- What to know about adult-onset asthma
- What is Asthma?
- Key messages
- Asthma in later adulthood
- Ageing and lung function
- Symptoms of asthma
- Asthma tests and checkups
- Doing spirometry (breathing tests)
- Taking care of yourself if you have asthma
- Managing asthma when you have other medical conditions
- Further information
- Battling asthma can get harder, and scarier, as you age
- How is Asthma Treated?
- Jenny’s Journey
- Adult-onset Asthma: Know Fact from Fiction
- Can you get asthma as an adult?
- Is it triggered by allergies?
- What causes people to develop it later in life?
What to know about adult-onset asthma
People can treat adult-onset asthma with a combination of lifestyle changes and medications. Everyone has their own treatment plan with asthma.
Adults are more likely than children to have other medical conditions as well, which is a consideration when developing an asthma treatment plan.
A comprehensive treatment plan often includes:
Treatment for most types of asthma includes bronchodilators. Different types of bronchodilators are available, including long-acting and fast-acting ones. Both types can play a role in the management of asthma.
Fast-acting bronchodilators, such as albuterol, work by relaxing the muscles of the airways. As the muscles relax, the airways widen, making breathing easier. People take fast-acting bronchodilators via an inhaler or through a nebulizer. The medications reduce sudden symptoms, such as wheezing and shortness of breath.
People can also use long-acting bronchodilators to manage adult-onset asthma. These drugs also relax the airways, but they last longer than fast-acting inhalers. Instead of treating sudden symptoms, they prevent symptoms.
In some instances, people can also use inhalers that contain corticosteroids to treat adult-onset asthma. Steroids decrease airway inflammation.
Inhalers that contain corticosteroids do not treat sudden symptoms. Instead, they decrease the frequency of symptoms.
In some cases, treatment includes oral steroids. However, oral steroids may increase blood sugar levels and possibly worsen other conditions, such as glaucoma and osteoporosis, which can occur in adulthood.
One of the most important factors that influences the severity of the disease is cigarette smoking.
A 2014 study looked at the factors affecting asthma severity in 128 adults with new onset of adult asthma.
After two years, researchers assessed changes in asthma severity, using the Global Initiative for Asthma Score. They noticed the following changes:
- asthma severity increased in 13.3% of the people
- severity decreased in 41.4% of people
- cigarette smoking predicted the worsening of symptoms
Older adults can have asthma too. Some people develop asthma for the first time in later adulthood. It is important to mention breathing problems to your doctor, because undiagnosed asthma is risky, or the problem could be something else.
- What is asthma?
- Key messages
- Asthma in later adulthood
- Ageing and lung function
- Symptoms of asthma
- Asthma tests and checkups
- Doing spirometry (breathing tests)
- Taking care of yourself if you have asthma
- Managing asthma when you have other medical conditions
- Further information
- For Health Professionals
What is Asthma?
Asthma is a disease of the airways, the small tubes which carry air in and out of the lungs.
When exposed to certain asthma triggers (such as cold air, exercise, pollen, and viruses) the sensitive airways react. They can become red and swollen (inflamed) which causes the airway muscles to tighten and produce excess mucus (phlegm).
This makes the airways narrow and difficult for a person to breathe.
Common asthma symptoms include:
- shortness of breath
- a feeling of tightness in the chest
Asthma is a manageable health condition.
Although at the moment there is no cure, with good asthma management and education, people with asthma can lead normal, active lives.
- Older adults can have asthma too. Some people develop asthma for the first time in later adulthood.
- It is important to mention breathing problems to your doctor, because undiagnosed asthma is risky, or the problem could be something else.
- Quit smoking and avoid other people’s tobacco smoke.
- Follow your written asthma action plan. If you don’t have one, ask your doctor.
- Tell your doctor and pharmacist about all the medicines you are taking for other medical conditions.
- Ask your doctor, nurse or pharmacist to show you exactly how to use your asthma inhaler correctly.
Tell your doctor if you:
- have any trouble using an inhaler or are unsure
- have any concerns about a medicine
- think that your asthma medicines are causing side-effects.
