Metered dose inhalers and inhaler technique in the older adult

Why it matters. Inhaled therapy is first-line in COPD and asthma, but the drug only reaches the airway if the technique is correct. Using inhaler devices is a demanding task for older patients because it needs coordination and respiratory muscle strength. Poor technique is a major cause of apparent "treatment failure" and leads to unnecessary escalation of therapy — always check the technique before stepping up treatment.

Correct MDI technique (stepwise). (1) Remove the cap and shake well; (2) sit or stand upright and breathe out fully, away from the device; (3) seal the lips around the mouthpiece; (4) begin a slow deep inhalation and actuate the canister at the same moment; (5) continue inhaling steadily over 4–5 seconds; (6) hold the breath for 10 seconds; (7) wait 30 seconds before a second puff; (8) rinse the mouth after an inhaled corticosteroid.

Common errors. Failure to shake the canister; not exhaling first; poor hand–breath coordination — actuating before or after inhalation; inhaling too fast; no breath-hold; firing into the mouth while breathing out; using an empty canister; and not rinsing, leading to oropharyngeal candidiasis and dysphonia. Multiple puffs fired in quick succession.

Age-related barriers. Most cognitively intact older patients without physical limitation can use an inhaler correctly, but learning and coordination difficulties are present in about 20%. Cognitive impairment has a dramatic impact: an MMSE score below 24 is associated with a very high risk of failure, and the abnormal pentagon-copying test alone identifies patients unable to use inhaler devices. Other barriers: poor manual dexterity, weak hand grip, arthritis, impaired vision and impaired executive function — the last is especially common in hospitalised patients.

Device selection. The perfect device does not exist — the choice must be individualised to the patient's cognition, dexterity and inspiratory flow. An MDI with a spacer (valved holding chamber) removes the need for hand–breath coordination and reduces oropharyngeal deposition, candidiasis and dysphonia; it is the preferred combination in most older adults. Dry powder inhalers need adequate inspiratory flow, often lacking in severe COPD and frailty, but need no coordination. Breath-actuated MDIs help coordination problems. Nebulisers are reserved for very advanced disease or when the inhaler technique is so poor that no other relief is possible; adapters fitted to the inhaler ends can help weak grip.

Improving technique and adherence. Use fixed-dose combination inhalers to reduce the number of devices, since device quantity impacts adherence; keep the patient on one device type wherever possible. Teach by physical demonstration with teach-back, not verbal instruction alone. Ask the patient to bring all inhalers to every clinic visit, and re-train the patient and/or the caregiver. Screen cognition (MMSE or a secondary memory test) to identify those at risk of poor compliance, and involve the carer or care-home staff for supervised administration.

GOLD 2025 / 2026 makes checking inhaler technique a mandatory step at every visit and a required check before any escalation of therapy, and emphasises choosing the device before choosing the drug. GOLD now also asks clinicians to consider the environmental impact of inhalers — conventional pressurised MDIs use high global-warming-potential HFA-134a/227ea propellants, and the shift is towards low-GWP propellants (HFA-152a, HFO-1234ze) and greater use of dry powder inhalers where clinically appropriate — though in older adults clinical suitability and inspiratory flow must always outweigh environmental considerations.