Asthma in older people

Evaluation of the use of inhaled medications by hospital inpatients with chronic obstructive pulmonary disease

BACKGROUND

The prevalence of chronic obstructive pulmonary disease (COPD) is increasing. Patients with COPD are treated with a variety of inhaled medications. Previous studies evaluating inhaler technique have had varied results but have generally found high rates of misuse of these devices. There is a paucity of studies of inhaler technique focusing on North American patients with COPD who have been admitted to hospital.

OBJECTIVE

To evaluate the inhaler technique of patients with COPD who have been admitted to hospital and to identify baseline patient characteristics and/or inhaler devices associated with poor inhaler technique.

METHODS

Patients with a diagnosis of COPD who were admitted to the hospitalist or internal medicine service at a tertiary care hospital in British Columbia between October 2010 and April 2011 were identified. After giving informed consent, recruited patients demonstrated their inhaler technique, which was evaluated with standardized checklists. Errors in technique were categorized as either noncritical or critical. Critical errors were defined as those resulting in little or no medication reaching the lungs.

RESULTS

Thirty-seven patients (mean age 78 years) participated in the study. Twenty-two (59%) of the patients made critical errors while demonstrating their inhaler technique. Patients using metered-dose inhalers were more likely to make a critical error than patients using other inhalers (13/14 [93%] versus 9/23 [39%]; relative risk 2.38, p = 0.002). On average, 26% of the steps for using an inhaler were performed incorrectly. Twenty-three (62%) of the patients reported having received previous counselling on inhaler technique, but only 13 (57%) of these 23 patients had received such counselling in the previous 6 months.

CONCLUSIONS

More than half of the patients in this study misused their inhaler devices, and many made critical errors that would result in inadequate amounts of drug reaching the lung. Many of the patients were not receiving regular counselling on appropriate inhaler technique. Health care professionals should be aware of poor inhaler technique, should routinely evaluate their patients' inhaler technique, and should provide counselling.

Optimal management of asthma in elderly patients: strategies to improve adherence to recommended interventions

Adherence to asthma medications presents a problem in all age groups, and older people with chronic illnesses such as asthma also have multiple co-morbidities and consequently complex healthcare needs. It has been suggested that older people are also less likely to adhere to medication and treatment than younger people. Although the prevalence of asthma in older people is similar to that of the general population, over two-thirds of those who die from asthma are >50 years of age and there is strong evidence for under-diagnosis. Clinicians therefore face specific challenges in providing healthcare with respect to both asthma diagnosis and treatment in older age groups. Non-adherence to medication can be defined as either 'intentional' or 'unintentional'. Unintentional non-adherence is more likely to be associated with sociodemographic or physical barriers to the use of medication. Intentional non-adherence results from the balance of individual reasoning of risks versus the benefits of taking medication and acceptance of asthma diagnosis. Intentional non-adherence can be addressed through strategies that influence health beliefs and concerns about the adverse effects of medicine. Unintentional adherence can be addressed by assessing and educating the patient in relation to device use and providing education and clear written instructions about medication requirements. However, some barriers to medication use, such as financial ones, may be systematic. Most studies of medication use, efficacy, adverse effects and adherence in patients with asthma primarily involve younger people. Studies of strategies to improve asthma adherence outcomes specifically in older people are urgently needed.

