General Principles in Older Adults
Dyspnea, also known as shortness of breath, is a common symptom affecting the geriatric population. In a 2012 consensus statement, the American Thoracic Society defined dyspnea as follows:
“Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioral responses.”
This chapter discusses special considerations pertaining to the presentation, evaluation, and management of dyspnea in the geriatric patient. This chapter is particularly oriented toward outpatient evaluation in the context of primary care follow-up or the urgent care visit. However, the key principles also can be applied in the acute or long-term care setting.
Dyspnea is often inadequately addressed in the geriatric patient because of factors such as limited appointment time, or a clinician’s inappropriate presumption that the dyspnea is caused by a chronic condition and cannot be treated further. In fact, it is common for dyspnea to signal either a new significant medical problem, or a worsening of 1 (or more) of the chronic cardiopulmonary diseases that are prevalent among older adults. Dyspnea is also often a very distressing physical symptom, which, left untreated, can substantially impair physical function and quality of life. For these reasons, dyspnea in the geriatric patient should never be ignored.
Clinicians should consider the following key principles of geriatric care when evaluating and treating the older patient with shortness of breath.
Consider soliciting history from caregivers or other knowledgeable informants.
Although many geriatric patients are very capable of providing an excellent history, others may be limited by cognitive problems, hearing impairments, or even speech difficulties. Soliciting information from caregivers can uncover additional information of importance, and helps to obtain a more robust and useful history. Clinicians should also bear in mind that other clinicians often fail to recognize or document cognitive impairment. Hence, the absence of a cognitive impairment diagnosis should not preclude a clinician from considering this possibility, and from seeking additional information from a knowledgeable informant, especially if the history is unclear or does not cohere as expected.
Consider the possibility of alternative presentations.
In some cases, breathing problems in the geriatric patient may manifest as another complaint or symptom, such as fatigue, chest discomfort, or decreased physical activity. Patients with moderate or worse dementia may no longer be able to clearly articulate a breathing complaint. Dyspnea is sometimes identified by the astute clinician after a caregiver simply notes that the patient is not his or her usual self.
Pay special attention to medications.
Geriatric patients are often prescribed multiple medications for chronic and acute use, and many struggle with medication management (see Chapters 9, “Principles of Prescribing for Older Adults,” and 53, “Addressing Polypharmacy & Improving Medication Adherence in Older ...