An estimated 11.7% of adults 65 and older in the United States have reported a diagnosis of chronic obstructive pulmonary disease (COPD) from their physician (Centers for Disease Control and Prevention [CDC], 2012). The Global Initiative for Chronic Obstructive Lung Disease (GOLD, 2018) recommends regular and as-needed use of short-acting beta-agonists (SABAs) to improve forced expiratory volume over 1 second and symptoms of COPD. For chronic management of COPD, inhalers with a long-acting beta-agonist (LABA), long-acting muscarinic antagonist (LAMA), and/or inhaled corticosteroid (ICS) are recommended for daily symptom control. Older adults with greater symptoms and exacerbations requiring hospitalization are likely to be prescribed two to three short- and long-acting inhalers (GOLD, 2018). There are several inhalers available in the United States, each with specific steps that can make proper administration challenging.
Age-related visual, cognitive, and functional limitations increase the risk for poor inhaler technique (Dow, Fowler, & Lamb, 2001; Fraser, Patel, Norkus, & Whittington, 2012; Vanderman, Moss, Bailey, Melnyk, & Brown, 2015). The incidence of visual impairment and blindness in American individuals rises from 1.2% and 0.3%, respectively, in adults ages 65 to 74 to 12.1% and 5.6% in individuals 75 and older (Prevent Blindness America®, 2012). Approximately 5.7 million American individuals have a diagnosis of Alzheimer's disease; this number is projected to increase to 14 million by 2050 (Alzheimer's Association, 2018). Approximately 50% of adults 65 and older in the United States report a diagnosis of arthritis (Barbour, Helmick, Boring, & Brady, 2017). In addition, older adults may have other conditions or comorbidities that prevent proper inhaler administration, such as poor hand grip strength, history of stroke or transient ischemic attack, or Parkinson's disease (Vanderman et al., 2015).
Based on manufacturer prescribing information, there are 10 universal steps for inhalers plus one to four device-specific steps. Examples of device-specific steps include twisting an inhaler until it clicks or loading and puncturing a capsule. Trials that investigate inhaler use in older adults raise concerns about metered dose inhalers (MDIs) and dry powder inhalers (DPIs), such as the Diskus®, Ellipta®, and HandiHaler® devices. One study observed that older adults make critical administration errors with up to 79% of MDI doses and 88% of DPI doses (Vanderman et al., 2015). A critical error significantly affects dose delivery due to failure to complete certain steps, such as removing the mouthpiece cover, loading a DPI capsule, priming, sealing mouth over the mouthpiece, and deeply inhaling at the appropriate rate (Franks & Briggs, 2004; Vanderman et al., 2015). Dexterity limitations can negatively impact administration of MDIs in particular because the dose is released at a high velocity, which requires simultaneous inspiration and actuation by the patient (Chrystyn, 2007; Dow et al., 2001). In contrast, this “hand–lung” coordination is not necessary for DPIs (Chrystyn, 2007). A comparison between the HandiHaler DPI and MDI showed higher rates of correct use across all age groups with the HandiHaler, even in patients with more experience using a MDI than a HandiHaler (Dahl, Backer, Ollgaard, Gerken, & Kesten, 2003). However, dose delivery with a DPI is dependent on a strong inspiratory rate, which could be difficult for patients with severe COPD (Chrystyn, 2007).
The use of DPIs may be considered more complex than MDIs due to a greater number of administration steps. Multi-dose DPIs, such as the Diskus or Ellipta, are pre-loaded with a 30-day supply of medication. However, a single-unit or capsule DPI, such as the HandiHaler, requires loading a new capsule with each dose (Chrystyn, 2007). Therefore, the single-unit HandiHaler may have lower rates of correct use than the multi-dose Diskus, as was observed in a study of inhaler usability and critical errors in older adults (Franks & Briggs, 2004). A study of predictors of incorrect inhaler technique also found errors occurred more often with devices that require patients to load and unload versus multi-dose devices (Rootmensen, van Keimpema, Jansen, & de Haan, 2010).
