***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND patients with dementia are almost invariably unable to use any form of inhaler . Some elderly patients are unable to learn to use a metered dose inhaler or Turbohaler despite a normal abbreviated mental test score . Studies have shown that in many people this is due to unrecognised cognitive impairment and /or dyspraxia . The executive domains of cognition are particularly important in planning and sequencing ; it might be expected therefore that disordered frontal ( executive ) function could be a predictor of poor inhaler technique in subjects with no overt features of dementia . OBJECTIVE to explore the relationship between cognitive , and executive , function and the ability to acquire metered dose inhaler and Turbohaler technique in old age . DESIGN a prospect i ve r and omised observational study with blinded evaluation . SUBJECTS 30 inhaler-naive in patients ( 21 female ) with a mean age of 85 ( range 75 - 94 ) and having a normal ( 8 - 10 ) abbreviated mental test score . METHODS subjects received st and ardised metered dose inhaler and Turbohaler training and were scored on an analogue scale ( for metered dose inhaler ) or for competence ( Turbohaler ) the following day . The Mini-Mental State Examination and EXIT25 ( for executive function ) were performed by separate observers . RESULTS significant correlation was found between the metered dose inhaler score and Mini-Mental State Examination ( r 0.540 , P<0.002 ) and EXIT25 ( r -0.702 , P<0.0001 ) . Threshold effects emerged for the metered dose inhaler in that 18/19 with a competent score compared to 2/11 scored as incompetent had a Mini-Mental State Examination of > 23 ( P<0.01 ) and 19/19 compared to 0/11 had an EXIT25 of < 15 ( P<0.01 ) . Similarly , for the Turbohaler 21/21 of the competent subjects had a Mini-Mental State Examination of > 23 compared with 3/9 incompetent subjects ( P<0.01 ) , with 21/21 competent compared with 0/9 incompetent having an EXIT25 < 15 ( P<0.01 ) . CONCLUSION acquisition and short-term retention of metered dose inhaler and Turbohaler techniques is unlikely to be successful in frail elderly people who have an abnormal Mini-Mental State Examination and /or EXIT25 test . The latter test , when abnormal , is probably the superior predictor of inability to learn inhaler techniques Background : Little is known about adherence to inhaled medication in chronic obstructive pulmonary disease ( COPD ) and the impact on mortality and morbidity . Methods : Data on drug adherence from a r and omised double-blind trial comparing inhaled salmeterol 50 μg + fluticasone propionate 500 μg twice daily with placebo and each drug individually in 6112 patients with moderate to severe COPD over 3 years in the TORCH study were used  . All-cause mortality and exacerbations leading to hospital admission were primary and secondary end points . The study of adherence was not specified a priori as an ancillary study . Results : Of the 4880 patients ( 79.8 % ) with good adherence defined as > 80 % use of study medication  , 11.3 % died compared with 26.4 % of the 1232 patients ( 20.2 % ) with poor adherence .  The annual rates of hospital admission for exacerbations were 0.15 and 0.27 , respectively . The association between adherence and mortality remained unchanged and statistically significant after adjusting for other factors related to prognosis ( hazard ratio 0.40 ( 95 % CI 0.35 to 0.46 ) , p<0.001 ) . The association was even stronger when analysing on-treatment deaths only . Similarly , the association between adherence and hospital admission remained unchanged and significant in a multivariate analysis ( rate ratio 0.58 ( 95 % CI 0.44 to 0.73 , p<0.001 ) . The association between increased adherence and improved mortality and reduction in hospital admission was independent of study treatment . The effect of treatment was more pronounced in patients with good adherence than in those with poor adherence . Conclusion : Adherence to inhaled medication is significantly associated with reduced risk of death and admission to hospital due to exacerbations in COPD . Further research is needed to underst and these strong associations Aim : To investigate the effects of inhaler device technique education on improving inhaler technique in older