This article discusses the evaluation and management of stable and unstable elderly patients with dyspnea. Several of the changes in the elderly that alter cardiopulmonary physiology are discussed. A review of common presenting illnesses and their evaluation and management are highlighted. The reader should be left with a better understanding of this unique population and the overall evaluation and treatment.
Key points
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Acute and Chronic Dyspnea is a frequent presentation of Elderly Patients to the Emergency Department.
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Elderly patients have several anticipated alterations in cardiac and pulmonary physiology that contribute to illness when presenting with acute dyspnea.
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Understanding the important historical and physical findings in certain diseases assist with evaluation and management of typical diseases that cause dyspnea in the elderly.
Keyword definitions
Dyspnea
Throughout the medical literature and clinical practice, many terms and definitions are encompassed by the broad term of dyspnea . These descriptions range from breathlessness, to painful breathing, to air hunger, to shortness of breath. There are many more terms used by patients to try to express the symptoms that they are experiencing. To more broadly define dyspnea to fully include each individual experience this article will use the definition proposed by the American Thoracic Society: “Dyspnea is a term used to characterize a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.” Under this broad definition, each individual’s personal and subjective description of any form of discomfort related to the physiologic act of breathing will be included in the term dyspnea .
Elderly
Traditionally in medicine and society as a whole the term elderly is used to describe any person older than 65, regardless of their health or frailty score. We will use this definition; however, special emphasis is given to those with elevated frailty scores or with multiple comorbid medical conditions that are prevalent in advanced age.
Keyword definitions
Dyspnea
Throughout the medical literature and clinical practice, many terms and definitions are encompassed by the broad term of dyspnea . These descriptions range from breathlessness, to painful breathing, to air hunger, to shortness of breath. There are many more terms used by patients to try to express the symptoms that they are experiencing. To more broadly define dyspnea to fully include each individual experience this article will use the definition proposed by the American Thoracic Society: “Dyspnea is a term used to characterize a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.” Under this broad definition, each individual’s personal and subjective description of any form of discomfort related to the physiologic act of breathing will be included in the term dyspnea .
Elderly
Traditionally in medicine and society as a whole the term elderly is used to describe any person older than 65, regardless of their health or frailty score. We will use this definition; however, special emphasis is given to those with elevated frailty scores or with multiple comorbid medical conditions that are prevalent in advanced age.
Introduction
Over the last several decades, the aging population has continued to expand and grow. According to the US Census Bureau, by 2050 the elderly population is estimated to reach a staggering 20.9% of the US population with a total 83.739 million people. With this boom of the geriatric population comes an increase in a new variety of geriatric-specific symptoms and conditions, along with an increase in encounters between the geriatric patients and acute care physicians. Among the top 3 complaints of these patients is dyspnea, and with the projected increase of the geriatric population over the next 35 years, it can be expected that this number will continue to grow exponentially. With a substantial increase in this patient population, it is increasingly important to understand the unique characteristics of evaluating and treating elderly patients and specifically to understand the unique pathology and physiology of dyspnea in this patient population.
Relevant physiology in the geriatric population
The growth of the aging population poses an ever-increasing need to adapt care and acute interventions while addressing the elderly patient in the acute care setting. To do this, one must first understand the differences in the physiology of the elderly patient versus the average adult patient, specifically, the physiology of the respiratory and cardiovascular system and this effect on the perception of dyspnea.
Cardiovascular Physiology
Among the changes that occur to the cardiovascular system, several can have a direct or indirect effect on the symptoms of dyspnea.
As individuals age, the connective tissue that constitutes our cardiovascular system tends to stiffen and become less compliant. This, in turn, leads to decreased compliance and overall stiffening of veins, arteries, and myocardium. There are consequences of this change on our cardiovascular system as a whole. Arterial stiffening causes increase in systolic hypertension and impaired impedance matching between the heart and the aorta and can lead to myocardial hypertrophy. Venous stiffening causes a decreased ability to maintain stable cardiac preload, which leads to increased volume and distribution dependence.
Myocardium stiffening can lead to diastolic heart failure. Additionally, within the myocardium, there is a stiffening and fibrosis of the cardiac skeleton, which can cause valvular, disease particularly with calcification at the base of the aortic valve.
Further effects of aging on the cardiovascular system include the decrease in the response to β-receptor stimulation. This decrease contributes to a reduced heart rate and contractile response to hypotension, exercise, and exogenous catecholamine administration. Additionally, atrial pacemaker cells are reduced in function, which results in a decreased intrinsic heart rate.
