Abstract

The morbidity and mortality from asthma remain high in patients over the age of 75 years in developed countries, in contrast to the improving mortality from that condition in children and younger adults. One of the reasons for this might be the relatively poor performance with inhaler devices confirmed by surveys of technique in elderly patients. Also, it has been shown that the most prominent determinants of adequate inhaler technique in old age are global cognitive function, frontal executive function and ideo-motor praxis. This review explores the pattern of observed and measured errors in the use of various inhalers in old age. The cognitive barriers to a successful grasp of inhaler technique are explained. The review then proceeds to describe a systematic research sequence by the author and others to identify factors that determine the likelihood of an aged person being able reliably to self-administer medication by the inhaled route, also drawing on parallel evidence from studies of spirometry technique. Relatively simple tests of cognition, praxis and executive function are described which have been shown to have predictive value in assessing frail elderly subjects for potential inhaler therapy or spirometry. The evidence presented can enable clinicians, particularly geriatricians, internists and pulmonologists to approach inhaled therapy for asthma and chronic obstructive pulmonary disease in a logical and effective way for their frail elderly patients. Further, it will be argued that the relation between congitive function and inhaler technique can be seen as a clinical metaphor for other self-administered tests or treatments, such as insulin therapy. There is scope for research to determine the predictive role of cognitive function tests in a wide range of self-treatment settings, particularly for patients with relatively mild unrecognized cognitive impairment.