Importance of Assistance by Caregivers for Inhaled Corticosteroid Therapy in Elderly Patients With Asthma

To the Editor: Complications accompany asthma in elderly patients more often than in other age groups, and some complications could interfere with the procedure of inhalation therapy.1–3 Even in such cases, regular and accurately calibrated inhaled corticosteroid (ICS) therapy can be made possible with the assistance of a caregiver.3 Although assisted inhalation therapy is currently in practice, no clinical studies have evaluated its effects. This objective of this study was to investigate the usefulness of assistance by caregivers during the inhalation procedure in elderly patients with asthma whose pulmonary functions were not improved by self-administered ICS therapy. Patients aged 65 and older with severe asthma and less than 60% of percentage peak expiratory flow (PEF) received self-administered ICS therapy (equivalent to 800 μg beclomethasone dipropionate (BDP)/d) for 8 weeks. Of the patients who received the above therapy, 10 cases with PEF improvement of less than 15% were enrolled. While investigating the causes of the poor responsiveness to self-administered ICS therapy, we conducted a survey on the caregivers' preferences concerning the devices used for assistance and their reasons by giving them three types of ICS devices for training: one metered-dose inhaler (MDI; hydrofluoroalkane–BDP) and two dry powder inhalers (DPIs: fluticasone propionate and budesonide). After that, assisted ICS therapy (equivalent to 800 μg BDP/d) was administered for 8 weeks using the devices selected by the caregivers to prospectively evaluate the effects of assisted inhalation on PEF and forced expiratory volume in 1 second (FEV1). Statistical analysis was performed using the multiple comparison Tukey tests. The subjects consisted of five men and five women with an average age of 81.6. All the patients had severe asthma with a mean percentage FEV1 of 58.0% and a mean percentage PEF of 43.2%. Poor responsiveness to self-administered ICS therapy was attributed to problems with the inhalation technique in seven cases and compliance in nine cases. The presence of one or more complications was observed in all patients. These complications consisted of rheumatoid arthritis, diabetic neuropathy, or cerebral infarction causing motor dysfunction in seven cases; Alzheimer's disease or cerebral infarction causing intellectual dysfunction in five cases; and chronic obstructive pulmonary disease (COPD) in four cases. PEF was increased more than 15% in 70% of the study subjects with assisted ICS therapy. Significantly greater improvement was observed in PEF and FEV1 at the end of assisted ICS therapy than with self-administered ICS therapy (Figure 1; P<.001 in both cases). With regard to the three cases in which the assisted ICS therapy did not bring about improvement in pulmonary function, one was attributed to failure in compliance because of the complication of stomatitis, and the other two were attributed to airflow limitation with less reversibility associated with COPD or the progress of asthmatic airway remodeling. Nine caregivers selected MDI inhalers for assisted inhalation. The reasons for selecting the MDI inhaler were that MDI inhalers were easy to use, because they enable one-step inhalation and that MDI inhalers could be used without anxiety, because the spraying and inhaling conditions can be observed visually. Changes in (A) peak expiratory flow (PEF) and (B) forced expiratory volume in 1 second (FEV1) at the start and end of self-administered inhaled corticosteroid (ICS) therapy and at the end of assisted ICS therapy. Bold horizontal bars represent means of PEF and FEV1 in each period. It is often the case that functional disorders accompanying asthma in elderly patients interfere with their inhalation technique, and this has led to hesitation on the part of physicians to prescribe inhalation therapy for such patients. One study reported that the more complications an elderly asthma patient has, the lower the ICS prescription rate will be.2 Intellectual dysfunction, such as Alzheimer's disease, can result in a poor understanding of the inhalation technique, and motor dysfunction, such as rheumatoid arthritis, will directly affect the physical ability to perform the inhalation procedure. It is assumed that, because the ICS therapy was not performed regularly, the improvement in asthma symptoms was limited, which in turn, led to poorer patient compliance. When asthma management is insufficient in spite of repeated inhalation guidance, assisted inhalation may be indicated. For assisted inhalation therapy, it is important to select inhalants that are easy for caregivers to use. Hydrofluoroalkane-BDP is considered appropriate for assisted ICS therapy, because it allows the caregiver to visually check the drug-spraying and inhalation conditions of the patient. In conclusion, assistance by caregivers in ICS therapy is an important therapeutic strategy for elderly patients with asthma, especially those with complications that result in problems with the inhalation technique or compliance, and this strategy can be expected to expand the application of ICS therapy for elderly patients with asthma. We thank Mr. Brent Bell for reading this letter. Financial Disclosure: The authors of this paper have no financial disclosures to report concerning this letter.