falls risk factor reduction is possible in residents of care homes. A modest reduction in falls rates was demonstrated but this failed to reach statistical significance.

This article explores the structural and physiological changes that occur in the ageing lung, and the impact that lung disease and other co-morbidities may have on it. The major changes associated with ageing are reduced lung elasticity, respiratory muscle strength and chest wall compliance, all of which may be influenced by impaired lung growth in early childhood and adolescence. The resultant reduction in diffusing capacity may not be relevant in a fit older adult, but co-morbidities may interact to cause breathlessness and impairments in quality of life. Lung function declines with age, but forced vital capacity (FVC) begins to decline later than forced expiratory volume in 1 s (FEV 1 ) and at a slower rate. This results in a natural fall in the FEV 1 /forced vital capacity (FVC) ratio which may result in overdiagnosis of chronic obstructive pulmonary disease, and hence the need to ensure the FEV 1 is less than 80% before confirming the diagnosis. As older adults probably have a diminished response to hypoxia and hypercapnia, they become more vulnerable to ventilatory failure during high-demand states such as heart failure and pneumonia and therefore to possible poorer outcomes. Poor nutritional status is likely to be an important factor, as is cognitive impairment. It is important to assess older patients using a range of clinical and physiological parameters rather than on the basis of age per se which is a poor predictor of outcome.

Aim: To identify patient needs following discharge from hospital after an exacerbation of COPD.Methods: Qualitative and semi-quantitative study using home-based structured interviews and focus groups involving 25 COPD patients after hospital discharge. Interviews were performed seven days and three months post-discharge. Quantitative data were analysed using descriptive statistics and were triangulated with the qualitative data from interviews and the focus groups.Results: There were high levels of depression (64%) and anxiety (40%). Feelings of anxiety after discharge were associated with the fear of another "attack" and with uncertainties about social and medical care provision, especially the provision of oxygen.Conclusions: Interventions to reduce readmission for COPD exacerbations need to consider the psychosocial as well as the medical needs of patients. There appears to be a need for improved hospital discharge procedures and community follow-up -including the provision of pulmonary rehabilitation and encouragement of self-management strategies.

Background: There is a concern that comorbidity or frailty in older people could limit the usefulness of currently available exercise tests for chronic lung disease. This study evaluated the feasibility and reproducibility of the incremental shuttle walking test (SWT) in people aged 70 years or over, compared exercise tolerance with other disability markers, and assessed whether the SWT is responsive to change after bronchodilators. Methods: Fifty elderly patients with chronic airflow limitation (CAL) and 32 controls without airflow limitation attempted the SWT before and after combined nebulised salbutamol/ipratropium bromide. Subjects also completed the Nottingham Extended Activities of Daily Living index (NEADL) and the London Handicap score (LHS). Results: Forty four subjects with CAL (88%) and 29 controls (84%) completed the SWT, including many with co-morbidities. Two week repeatability was good and the SWT was strongly associated with EADL (r=0.51, p<0.001) and LHS (r=0.43, p<0.004), but only weakly with forced expiratory volume in 1 second (FEV 1 ) (r=0.31, p=0.05). Subjects with CAL walked a mean distance of 177.7 m compared with 243.3 m in controls (p<0.001); following bronchodilator therapy the distance walked increased in the CAL group by 13.2% (p=0.009). Conclusion: The SWT is a feasible and reproducible measure of exercise tolerance in elderly people with and without airflow obstruction and correlates with other markers of disability. It is sensitive to change following bronchodilation in subjects with CAL, although the change correlates less well with improvements in FEV 1 . Overall, these results suggest that the SWT might be an appropriate measure to assess interventions in elderly people.

The aim of this study was to assess health-related quality of life (QoL) in elderly subjects with a diagnostic label of asthma from a general practice population, and to determine the main contributory factors.Sixty people aged $70 yrs with a primary care diagnostic label of asthma, and 43 control subjects were recruited. Assessment of bronchodilator response, and oral steroid trials were conducted where possible. The main outcome measures were QoL scores for the Short Form (SF)-36 and the St George's Respiratory Questionnaire (SGRQ).In the asthma group, 29 subjects demonstrated a significant airway response to bronchodilators or steroids. Mean SF-36 scores were significantly worse in the total asthma group for components of physical function, physical role limitation, and general health, although psychological scores were similar. QoL remained worse than controls in those subjects with a significant bronchodilator response. Dyspnoea and depression accounted for 61% of the variance in the SGRQ, but forced expiratory volume in one second was not an independent variable.Quality of life is impaired in elderly people with a diagnosis of asthma, including those with demonstrable airway variability. Many older subjects with asthma note a variety of symptoms, highlighting the need for further research into the adequacy and efficacy of their treatment. Eur Respir J 1999; 14: 39±45.

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Asthma is a common but neglected problem in older people, the impact of which is relatively unstudied. The aim of this study was to objectively assess quality of life and depression in older asthmatics.The subjects studied were 50 hospitalized known asthmatics, over 55 yrs of age (mean age 72 yrs). Of these, 40 had objective evidence of asthma, and were compared to 40 age-and sex-matched controls. Using a structured questionnaire, the Geriatric Depression Score, subjective health status (short form (SF)-36), and other comparative disability data were recorded. Spirometric results were also recorded.Depressive symptoms were common in both groups but were not significantly different. Mean SF-36 scores were significantly worse in the asthmatics, especially for components of physical function (p=0.04), physical role limitation (p=0.01), energy (p=0.01), health change (p=0.01), and general health perception (p=0.01). However mental, mental role and social scores were similar in both groups.We conclude that quality of life is impaired in hospitalized asthmatics compared to controls. Physical components appear to be most adversely affected. Depressive symptoms are common but no overall difference was found for psychological disability. Older asthmatics appear to adapt well to adverse situations.

ward-based intervention showed limited capacity to identify risk factors for falls: a dedicated clinic was more successful. The use of a portable computer with a programme to screen fallers for risk factors is worthy of consideration.