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Curr Allergy Asthma Rep. Author manuscript; available in PMC 2014 April 01.

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Published in final edited form as:

Curr Allergy Asthma Rep. 2013 April ; 13(2): 171177. doi:10.1007/s11882-013-0342-3.

Rhinitis in Older Adults

Sharmilee Nyenhuis1 and Sameer K. Mathur2,3
1Section of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago,
IL
2Division

of Allergy, Pulmonary and Critical Care, Department of Medicine, University of

Wisconsin School of Medicine and Public Health, Madison, WI
3William

S. Middleton Veterans Hospital, Madison, WI

Abstract
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Rhinitis symptoms of rhinorrhea, congestion, sneezing, nasal/ocular pruritis, and postnasal

drainage can significantly affect the quality of life for older adults. As the US population ages, it
will be increasingly important for healthcare providers to effectively diagnose and manage rhinitis.
Rhinitis is categorized broadly into allergic rhinitis and non-allergic rhinitis. Environmental
changes and avoidance measures are a primary means of intervention. In addition, there are
several topical therapies (nasal sprays) that can be effective for symptom control.

Keywords
Rhinitis; Older adults; Elderly; Treatment; Allergic rhinitis; Nonallergic rhinitis; Aging

Introduction

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Rhinitis in its various forms can affect people of all ages and significantly affect quality of
life. In adults, it is recognized as a contributor to days off work, decreased productivity, and
significant expense in additional healthcare expenditures.1 Although these data are not
examined separately in older adults, it is expected that symptoms are similarly debilitating
and costly. Nevertheless, rhinitis is often not adequately addressed in the healthcare setting
as it does not represent a life-threatening condition and especially in the older population,
there are often other health issues that take precedence. However, an appropriate evaluation
and management of rhinitis in older adults can significantly enhance quality of life.
In a recent study by Colas et al., validated tools to assess allergic rhinitis and sleep quality
were used to demonstrate the rhinitis contribution to poor sleep quality.2 There is also
increased fatigue and social burden including embarrassment, inconvenience of carrying
tissues, rubbing eyes, and blowing ones nose that all contribute to diminished quality of
life.3 Furthermore, rhinitis is recognized as a significant risk factor for development of
frequent or chronic sinus infections. Whether the effects of rhinitis on quality of life are
different in older adults has not been examined.

Correspondence: Sameer K. Mathur, MD, PhD, Assistant Professor, Division of Allergy, Pulmonary and Critical Care, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, H4/618 CSC, MC 9988, 600 Highland Avenue, Madison,
WI 53792, [email protected].
Disclosure Dr. Nyenhuis has had travel/accommodations expenses covered/reimbursed by the American Thoracic Society.
Dr. Mathur has served as a consultant for Teva Pharmaceuticals.

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The US and global population is getting older, with the age group of over 65 expected to
double in the US by 2030 based on US Census estimates. Therefore, understanding the
management of all diseases in an older population will become increasingly important. The
burden of rhinitis in the US is estimated between 1030% of adults. The causes of rhinitis
can differ in younger versus older patients; however, the evaluation and management are
similar. As shown in Table 1, the diagnosis of rhinitis can be divided into two major
categories of allergic rhinitis (AR) and non-allergic rhinitis (NAR), which is then subdivided
into several variants. In patients above age 50, it is thought that over 60% of rhinitis is due
to NAR.4 The categorization of rhinitis is important for the management of rhinitis,
particularly with respect to providing guidance on avoidance measures. Otherwise, the same
modalities of treatment are used for treatment rhinitis with some special considerations for
use in older adults and preferred use of particular classes of medication for specific
categories of rhinitis.

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The same types of rhinitis that are common in other age populations are present in older
adults, but with different levels of prevalence. Physiologic age-related changes occur in the
nose that makes older adults more susceptible to rhinitis. These changes include an increase
in cholinergic activity and mucosal gland and collagen fiber atrophy and a decrease in
vascular elasticity, impaired mucociliary function and fragmentation and weakening of
septal cartilage. These changes result in dryness of the mucus membranes and increased
nasal congestion in older adults can contribute and exacerbate rhinitis.

