HEA610 Integrated literature Oz Assignments

HEA610 Integrated literature Oz Assignments

HEA610 Integrated literature Oz Assignments

This template is intended to help you plan your integrated literature review in a systematic way.


Challenges faced in asthma management in older adults






Asthma is a long term inflammatory disease of the airways that causes the burden of asthmatic attacks over 3 million people all over the world (Ozturk & Iliaz, 2016). The main clinical manifestation of asthma are wheezing, coughing, chest tightness, reversible airway obstruction and bronchoconstriction (Bonini & Usmani, 2015). Although asthma is a common within the pediatrics, the symptoms are also common in many elderly people having chronic asthma. The disease burden of asthma is associated with a great reduction in the quality of life affecting the social, personal and the professional life (Ehteshami-Afshar et al., 2016). 15% of the children population has been diagnosed with the asthmatic symptoms. Young adults within the age range 30-34 years have been found to have the lowest impact and pediatrics and the geriatric population experience the greater burden of the clinical condition. Extreme asthma exacerbations in the elderly people have been linked high number of comorbidities within the geriatric population experiencing asthma symptoms (globalasthmareport.org, 2014). Although a wide range of scientific articles exists about the prevalence of asthma in children but less focus is given on the geriatric population.

Asthma among the older adults helps is a major public health concern. With the continuous growth of the aged population, it can be expected that the number will get doubled by the year 2030 (Ortman, Velkoff & Hogan, 2014). Hence it is important to have a clear understanding of the pathophysiology , assessment, interventions , treatments and the barriers to asthma interventions among the adults. Older population are subjected to multiple comorbidities and are also phenotypically different from the other population groups that provides the rationale for research using this population group. The main risk factors for asthma are poor hearing, poor level of hygiene due to frailty, poor self-management skills and poor education about the asthma management strategies (Ozturk & Iliaz, 2016). Hence an in depth research is required to understand the risk factors and eradicate the barriers to asthma management among the elderly population. The main aim of this research is to conduct a systematic review for understanding how comorbidities may lead to poor asthma outcome and evaluating the asthma management interventions for the elderly population.



The main clinical issue is the increase in the older population and poor quality of life among the elderly population due to the diagnosis of asthma and the presence of multiple chronic diseases. The clinical question is represented in the PICO format written below:-

  • P (Population)- Elderly population

  • I (Intervention)- management of asthma

  • C (Comparator)- no action

  • O (Outcome)- Challenges

The PICO question can be written as -‘Are asthma management strategies (I) less complicated for elderly population (P) compared to that of the younger group of population (C) in reducing asthma symptoms (O)?



The main objective of the systematic review is to understand about the factors that enhances the difficulties for the elderly patients in the management of asthmatic symptoms.



  • To provide a vivid understanding regarding the asthma management in the elderly population.

  • To link the elderly comorbidities with the symptoms of asthma.

  • To understand the effectiveness of the asthma intervention in the older patients.

  • To evaluate the outcome of the implemented intervention in the older population.


  • Population/Participants

  • Interventions/Exposures

  • Comparisons/Control Group/s

  • Outcomes Of Interest

  • Setting

  • Study Designs To Be Included

Inclusion criteria-

  • Population/participants: Research articles with only elderly participants were included.

  • Intervention/exposure: Research articles that contain younger people as the control group were taken in to consideration to facilitate comparison.

  • Outcome of interest: Improvement in the various asthmatic symptoms like breathlessness, wheezing and bronchoconstriction due to formation of the mucus plugs.

  • Setting: Primary care settings providing asthma management services.

  • Study designs to be included: Both qualitative and quantitative papers will be taken in to consideration that is relevant to the clinical question.