Frail Community-Dwelling Older Adults
A specific population of concern may be older adults who are frail and eligible for long-term care placement but live in the community. The current authors evaluated 40 such patients from the Program of All-Inclusive Care for the Elderly of Rhode Island (PACE-RI) in a retrospective chart review (Bystrak & Eisenhower, 2016). The PACE program provides services to older adults (age ≥55) that allow them to maintain their independence and remain in the community longer before transitioning to long-term care. The study included community-dwelling PACE patients with an International Classification of Disease Tenth Edition (ICD-10) diagnostic code related to COPD who self-administer inhalers, and met with a clinical pharmacist and/or professional year 4 (P4) PharmD student between January 1, 2016 and May 31, 2017. The study was exempt from informed consent by the Institutional Review Board at the University of Rhode Island.
The primary objective of the study was to determine the overall rate of correct inhaler technique among these patients. Secondary objectives included rates of correct technique for the most commonly used inhalers (SABA MDI, Diskus, and HandiHaler); an analysis of problematic inhaler steps for those three inhalers; a comparison of pass rates between the Diskus and Handi-Haler (to compare results from Franks and Briggs ); and a subgroup analysis of pass rates based on select demographics.
Inhaler technique was assessed by the pharmacy team using standardized inhaler checklists, based on the instructions for use in the manufacturer prescribing information. Technique for each device was documented as incorrect if one or more steps was performed improperly, forgotten, or required assistance or cueing to complete. Patients who did not bring their inhalers to the visit were allowed to demonstrate technique with demo inhalers and mimic sealing their lips over the mouthpiece of the inhaler(s). This mimicking, however, limited the ability to accurately assess whether patients tightly seal their mouths around the inhaler mouthpiece and whether their inspiratory rate was appropriate.
Demographics were obtained from the electronic health record. Visual, cognitive, and/or functional impairments were documented. Visual impairment was defined as difficulty seeing (i.e., blindness, blurry or cloudy vision, poor depth perception) as reported by patients during their most recent assessment by a PACE-RI occupational therapist (OT). Cognitive impairment was defined as an ICD-10 code related to mild cognitive impairment, dementia, and/or Alzheimer's disease. Severity of cognitive impairment was not included in the study. Functional impairment was defined as range-of-motion and strength assessments of the left and right forearm/wrist and fingers that were outside of functional limits, and/or observation of tremor by the PACE-RI OT.
For statistical analysis, Fisher's Exact test was performed to compare the difference between proportions of correct use for the Diskus and HandiHaler. Differences were considered significant at p < 0.05. The subgroup analysis of inhaler pass rates based on demographics is descriptive.
The 40 patients in the study used a total of 74 inhalers. This total included 35 assessments for a SABA MDI, 18 for the Diskus, 11 for the Handi-Haler, and 10 for other inhalers. No patients in the study were prescribed a Neohaler® device, but it should be noted that the administration steps are similar to that of the HandiHaler. Patients were between ages 55 and 88, with a mean age of 68. The majority of patients were White (70%), female (65%), and spoke English as a primary language (85%). The highest level of education for 54.1% of patients was high school. Fifty percent of patients had visual impairment, 30% had cognitive impairment, and 40% had functional impairment.
The overall rate of correct inhaler technique was only 59.5% (44/74 inhalers). The rate of correct technique was lower for the SABA MDI (“rescue inhaler”) than for the Diskus or HandiHaler (Table 1). The most commonly missed step for the SABA MDI was shaking the canister before use, with a 37.1% failure rate. This step is crucial to ensuring that the medication and propellant have sufficiently mixed so that patients receive the full dose. Patients using other MDIs (ICS +/− LABA) also failed to shake the inhaler before use. Regarding the DPIs, correct technique was more often demonstrated with the HandiHaler than the Diskus. This finding differs from the results observed by Franks and Briggs (2004); however, the current authors' sample size was smaller, and the study design did not include inhaler technique education at the start of the study. Failure to click the Diskus lever into place or puncture the HandiHaler capsule was observed in several patients, which entirely prevents delivery of the dose. There was no statistically significant difference in the proportion of correct use between the Diskus and HandiHaler (p = 0.194); however, sample sizes were small.
