Spring 2021 Newsletter
By Stacy E Harris, DNP, APRN, ANP-BC
School of Nursing
University of Central Arkansas
Rhinitis, commonly known as inflammation of the nasal mucous membranes, affects adults of all ages. There are two major categories of rhinitis: Allergic rhinitis (AR) and Non-allergic rhinitis (NAR). Most people are familiar with the symptoms of AR: sneezing; itching, watery eyes; conjunctival redness; and rhinorrhea, a watery nasal discharge. The most typical course of AR is exposure to a seasonal (spring or fall) allergen, such as tree, grass, or weed pollen. This type of rhinitis begins to emerge in adults around in the late teens and peaks in the 5th decade of life. Non-allergic rhinitis presents with similar symptoms: rhinorrhea and nasal congestion, but without the sneezing or eye symptoms. This type of rhinitis affects more adults and older adults (Yilmaz & Corey, 2006). Non-allergic rhinitis has many subtypes: vasomotor, atropic or geriatric non-allergic, rhinitis medicamentosa, drug induced, hormonal, gustatory and infectious (Kennedy-Malone, Martin-Plank and Duffy, 2019). This article will focus on NAR, specifically “geriatric “ sometimes known as physiologic rhinitis, the most common type effecting older adults.
Physiologic age-related changes to the nose are well known. It is common for an older adult patient to verbalize a decrease in the ability to smell. Besides olfactory changes, several other physiologic changes occur in the nose. The tough structures of the nose atrophy. This causes the nose to lengthen and the nasal tip to begin to droop. When the supporting upper and lower cartilages weaken, the nasal passages begin to narrow and produce a feeling of or an actual obstruction. Previous nasal injuries of youth or septal deviation confound the narrowing. These changes explain why many older adults complain of nasal obstruction. The vascular bed of the nose undergoes microvascular changes. The turbinates receive a decrease in blood flow which reduces the size of the turbinates and predisposes the nose to dryness and crusting. The changes in the nasal mucosa are impactful too. The nasal mucosa goblet cells increase, and the function of the submucosal serous glands decrease. The submucosal glands are responsible for watery, clear, thin mucous. The goblet cells produce a thick, tenacious mucus. Both types of secretions are responsible for humidifying the air we inhale and mostly importantly, trapping and removing potential organisms from entering the respiratory tree. These mucosal changes explain why many adults complain of daily thick, mucus production and have frequent throat clearing (Jordan and Mabry, 1998; Yilmaz & Corey, 2006).
Older adults may present to their healthcare provider with complaints of “sinus trouble” characterized by thick post-nasal drainage, nasal congestion, and frequent throat clearing. However, differentiating these symptoms from the typical symptoms of sinusitis (post-nasal drainage, nasal congestion, face pain and pressure, fever, headache) is not always clear to the provider. This can lead to misdiagnosis and unneeded treatment. The older adult may be treated inappropriately with antibiotics or first-generation histamine blockers when more supportive treatments are indicated.
There are numerous pharmacologic and nonpharmacologic ways to improve the older adults’ nasal complaints. First, the provider must rule out any allergic or infectious causes for the rhinitis. Once an accurate diagnosis of geriatric rhinitis has been made, a through explanation of the age-related nasal changes must be shared with the patient. This may not be the answer the patient is expecting but it is needed for long term management. Humidification is the key to improving geriatric rhinitis. Increasing moisture inside the nose is the main goal. This can be done by increasing moisture in the home, specifically the bedroom, and using over the counter (OTC) saline nasal spray as much as 4-6 times per day. There are many types of delivery methods, such as nasal douching, water-picks or Neti pots to inject saline into the nasal mucosa. Pure sesame oil has been shown to aid in nasal dryness (Jordan and Mabry, 1998)
Pharmacologic treatment including using mucous-thinning agents such as OTC guaifenesin has been shown to improve symptoms in patient with complaints of thick secretions. Topical and systemic decongestants can improve congestion but should be avoided due to the exacerbation of nasal mucosa dryness. Also, using first generation antihistamine (diphenhydramine, hydroxyzine) to treat nasal congestion should be avoided in older adults due to the sedating and anticholinergic activity. Newer second-generation antihistamines (loratadine, cetirizine, fexofenadine) are safe to use in older adults particularly if patients suffer from some allergic rhinitis too. Inhaled nasal steroids (Flonase, beclomethasone) are appropriate and safe in older adults suffering from allergic rhinitis, but long term can increase nasal dryness (Yilmaz & Corey, 2006).
Little research has been published regarding geriatric rhinitis. However, providers can improve the quality of life in the older patient by thoughtful education on age-related nasal changes. Also informing the older patient about OTC medications to avoid while providing them with simple treatments to increase humidification will ultimately improve rhinitis in the geriatric population.
Yilmaz, A. A. S. & Corey, J. P. (2006). Rhinitis in the elderly. Current Allergy and Asthma Reports, 6:125-131.
Jordan, J. A., & Mabry, R. L. (1998) Geriatric rhinitis: what it is and how to treat it. Geriatrics. 53(6) 76-80. Kennedy-Malone, L., Martin-Plank, l., & Duffy, E. (2019) Advanced practice nursing in the care of older adults, 2nd Ed. FA Davis.