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are apparent in the United States, Western Europe,
and even countries with younger age distributions
such as China [1]. Hence, we need to accelerate
our understanding of the effects of aging and both
normal physiology and disease. Given these demographic shifts, physicians caring for patients with
upper airway diseases must be ready to address the
special needs of this expanding group of patients.
All organ systems are affected by aging in a myriad of ways, making this a population with a signicant medical need and a signicant challenge
for clinicians.
The study of geriatric medicine has its origins
in training programs dating back to the 1970s.
Programs such as the Department of Veterans
Affairs Geriatric Research, Education, and Clinical
Centers (GRECC) were organized to increase
translational research in geriatric medicine and
promote the advancement of clinical care for older
people [2]. The creation of the National Institute
on Aging (NIA) in 1974 and efforts of private
organizations (e.g., the American Federation for
Aging Research [AFAR]) have resulted in
increased efforts to understand aging and disease
and treat or mitigate its effects. Parallel efforts in
Otolaryngology-Head and Neck surgery have
begun (e.g., the [3]) and more are needed in specic areas such as Rhinology if we are to meet the
needs of our older patients. However, our eld still
needs more research in and clinical focus on oto-
laryngologic manifestations of aging and the relationship between aging and disease.
One key principle of geriatrics is to prioritize
equally prolongation of life and quality of life.
Here we address how the anatomy and function
of the nose change with age, important diseases
of the nose in older adults, and treatment methods allowing us to provide the best rhinologic
care for older patients.
14.2 Anatomical Changes
oftheAging Nose
14.2.1 Anatomy
Aging affects all portions of the face including
the nose, starting with its surface cover, and the
skin (Figs.14.1 and 14.2a, b) [4]. Thinning of the
epidermis and decreased collagen production
cause the skin to lose its elasticity. This may
affect the development of rosacea and rhinophyma, which are more common with age.
Anatomical changes in older adults that affect the
structure and function of the nose include thinned
nasal skin, weakened nasal cartilages, weakened
brous attachments between upper and lower lateral cartilages, and ptosis of the nasal tip [5].
Edelstein and others have found that the anatomy
of the nose undergoes several changes with age,
Fig. 14.1 (a, b) Two examples of the geriatric nose, prole and frontal views. Note the skin changes and external
structural effects of aging
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a b
Fig. 14.2 (a, b) Two examples of the geriatric nose, prole and frontal views. Note the skin changes and external
structural effects of aging
including a decrease in the nasolabial angle, a
decrease in the height to length ratio of the nose,
weakening/separation of the upper and lower
nasal cartilages, decreased glycosaminoglycans
causing increased porosity of nasal cartilage,
retraction of the nasal columella, resorption of
bone resulting in maxillary hypoplasia, atrophy
of collagen bers, and attenuated and fragmented
broelastic attachments [6–9]. These changes
make the nose appear longer, deprojected, and
underrotated [10]. Some studies have revealed
increased cross-sectional area at the internal
nasal valve in older adults. For example, although
it is difcult to objectively assess patency at the
internal nasal valve, Kalmovich etal. attempted
to measure endonasal geometry changes in the
geriatric population. Using acoustic rhinometry,
they found that there was a statistically signicant gradual increase of endonasal volumes and
minimal cross-sectional areas with age, except in
the oldest group of men over 80years of age [11].
Studies utilizing computed tomography (CT)
volumetric analyses have corroborated these
ndings and demonstrated that intranasal cavity
volumes signicantly increase with old age [12,
13]. Similarly, Kim et al. demonstrated an
increased cross-sectional area at the internal
nasal valve associated with age, but no difference
in nasal resistance before and after decongestion
in any age group greater than 20years old, sup-
porting their hypothesis that the increased area is
related to changes in the non-erectile structures
of the nose. In general, however, the sum result is
a restriction in nasal airow, particularly at the
nasal valve region, an important site of nasal
resistance. In summary, the structural changes
seen in the aging nose may result in nasal obstruction and abnormal airow.
