In early June, Donna Bilgore Robins stood on a patio in Beaver Creek, Colo., under a crystal-clear blue sky and tried to catch her breath.
She couldn't.
With mountain vistas around her, Robins felt as if she was drowning. She gasped for air hungrily again and again.
Robins knew all too well what was happening. Something -- some kind of plant? something in the mountain air? -- had triggered her asthma, a lifelong condition.
She also knew she was in danger, even with a rescue inhaler at hand. "I don't slowly get sick -- I just drop," said Robins, who with help from her husband was soon on the road to seek medical attention over 100 miles away at National Jewish Health in Denver, a leading hospital for people with respiratory conditions.
For people like Robins, 63, diagnosed with asthma as a young child, aging with this condition can be fraught with difficulty.
Death rates for older adults with asthma are five times that of younger patients, according to a new review of asthma among seniors. And medical complications are more common.
As the prevalence of asthma climbs in people 65 and older, more seniors will grapple with its long-term impact. Estimates vary, but up to 9 percent of older adults are thought to have asthma -- a respiratory condition that inflames the lungs and interferes with breathing.
With the advance of years, physical changes take a toll. People's lungs become less elastic, their chest walls more rigid, and the muscles that help power the respiratory system less strong, exacerbating breathing problems, explained Dr. Michael Wechsler, a professor of medicine and co-director of the Cohen Family Asthma Institute at National Jewish Health, and co-author of the new review.
Compromised vision, fine motor coordination and cognition can make it difficult for seniors to use inhalers correctly. Fewer than half of older adults with asthma do so, some research suggests, and many people on fixed incomes can't afford these expensive medications, which can cost up to $300 a month.
With age, the immune system's response to inflammation -- a key contributor to asthma -- becomes blunted, making it harder to fight off infections that can trigger asthma exacerbations.
Other biological changes, notably shifts in patterns of inflammation, may reduce older patients' response to inhaled corticosteroids such as Advair or Flovent -- medications that need to be taken daily to control inflammation.
"Either patients have more inflammation and they need higher doses or they have a different kind of inflammation and steroids may not work as well," Wechsler said.
Then, there are other medical conditions such as chronic obstructive pulmonary disease, congestive heart failure and heart disease that can coexist with asthma and complicate diagnosis and treatment.
Research shows that older adults tend to prioritize other medical conditions over asthma, perhaps because they minimize symptoms and underestimate their impact, suggested Miichael Wolf, a professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago.
"Older adults have a tendency to ignore difficulties with breathing," noted Dr. Rachel Taliercio, a pulmonologist at the Cleveland Clinic. "Instead of thinking this could be asthma, they think, 'I'm overweight, I'm out of shape, I'm getting older, and this is normal at this time of life.'"
Physicians can be slow to recognize asthma as well. "In the elderly, sometimes the only manifestation of asthma is shortness of breath and a cough," said Dr. Kaiser Lim, a pulmonologist and critical care specialist at the Mayo Clinic in Rochester, Minn. "But some primary care doctors kind of shrug off these symptoms."
Up to half of older adults with asthma haven't been accurately diagnosed, according to a review article in The Lancet. That includes people with adult-onset asthma who first developed this condition in middle age or later.
Wechsler tells of a patient who started coughing, wheezing and becoming short of breath in his 60s. Diagnosed with chronic obstructive pulmonary disease by two physicians, he was given a rescue inhaler but was not treated for ongoing airway inflammation. When the patient failed to improve, he went to National Jewish, which performed a round of sophisticated tests that indicated asthma.
"I prescribed a high dose of inhaled corticosteroids in combination with a long-acting bronchodilator, and he came back a month later and said, 'I don't know what the hell you gave me, doctor, but I haven't breathed this well in five years.' "
When Robins arrived in Denver, with an acute asthma exacerbation, her treatment was far more difficult.
Diagnosed with severe allergies and intractable asthma as a child, she'd lived full time in a dormitory at National Jewish from age 6 to 8, along with a group of youngsters with life-threatening variants of these conditions.
Robins learned to hide the severity of her illness in the years that followed. "Everyone knew I had asthma, but no one except a few close friends and family knew how bad it was," she recalled.
Youth afforded her a form of protection. "Even when you have setbacks, there's a vigor and a lust for life when you're young that will not be denied," Robins said. "You feel you're invincible, and even if you don't feel great, it's like, so what, I'll get better."
Despite asthma exacerbations that required hospitalization, Robins managed fairly well until she reached her 50s. "Things became very different as I got older," she explained. "I couldn't recoup from exacerbations as easily. The episodes were longer. The periods where I felt decent were shorter."
In Denver, Robins hoped she'd stabilize in a few days. Instead, she stayed nearly seven weeks, being treated with a higher dose of intravenous steroids than she'd ever had, before returning home to Florida in late July.
Toward the end of her treatment at National Jewish, Robins reflected on growing older with a serious chronic illness. "I used to feel like I was in control of my asthma," she said, "but I'm not in control anymore, and that has been very difficult to accept."
"I know now that I can't get away with putting this on the back burner, the way I did when I was younger," she continued. "You realize you have to adjust to a different lifestyle, and if you're not smart about what you can and can't do, you'll pay the price."
Acknowledging her vulnerability after years of toughing out being sick is an ongoing challenge. "It's empowering to know that you're doing as much as you can to be healthy. But it's scary at the same time," Robins said. "It doesn't mean you can change things. But you're doing what you can."