Inhaler Technique Errors
Trends were not identified for the impact of age, total number of inhalers, level of education, or number of concomitant medications on inhaler technique. However, patients who spoke Spanish instead of English as their primary language more often demonstrated incorrect technique with the SABA MDI and Diskus. During the pharmacy visits, an interpreter was present if Spanish was the primary language; however, it is unknown whether patients had an interpreter at the time of initial prescribing of the current inhaler regimen. Functional impairment did not impact pass rates in this study. More patients failed the Diskus if they had visual impairment, and more patients failed the SABA MDI if they had cognitive impairment.
These results reiterate that periodic evaluation of inhaler technique is important, as well as thorough initial education. Older adults should be educated on the importance of critical steps that, if missed, can prevent them from receiving the full dose of medication. One possible method to improve technique involves creating individualized inhaler labels to highlight patient errors. A recent study investigated patients using DPIs and provided inhaler training with or without individualized inhaler labels. After 3 months, patients who were provided with inhaler labels demonstrated a 67% retention rate of correct technique versus 12% for patients who were not provided with labels (Basheti, Obeidat, & Reddel, 2017). Patients and/or caregivers could be instructed to keep the originally labeled inhaler to refer back to after they receive a new inhaler refill. In addition, medication guides are available online from inhaler manufacturers and generally include pictures to accompany each step.
Clinical Implications for Nursing
Home health nurses have the opportunity to assess inhaler technique and reinforce correct inhaler administration steps. Nurses can also identify and communicate potential risk factors for incorrect inhaler use in older adults to other interdisciplinary team members, such as prescribers, pharmacists, OTs, and social workers. Interdisciplinary teams should assess and discuss a variety of factors that impact outcomes, such as: the severity of COPD; status of comorbidities; visual, cognitive, and functional limitations; recommended COPD treatment based on the GOLD guidelines; correct or incorrect inhaler use based on steps listed in the prescribing information; inhaler adherence; and affordability and insurance coverage. All health care professionals should be aware of the possible advantages of certain inhalers. Device-specific advantages include: the option to add a spacer to an MDI if a patient has difficulty sealing his/her lips around the mouthpiece; fewer device-specific steps with the Respimat®; a large cover with grips on the side of the device and a large dose counter on the Ellipta; and the option to inhale more than one time after puncturing the capsule with the HandiHaler or Neohaler. It is also important to consider patient opinions about inhalers. Table 2 provides unsolicited comments from older adults in the current study regarding their inhaler regimens.
Patient Feedback on Inhalers
Poor adherence to inhalers is a significant concern and is estimated at more than 50% in patients with COPD (Lareau & Yawn, 2010). Adherence may be negatively impacted by complex inhaler regimens, poor patient–clinician relationships, lack of social support, low self-efficacy, and certain health beliefs (Lareau & Yawn, 2010). Health care professionals should work closely with patients to improve adherence by simplifying inhaler regimens when possible (i.e., use of combination inhalers), implementing cueing (i.e., storing inhalers in routine places such as by a toothbrush), and incorporating the personal goals of patients into their care (i.e., use of maintenance inhalers to help patients play with their grandchildren without experiencing shortness of breath) (Lareau & Yawn, 2010). Nurses and other health care professionals should consider that demonstration of correct inhaler technique during a clinic visit does not guarantee that the inhaler is or will be used as prescribed. Home visits may reveal that patients are unable to afford their inhalers and/or have poor adherence. For example, in the current study, six patients were found to be using the Diskus once daily instead of twice daily, one patient used his/her Diskus as needed, and one patient was not using his/her HandiHaler at all. Enrollment in the PACE-RI program includes coverage of medications, and refills of maintenance inhalers are automatic by the contracted pharmacy. Therefore, these patients may have extra, unused inhalers in their homes. In the general outpatient setting, nurses may find a lack of inhalers or expired inhalers in the homes of patients with poor adherence or inability to pay for refills.