Allergic Rhinitis
Allergic rhinitis (AR) is characterized by intermittent or persistent symptoms of nasal
congestion, rhinorrhea, nasal/ocular pruritis, sneezing, and postnasal drainage. These
symptoms are due to IgE mediated allergic inflammation in the nasal mucosa. The
symptoms can exhibit a seasonal pattern with allergy to pollens or mold versus a perennial
pattern with allergy to dust mite or pet dander.
The key element to the diagnosis of AR is demonstration of allergic sensitivity to allergen.
This is typically done by either skin prick testing or serum testing for specific IgE to
common seasonal (trees, grasses, molds, weeds) and perennial (dust mite, cockroach, pets)
allergens. In older adults, it has long been recognized that total IgE levels are lower
compared to younger patients.5 However, in the older adults with relatively higher levels of
IgE, there is increased atopic disease.

Non-allergic Rhinitis
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Non-allergic rhinitis (NAR) is characterized by intermittent or persistent symptoms of nasal

congestion, rhinorrhea, and postnasal drainage that are not the result of IgE mediated
events.6 The symptoms of NAR may be perennial, persistent, intermittent, seasonal
(climatic) and/or elicited by recognized triggers. These triggers include cold air, changes in
climate, strong odors, pollutants, chemicals and exercise. One or more of these triggers may
elicit the symptoms of NAR. Additionally, NAR may occur concurrently with allergic
rhinitis in 44% to 87% of people with allergic rhinitis leading to a mixed rhinitis that has
multiple triggers.7
As allergic sensitization has been shown to decrease with age, it is often thought that much
of the rhinitis in older adults is non-allergic rhinitis.8 There have been very few studies that
have examined the prevalence of non-allergic rhinitis in older adult populations. Jessen et al
found that the prevalence of non-allergic symptoms had a U-shaped relationship with age
with the lowest prevalence occurring in middle aged (5060 y.o.) persons and an increase
thereafter.9 Other studies have found little relationship with age and self-reported nonCurr Allergy Asthma Rep. Author manuscript; available in PMC 2014 April 01.

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allergic symptoms.10;11 More recently, Crawford and colleagues found that in a cohort of
134 men that there was not a decline in allergic rhinitis prevalence in older adults compared
with younger adults but as others have shown that there is a decrease in allergic sensitization
with age.12 Thus, allergic rhinitis remains common in older adults but nonallergic causes of
rhinitis may be more prevalent with age. Further studies are necessary to determine the true
prevalence of non-allergic rhinitis symptoms in older adults.

Mixed Allergic and Non-allergic Rhinitis

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Many people with rhinitis have both AR and NAR, which often makes it difficult to study
pure AR or NAR.13 In a study by Simola et al., which examined patients with AR at a
follow up after 23 years, it was noted that skin test positivity and specific IgE levels
declined. However, the changes in symptoms did not correspond to the changes in markers
for allergy, which suggests that older patients may have a combination of AR and NAR
contributing to symptoms.14 In 2002, the Agency for Healthcare Research and Quality
(AHRQ) began to address the issue of AR versus NAR by evaluating the available evidence.
The AHRQ Evidence Report found no study at that time that could distinguish these
separate but overlapping conditions.15 Allergy skin testing or specific IgE testing in the
blood has often been used as a determinant between allergic and non-allergic rhinitis.
Though studies have shown a decline in allergen sensitivity in older adults, a robust
correlation between the prevalence of allergen sensitization (skin prick test or specific IgE
test) and allergic rhinitis exists even in older adults. Recently, Di Lorenzo and colleagues,
examined over 1,000 patients with both clinical and laboratory parameters to characterize
the similarities and differences between the 2 conditions.16 Overall, 10 variables were
statistically different between AR and NAR. NAR subjects were older, had milder
symptoms and less symptoms of sneezing, nasal pruritus and conjunctivitis, less of a clinical
response to antihistamines and lower visual analog scores, peak nasal inspiratory flow and
nasal eosinophils. Distinguishing between non-allergic and allergic rhinitis will help
clinicians provide the most effective and appropriate treatment and help impact the
morbidity associated with both diseases.

Sub-types of Non-allergic Rhinitis

Atrophic rhinitis is a type of rhinitis which is much more prevalent in older adult
populations, with mean occurrence ages of 52 and 56 years, respectively.17 This type of
rhinitis is manifested by symptoms of congestion, nasal crusting and fetor. Decreased blood
flow to the nasal mucosa contributes to the local atrophy and leads to the enlargement of
nasal space with paradoxical complaint of nasal congestion.