Respiratory findings in a nursing home population

The prevalence of respiratory abnormalities was studied in an elderly nursing home population. This study investigated 475 female and 147 male individuals living in five nursing homes in Zagreb, Croatia. Chronic respiratory symptoms were recorded using the British Medical Research Council questionnaire. Ventilatory capacity was measured with maximum expiratory flow-volume (MEFV) curves on which forced vital capacity (FVC), one-second forced expiratory volume (FEV1), maximum expiratory flow rate at 50% FVC (FEF50), and maximum expiratory flow rate at 25% FVC (FEF25) were measured. A high rate of chronic respiratory illness and symptoms was found in both female and male nursing home residents. The highest rates were for asthma, chronic cough, and for chest tightness. Odds ratios (OR) showed that smoking and the length of employment were significant risk factors among men. Pulmonary function testing demonstrated a decrease in measured values compared to predicted (p<0.01). This was particularly pronounced for FEF50 and FEF25, suggesting obstructive changes in smaller airways. Regression coefficients were significant for smoking and employment primarily for FEF50 and FEF25. Our data suggest that older individuals residing in nursing homes exhibit an excess of respiratory symptoms, and lung function abnormalities. Smoking and past employment are important risk factors for these respiratory findings. Medical surveillance and preventive strategies should be implemented for this high risk population.

Spirometric criteria for asthma: adding further evidence to the debate

BACKGROUND

Objective assessments of pulmonary function are considered essential for the diagnosis of asthma. The degree of reversibility of FEV(1) considered supportive of asthma varies between international asthma guidelines.

OBJECTIVE

We sought to compare the relative performance of international guideline reversibility criteria for identifying impairment in persons with a significant bronchodilator response (SBR) without an asthma diagnosis.

METHODS

The North West Adelaide Health (Cohort) Study, a population biomedical study of 4060 subjects, conducted spirometry according to American Thoracic Society criteria. SBR was defined as postbronchodilator FEV(1) responses of at least 12% or 15% of baseline values, 9% of predicted values, or 400 mL. A self-completed questionnaire assessed current asthma (CA), respiratory symptoms, and participant demographics.

RESULTS

The prevalence of CA was 9.4% (n = 380), whereas 1.3% (>/=400 mL) to 4.5% (>/=9% of predicted value) of participants demonstrated an SBR in the absence of CA. With the exception of the 9% predicted criterion, prebronchodilator mean FEV(1) (percent predicted) in those demonstrating an SBR but no CA was significantly worse than that in the CA group. Significantly more respiratory symptoms were experienced by the SBR groups than the group without asthma. Logistic regression analyses identified different characteristics of those classified by the following criteria: 12% and 15%, age of 40 years or greater and household income of less than $40,000; 9% predicted, household income of less than $40,000; 400 mL, male sex (odds ratio, 4.5; 95% CI, 2.1-9.3).

CONCLUSIONS

Different criteria identify different persons, but SBR by any criteria was associated with significant respiratory impairment, some of which might be attributable to asthma. Postbronchodilator change as a percentage of predicted value was the least biased of the criteria.

Use of a cognitive ergonomics approach to compare usability of a multidose dry powder inhaler and a capsule dry powder inhaler: an open-label, randomized, controlled study

BACKGROUND

Usability (ease of use) is an important feature of inhalers to ensure optimal dose delivery

OBJECTIVE

The aim of this study was to compare the usability of a multidose dry powder inhaler (mDPI) and a capsule dry powder inhaler (cDPI) in older individuals, using a range of qualitative and quantitative techniques from the field of cognitive ergonomics.

METHODS

Participants aged >50 years were enrolled in this 2-visit, open-label, randomized, controlled, parallel-group study conducted at Northumbria University, Newcastle upon Tyne, United Kingdom. Participants who had used an inhaler or were inhaler naive were randomized to use the mDPI or cDPI. At visit 1, the inhaler procedure was demonstrated twice by the investigator. Participants then repeated the procedure (although they were not expected to inhale because no drug was to be administered) until they made 3 consecutive correct attempts. They also undertook a range of tests to assess their confidence in using the device, manual dexterity, and self-efficacy At visit 2 (2 days later), participants made a single inhaler attempt before receiving any demonstrations from the investigator; this was intended to simulate clinical practice, in which the patient may not use an inhaler for a few days after it is prescribed. Participants then completed the inhaler procedure 10 times while undertaking a concurrent distracter task. The number of critical errors (ie, those having a high impact on dose delivery) was recorded for all attempts. To facilitate subsequent correlation analyses, an overall performance measure was derived from a combination of the results of the single inhaler trial and the 10 trials with a distracter.