Asthma in later adulthood
Asthma is just as common in people aged 65 years or older as it is in all adults.
An estimated 7–15% of Australians aged 65 years or over have asthma – up to one in seven people. This includes people who first get asthma in later life, as well as people who have had asthma all their lives.
About half of all people with asthma aged 75 years or more have not been diagnosed by a doctor. Many older people don’t mention a breathing problem to their doctor because they think it’s just due to age, lack of fitness, being overweight, or some other health problem.
Untreated asthma is especially risky in older people. People of any age should tell their doctor if they ever have shortness of breath, a whistling sound when they breathe, or a tight feeling in the chest.
Ageing and lung function
Lung function is measured by how well a person can fill their lungs with air, and how hard and fast they can breathe out. Lungs develop throughout childhood and early adulthood, reaching peak performance by about age 20–25 years.
Lung function is gradually lost throughout adulthood. Typically, men lose lung function faster than women. As a person ages, the lungs and muscles have to work harder to breathe. Muscles used for breathing can become weaker. For most people, this is not a problem – they may just get breathless more easily when they exercise.
Untreated asthma can make a person’s lung function worsen faster.
Over many years, this becomes a health problem.
Looking after your lungs is important, because unhealthy lungs can spoil your quality of life, by making it harder to take part in everyday activities.
Symptoms of asthma
For most people with asthma, the main symptoms are:
- breathlessness or difficulty breathing from time to time
- wheezing – a high-pitched or whistling sound when you breathe out
- a feeling of tightness in the chest from time to time.
Not everyone with asthma will have all these symptoms, and some people also have other problems. Other conditions, apart from asthma, can also cause these symptoms.
Older people should not ignore problems with breathing, or assume that symptoms are just due to getting older. Tell your doctor about any breathing problems, because it is important to have a thorough health check for asthma and other medical conditions.
Tell your doctor when the symptoms occur (e.g. when you first wake up, when you are physically active, or when you are in certain situations), because these clues can help with diagnosis and finding the cause.
Tell your doctor if you have ever been a smoker, even if you quit years ago.
Asthma tests and checkups
If you have symptoms that could be due to asthma, your doctor may:
- ask for detailed information about your symptoms and when they occur
- give you a full physical examination, which includes listening to your chest with a stethoscope
- use a spirometer to test your lungs before and after breathing in asthma medicine from an inhaler (‘puffer’) – or arrange for you to have this test in a lung testing facility.
- prescribe asthma medicines on a trial basis for a few weeks, then recheck
- arrange for you to have other tests.
For people who already have a diagnosis of asthma, doctors normally arrange check-ups from time to time, usually twice a year.
An asthma check-up usually involves:
- asking about your current medicines, recent symptoms, whether you cough up or spit much mucus (phlegm), and whether you have had any recent chest infections
- asking about your social life and state of mind
- checking whether you are taking your inhaled medicines correctly
- testing your lungs on a spirometer machine
- fine-tuning your medicines.
Tell your doctor or pharmacist if you:
- are worried about side-effects
- are finding your medicines too expensive
- are not sure exactly how to use your inhaler properly.
Spirometers are used to measure how well your lungs are working, compared with what is normal for a person of your age, sex and height.
Doing spirometry (breathing tests)
The spirometry test involves blowing air through a mouthpiece into a machine (spirometer).
The machine measures the amount of air you can breathe in and out of your lungs, and how hard and fast you can breathe out.
If your doctor uses a spirometer to test your breathing, you will usually be asked to follow these steps:
- Sit upright in a chair with your legs uncrossed and your feet flat on the ground
- Breathe in completely and rapidly
- Put the mouthpiece in your mouth and close your lips firmly around it so no air escapes
- Breathe out as fast and as hard as you can, until your lungs are completely empty, or until you cannot blow out any more air.
Adults of any age can do the spirometry test. Your doctor or a trained operator will explain everything you need to do.
It is a good idea to go to the toilet before the test. You will need to blow out air from your lungs very forcefully, which will be easier if you don’t have to think about your bladder.
