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