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.