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GENERAL PRINCIPLES

Dyspnea is a common symptom affecting older adults, occurring in 17% to 62% of community-dwelling adults >65 years old, with the highest rates in those 80 years and older. According to Smith and colleagues (2016), “one in four adults aged 70 and older in the United States experiences breathlessness, which is associated with lack of well-being, greater health services use, and a 40% greater risk of worsened function and 60% greater risk of death over the next five years.” The 2012 American Thoracic Society consensus statement defines dyspnea as “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.” Descriptions of dyspnea can be further classified into three domains: (1) sensory-perceptual experience (eg, what breathing “feels like” to the patient), (2) affective distress (eg, the perception of immediate unpleasantness), and (3) symptom impact or burden (eg, how breathing affects behaviors, function, or quality of life). Importantly, dyspnea is a symptom that is self-reported and should be distinguished from clinical signs of respiratory distress, such as tachypnea, the use of accessory muscles, or nasal flaring.

Dyspnea is often inadequately addressed in older adults. It may not be routinely assessed due to limited appointment time, a clinician’s inappropriate presumption that the dyspnea is caused by a chronic condition and cannot be treated further, or underreporting among older adults. Consequently, older adults may experience dyspnea with minimal symptomatic management along with underdiagnosis of the underlying cause. Indeed, it is common for dyspnea to signal either a new significant medical problem or a worsening of one (or more) of the chronic cardiopulmonary diseases that are prevalent among older adults. Moreover, dyspnea is a distressing physical symptom, which, if left untreated, can impair mobility, social function, mood, and ability to perform activities of daily living (ADLs), all while independently increasing mortality risk. For these reasons, clinicians should consider routine assessment of dyspnea in the geriatric patient, and its presence should never be ignored.

Clinicians should be aware of the following key principles of geriatric care when evaluating and treating the older patient with shortness of breath: (1) recognize that dyspnea commonly arises from nonrespiratory mechanisms; (2) consider soliciting history from caregivers or other knowledgeable informants; (3) consider the possibility of alternative presentations or symptoms; (4) pay special attention to medications; (5) consider the benefits and burdens of diagnostic procedures and treatments; and (6) consider palliative care if the patient has advanced chronic cardiopulmonary illness.

DIAGNOSTICS

Evaluations of dyspnea in older adults often focus on cardiopulmonary diseases; however, recent literature suggests that dyspnea should be considered a multifactorial geriatric syndrome with potential contributors from multiple domains of health. Sarcopenia or deconditioning, chronic kidney disease, anemia, medication-related adverse events, and psychiatric illness can all contribute to the presence of dyspnea. Each factor on its own might not seem great enough to cause dyspnea, but combined, these factors ...

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