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Inhalation AUGUST 2015 19 helpful if the prescribing clinician considers the general aspects listed in Table 2 that pertain particularly to the older patient. Conclusions The inhalation route of drug administration remains an important means of providing the older patient with necessary topical therapies for asthma, COPD and com- binations of both diseases. Furthermore, its use to deliver drugs to the systemic blood circulation for the treatment of disease in distant organs, for example, the pancreas in type-II diabetes, is on the increase. In recent years, there have been significant improvements in the choice of for- mulations, and as a result, the choice of types of inhalers has widened. Thus far, much of the thrust in the devel- opment of OIPs has been focused largely on meeting the important and challenging needs of infants and small children, who have a high incidence of asthma and related allergic airway disease. Less has been done in the way of tailoring the inhaler designs to improve the qual- ity of medication delivery for the increasing population at the opposite end of the age range. This short article has sought to identify two separate challenges. Firstly, inhaler developers are encouraged to build-in user-friendly and enabling features at min- imum added cost, which simplify the process of preparing, operating and maintaining the inhaler cor- rectly. Such features should be supported with high quality IFUs that enable rapid and accurate assimila- tion of key information pertinent to their successful use. It is highly likely that improvements in design will translate into a better inhaler use experience for the general population as well as the older users. The sec- ond challenge is directed at the prescribing physician to ensure that the inhaler is selected to match the phys- ical and mental capabilities of the patient. The clini- cian, likely with the support of the pharmacist, should ideally review the choice(s) made on a regular basis, especially if other aspects of the patient's physical and mental condition deteriorate markedly with time. Under such circumstances, a caregiver may need to become involved with the medication delivery process, and it follows that adequate training of such persons is also a highly desirable goal. Table 2 General Considerations for Use by the Older Patient/Caregiver by OIP Type Question pMDI DPI SMI NEBULIZER Has the patient ade- quate cognitive ability to coordinate actuation with inhalation? If not, consider a VHC, even for patients having excellent technique, because performance can deteriorate over time. A strong inhalation is needed. Consider a pMDI, SMI or nebulizer if the patient cannot pro- vide adequate force to overcome device resis- tance during inhalation. If not, consider caregiver training and support. Otherwise, the patient may be better treated either by pMDI-VHC- facemask or nebulizer. This is the 'fallback' mode of therapy if other inhalers are unsuitable. Has the patient the mechanical strength to actuate the inhaler? If not, consider an aid to provide additional mechanical advan- tage, especially if the patient has arthritis. If not, consider a multi- dose DPI with integral dosing, where the need to manipulate single doses is avoided alto- gether. If not, consider caregiver support and training if the patient cannot use either of these inhaler classes. The mechanical strength limitation does not apply to actuation of nebulizers. Can the patient use a mouthpiece to inhale? If not, a pMDI-VHC- facemask is the best solution for patients with limited cognitive ability or with inadequate motor control, as with Parkinsonism. If not, consider the patient for therapy by pMDI-VHC or nebulizer. DPIs, in general, are not supplied with a face- mask. If not, consider a pMDI + VHC or nebulizer. Currently, the Respimat ® device does not have a facemask. If not, consider the use of a facemask. How should a caregiver assist patients? Provide training for the caregiver in correct preparation of the inhaler and VHC, fitting of the facemask and actuation of the pMDI. Provide training for the caregiver in correct preparation of the nebu- lizer, fitting of the face- mask, and cleaning/ maintenance of the device and associated equipment. Is there a concern about ocular exposure? Instruct the patient to inhale as soon as SMI is actuated to avoid aerosol cloud exposure to eyes. If the formulation is only available for nebuliza- tion, use mouthpiece where possible, select a BAN and/or a facemask that avoids eye exposure to exhaled medication. If the patient has glaucoma, consider ensuring that anticholinergics are taken via SMI or VHC with mouthpiece/tight-fitting facemask. In the event that the patient has arthritis in the hands, but can otherwise coordinate the actuation/ inhalation process, provide training for the caregiver in correct preparation of the inhaler, focusing on timing of the actuation of the inhaler with inhalation.