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Vasomotor rhinitis (VMR) is manifested by rhinorrhea, congestion and less often sneezing
typically after exposure to irritants including cold air and strong odors. Allergic sensitization
is not a feature of VMR. The exact pathophysiology of VMR has never been established
although it is thought that the rhinorrhea is caused by enhanced cholinergic glandular
secretory activity and the nasal congestion due to heightened sensitivity of nociceptive
neurons to stimuli.6
Non-allergic rhinitis with eosinophilia syndrome (NARES) is an inflammatory non-allergic
condition and presents similarly to allergic rhinitis. The symptoms of NARES: paroxysmal
exacerbations of sneezing, profuse watery rhinorrhea, nasal pruritus, nasal congestion, and
occasional anosmia typically begin in the 3rd and 4th decades of life and may precede the
development of Aspirin Exacerbated Respiratory Disease (AERD).18;19 A key feature of
NARES is the infiltration of eosinophils (> 5%) in nasal tissue without evidence of allergen
sensitization.20 As nasal cytology is rarely performed in clinical practice today and NARES

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is responsive to typical rhinitis treatment (intranasal corticosteroids), the significance of

identifying NARES in relationship with other forms of NAR is not clear.

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It is important, especially in the older adult, to examine for comorbidities that may cause or
contribute to rhinitis. The differential is varied from granulomatous diseases such as
Wegners granulomatosis and sarcoidosis to nasal polyposis, hypothyroidism, cerebrospinal
fluid leak and side effects from medications. Medications that are known to cause rhinitis
symptoms are widely used in an older adult population and range from anti-hypertensives,
psychotropics, alpha-adrenergic antagonists and phosphodiesterase-5 inhibitors (See Table
2). If a patient presents with unilateral nasal symptoms, it is important to consider a
nasopharyngeal neoplasm. Thus the diagnosis of NAR should be one of exclusion after other
diagnoses have been ruled out.

Treatment of Rhinitis

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The same medications are used for treatment of AR and NAR in older adults (Table 3).
Evidence-based guidance for the treatment of NAR in older adults is lacking as NAR has
been less extensively studied compared to its more common counterpart, allergic rhinitis.
The treatment of NAR typically includes the use of intranasal steroids (INSs), topical
antihistamines, intranasal anti-cholinergics, oral decongestants and nasal lavage. Specific
types of NAR may require unique regimen. For example, the treatment of atrophic rhinitis is
focused on instituting a regimen of nasal hygiene, with nasal lavage and crust debridement,
and the use of topical and/or systemic antibiotics upon the onset of purulent nasal secretions
or an acute infection.17 INSs are recommended for long-term therapy in NAR. It has shown
to improve the symptoms of nasal congestion compared to intranasal anti-cholinergics (ie.
ipratropium bromide) in randomized controlled trials.15 Due to the wide availability of oral
antihistamines now, many patients with rhinitis symptoms have tried an oral antihistamine at
some point during their course of treatment. As the mechanisms of NAR typically do not
involve histamine release it is intuitive to believe that antihistamines have little impact on
NAR. There has been no randomized controlled study which has examined the use of
antihistamines alone in the treatment of NAR.15 One study from 1982, used a firstgeneration antihistamine in combination with a decongestant and found an improvement in
NAR symptoms with this regimen.21 While the first-generation antihistamines do carry
some anti-cholinergic properties, which might improve rhinorrhea, it is likely the
decongestant providing more benefit especially with the symptom of congestion. Secondgeneration antihistamines carry no anti-cholinergic properties, thus no benefit for NAR is
anticipated. Interestingly, the topical antihistamines have been shown to be effective in NAR
possibly due to the anti-inflammatory and neuroinflammatory blockade properties that
azelastine and olopatadine carry.20 Studies that have compared topical antihistamines
(azelastine, olopatadine) to INSs (fluticasone) have found no superiority of either drug in the
treatment of NAR.22;23 Furthermore, when topical antihistamines and INSs have been used
concurrently, patients obtained greater symptomatic relief than with the use of either drug
alone.2426 Although oral decongestants are effective in treating congestion, few studies
have examined the use of oral decongestants for the treatment of NAR. Two randomized
controlled studies using phenylpropanolamine found a decrease in nasal congestion and
rhinorrhea though this drug has since been removed from the market.15 No studies using
pseudoephedrine in NAR have been reported. Anticholinergics such as ipratroprium
bromide have demonstrated efficacy in reducing rhinorrhea in several randomized controlled
trials.15 Despite its potent effect on rhinorrhea, it has little effect on the symptom of nasal
congestion. This class of medications is best used when the main rhinitis symptom is
rhinorrhea as in vasomotor rhinitis. Moreover, despite the lack of an allergic component in
non-allergic rhinitis, environmental controls should be discussed and targeted at irritant
triggers such as tobacco smoke, strong odors, and extremes in temperature and humidity.