people with asthma . Methods : In a r and omised controlled trial , device technique education was provided to a sample of 123 adults aged > 55 years who had a doctor diagnosis of asthma . The active education group received one-on-one technique coaching , including observation , verbal instruction and physical demonstration at baseline . The passive group received a device-specific instruction pamphlet only . Inhaler technique , including the critical steps for each device type , was assessed and scored according to Australian National Asthma Council ( NAC ) guidelines . Device technique was scored objective ly at baseline and again at 3 and 12 months post education . Results : The majority of participants demonstrated poor technique at baseline . Only 11 ( 21 % ) of the active intervention group and 7 ( 16 % ) of the passive group demonstrated 100 % correct technique . By 3 months 26 ( 48 % ) of the active group achieved adequate technique . Improvement in technique was observed in the active group at 3 months ( P<0.001 ) and remained significant at 12 months ( P<0.001 ) . No statistically significant improvement was observed in the passive group . Conclusion : The provision of active device technique education improves device technique in older adults . Passive education alone fails to achieve any improvement in device technique AIMS Few well- design ed r and omized controlled trials have been conducted regarding the impact of community pharmacist interventions on pharmacotherapeutic monitoring of patients with chronic obstructive pulmonary disease ( COPD ) . We assessed the effectiveness of a pharmaceutical care programme for patients with COPD . METHODS The pharmaceutical care for patients with COPD ( PHARMACOP ) trial is a single-blind 3 month r and omized controlled trial , conducted in 170 community pharmacies in Belgium , enrolling patients prescribed daily COPD medication , aged ≥ 50 years and with a smoking history of ≥ 10 pack-years . A computer-generated r and omization sequence allocated patients to an intervention group ( n = 371 ) , receiving protocol -defined pharmacist care , or a control group ( n = 363 ) , receiving usual pharmacist care ( 1:1 ratio , stratified by centre ) . Interventions focusing on inhalation technique and adherence to maintenance therapy were carried out at start of the trial and at 1 month follow-up . Primary outcomes were inhalation technique and medication adherence . Secondary outcomes were exacerbation rate , dyspnoea , COPD -specific and generic health status and smoking behaviour . RESULTS From December 2010 to April 2011 , 734 patients were enrolled . Forty-two patients ( 5.7 % ) were lost to follow-up . At the end of the trial , inhalation score [ mean estimated difference (Δ),13.5 % ; 95 % confidence interval ( CI ) , 10.8 - 16.1 ; P < 0.0001 ] and medication adherence ( Δ , 8.51 % ; 95 % CI , 4.63 - 12.4 ; P < 0.0001 ) were significantly higher in the intervention group compared with the control group . In the intervention group , a significantly lower hospitalization rate was observed ( 9 vs. 35 ; rate ratio , 0.28 ; 95 % CI , 0.12 - 0.64 ; P = 0.003 ) . No other significant between-group differences were observed . CONCLUSIONS Pragmatic pharmacist care programmes improve the pharmacotherapeutic regimen in patients with COPD and could reduce hospitalization rates UNLABELLED Twenty-five COPD patients , aged 65years or above , were recruited to test their ability to use dry powder inhaler H and ihaler ( Boeringher-Ingelheim ) and Aerolizer ( Novartis ) . The results of a score created to evaluate the inhalation technique were compared with age , MMSE , Barthel Index , FEV(1 ) , maximum inspiratory and expiratory pressures , and peak inspiratory flow ( PIF ) . RESULTS Dry powder inhalers were correctly used by 60 % of the patients ( 15 out of 25 ) . Among the capable ones , 13 out of 15 were aged less than 80 years ( p < or = 0.02 ) , 13 out of 15 had a maximum inspiratory pressure greater or equal to 53 cm H(2)O ( p < or = 0.001 ) and a PIF greater or equal to 120l/min ( p < or = 0.05 ) . All skilled patients had a minimum MMSE of 25 ( p < or = 0.001 ) . CONCLUSION In a geriatric population , age , the decrease of maximum inspiratory pressure and PIF as well as cognitive functions , limit the use of dry powder