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Dear editor  We read the article entitled “Sex differences in use of inhalants by elderly patients with asthma” by Hirose et al with interest.1 In this study, the authors examined the relationship between inhalation procedure and sex difference in elderly patients with asthma. They reported that females failed more in “breath holding”. Therefore, they suggested that elderly female patients with asthma have less understanding of inhaled steroid therapy and thus it is particularly important to confirm that the correct inhalation procedure is used by elderly female patients with asthma.  We would like to comment on their article with some points. It is reported that the patients included 66 males and 89 females with mean ages of 75.5±5.65 vs 78.7±6.87 years, respectively, who did not have dementia, neurological disorders, or muscular disorders. Obviously, the female patients were older than the male patients while there is no information whether this is statistically significant or not. The authors already noted that inhalation therapy may be difficult to administer in aged patients – stressing the age itself as an important factor for appropriate inhalation. We would like to ask whether the age difference between the male and female subjects was analyzed statistically.  The other point is that they reported as they excluded the subjects with dementia, neurological disorders, or muscular disorders. Although the diagnoses of muscular and most neurological disorders that might affect inhalation are generally straightforward and recognizable by history and/or physical examination, diagnosis of dementia is easily dismissed as it can mistakenly be considered as part of the normal aging process.2 We would like to ask the methodology they used to exclude dementia – ie, if they performed any screening to exclude dementia or judged only by review of current prespecified diagnoses. We suggest that as age and female sex are very well-known risk factors for Alzheimer’s dementia,3 the more common failure of the female sex in “breath holding” may be due to higher prevalence of cognitive disorders in this older-female patient group.

Higher failure of female older asthma patients in use of inhalants: is it due to older age and/or cognition problems?