Taking care of yourself if you have asthma
Asthma is a long-term medical condition. It is still there even when the person is not experiencing symptoms or having an asthma ‘attack’. This means you need to keep managing your asthma all the time, not just when you are troubled by symptoms.
Managing your asthma means avoiding tobacco smoke, avoiding other things that worsen your symptoms, having your asthma checked by a doctor from time to time, taking any prescribed asthma medicines exactly as instructed, and following your written asthma action plan.
Smoking harms your lungs at any age. Don’t smoke (and avoid other people’s tobacco smoke) because smoke can:
- trigger asthma ‘attacks’
- make your asthma harder to control (even if you don’t feel it)
- cause permanent damage to your lungs.
If you smoke, try to quit. It is never too late – quitting can improve your health at any age.
Older people can successfully quit smoking, and may even be better at staying smoke-free than younger adults.
Ask your doctor or pharmacist for help, and call the national Quitline 13 78 48 (13 QUIT) or get information from the Quit website quitnow.gov.au.
Know how to take your asthma medicines correctly
Anyone who takes asthma medicines using an inhaler or ‘puffer’ needs careful training to use them properly.
Using inhalers the wrong way can make asthma medicines less effective.
Some older people are unable to breathe in strongly enough to get enough medicine into their lungs. Some have trouble connecting their puffer to a spacer, and some have trouble using their hands due to arthritis.
Different types of inhalers suit different people. You should work with your doctor to find the type of inhaler that is easiest for you to use, and ask your doctor or pharmacist to watch you take it, to make sure you are using it correctly.
Gadgets to help grip the inhaler (such as Haleraids) are available for people with weak hands or osteoarthritis.
Inhalers or “puffers” are recommended for most people instead of nebulisers, however, some older people use nebulisers. Nebulisers are machines that convert liquid medicine into a mist, which is breathed through a mask.
When using a nebuliser, the mask must be tight-fitting. Loose masks allow some of the medicine to escape into the air, and this can cause eye problems such as enlarged pupils, blurry vision, or glaucoma. Nebuliser masks can also pass on infections, so they need to be cleaned carefully.
Tell your doctor if you have any trouble using an inhaler, have any concerns about a medicine, or think that your asthma medicines are causing side-effects.
Follow your written asthma action plan
You should never ignore or ‘put up with’ asthma symptoms, because asthma ‘attacks’ are very risky – especially for people over 65 years.
A written asthma action plan tells you which medicines to take, what to do when you have symptoms (or your asthma worsens over a few days), and what to do in an emergency.
If you don’t have a personal written asthma action plan, ask your doctor to write one for you. Several different types of written asthma action plans are available depending on your needs or preferences.
People who have more than one medical condition may need a written action plan that includes instructions for all their medicines and healthcare needs.
Managing asthma when you have other medical conditions
Most older people will have one or more health conditions, and many are taking one or more medicines regularly.
Whenever you start taking any new medicine for asthma or another condition, make sure your doctor and your pharmacist know about all the other medicines you are taking, including any over-the-counter or complementary medicines you use.
Some medicines can cause asthma symptoms.
Common examples are:
- blood pressure-lowering medicines that end with the letters L-O-L, such as atenolol, bisoprolol, carvedilol, labetolol, metoprolol, and pindolol
- eye drops for glaucoma, such as betaxolol, carbachol, timolol, and pilocarpine.
Tell your pharmacist if you have asthma and you are taking any of these medicines.
Health conditions can affect your asthma
Some common medical conditions can make asthma worse or harder to manage. Tell your doctor if you have any of these health problems:
- gastro-oesophageal reflux (stomach reflux)
- breathing problems during sleep (such as snoring or obstructive sleep apnoea)
- memory problems
- poor physical fitness.
Some people with asthma have other lung conditions at the same time. One lung condition that is fairly common among older people is chronic obstructive pulmonary disease (usually called COPD). Pulmonary rehabilitation is recommended for people who have COPD as well as asthma.