RESULTS

Eighty individuals (51 women, 29 men; mean [SD] age, 74.1 [7.5] years) participated in the study(40 participants per device). Forty of the participants (50%) had used an inhaler previously; 40 (50%) were inhaler naive. Based on the overall performance measure, participants testing the mDPI made significantly fewer critical errors than participants testing the cDPI (P < 0.001). Participants rated both inhalers as easy to use but were overconfident concerning their ability to use the 2 devices.

CONCLUSIONS

In this study of usability of an mDPI and a cDPI in older participants, participants found both inhalers easy to use, but fewer critical errors were made with the mDPI compared with the cDPI. However, the results suggest a degree of overconfidence and the need for continual monitoring of patients' inhalation technique, especially with the cDPI.

Age of onset and the characteristics of asthma

OBJECTIVE

The aim of this study was to evaluate the characteristics of asthma in patients with different ages of disease onset.

METHODOLOGY

Five hundred and four asthmatic patients (303 males and 201 females) were divided into five groups based on age of onset (group I, age of onset < 15 years old; group II, 15-24 years old; group III, 25-44 years old; group IV, 45-64 years old; and group V, > 64 years old). The relationship between age of onset and the characteristics of asthma, including lung function, reversibility, atopic status and the incidence of coexistent allergic rhinitis was assessed. Multivariate analysis, adjusted for the duration of disease, gender, educational level, smoking status, and degree of previous inhaled corticosteroid treatment, was performed.

RESULTS

Thirty per cent of the patients developed asthma before they were 14 years old (group I), and the percentages of those developing asthma at other ages of onset were: group II, 12%; group III, 29%; group IV, 21% and group V, 8%. In all, 57.6% of the asthmatic patients had coexistent allergic rhinitis; younger patients tended to have this comorbidity. The pulmonary function of older onset asthma patients was worse than that of early onset patients. The multivariate analysis showed that there was a positive correlation between the reduction of pulmonary function and duration of the disease (P < 0.001), but there was no relationship between pulmonary function and gender (P = 0.502), educational level (P = 0.734), smoking pack-years (P = 0.902), or degree of use of inhaled corticosteroid treatment (P = 0.586).

CONCLUSION

Asthma is a heterogeneous disease with a wide variety of presentations. This study provides information about the disease characteristics and their relationship with age of onset. Further study is necessary to determine why these differences exist.

Dyspnoea in the elderly: a clinical approach to diagnosis

This review briefly overviews the pathophysiology of dyspnoea and then focuses on discussion of the most frequent causes of chronic and acute dyspnoea in the elderly. The most common causes of dyspnoea in the elderly include heart failure, chronic obstructive pulmonary disease and asthma. Other causes include parenchymal lung disease, pulmonary vascular diseases, upper airway obstruction and pneumonia. Dyspnoea should not be attributed to aging alone. Careful clinical evaluation and spirometry is indicated, and additional testing may be appropriate. In this article, emphasis is placed on the clinical manifestations of dyspnoea in the elderly and an approach to their differential diagnosis is provided. Discussion of available therapy is beyond the scope of this article.

Helping patients to master correct inhaler techniques: nursing role

The use of inhalers is widespread for asthma and conditions such as chronic obstructive pulmonary disease and yet many people have difficulties in mastering correct inhaler technique. Elderly people and children have specific problems with inhaler use and require both targeted and appropriate help in order to improve their inhaler technique and minimize waste of inhaled medication and therefore lack of therapeutic effect. Nurses need to be able to not only demonstrate correct inhaler technique themselves, but also identify what is going wrong and be knowledgeable concerning the various options available. Frequent assessment of inhaler technique needs to become a regular feature of health promotion for all patients using these devices.