Anatomic changes in the nose are, in part,
related to changes in the cartilaginous structures
as well as the weakening of soft tissue attachments. The biochemical composition and
mechanical properties of cartilage change with
age, resulting in a tendency to collapse. For
example, there is a decrease in the glycosaminoglycan content of nasal septal cartilage with
increasing age, resulting in stiffening with
decreased uid ow through the tissue.
Additionally, there appears to be a slight increase
in hydroxyproline content with increasing age.
These changes are similar to those seen in articular cartilage during the aging process. Although
the physical stresses on articular cartilage are
much different than that of septal cartilage, the
similarity of their biochemical changes may represent systemic effects on cartilage with age [14].
Indeed, histological analysis of nasal cartilage
showed that increased age signicantly correlated with abnormal reductions in proteoglycan
content and decreased chondrocyte activity [15].
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Riedler et al. further demonstrated that glycosaminoglycan content, cell size, and cell density
found in septal cartilage all signicantly decrease
with increasing age [16]. Using image analysis of
300 men in Turkey, mean nasal bridge length was
the longest in the oldest age group as was the
mean nasal tip protrusion [17]. There were notable differences in nasal width and root width
between age groups (p<0.05). Similar ndings
have been identied in other studies, and these
make affect surgical decision-making during rhinoplasty or other reconstructive or airway procedures [18]. Differences in facial aging can be
analyzed by surface scanning and have been
shown to be similar in men and women, but
divergent after menopause [19]. Such techniques
conrm direct measurements of nasal changes
with aging [20] in diverse populations [21].
This information leads to two practical considerations for clinical practice. First, anatomic
changes are likely to affect airow through the
nose in older patients, resulting in restrictions
that may cause dryness, irritation, and obstruction. These problems may exacerbate existing
conditions and contribute in a large way to patient
symptoms.
Second, older adults may seek septorhinoplasty to alleviate such functional problems and
also for cosmetic rejuvenation. Knowledge of
age-related anatomic changes in the nose necessitates specic surgical considerations for performing such operations [22]. Also, careful
consideration must be given to these patients as
they may have underlying signicant medical
comorbidities, such as hypertension, coronary
artery disease, or diabetes, placing them at higher
risk for elective surgery. Cochran etal. noted that
many older patients at the time of rhinoplasty had
ossied septal cartilage, making it more frequently necessary for auricular or costal cartilage
to be harvested [5], potentially lengthening operative time. Medical and anesthesia clearance is
prudent prior to proceeding with elective surgery
in any older patient and several guidelines exist
to make this determination [23, 24]. Nevertheless,
nasal surgery in older subjects can be safe and
effective when approached carefully [25]. As
with all rhinologic patients, psychological moti-
vation for the procedure needs to be assessed.
Geriatric patients frequently have to deal with
signicant life issues, including the death of
loved ones, lack of social support, nancial challenges, and struggles with quality of life. One
must assess whether older patients have taken
ample time to consider any cosmetic surgery
prior to proceeding. Most importantly, assessment of the functional consequences of rhinoplastic procedures on this patient subset is critical
to maintain airow.
14.3 Physiological Changes
withAge
Many subtle changes in the physiology of the
nose occur over time and may lead to symptoms
and/or disease in older adults. Although we are
far from fully understanding comprehensively
how the nose changes over time, further study of
the known physiological changes will help us to
provide better medical and surgical treatment
regimens for these patients.
14.3.1 Alterations inNasal Function
Nasal dryness is a frequent complaint in older
patients. This condition presents with crusting,
irritation, epistaxis, or obstruction. Several etiologies have been suggested to cause this condition, including mucosal and glandular atrophy,
vascular changes which reduce nasal humidication, and medication use (e.g., antihypertensives,
which affect vascular regulation in the nose, or
rst-generation antihistamines, which inhibit
cholinergic responses in the nose). Structural
changes in the nose, such as increased intranasal
cavity volume, may also contribute by causing
turbulent airow which dries the mucosa.
The mucosa itself is altered with age.