- Talk to your doctor or pharmacist
- Visit the National Asthma Council Australia website at: nationalasthma.org.au
- Contact your local Asthma Foundation 1800 645 130 asthmaaustralia.org.au
For Health Professionals
Visit the National Asthma Council Australia website to:
- order printed copies of this brochure
- access the related information paper for health professionals
Developed by the National Asthma Council Australia in consultation with an expert panel of respiratory clinicians.
Supported through funding from the Australian Government Department of Health.
National Asthma Council Australia. Asthma & Older Adults: A guide to living with asthma for people aged 65 years and over. Melbourne. National Asthma Council Australia, 2013.
Although all care has been taken, this brochure is only a general guide; it is not a substitute for individual medical advice/treatment. The National Asthma Council Australia expressly disclaims all responsibility (including negligence) for any loss, damage or personal injury resulting from reliance on the information contained.
Battling asthma can get harder, and scarier, as you age
Up to half of older people 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 recalled a patient who started coughing, wheezing and becoming short of breath in his 60s. Diagnosed with chronic obstructive pulmonary disease by two physicians, he had been 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 tests that indicated asthma.
“I prescribed a high dose of inhaled corticosteroids in combination with a long-acting bronchodilator,” Wechsler said, “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 from Beaver Creek, her treatment was far more difficult.
Diagnosed with severe allergies and intractable asthma as a child, she’d lived in a dormitory at National Jewish from age 6 to 8, along with 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.
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 vulnerability after years of toughing out her condition 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.”
This column is produced by Kaiser Health News, an editorially independent news service that is a program of the Kaiser Family Foundation.
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If this sounds familiar, you may have adult-onset asthma.
“People think about asthma starting in childhood, but developing asthma later on is more common than you think,” says pulmonologist Rachel Taliercio, DO. “However, we are not as good at recognizing asthma in older adults.”
The resulting delays in diagnosis and treatment can lead to serious problems.
Here, she answers common questions about adult-onset asthma and explains why it is often more serious later in life:
Q: What causes adult-onset asthma and what are its symptoms?
A: The reason adults develop asthma isn’t always clear. Respiratory infections, allergies and airway irritants, such as smoke and mold, can be triggers.
Asthma inflames the airways, triggering excess mucus production and smooth muscle spasms. This narrows the airways, causing symptoms such as:
- Chest tightness or pressure
- Difficulty breathing
- Wheezing as you exhale (a whistling sound)
- Shortness of breath after exertion
- A dry cough
- Colds that quickly move to the chest and symptoms that can linger
While the symptoms for adult-onset and childhood asthma are the same, they are typically intermittent in childhood and persistent in adulthood.
Inhaled and oral asthma medications, which open the airways and soothe inflammation, are used to treat acute symptoms and prevent flare-ups.
Q: Is asthma more dangerous for adults?
A: Yes. The death rate for adult-onset asthma is substantially higher than the death rate for childhood asthma.
One reason may be that adults either ignore asthma symptoms or attribute them to being overweight, being out of shape or getting older.
Asthma symptoms can also mimic those of other illnesses, including:
- Hiatal hernia
- Stomach disorders
- Heart failure
- Rheumatoid arthritis
- Chronic obstructive pulmonary disease (COPD)
Unfortunately, any delays in the diagnosis and treatment of asthma can permanently impair lung function.
Q: What increases your risk for adult-onset asthma?
A: Most childhood asthma disappears in adulthood. But having childhood asthma increases your risk of a relapse in your 30s or 40s. Other factors that increase the risk of adult-onset asthma include:
- Being overweight or obese: A low level of physical activity, changes in lung physiology and higher levels of inflammation are among several factors at play.
- Being female: Hormonal fluctuations in pregnancy and menopause can trigger asthma.
- Allergens: Cats, cigarette smoke, chemicals, mold or dust can trigger asthma.
Q: How well does treatment work for adults with asthma?
Asthma can be more difficult to control in adults for several reasons:
- Asthma medications can be less effective later in life, particularly for those who are obese.