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Special Considerations of Treatment in Older Adults

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The selection of medications for the treatment of NAR should take into account that older
adults may be more susceptible to adverse effects of many of these medications. Though
oral antihistamines are not typically effective in NAR, they are often used due to their wide
availability. Adverse effects of first generation antihistamines include urinary retention, dry
mouth, constipation, arrhythmias and postural hypertension, all of which tend to be more
prevalent in older adults. Fortunately, it appears that topical antihistamines are better
tolerated than the oral antihistamines. The sympathomimetic effects of oral decongestants
are of concern in the presence of comorbidities that are known to be more common in older
adults. Intranasal corticosteroids seem to have favorable safety and efficacy profiles in older
individuals with allergic rhinitis, similar to their younger counterparts. Anticholinergics may
cause excessive nasal drying and caution should be taken in patients with benign prostatic
hypertrophy and narrow-angle glaucoma. At each encounter, the following should be
considered especially in the older adult population: review all the current to assess for any
drug interactions, examine the technique of nasal instillation and provide written treatment
plans as memory may be an issue.

Future Directions
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There are several recent areas of research interest in rhinitis which may be relevant for
rhinitis in older adults. For example, there are data demonstrating an altered microbiome in
patients with chronic rhinosinusitis compared to control patients.27 Alterations in local
microbiome diversity are also related to presence of allergic disease.28 Whether there are
age-related changes in microbiome diversity in the nose/sinuses and the impact on clinical
symptoms of rhinitis or development of acute or chronic sinusitis are not known.
There have been several recently described inflammatory pathways involving epithelial
cells, including cytokine production (IL-25, IL-33, and thymic stromal lymphopoietin), that
have been associated with allergic inflammation.29 Whether these responses are equally
potent and equally responsive to traditional therapies in older adults is not known.
There are data to suggest that patients may have localized production of IgE (also known as
entopy) leading to allergic inflammation specific in the nose without evidence of allergic
sensitivity assessed by conventional testing.30 Whether the decline in allergic sensitization
in older adults represents a conversion of allergic responses to a more localized process is
not known. For example, it is possible that some of the high prevalence of NAR is actually
localized AR.

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Conclusions
There remain significant gaps in our knowledge of AR and NAR in older adults ranging
from the pathophysiology to the prevalence to effective treatments. With the rise in numbers
of older adults in the US population, the prevalence of rhinitis is projected to increase and
thus it is imperative to raise awareness of these conditions to facilitate the diagnosis and
appropriate management to minimize the impact it has on the quality of life of individuals
suffering with rhinitis.

Acknowledgments
Dr. Mathur has received research grant support from the National Institutes of Health. Dr. Mathur has also served
as chair of the AAAAI Asthma and Allergic Diseases in the Elderly Committee and as secretary/treasurer of the
Wisconsin Allergy Society.

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MJ, Blanca M. Prevalence and clinical relevance of local allergic rhinitis. Allergy. 2012;
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Table 1

Categorization of Rhinitis

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Allergic Rhinitis
Non-allergic Rhinitis
Atrophic Rhinitis
Vasomotor Rhinitis
Non-allergic Rhinitis with Eosinophilia (NARES)
Gustatory Rhinitis
Drug-Induced Rhinitis

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Table 2

Medications that can cause or contribute to rhinitis

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ASA/NSAIDs

Alpha blockers (doxazosin, terazosin)

ACE inhibitors

Beta-blockers (carvedilol, labetalol, nadolol)

Calcium channel blockers

Diuretics

Oxymetolazone

Oral contraceptives

Phosphodiesterase 5 inhibitors (sildenafil, tadalafil, vardanafil)

Psychotropics (risperidone, chlorpromazine, amitriptyline)

Phentolamine

(Adapted from Dykewicz et al. [6].)