Schrödter performed biopsies of the middle turbinate in 40 subjects of varying ages and found
signicant atrophy of the epithelium in the older
subjects (Fig.14.3) [26]. This analysis found thin
epithelium and also increased thickness of the
basement membrane. Also, the percentage of
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Fig. 14.3 Endoscopic view of a geriatric patient with
atrophy of endonasal mucosa
normal ciliated respiratory epithelium declined in
the older subjects. Similar studies using electron
microscopy are consistent with these ndings
[27]. Increased expression of caspase 3, an apoptotic marker, indicates that part of the defect may
be in the ability of the epithelium to renew itself,
and there are other functional aspects of the epithelium (e.g., toxin neutralization) that may be
affected [28]. This matches what has observed in
nasal endoscopy in clinical practice: a thinner,
atrophic epithelium.
Another major alteration affecting this symptom is in one of the main functions of the nose:
the ability to warm and humidify air [29]. The
two major mechanisms leading to the alteration
in nasal conditioning capacity (NCC) are changes
in the nasal mucosal temperature (NMT) and the
volume of the nasal cavity. During inspiration of
air, water evaporates from the nasal mucosa to
condition inspired air, leading to heat loss and,
consequently, a decrease in NMT [30].
Lindemann found that using invivo air temperature and humidity measurements at the nasal
valve and the region just anterior to the head of
the middle turbinate, both temperature and
humidity values were signicantly lower in older
subjects (mean age 70 years) compared to
younger subjects (median age 27years) [31]. The
decrease in NMT, which has been suggested to be
161
partly caused by decreased nasal mucosal blood
ow [32], could be demonstrating an agedependent effect due to the fact that blood ow to
the nasal mucosa has been shown to decrease
with age [33]. Additionally, nasal volumes in the
Lindemann etal. study appeared to be larger in
the older age group. Increased turbulence of airow may be one result causing the sensation of
nasal obstruction despite larger space (paradoxical nasal blockage). Endonasal geometries are
indeed enlarged in older subjects [11–13]. This
suggests that NCC in older subjects is compromised. When analyzed via CT imaging, nasal
cavity volumes also increased markedly with
age, in analyses that adjusted for sex and head
size [12]. Thus, a lower ability to warm and
humidify air may be present in older subjects,
potentially affecting lower airway function. This
may also contribute to increased nasal dryness in
older adults.
We may take some analogy from changes in
the oral mucosa. As with the nose, the lubrication
of the oral cavity changes with age. Although
there should not be a decrease in saliva production with age, unless altered by medications or
systemic conditions, there are changes in the consistency of the saliva, including a decrease in
mucin concentration and decreased secretion of
protective IgA antibodies [34]. This may lead to
increased caries, periodontal disease, and poorer
nutritional status.
A second altered physiological function with
age is mucociliary clearance. Ciliary beat frequency is decreased in vitro in nasal epithelial
cells taken from patients older than 60years of
age [35]. Ho et al. also found decreased nasal
mucociliary clearance by the crude saccharin
clearance test and the more sensitive measure of
ciliary beat frequency by a photometric test [36].
Using the same saccharin clearance test, Paul
et al. also found decreased nasal mucociliary
clearance among older women compared to
younger women [37]. However, there is likely
signicant interindividual variability in this phenomenon since Sakakura etal. showed that 70%
of patients older than age 60 retained saccharin
transport times comparable to their younger
counterparts [38].
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Age-related decline in nasal mucociliary
clearance can be attributed to many possible
causes. Multiple studies have demonstrated that
oxidative stress can decrease ciliary beat frequency [39, 40]. The mechanism by which oxidative stress slows down ciliary beat frequency may
be due to the upregulation of PKCε signaling. In
addition to oxidative stress, trauma, damage after
infection, or exposure to toxins have also been
proposed to reduce ciliary function [36]. Diabetes
and hypertension, both increased in prevalence in
older subjects, are also associated with the
decreased ciliary function [41]. In summary, if
the cilia are not moving as rapidly, this can lead
to symptoms of mucus buildup, rhinitis, inammation, or infection, from the persistence of
organisms and molecules trapped in the mucus
layer (Fig.14.4). Hence, both the structural components and the function of the epithelial lining
of the nose in older patients demonstrate signicant changes with age that may affect airow,
mucus quality and production, and mucociliary
clearance.
A third way nasal function is altered with age
is via dysregulation of vascular responses in the
nose. Nervous control of vascular tone in the
nose is important in the regulation of the critical
functions of the nose, to warm and humidify the
air, and also may affect diseases involving vasodilation such as allergic and nonallergic rhinitis.