- Oral steroids can worsen glaucoma, cataracts and osteoporosis.
- Being on beta-blockers for heart problems can increase the severity of asthma.
- The lungs and chest walls are stiffer and the muscles supporting deep breathing are weaker in adults.
For these reasons, adults with asthma are at increased risk for flare-ups and even hospitalization.
Q: How can you improve your asthma control in adulthood?
A: To keep asthma under control, follow your doctor’s instructions as closely as possible. Here are some additional tips:
- Take prescription drugs as directed. Consult your doctor before making any changes. Let your doctor know if you are taking any over-the-counter medications.
- Monitor your lung capacity. Visit your doctor frequently to have your lung function checked. You can also monitor your lung function at home with a peak flow meter. This will detect lung changes even before you notice them.
- Develop an action plan and follow it. Create a step-by-step treatment plan with your doctor that walks you through what to do if asthma symptoms worsen.
- Use your rescue inhaler correctly. This can be the toughest part of managing asthma (especially if you struggle with strength or dexterity due to arthritis or other health problems). If using your inhaler is too frustrating, ask your doctor about nebulized medication that you can breathe in over 10 to 15 minutes.
If you suspect you might have asthma, see your doctor as soon as possible.
“Undiagnosed asthma can contribute to further loss of lung function that may be permanent,” Dr. Taliercio says. “Don’t ignore your symptoms.”
You’ll breathe a whole lot easier once you address the problem.
How is Asthma Treated?
Asthma can be controlled, but there’s no asthma cure. There are, however, certain goals in asthma treatment. If you are unable to achieve all of these goals, it means your asthma is not under control. You should contact your asthma care provider for help with asthma.
Treatment goals include the following:
- Live an active, normal life
- Prevent chronic and troublesome symptoms
- Attend work or school every day
- Perform daily activities without difficulty
- Stop urgent visits to the doctor, emergency room, or hospital
- Use and adjust medications to control asthma with little or no side effects
Properly using asthma medication, as prescribed by your doctor, is the basis of good asthma control, in addition to avoiding triggers and monitoring daily asthma symptoms. There are two main types of asthma medications:
- Anti-inflammatories: This is the most important type of medication for most people with asthma. Anti-inflammatory medications, such as inhaled steroids, reduce swelling and mucus production in the airways. As a result, airways are less sensitive and less likely to react to triggers. These medications need to be taken daily, and may need to be taken for several weeks before they begin to control asthma. Anti-inflammatories lead to a reduction in symptoms, better airflow, less sensitive airways, less airway damage, and fewer asthma episodes. If taken every day, they are helpful in controlling or preventing asthma flares. Oral steroids are taken for acute flares and help increase the efficacy of other medications and help reduce inflammation.
- Bronchodilators: These medications relax the muscle bands that tighten around the airways. This action rapidly opens the airways, letting more air in and out of the lungs and improving breathing. As the airways open, the mucus moves more freely and can be coughed out more easily. Both short-acting and long-acting beta-agonists can be used for prevention of symptoms of exercise-induced asthma. An anticholinergic, such as tiotropium bromide (Spiriva Respimat), which is available for individuals ages 6 and older, is another long-term maintenance medication for treating asthma.
Asthma medications can be taken by inhaling the medications (using a metered dose inhaler, dry powder inhaler, or asthma nebulizer) or by swallowing oral medications (pills or liquids). If you are also taking drugs for other conditions, you should work with your providers to check drug interactions and simplify medications when possible.
- Allergies, Asthma, and Lung
- Your Family’s Health
Adult-onset Asthma: Know Fact from Fiction
Women. Wisdom. Wellness. Aug 26, 2016
1. Asthma Doesn’t Occur in Adults
Fiction: Asthma symptoms can occur at any age. After the age of 20, women are more likely than men to develop adult-onset asthma, and obesity increases your risk of developing asthma.