  • Electronic Databases

    • please list all databases that are to be searched and include the interface (eg nhs, ebsco, etc) and date ranges searched for each

  • Other Methods Used For Identifying Relevant Research

    • ie contacting experts and reference checking

  • Journals Hand Searched

    • if any are to be hand searched, please list which journals and date searched from, including a rationale

Electronic databases:

A wide range of biomedical databases like CINAHL, PubMed, Medline and EMBASE will be brainstormed using the relevant keywords. In order to search the databases the interface that will be used are NHS and EBSCO. The search filters that will be used for searching the databases are the publishing date of the articles within 2009 to 2018. This will help in the inclusion of the articles within the recent 10 years. Primary search terms like ‘asthma in elderly”, “asthma management strategies”, “barriers to asthma management”. Addition of more specific search terms help in advanced search. Boolean operators such as AND, OR is normally used to conduct search in the CINAHL database. Use of appropriate search terms and keywords is an essential step for research (Peters et al., 2015).

Other search methods:

Other inclusion criteria for the research articles are full text articles and peer reviewed journals. Final selection of the research articles will be validated by two experts in this field. Both the experts will be checking and reviewing the summary and the title of the papers, followed by checking of the reference list.


Details Of Methods

  • Number Of Reviewers, How Agreements To Be Reached And Disagreements Dealt With, etc

  • Quality Assessment Tools Or Checklists Used With References Or Urls

Data Extraction

  • what information is to be collected on each included study. if databases or forms on word or excel are used and how this is recorded narrative synthesis

  • details of what and how synthesis will be done


  • details of what and how analysis and testing will be done. if no meta-analysis is to be conducted, please give reason.

Details of methods:

The main eligibility criteria for the selection of the articles is the inclusion criteria. The two articles will be reviewed by the reviewer and will possibly eliminate the presence of any selection bias (Whiting et al., 2016). Elimination of the selection bias will prevent the effect of the individual bias at the time of the selection procedure. Initially the two reviewers would choose screen the title and the abstract of the papers and the body of the articles. The reference list of the selected papers will also be checked for finding associated research articles relevant to the clinical question. Articles other than English articles are excluded from the study. Independent extraction of the data for research was carried out by each of the reviewers and incase of any conflict of interest, an independent researcher will be taking care of the issue and settling the disagreement.

In order to increase the credibility and the validity of the research, it is necessary to perform a quality assessment of the studies, which will make the research more transparent and credible (Almeida & Goulart, 2017). Relevant assessment tools and representation of the research findings systematically based upon the research rigor (Ahmed, Sutton & Riley, 2012) . Cochrane Risk of Bias Assessment tool is used for the bias assessment, as a part of evaluation techniques. This tool is appropriate for assessing different kinds of biases such as the performance bias, the selection bias, attrition bias and the detection bias. The tool consists of six domains like allocation concealment, random sequence generation, blinding of the participants, blinding the assessment of the outcome, incomplete outcome data, selective reporting and other biases for rating the study quality (Cochrane Methods, 2018). The quality of the papers will be judges based upon these six domains.

Data extraction:

In order to reduce the time taken for completing the review specific methods will be used to extract the data. A systematic review helps in the identification, synthesis and interpretation of the evidences for improving the decision making process for the policy makers, health care professionals and other stakeholders involved. The strategies use for extracting the data is the time taken to conduct the review (Jonnalagadda, Goyal & Huffman, 2015). A summary table will be used for summarising the studies. These are the information that will be extracted from the studies-

  • Author details

  • Country and publication year

  • Participants of the study

  • Research setting

  • Severity of symptoms for asthma

  • Interventions

  • Study duration

  • Study design

  • Outcome measures


Thematic analysis process will be used to analyse the research evidence (Thomas & Harden 2008). Meta- analysis for this systematic review is not appropriate as meta-analysis aims to identify the consistency between the research studies done to analyse any treatment effect and analysis pf the effect of the treatment is not the main aim of this systematic review. Instead the different barriers faced by the patients will be categorised under different themes. This can be considered as an effective approach for linking the chosen studies and with the clinical question and the research objectives. Thematic analysis helps in refining the research findings in its themes and is normally used in the analysis of the qualitative data (Bearman & Dawson, 2013). This classification of the findings in to defined themes would help in the processing of the text and refining of the study findings. This would further help in critical assessment.