Tillmann found that vascular regulatory responses
are reduced with age [42]. Fifty-two subjects
were acclimated to the laboratory environment
for 5min and baseline measures of perfusion by
optical rhinometry were performed. The subjects
were then moved to a supine position for 30min,
which should alter blood ow. Older subjects had
more rapidly increased perfusion but did not
return to baseline in contrast to younger subjects.
This study suggests that autonomic control of
nasal blood ow is altered in older subjects,
potentially affecting humidication (as described
above) and the other functions of the nose discussed above. Using liquid crystal thermography
exhalation monitoring to measure the nasal cycle,
Doty found decreased regulation of the nasal
cycle in older adults [43]. Overall, the proportion
of subjects exhibiting the alternating rhythmicity
associated with the classic nasal cycle decreased
with age. No association was present between
nasal cycle parameters and scores on the minimental state examination (MMSE). The results
suggest that the classic nasal cycle may be a
marker for age-related central nervous system
changes. These phenomena may also be important in nonallergic rhinitis, which is relatively
common in older adults.
Fig. 14.4 Endoscopic view of a geriatric patient with
thickened nasal mucus, a common complaint in this
patient population
14.3.2 Olfaction andNasal
Sensitivity
Olfaction, mediated by the olfactory nerve, and
sensitivity of the nose, controlled by the somatosensory system and mediated by the trigeminal
nerve, both decrease with age. In 1994, the
National Health Survey determined that 3.2 million people, or 1.65% of adults in the United
States, had self-reported chronic chemosensory
problems involving smell and/or taste; 40% of
these adults were aged 65years and older, with
an exponential increase seen with increasing age
[44]. Using a validated odor identication test,
Murphy etal. found that among adults over the
age of 53 the prevalence of olfactory impairment
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was 24.5% [45]. Prevalence rates among adults
between the ages of 80 and 97 reached as high as
62.5% [45]. Additionally, adults over 65years of
age have approximately half the intensity of
smell and irritant sensation as subjects between
the ages of 18 and 25 [46]. In another study, the
sensitivity of the nose was assessed by providing
tactile stimulation with monolaments of progressively larger sizes. Adults 50–65years of age
required signicantly less stimulation to detect
the sensation of the monolament as compared to
adults aged 66 and above [47].
In order to understand how the olfactory system is altered with age, we rst need a better
understanding of the normal olfactory system.
The olfactory mucosa is distributed along the
upper portion of the nasal septum, below the cribriform plate, and along the medial aspect of the
superior turbinate, as well as along the roof of the
middle turbinate [48]. On histologic examination, there is a patchy distribution of olfactory
epithelium, which becomes increasingly sparse
with aging because olfactory epithelium becomes
replaced with respiratory epithelium over time.
In support of this nding, several studies have
demonstrated increased respiratory metaplasia of
the olfactory epithelium with increased age in
both mice and humans [49–51]. Other age-related
changes in the olfactory epithelium also include
increased thinning, as demonstrated in mice
models [52, 53]. Robinson etal. demonstrated in
a murine model that there is an increase in apoptotic gene expression of olfactory neuron receptors with increasing age, likely resulting in
increased cell death [54]. Additionally, Ueha
et al. demonstrated that there was a decline in
mature and immature olfactory receptor neurons
in the aged olfactory mucosa of mice [55]. Over
time, even small toxin exposures, including
heavy metals, such as manganese, cigarette
smoke, or volatile chemicals, may cause harm to
the olfactory epithelium [56]. In mice it has also
been seen that following chemical damage, there
is decreased regeneration of the neuroepithelium
of the olfactory bulb with increasing age [49].
Because olfactory stem cells regenerate with
time, any alteration of this turnover may also
contribute to age-related olfactory loss, either
from insult or from inherent aging. Several studies corroborate the suggestion that the basal proliferation of cells in damaged and undamaged
epithelium decreases with age [52, 55, 57, 58].
All of these mechanisms may contribute to a
decrease in the function of the olfactory system
as one ages.
