Objective To determine whether elderly people can learn to use the inhaler used to deliver zanamivir (Relenza Diskhaler) as effectively as the Turbohaler and to identify which aspects of inhaler technique are most problematic. Design Randomised, controlled, intervention study. Setting Wards for acute elderly care in a large district general hospital. Participants 73 patients who were unfamiliar with the use of an inhaler, aged 71 to 99 (mean 83) years. Main outcome measures Initial scores and changes in scores 24 hours later using a 10 point scoring system of five aspects of inhaler technique. Results 38 patients were allocated the Relenza Diskhaler and 35 the Turbohaler. The mean total score was significantly greater in the Turbohaler than Diskhaler groups both initially (8.74 v 7.05) and after 24 hours (8.28 v 5.43). The major difference between inhalers was in loading and priming. After tuition 50% (19 of 38) of patients allocated the Diskhaler were unable to load and prime the device and 65% (24 of 37) were unable to do so 24 hours later. Of those allocated the Turbohaler, two patients were unable to load and prime the device after initial review and one after 24 hours. Conclusion Most elderly people cannot use the inhaler device used to deliver the anti-influenza drug zanamivir. Treatment with this drug is unlikely to be effective in elderly people unless the delivery system is improved.

No abstract

There has been an accumulation of evidence in recent years to demonstrate that surgical treatment is more effective than eyedrops at lowering intraocular pressure and preserving the visual field in primary open angle glaucoma.' 2 The argument against primary surgery for glaucoma has been the risk to the eye of performing an intraocular operation. Respiratory and cardiovascular disease are also common in this age group and both may be affected by eyedrops prescribed for glaucoma. Topical 1 antagonistsThere are two main classes of 1 adrenergic antagonists; non-selective, which affect both 13 receptors, found predominantly in the heart, and 12 receptors, found in the lungs. Timolol, cartelol, and levobunalol are non-selective preparations. Cardioselective 1 antagonists bind to 13 receptors preferentially and have relatively less effect on 12 receptors. Respiratory side effects are less common with cardioselective preparations but they may still occur and they should be avoided in patients with airways obstruction.Side effects of treatment with oral 1 antagonists include heart failure, hypotension, and bronchospasm.The same side effects occur with topical therapy.6 7 Drugs administered topically to the eye gain access to the systemic circulation via the nasolacrimal duct and the nasal mucosa. This avoids first pass metabolism by the liver and significant amounts of topically administered drugs may be absorbed into the systemic circulation. For example, two drops of a 0 5% timolol solution, one to each eye, can approximate to the 10 mg oral dose given to treat systemic hypertension or angina. The first study, recently published in the Lancet, recorded nges in spirometry, an exercise walk tolerance test and measurement of blood pressure, and resting and exercise pulse.'8 Eighty patients, aged over 60 years, without history of airways disease, using timolol for at least 1 year, were recruited into a randomised, double masked, crossover study changing therapy to betaxolol or dipivefrine. The study comprised two phases and all patients who completed both phases underwent a change in therapy. Third party randomisation produced four groups: TTB (timolol-timolol-betaxolol); TTD (timolol-timololdipivefrine); TBT (timolol-betaxolol-timolol); and TDT (timolol-dipivefrine-timolol). During phase I, group TBT was allocated to receive one drop to both eyes of 05°/o betaxolol and group TDT one drop of 0 1% dipivefrine twice daily for four weeks. Groups TTB and l-lTD continued to receive topical timolol for four weeks. In the second phase, groups TBT and TDT returned to timolol while group TTB was allocated to receive one drop to both eyes of 0-/5% betaxolol and group TTD one drop of 0 1% dipivefrine twice daily for 4 weeks. Outcome measures were recorded on enrolment and at the end of each phase.

A prospective study of inhaler technique using aerosol metered dose inhalers (MDIs), Rotahalers and a breath-activated device (Aerolin Autohaler) was undertaken to assess how effectively elderly patients use their inhalers. Fifty-one patients aged 67-89 years (mean 77.4 years) were enrolled. Peak flow, FEV1 and FVC were recorded, before and after inhalation of 2.5 mg of salbutamol via a nebulizer, to assess the extent of reversible airways obstruction. Inhaler technique was assessed using a scoring system, based on performance in five aspects of inhaler use. Those with poor technique were randomly allocated to an alternative inhaler and reassessed. Twenty-nine of 51 patients demonstrated reversibility in their airways disease. Twenty-one of 47 had poor technique using an MDI and were given Rotahaler or Aerolin devices to use. Ten of 11 given Aerolin Autohalers improved but seven of ten using Rotahaler showed no improvement (p = 0.006). Subsequently, five of these seven were able to improve their technique with the breath-activated autohaler. The breath-activated Aerolin Autohaler is a better delivery system than Rotahalers for inhaled bronchodilators for elderly patients.

SUMMARYFifty-two elderly glaucomatous patients, without a history of asthma or obstructive airways disease, who were using topical timolol for control of intraocular pres sure were recruited. Their topical therapy was changed to either betaxolol or pilocarpine. The change was associ ated with improvement in mean peak flow from 278 I/min to 328 I/min (t = 5.73, p