications typical of advanced age. Concurrent diseases, drug polytherapy and adverse drug reactions could be frequent complications • The contribution of epigenetic regulation to allergic diseases is a crucial topic. Discovering and validating epigenetic biomarkers linking exposure to allergic diseases could help to a better definition of risk, prognosis, response to therapy and development of novel treatments • Collaborative translational and interdisciplinary research is needed to identify new biomarkers of disease, accounting for the unique phenotypic makeup of the elderly allergic and for the immunological and physiological changes associated with the natural process of aging that affect diagnosis and management
Table 2 key issues
Figure 1. Age-related changes underlying allergy in the elderly. The onset of allergic diseases in the elderly is driven by cell aging at large and by immunosenescence and tissue structure modifications typical of advanced age. The figure illustrates the age-related functional and structural changes in upper and lower airways, skin and gut underlying the onset of allergy reactions in the elderly. ACE = angiotensin-converting-enzyme; CHF = chronic heart failure; COPD = chronic obstructive pulmonary disease; GERD = gastroesophageal reflux disease; NSAIDs = nonsteroidal anti-inflammatory drug; PPI = proton pump inhibitors.
• New and detailed epidemiological research is needed. Most studies on allergy prevalence were conducted in childhood than in adulthood, when immune-senescence, concurrent diseases, polytherapy and adverse drug reactions could be frequent confounding factors and could potentially impact on diagnosis, assessment and management. • Research in the field needs to focus on both human and animal model systems to investigate the impact of the aging process on the immunologic pathways underpinning allergy and its different facets. • Particular attention must be paid to diagnostic tools. The same diagnostic tests and clinical findings applied in young are used to diagnose allergy in older people, but interpreting clinical data becomes more difficult in the elderly. Future research should also address the identification of possible new biomarkers for early diagnosis and prognosis in the elderly. While new standardization of old diagnostic procedure is essential in a geriatric setting. • The contribution of epigenetic regulation to allergic diseases is another crucial topic that needs to be further investigated. The identification of more specific biomarkers and key pathogenic molecules will add valuable insights into molecular networks operative in allergic diseases in the elderly. Moreover, it could be the base for both discovering potential mechanisms linking environment and epigenetics, and for modern therapeutic approaches. Indeed, new treatment strategies must be developed: translational investigation of novel therapeutic targets must be pursued.
Table 3 Future perspective
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