Age-related olfactory loss (presbyosmia) is an
important public health problem worldwide [44,
45, 59–63]. In the USA, olfactory complaints
from the approximately 14 million individuals
over age 55 who are affected lead to over 200,000
physician visits annually [64, 65]. This sensory
impairment of aging affects critical functions
such as nutrition [66–69], sensation of pleasure
[70], detection of environmental hazards [71],
mood, cognition, behavior [72–74], sexuality
[75–77], quality of life [78], and general wellbeing [79], and therefore, it poses a profound
burden on older adults. Indeed, up to one-third of
older subjects report dissatisfaction with their
ability to smell [80], and ~50% are unable to
detect the standard warning odor in natural gas
[81]. Importantly, the decline in olfaction has
been linked to several neurodegenerative conditions, such as mild cognitive impairment, dementia (Alzheimer’s disease), and neuromotor
disorders (Parkinson’s disease) [82–91]. If this
link involves shared genetic or environmental
risk factors, then understanding the pathogenesis
of presbyosmia may have broad implications for
a wide array of problems, especially regarding
other sensory impairments of aging [92]. Thus,
the olfactory sensory loss is related to factors that
are critical to the physical well-being, social
function, and quality of life of older adults.
Because olfaction declines over time, the clinical
impact will increase as our population ages.
Acquired chemosensory complaints are also
important in Otolaryngology. In addition to traumatic injury or post-viral olfactory loss, cancer
chemotherapy can negatively impact olfaction
[93–95]. Furthermore, t older patients are more
susceptible to olfactory decline caused by chemotherapy agents. Because the olfactory epithelium regenerates, one cause of this could be a
decrease in stem cells with age in the olfactory
mucosa, either inherently or after stimulation of
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regeneration by injury. Indeed, telomere shortening has been observed in the regenerative
response to chemical injury of the olfactory epithelium in a mouse model, providing evidence
that telomere shortening impairs the regenerative
capacity of this tissue [96]. So, aging may lessen
the ability of the olfactory mucosa to survive
respiratory insult by toxins. Olfactory decline
among chemotherapy patients can have detrimental health consequences. For example,
patients undergoing palliative chemotherapy
treatment for cancer frequently had complaints of
dysgeusia and sensitivity to odors while undergoing treatment. Those patients with severe complaints were found to have lower calorie intake,
increased weight loss, and lower quality of life
scores, than in patients with less severe complaints [97].
There are many systemic causes of chemosensory dysfunction. Olfactory decits are seen in
neurologic disorders, such as Alzheimer’s disease, Huntington’s disease, Parkinson’s disease,
and Korsakoff’s psychosis, all of which generally
affect the elderly. It is important to counsel
patients with hyposmia or anosmia, as they may
be unaware of noxious materials in their surroundings. They should obtain natural gas detectors if they have natural gas stoves, ovens, or heat
at home as they may not be able to detect a fuel
leak. Additionally, they should be aware of dates
on food products, label leftovers, and dispose of
foods reaching their expiration dates to avoid
food spoilage. Lastly, smoke detectors should be
checked regularly for function and efforts must
be maintained to promote nutrition.
14.3.3 Immunosenescence
Immunosenescence is the term used to describe
the decreased function of the immune system
with age. Both the adaptive and innate immune
systems are impaired [98, 99]. Decreased immune
response is believed to contribute to increased
infections, autoimmune diseases, and cancers in
the elderly population.
There are several effects of immunosenescence in the nose. IgA is an immunoglobulin that
is secreted along the respiratory and gastrointestinal tracts, where it helps to neutralize a variety
of pathogens. Alford demonstrated that IgA levels can be measured in nasal secretions and comprise approximately 38% of nasal wash proteins
in normal patients. He also showed that IgA levels in nasal secretions decrease signicantly with
age [100]. In a murine model, it has been shown
that mucosal immunity wanes prior to systemic
immunity in studies where vaccination to cholera
toxin was performed by mucosal and subcutaneous methods, respectively, in different ages of
mice [101].