Presentation Of Results

  • additional material

  • summary tables, flowcharts, etc, to be included in the final paper

  • outputs from review

  • papers and target journals, conference presentations, reports, etc

A Summary table has been attached below:-Table 1- Summary table



Table 2- Quality assessment table


The positive and the negative signs will be used to measure the risk of bias from high, unclear to low. Positive sign would represent high bias, negative signs would indicate low risk bias and the question mark would mean an unclear risk for bias.

Prisma Chart

7. Timeline For Review – When do you aim to complete each stage of the review

  • Literature Searching

  • Quality Appraisal

  • Data Extraction

  • Synthesis

  • Writing Up

Different stages of systematic review such as the searching of literature, appraisal of the quality, extraction of the data, synthesis and the establishment of the write up require ample time. The timeline for the completion of each of the stages are provided below-


1. Ahmed, I., Sutton, A. J., & Riley, R. D. (2012). Assessment of publication bias, selection bias, and unavailable data in meta-analyses using individual participant data: a database survey. Bmj, 344, d7762, doi: https://doi.org/10.1136/bmj.d7762
2. Almeida, C. P. B. D., & Goulart, B. N. G. D. (2017). How to avoid bias in systematic reviews of observational studies. Revista CEFAC, 19(4), 551-555, Doi: http://dx.doi.org/10.1590/1982-021620171941117
3. Bearman, M., & Dawson, P. (2013). Qualitative synthesis and systematic review in health professions education. Medical education, 47(3), 252-260, doi:10.1111/medu.12092
4. Bonini, M., & Usmani, O. S. (2015). The role of the small airways in the pathophysiology of asthma and chronic obstructive pulmonary disease. Therapeutic advances in respiratory disease, 9(6), 281-293
5. Cochrane Methods (2018). Assessing Risk of Bias in Included Studies. Retrieved from: http://methods.cochrane.org/bias/assessing-risk-bias-included-studies
6. Ehteshami-Afshar, S., FitzGerald, J. M., Doyle-Waters, M. M., & Sadatsafavi, M. (2016). The global economic burden of asthma and chronic obstructive pulmonary disease. The International Journal of Tuberculosis and Lung Disease, 20(1), 11-23, DOI: https://doi.org/10.5588/ijtld.15.047
7. globalasthmareport.org (2014). The Asthma Global Report 2014. Retrieved from: http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
8. Jonnalagadda, S. R., Goyal, P., & Huffman, M. D. (2015). Automating data extraction in systematic reviews: a systematic review. Systematic reviews, 4(1), 78, doi:  10.1186/s13643-015-0066-7
9.Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: the older population in the United States (pp. 25-1140). United States Census Bureau, Economics and Statistics Administration, US Department of Commerce, http://bowchair.com/uploads/9/8/4/9/98495722/agingcensus.pdf
10. Ozturk, A. B., & Iliaz, S. (2016). Challenges in the management of severe allergic asthma in the elderly. Journal of asthma and allergy, 9, 55, doi:  10.2147/JAA.S85420

11. Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews. International journal of evidence-based healthcare, 13(3), 141-146, DOI: 10.1097/XEB.0000000000000050
12. Scichilone, N., Pedone, C., Battaglia, S., Sorino, C., & Bellia, V. (2014). Diagnosis and management of asthma in the elderly. European journal of internal medicine, 25(4), 336-342, DOI: https://doi.org/10.1016/j.ejim.2014.01.004
13. Song, W. J., & Cho, S. H. (2015). Challenges in the management of asthma in the elderly. Allergy, asthma & immunology research, 7(5), 431-439.
14. Thomas, J., & Harden, A. (2008). Research Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology, 8(1), 45, Doi: https://doi.org/10.1186/1471-2288-8-45
15. Whiting, P., Savovi?, J., Higgins, J. P. T., Caldwell, D. M., Reeves, B. C., Shea, B., … ROBIS group. (2016). ROBIS: A new tool to assess risk of bias in systematic reviews was developed. Journal of Clinical Epidemiology, 69, 225–234. http://doi.org/10.1016/j.jclinepi.2015.06.00