Interdisciplinary teams should make a conscientious effort to ensure that older adults can afford their inhaler regimens. It can be difficult for older adults to navigate the health care system, and patients should be supported by senior care services and/or patient navigators (Ferrante, Cohen, & Crosson, 2010). Team members can also assist patients with checking drug costs and coverage on the Medicare webpage with the Medicare Plan Finder (access https://www.medicare.gov/find-a-plan/questions/home.aspx). Patients can view the full cost of the drug, deductible, initial coverage level, coverage gap, and catastrophic coverage (Centers for Medicare & Medicaid Services [CMS], n.d.). Initial coverage for inhalers included in the plan may be less than $100 per month but will increase when patients are in the coverage gap. As an example, an older adult may pay $45 per month for a LABA/LAMA Ellipta but $150 per month during the coverage gap (CMS, n.d.). For patients with Medicare or other insurance coverage, Medscape (n.d.) includes a feature to search and select an inhaler, add insurance plans, and view tier and restrictions such as quantity limits and prior authorizations. Older adults should also be informed that manufacturer savings may be available. Some manufacturers offer the first inhaler for free if it is not submitted for reimbursement and does not count toward out-of-pocket costs through government or Medicare programs. Other manufacturers provide co-pay discounts for U.S. residents, but this benefit is often available only to patients younger than 65.
Inhalers pose several challenges for older adults. By emphasizing critical inhaler steps and requiring older adults to demonstrate inhaler technique in-person at clinic or home visits, health care professionals can work to reduce the likelihood of errors. Demo inhalers can be used for teaching so that patients can determine if any device features will be difficult for them. Step-by-step instructions for inhaler use are available online from each manufacturer. Nurses and other clinicians can refer to these documents, which are often accompanied by pictures, when teaching patients. The Institute for Safe Medication Practices also recommends How to Use Inhalers: Interactive Guidance and Management (access https://use-inhalers.com), a website that includes free training videos in multiple languages. If possible, older adults should be offered several inhaler options based on disease severity, comorbidities, and affordability. Inhalers that are offered for free for the first 30-day supply should be considered, with follow up scheduled to assess ease of use and change inhalers, if necessary. Over time, progression of disease, worsening of comorbidities, and changes in insurance coverage should be monitored to determine whether the current inhaler regimen is still most appropriate for individual older adults.
- Alzheimer's Association. (2018). Alzheimer's disease facts and figures. Retrieved from https://www.alz.org/media/Documents/alzheimers-facts-and-figures-infographic.pdf
- Barbour, K.E., Helmick, C.G., Boring, M. & Brady, T.J. (2017). Vital signs: Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2013–2015. MMWR Morbidity and Mortality Weekly Report, 66, 246–253. doi:10.15585/mmwr.mm6609e1 [CrossRef]
- Basheti, I.A., Obeidat, N.M. & Reddel, H.K. (2017). Effect of novel inhaler technique reminder labels on the retention of inhaler technique skills in asthma: A single-blind randomized controlled trial. NPJ Primary Care Respiratory Medicine, 27, 9. doi:10.1038/s41533-017-0011-4 [CrossRef]
- Bystrak, T. & Eisenhower, C. (2016, December). Rates of correct inhaler technique in high-risk, community-dwelling older adults with chronic obstructive pulmonary disease (COPD). Presented at the American Society of Health-System Pharmacists Midyear Clinical Meeting. , Las Vegas, NV. .
- Centers for Disease Prevention and Control. (2012). Chronic obstructive pulmonary disease among adults—United States, 2011. MMWR Morbidity and Mortality Weekly Report, 61, 938–943.