IgE levels also decrease with age. Mediaty
and Neuber studied 559 individuals with atopic
dermatitis, allergic rhinitis or asthma, and insect
allergy. In all patients, except those with atopic
dermatitis or those with high total serum IgE
>300 kU/L, total and specic serum IgE levels
were signicantly decreased in patients aged
greater than 60 compared to their younger counterparts. They hypothesized that there may be
more robust mechanisms in atopic dermatitis or
conditions resulting in high serum IgE that lead
these patients to have a more persistent response.
Additionally, the type of atopic disease and the
age of disease onset may impact IgE levels [102].
Although not specic to the nose, there are
many age-related defects in T cell functioning as
well. As age increases, the thymus involutes, thus
leading to decreased production of naïve T cells
and consequently diminished ability to ght
infection [103, 104]. T cell diversity signicantly
diminished among the older adults in their 70s
and 80s, thus reducing their ability to respond to
new antigens [105]. Additionally, multiple studies have shown an increased propensity to shift
from a Th1 to Th2 subtype with increasing age
[106, 107].
Immunosenescence is poorly studied in the
upper airway but one can extrapolate ndings
from the lower airway [108]. In that lung, there are
several immune alterations that might facilitate the
persistence of asthma, a related airway disease to
rhinitis. These include changes in airway neutrophil, eosinophil, and mast cell numbers and function as well as altered antigen presentation,
decreased specic antibody responses, and altered
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cytokine proles. The sum of these changes might
affect susceptibility to upper respiratory tract
infections. Indeed, it has been shown that the incidence of nonallergic rhinitis, an inammatory condition affecting the nasal mucosa, increases with
age [109, 110]. In addition, studies have found a
high prevalence of nonallergic rhinitis among the
elderly population [111, 112]. Although the specic mechanisms underlying the link between
immunosenescence and the development of rhinitis in the elderly have not been fully elucidated, it
has still been hypothesized that immunosenescence plays some important role in the etiology of
the condition [113].
In summary, this is a complex area in which
there is little data on the nose specically, but
age-related changes in immune function are
likely to impact nasal physiology and disease in
older patients.
14.4 Geriatric Rhinitis
14.4.1 Overview
Rhinitis is a pervasive complaint in physicians’
ofces. It is estimated that 20–40% of subjects
living in Western countries are affected by rhinitis. Rhinitis may be allergic or nonallergic in
nature, with approximately 50% of rhinitis
patients belonging to each group [114]. These
forms of rhinitis affect older subjects as well,
though because allergy wanes with age, nonallergic rhinitis tends to predominate [115]. There
are many potential causes of rhinitis in the geriatric population. Edelstein noted that six nasal
complaints were more prominent in older adults:
nasal drainage, postnasal drip, sneezing, coughing, olfactory loss, and gustatory rhinitis [6].
Regarding the quality of life in an Italian study,
geriatric patients with rhinitis underwent clinical
evaluation and responded to the Rhinasthma
questionnaire [116]. All patients also underwent
skin prick testing, measurement of total IgE level,
and nasal cytologic analysis. In the older patients,
the epithelial to goblet cell ratio was decreased.
The quality of life in older people was more
impaired than in young adults. These authors
concluded that quality of life is more heavily
impaired compared with young adults. In concordance with this conclusion, Song etal. found that
among an elderly population, rhinitis was signicantly associated with decreased quality of life
[112]. However, one study showed that nasalspecic quality of life measures shows no deterioration in older subjects and do not therefore
correlate with changes in nasal function [117].
Further investigation of this topic is warranted to
elucidate this paradox.
14.4.2 Allergic Rhinitis
Allergy is dened as an immediate type IgEmediated response to an allergen exposure, where
IgE is bound to mast cells and its attachment to
an allergen results in degranulation of the mast
cell with histamine release. The diagnosis of
allergy can be conrmed by skin, in vitro, or
provocation testing. The Allergic Rhinitis and its
Impact on Asthma (ARIA) consensus categorizes
allergic rhinitis as either intermittent allergic rhinitis (IAR) or persistent allergic rhinitis (PAR).
IAR denotes that symptoms are present less than
4days per week or less than 4 consecutive weeks
per year. PAR indicates that symptoms are present greater than 4 days per week and for more
than 4 consecutive weeks. These can be further
categorized as mild or moderate/severe based on
the impact of quality of life [118–120].