2. Shortness of Breath and Wheezing Are the Only Symptoms of Asthma
Fiction: It’s true that wheezing and shortness of breath are typical symptoms of asthma, but they’re not the only signs. Lesser-known symptoms include a persistent cough, trouble sleeping and even chest pain! You may feel short of breath after engaging in physical activity. Recovering from a respiratory infection may take an unusually long time. You could have increased mucus secretion in your airways, a general feeling of congestion and/or pressure in your chest.
Left untreated, asthma can cause permanent damage to your lungs.
3. Adult-onset Asthma Looks Different from Childhood Asthma
Fact: Childhood asthma symptoms tend to come and go and are caused by allergies or respiratory illness while adult-onset asthma tends to persist and may require daily medicine to manage symptoms. The way the symptoms show up may be different for childhood and adult-onset asthma, but the symptoms themselves are the same.
4. You Can Live a Healthy Life with Asthma
Fact: With the help of your health care provider, you can get the treatment you need, which may involve medication and a management plan for what to do when symptoms increase. You can also test your lungs at home using a peak flow meter. That gives you and your doctor the ability to see changes and patterns before they result in symptoms, so you can update your management plan to address them.
5. Asthma Can Go Away on Its Own
Fiction: If you are having trouble breathing, sleeping or catching your breath after exercise, it is important to get checked out by your physician. Your doctor may test your lung function, evaluate you for allergies, assess your symptoms and give you a physical exam. If you have asthma, it is important to get your condition diagnosed so that you can receive treatment. If left untreated, asthma can cause permanent damage to your lungs.
Source: Asthma & Allergy Foundation; National Institutes of Health; Healthline.com
ASTHMA is a serious breathing condition which has no cure.
While there are treatments, occasionally an asthma attack can prove fatal.
4 There is no cure for asthmaCredit: Getty – Contributor
According to the NHS the main symptoms of asthma are wheezing – a whistling sound when you breathe – breathlessness, a tight chest and coughing.
Treatment is usually in the form of an inhaler, which people carry around with them.
There are two types; a reliever inhaler, which quickly alleviates symptoms for a short period, and preventer inhalers, which are used every day to prevent symptoms occurring.
In some cases, people can take tablets for their asthma.
4 In some cases an asthma attack can prove fatalCredit: Getty – Contributor
Can you get asthma as an adult?
Asthma is a lung condition which causes breathing difficulties, and often affects children.
According to the NHS, it can affect people of all ages.
Their website says: “It affects people of all ages and often starts in childhood, although it can also develop for the first time in adults.”
Asthma UK states other causal factors are if you have a family history of asthma, allergies or eczema, a low birth weight, your mother smoked while pregnant, your parents smoke or you were around smoke as a child, or if you suffered from bronchiolitis as a child.
4 People can develop asthma at any ageCredit: Getty – Contributor
Is it triggered by allergies?
There are numerous ‘triggers’ for asthma, and people will often soon work out what their individual trigger is.
The NHS says common triggers include;
- Allergies – to house dust mites, animal fur or pollen
- Smoke, pollution and cold air
- Infections like colds or flu
But in adults, asthma triggers are less likely to be allergies, such as pets, pollen, house or dust mites, and more likely brought on by hormonal changes or work-related.
What causes people to develop it later in life?
4 Factors such as the menopause can bring on asthmaCredit: Getty – Contributor
There are many different causes of asthma, but if you develop it later in life this is known as adult-onset or late-onset asthma.
Asthma UK details the factors which could increase the risk of developing it as an adult.
these include being exposed to certain substances at work can cause it, and this is known as occupational asthma.
Work-related, or occupational asthma, can include things such as chemicals found in spray paint, flour or grain dust, animals, wood dust, latex or substances found in fumes.
According to the NHS, people who work in industries such as paint sprayers, bakers, pastry makers, nurses, chemical workers, animal handlers, timber workers, welders and food processing workers have a higher risk of being exposed to these substances.
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And if you’re a woman, hormones can affect asthma symptoms, and some women first develop asthma before and after the menopause.
Sometimes adults develop it after a viral infection.
Asthma UK state that one in 12 adults are being treated for the condition.
NHS Choices expert Dr Glenis Scadding explains how common place hay fever is and the symptoms