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Table 3

Medications for treatment of rhinitis

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Medication class

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Generic drug (Trade name)

Dose

Therapeutic considerations

Oral

Prednisone or methylprednisolone

variable

Short course (57 days) may be appropriate

for severe nasal symptoms

Intranasal

Beclomethasone monohydrate
(Beconase AQ)

12 sp nos bid

Fluticasone propionate (Flonase)

2 sp nos qdaily

Flunisolide (Nasarel)

2 sp nos bid-tid

Triamcinolone (Nasacort AQ)

12 sp nos qdaily

Side effects include nasal burning, dryness

and epistaxis
Without significant systemic SE in adults
though monitoring for glaucoma
recommended especially if patient is also
taking corticosteroids for other chronic
diseases.

Mometasone (Nasonex)

2 sp nos qdaily

Budesonide (Rhinocort AQ)

14 sp nos qdaily

Fluticasone furoate (Veramyst)

2 sp nos qdaily

Ciclesonide (Omnaris)

2 sp nos qdaily

Ciclesonide (Zetonna)

1 sp nos qdaily

Diphenyhydramine

2550 mg qid

Cyproheptadine

4 mg tid

Hydroxyzine

25 mg qid

Chlorphenerimine

4 mg qid

Promethazine

25 mg qid

Clemastine

1.34 mg bid- tid

Loratadine

10 mg qdaily

Desloratadine

5 mg qdaily

Cetirizine

510 mg qdaily

Levocetirizine

5 mg qdaily

Fexofenadine

180 mg qdaily or
60 mg bid

Acrivastine

8 mg qid

Azelastine (Astelin, Astepro)

2 sp nos bid

Olopatadine (Patanase)

2 sp nos bid

Corticosteroid +Antihistamine
Intranasal

Fluticasone +Azelastine (Dymista)

1 sp nos bid

Minimal side effects: possible sedation, bitter

taste

Anti-cholinergics
Intranasal

Ipratropium bromide (Atrovent)

2 sp nos bid-tid

Side effects: epistasis, nasal dryness

Leukotriene modifying agents

Oral

Zileuton (Zyflo)

600 mg qid or
1200 mg CR bid

Zarfilukast (Accolate)

20 mg bid

Montelukast (Singulair)

10 mg qdaily

Decreased clearance of zarfilukast in person >

65 yo Zafirlukast and zileuton are hepatically
metabolized and may produce liver function
abnormalities.
These 2 drugs may interfere with the
metabolism of other drugs commonly used in
the older adults, such as warfarin

Pseudoephedrine

3060 mg q4-6h
or 120 mg q12h

Corticosteroids

Antihistamines
Oral
1st generation
2nd generation

Intranasal

Side effects: sedation, dizziness, reduced

mental alertness and confusion, urinary
retention, constipation, arrhythmias and
postural hypotension

Preferred over 1st generation due to less

sedation, performance impairment and
anticholinergic effects

NIH-PA Author Manuscript

Minimal side effects: possible sedation, bitter

taste

Decongestants
Oral

Caution in those with a history of cardiac

arrhythmia, angina pectoris, cerebrovascular

Curr Allergy Asthma Rep. Author manuscript; available in PMC 2014 April 01.

Nyenhuis and Mathur

Medication class

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Intranasal

Page 11

Generic drug (Trade name)

Dose

Phenylephrine

1020 mg q4h

Oxymetalazone

46 sp nos bid

Xylometazoline

1 sp nos bid-tid

Cromolyn sodium (NasalCrom)

1 sp nos q4-6h

Therapeutic considerations
disease, hypertension, bladder neck
obstruction, glaucoma, or hyperthyroidism.
Side effects: tachycardia, dry mouth, anxiety,
insomnia and irritability.
Rhinitis medicamentosa with prolonged use
(>5 d)

Mast Cell Stabilizer

Intranasal

Less effective than corticosteroids and must

be taken for at least 1 week for detectable
symptom relief Minimal side effects

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NIH-PA Author Manuscript
Curr Allergy Asthma Rep. Author manuscript; available in PMC 2014 April 01.