Although allergy is well studied, the majority
of studies performed to date involve either the
pediatric population or young adults. In older
adults, the incidence and prevalence of allergic
rhinitis worldwide actually decrease with age
along with atopy as detected by skin prick tests
[121–124]. Karabulut etal. noted that only 50%
of older adults have positive skin prick tests as
compared to 70% of younger adults when
matched for allergic symptoms including nasal,
eye, pulmonary, and dermatologic symptoms
[125]. Subjects from the French cohort aged
65years and over (n=352) found that respiratory
allergy is present in older people and that there is
an association between smoking and IgE level
independent of allergic reactivity to common
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allergens in the elderly, highlighting the importance of environmental factors in rhinitis [126].
Population-based studies investigating the effect
of smoking on allergic rhinitis have been conicting, but one meta-analysis determined that
smoking was associated with a signicantly
lower risk of allergic rhinitis among adults [127].
The mechanism behind this may be that those
with asthma (many of whom have allergic rhinitis) could be more likely to avoid smoking and
irritating their airways [121]. A longitudinal
study analyzed allergic sensitivity 15years after
primary testing. Skin prick test (SPT) and evaluation of serum total and specic IgE and nasal
eosinophils were conducted on 108 subjects from
Palermo, Sicily, in Italy. In general, rhinitis
symptoms tended to be milder at follow-up. All
parameters examined decreased with time.
However, the changes in rhinitis symptoms
appear to be related to changes in the nasal eosinophils, independently of SPT and specic IgE
[128]. Consistent with these results, a 10-year
prospective study of Swedish adults demonstrated that allergen sensitization signicantly
decreases with age as measured by SPTs and
serum IgE levels [129]. In addition, multiple
other studies measuring allergen-specic IgE levels showed that the elderly were signicantly less
likely to be sensitized [124, 130]. Further,
Ciprandi et al. showed that among adults with
allergic rhinitis, elderly patients had less sensitizations, less severe symptoms, and reduced IgE
levels in comparison to adult patients [131].
Thus, in general allergic disease and markers
decline with age.
In the Korean National Health and Nutrition
Examination Survey (2008–2012), 9.05 of older
adults had allergic rhinitis whereas 27.07% had
nonallergic rhinitis. Rhinorrhea was signicantly
increased in the older adults (p=0.018) and sensitization to Dermatophagoides farina was signicantly decreased (p = 0.006) [124]. In the
Korean Longitudinal Study on Health and Aging
(KLoSHA, rhinitis was more prevalent than
expected, signicantly related to impairment in
quality of life, and formed close relationships
with abdominal obesity, sarcopenia, comorbidities, and urban environments [132].
One practical consideration for these patients
is that because elderly patients frequently have
atrophic or photodamaged integument, skin testing for allergy may actually be less reliable than
in younger adults. There is evidence that there are
decreased numbers of mast cells in atrophic skin,
thereby making the possibility of a false-negative
result higher [133, 134]. In older subjects, an area
of skin that is protected from the sun can be considered for skin testing, a histamine control used
so that the most dramatic obtainable response can
be visualized, and consideration given to invitro
testing if no reliable area of skin is present [135].
Both skin and invitro testing must always correlate with patient history for accurate diagnosis.
Allergic disease in the older patient population,
as well as its biological mechanisms, have been
reviewed recently [136–138].
14.4.3 Nonallergic Rhinitis
There are many causes of rhinitis which are not
allergic in nature but can be equally bothersome
to patients and have a marked impact on quality
of life. The data regarding this phenomenon are
less developed, as compared to those for allergic
rhinitis. Studies of patients presenting to allergists have demonstrated that 23–52% of patients
with rhinitis have the nonallergic form [139]. A
population-based study from Italy demonstrated
that the ratio of the prevalence of allergic to nonallergic rhinitis was 1.4 in adults older than
64years old [121]. Further, this ratio decreased
with age, suggesting that with age, a more signicant proportion of total rhinitis cases can be
attributed to nonallergic rhinitis [121]. No good
diagnostic techniques are available to distinguish
between the subtypes of nonallergic rhinitis, but a
diagnosis is based on history and symptoms and
negative allergy testing. Further convoluting the
issue is the notion that patients can also be sensitized to allergens at any time, thereby changing
the categorization of their rhinitis. Additionally,
there is neither a set classication system nor an
international consensus on a uniform denition
for nonallergic rhinitis. Further complicating this
issue is that allergic and nonallergic rhinitis can
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coexist (“mixed rhinitis”). Interestingly, it has
been observed that 70% of patients with nonallergic rhinitis present during adulthood (age
>20), whereas 70% of patients with allergic rhinitis initially present during childhood (age <20).