inhalers Non-compliance is a major problem in the treatment of any chronic disease . Asthma is one such chronic disease where non-compliance is a major problem . Several factors for non-compliance like cost of the drugs and relief of symptoms on taking medications for a short time are common to all chronic diseases but in asthma , inhalational therapy especially in elderly because of senile changes , economic factors and comorbidities is an added factor . Health education can improve the compliance . So a study was undertaken to observe the causes of non-compliance in asthmatics , to compare these causes in elderly and young asthmatics and to see the effect of health education on non-compliance in asthmatics . One hundred patients of bronchial asthma , group A consisting 50 patients > or = 65 years old and group B 50 patients < 40 years attending tuberculosis and chest diseases hospital , Patiala were studied . Initial compliance and reasons for non-compliance , initial usage of inhalational devices and their techniques of inhalation were studied . Patients were educated on asthma and inhalational techniques . These patients were followed up at 15th day , 1st , 2nd and 3rd months for changes in compliance and lung functions . At the initial stage , non-compliance was observed in 30 patients ( 60 % ) amongst elderly and only 15 patients ( 30 % ) amongst the young . Cause for non-compliance was cost in 6 , memory in 11 , both cost and memory in 7 and relief of symptoms in 6 in elderly and 4 , 0 , 0 and 11 in young respectively . Only 23 patients ( 40 % ) amongst the elderly and 33 patients ( 66 % ) amongst the young were put on  inhalational therapy . There were statistically significant differences between elderly and young with respect to all the above factors . Out of these 23 elderly , only 7 ( 30.4 % ) were confident of the technique of inhalation and demonstrated it correctly . The health education result ed in significant improvement in compliance in both the groups , but more so in the young . The compliance for medications improved from a baseline of 40 % to 88 % amongst elderly and from 70 % to 96 % amongst young . There was an improvement in the confidence and technique of inhalation from 44 % to 86 % amongst elderly and from 64 % to 98 % amongst young at follow-ups . Mean PEFR improved statistically significantly from 75.25 % to 81.13 % in elderly and 84.38 % to 89.74 % in young asthmatics . However , during the follow-up at 2nd month , it was realised that 7 patients amongst elderly and 1 amongst young could not be sustained on inhalational medications because of the cost factor , therefore they were put on only oral medications which were supplied free of cost to them and thus at followup at 3rd month , these patients were not on inhalational medications any more Turbuhaler and Salbutamol-Diskus produce therapeutic doses at peak inspiratory flow ( PIF ) of > 30 L/min . However , the optimum flow for Fluticasone-Diskus and Turbuhaler , in terms of total emitted dose and fine particle mass , is > 60 L/min . The Turbuhaler achieved a higher output at this flow , as compared to Diskus . For pMDI 25 < PIF < 90 L/min , an actuation time of 0.0 - 0.2 sec is optimal . The aim of this study was to examine the incidence of optimum inhalation profiles , the effect of instruction , reproducibility , and the relationship between inhalation profiles and patient characteristics in stable asthmatics and mild/moderate/severe COPD patients . For each device , triplicate inhalation profiles were recorded during 6 sessions in a 10-week period . All patients achieved PIF > 30 L/min using Diskus . After instruction , all Diskus inhalations were performed with > 60 L/min , except 7 % of the inhalations of the severe COPD patients . At least 95 % of the Turbuhaler inhalations was also performed with the minimum flow ; however , 19 % of the inhalations of the severe COPD patients were not optimally performed . The h and -lung coordination was inadequate in 40 % of pMDI inhalation profiles , and 80 % 
    Output:
    
All interventions seemed to improve inhaler performance and clinical ly relevant outcomes , but a placebo device could be the most effective .
There is evidence that interventions reduce exacerbation risk in older adults , although to an overall moderate degree .