- Centers for Medicare & Medicaid Services. (n.d.). Medicare plan finder. Retrieved from https://www.medicare.gov/find-a-plan/questions/home.aspx?AspxAutoDetectCookieSupport=1
- Chrystyn, H. (2007). The Diskus: A review of its position among dry powder inhaler devices. International Journal of Clinical Practice, 61, 1022–1036. doi:10.1111/j.1742-1241.2007.01382.x [CrossRef]
- Dahl, R., Backer, V., Ollgaard, B., Gerken, F. & Kesten, S. (2003). Assessment of patient performance of the HandiHaler compared with the metered dose inhaler four weeks after instruction. Respiratory Medicine, 97, 1126–1133. doi:10.1016/S0954-6111(03)00162-8 [CrossRef]
- Dow, L., Fowler, L. & Lamb, H. (2001). Elderly people's technique in using dry powder inhalers. New inhaler devices are rarely used by older people in the community. BMJ, 323, 49–50.
- Eisenhower, C. (2018, May). What is the best inhaler(s) to select for the older adult with COPD based on disease severity, comorbidities, and affordability? Presented at the Annual Scientific Meeting of the American Geriatrics Society. , Orlando, FL. .
- Ferrante, J., Cohen, D.J. & Crosson, J.C. (2010). Translating the patient navigator approach to meet the needs of primary care. Journal of the American Board of Family Medicine, 23, 736–744. doi:10.3122/jabfm.2010.06.100085 [CrossRef]
- Franks, M. & Briggs, P. (2004). 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. Clinical Therapeutics, 26, 1791–1799. doi:10.1016/j.clinthera.2004.11011 [CrossRef]
- Fraser, M., Patel, M., Norkus, E.P. & Whittington, C. (2012). The role of cognitive impairment in the use of the Diskus inhaler. Journal of the American Medical Directors Association, 13, 390–393. doi:10.1016/j.jamda.2011.04.004 [CrossRef]
- Global Initiative for Chronic Obstructive Lung Disease. (2018). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2018 report. Retrieved from https://gold-copd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf
- Lareau, S. & Yawn, B.P. (2010). Improving adherence with inhaler therapy in COPD. International Journal of Chronic Obstructive Pulmonary Disease, 5, 401–406. doi:10.2147/COPD.S14715 [CrossRef]
- Medscape. (n.d.). Drugs, OTCs & herbals. Retrieved from https://reference.medscape.com/drugs.
- Prevent Blindness America®. (2012). Vision problems in the U.S. Retrieved from http://www.visionproblemsus.org/vpus-search.html
- Rootmensen, G.N., van Keimpema, A.R., Jansen, H.M. & de Haan, R.J. (2010). Predictors of incorrect inhalation technique in patients with asthma or COPD: A study using a validated videotaped scoring method. Journal of Aerosol Medicine and Pulmonary Drug Delivery, 23, 323–328. doi:10.1089/jamp.2009.0785 [CrossRef]
- Vanderman, A.J., Moss, J.M., Bailey, J.C., Melnyk, S.D. & Brown, J.N. (2015). Inhaler misuse in an older adult population. The Consultant Pharmacist, 30, 92–100. doi:10.4140/TCP.n.2015.92 [CrossRef]
Inhaler Technique Errors
|Inhaler (Users, n)||Rate of Correct Technique (%)||Description of Errors|
Failure to shake inhaler before use
Did not remove cap of MDI before use
Did not hold breath for appropriate amount of time (approximately 10 seconds) after administering dose
Failure to shake inhaler before use
|Diskus® (18)||61.1||Failure to:
Open device before use
Click lever into place to load dose
Close device after use
Hold inhaler flat while breathing in
Rinse/spit after use
Failure to click green piercing button to puncture capsule
Unable to twist inhaler until it clicks to load dose
Blocked air vents with hand
Did not slide cover over until it clicks to load dose
Held inhaler with vent facing down
Failure to rinse/spit after use of ICS
Patient Feedback on Inhalers
|Inhaler||Older Adult Patients' Comments|
Difficult to depress canister (patient with arthritis)
Larger canister (120 doses) is harder to depress than smaller canister (60 doses)
Difficult to open mouthpiece (patient who is legally blind)
Dose counter is very small and difficult to read
Dry powder is irritating and/or results in cough (three patients)
Rinsing and spitting after use is inconvenient
Difficult to twist (left-handed patient)