Inhaler mastery and retention after stepwise training in cognitively impaired older COPD.

BACKGROUND: In older COPD patients with cognitive impairment, inhaler technique errors are common, but may be reduced by simplified designs and structured training. METHODS: We conducted a prospective, crossover study with follow-up at 5±1 weeks in device-naïve COPD patients aged ≥70 years with moderate cognitive impairment (Mini Mental State Examination score 10-24). Physical function was assessed (Fried's Frailty Phenotype and Barthel Index). Participants demonstrated technique with a multidose dry powder inhaler (mDPI), a capsule-based DPI (cDPI), and a pressurised metered-dose inhaler (pMDI) after reading the patient information leaflet, then received a standardised stepwise training programme. Co-primary end-points were mastery after reading the patient information leaflet and after expert tuition. Secondary end-points included time to mastery, 1-month technique retention, and satisfaction (10-item Feeling of Satisfaction with Inhaler questionnaire). RESULTS: 96 patients completed the study (mean age 79 years; 42% women; 66% pre-frail, 14% frail). After reading the patient information leaflet, correct technique was achieved by 29% with mDPI, 13% with cDPI, and 7% with pMDI. Errors were more frequent (p<0.001) with the pMDI (n=137) and cDPI (n=98) than with the mDPI (n=65). Training enabled all patients to achieve mastery, with shorter (p<0.001) times for the mDPI (3.1±1.1 min) than the cDPI (8.5±2.1 min) or pMDI (9.1±3.3 min). After 1 month, 85% maintained correct technique, higher (p<0.05) for the mDPI (97%) than pMDI (77%). Satisfaction scores favoured (p<0.01) the mDPI. CONCLUSIONS: Structured training allows older cognitively impaired COPD patients to master and retain inhaler technique. The mDPI was simpler, faster to learn, and better retained, supporting its use in geriatric COPD care.