There is also a greater propensity for females to
be affected, compared to males [140]. Nonallergic
rhinitis appears to be mediated in some patients
by local IgE production in the nose [141]. The
only approved treatment for nonallergic rhinitis
currently is intranasal antihistamines which are
effective in some cases. Additionally, intranasal
steroids can be useful in some circumstances and
are recommended by some expert panels [142].
Pollution exposure may explain some degree of
chronic rhinitis in older adults [143].
In summary, nonallergic rhinitis is a major disorder in older adults. Due to its complex nature,
however, our understanding of its pathophysiology
in general and specically in older adults is limited, resulting in limited ability to treat this problem effectively. A trial and error method of
different nasal medications is usually pursued.
14.4.4 Vasomotor Rhinitis
Vasomotor rhinitis is one form of nonallergic rhinitis and is often viewed as an idiopathic diagnosis that is considered when a patient has no
evidence of allergy, infection, eosinophilia, hormonal changes, or drug exposure [144].
Symptoms include nasal congestion, nasal drainage or postnasal drip, and perennial symptoms;
however, pruritus is rare [145]. There is also typically no cytological evidence of nasal mucosal
inammation [146]. Vasomotor rhinitis is a
poorly understood condition but believed that the
primary cause is autonomic nervous system dysfunction with either a diminished sympathetic
drive or an elevated parasympathetic drive causing increased nasal congestion and resistance
[142]. Upregulated expression of transient receptor potential vanilloid 1 (TRPV1) receptor could
play a role in the pathogenesis of vasomotor rhinitis [147]. Given the multiple hypotheses regarding the pathogenesis, a number of treatments are
used, including intranasal ipratropium, new tech-
niques for vidian neurectomy, and even capsaicin
for vasomotor rhinitis [148–151]. The latter is not
practical due to the side effects of pain.
14.4.5 Drug-Induced Rhinitis
Many medications affect nasal function and symptoms. Older adults take numerous medications, so
they are at high risk of this problem. When evaluating older patients with rhinitis, polypharmacy
must be considered as a cause of symptoms. First
and foremost, one must consider removing potentially offending medications rather than adding
ones. Aspirin, or other nonsteroidal anti-inammatory drugs (NSAIDs), which are commonly
taken by older adults, may cause acute inammation in the nose in susceptible patients via the inhibition of COX-1. The breakdown of arachidonic
acid to the lipoxygenase pathway is favored causing decreased prostaglandin E2 and an increase in
cysteinyl leukotrienes, which include LTC4 which
is thought to be a lead contributor to aspirin-exacerbated asthma [152]. Many other medications can
cause rhinitis in older patients. There are also neuromodulatory drugs, such as alpha- or beta-adrenergic antagonists, which work by decreasing
sympathetic tone. This causes primarily congestion but also rhinorrhea. Medications such as
clonidine and methyldopa fall within this category.
Phosphodiesterase-5 inhibitors, which are used for
erectile dysfunction, may reportedly impact the
erectile tissues of the nose and have been associated with nasal stufness and epistaxis [153].
Certain antihypertensives, psychotropic agents,
gabapentin, and hormonal treatments, including
estrogen therapy, can also cause rhinitis. Their
mechanisms of action have not been fully elucidated. Lastly, rhinitis medicamentosa can affect
adults who overuse nasal decongestants, causing
rebound nasal congestion.
When medication use is thought to be the
cause of rhinitis, a pharmacist or geriatrician may
be useful in giving recommendations about
changing the medication. Polypharmacy is frequently an issue in the geriatric population, and
these patients need close monitoring for drug
interactions, as well as adverse side effects.
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