I work with a lot of geriatric patients in my practice on respiratory medications and I get pretty concerned when I start to see patients with COPD, asthma, or other respiratory diseases who have frequent exacerbations that are causing emergency department visits or hospitalizations.
One of the most important things I review with patients is can they utilize their inhaler device. Let’s take tiotropium for example. Many elderly patients can have cognitive impairment or arthritis conditions that may not allow them to easily use their device as they had in the past. The best case scenario to assess this would be to have that patient come in and use that device. This isn’t always possible, but questioning them on that use can be helpful.
Another situation I think about, is can the patient adequately coordinate the use of their inhaler for those that need to have that happen. The metered dose inhalers need to have patients be able to time their inhalation at the same time that they hit the actuator. They also have to have the manual dexterity to use that inhaler.
Often the solution I recommend in this situation is to take advantage of nebulizers. Nebs like pulmicort, aformoterol, albuterol, Duonebs etc. certainly have their downsides as well (i.e. bulking machines, time consuming etc.), but they can really help us ensure that the patient is getting the dose of the medication that they need to prevent exacerbations.
If the patient already has a nebulizer and a MDI for rescue, ask them if they feel better after using the inhaler or if they feel better after using the nebulizer. If they seem to indicate that the inhaler doesn’t seem to work as well, they assessing their technique/ability to use the inhaler would be very important.
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