These consequences of aging contribute to increased systolic blood pressures, decreased left ventricular end-diastolic volumes, decreased stroke volumes, and decreased cardiac outputs. Subsequently, the heart becomes dependent on volume status, which dampens the ability to physiologically respond to any changes within the cardiovascular system.
Respiratory Physiology
With age, the lungs undergo significant structural and physiologic changes, which include a decrease in elastic recoil and lung volumes, enlargement of air spaces, decrease in alveolar surface area, decreased compliance of chest wall, and reduction of respiratory muscle mass. These changes lead to the gradual increase of functional residual capacity, functional residual volume, and subsequently a decrease in lung vital capacity, leading to an overall decrease in physiologic reserve. The aging process also has a detrimental effect on the gas exchange properties at an alveolar level, leading to a decrease in arterial oxygenation, lower tidal volume, and reliance on higher respiratory rates.
The elderly airway receptors also undergo functional changes and become less likely to respond to medications (such as inhaled β-agonists or corticosteroids); these are commonly used in younger individuals to treat common pulmonary disorders but are less effective in the elderly population. Typically, elderly patients have a decreased sensation of dyspnea and are unable to mount rapid and appropriate responses to conditions of hypoxia or hypercapnia, increasing their susceptibility to ventilatory collapse during high demand periods (eg, heart failure, pneumonia). This process can contribute to worse outcomes than their younger counterparts.
Additional changes include decrease in muscular pharyngeal support and decreased cough and swallowing reflexes. Often, these changes lead to increased risk of upper airway obstruction and aspiration, respectively.
Evaluation of the stable patient
In the stable elderly patient with dyspnea, evaluation begins with the traditional approach. Before taking a history, it is often important to note the vital signs, age, and chief complaint and evaluate airway and work of breathing before proceeding to a focused history and physical examination.
History
A general focused history of the patient is warranted and should include the following information: history of the onset, duration, and progression of symptoms. This history provides key information to the natural history of the illness and potential severity. Noting exacerbating or precipitating factors can yield diagnostic information and lead the physician toward the proper treatment modality.
Information specific to the elderly patient population that may assist with diagnostic evaluation includes the following:
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Lifetime exposures, including previous occupational environments with dust, asbestos, or noxious chemicals, may suggest underlying interstitial lung disease.
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Worsening exercise tolerance or exertional dyspnea can indicate patient deconditioning or an overall cardiopulmonary disease process.
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History of orthopnea (specifically note the number of pillows used at night) or increased peripheral edema can be a sign of decompensating heart failure.
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Smoking history is of particular importance, as this can lead to chronic obstructive pulmonary disease, chronic bronchitis, trigger for asthma, and risk factor for coronary artery disease.
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Miscellaneous information, such as recent hospitalization or travel and a detailed medical history can assist the provider in evaluating risk factors for potential infectious etiologies and progression or exacerbation of underlying disease, respectively.
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Information about medication changes or noncompliance may also reveal risk factors for any iatrogenic causes or exacerbation of undertreated disease.
Physical Examination
The physical examination should focus primarily on the cardiopulmonary systems. Vital signs are of particular importance and, if abnormal, can immediately alert you to the severity of the disease (and alert the provider to the potentially unstable nature of the patient). However, as discussed above, vital signs may lag behind the progression of the disease process and should be repeated often and trended over time (with respect to both the current visit and previous visits, if the data are available). Work of breathing must also be noted along with factors that comprise it. This evaluation should include airway patency, respiratory rate, the patient’s ability to speak in full sentences, any voice changes (perceived by the clinician, relatives of the patient, or the patient themselves), presence of audible respiratory noise, and the use of accessory respiratory muscles. For an experienced clinician, this evaluation takes only a moment and will guide the need for immediate or delayed intervention. The auscultation of heart and breath sounds is of great importance and provides pertinent clues as to the underlying physiology of the disease. Over-reliance on particularities of the physical examination (specifically characterizing lung sounds and the presence or absence of sounds) can potentially be avoided with the immediate availability of digital x-ray and point-of-care ultrasound scan.
Additional evaluation of the abdomen, extremities, and skin should be included in the physical examination of these patients. These can provide additional information pertinent to the cardiopulmonary system ( Table 1 ).
| Physical Examination | What to Evaluate |
|---|---|
| Vital signs | Heart rate, blood pressure, respiratory rate, oxygen saturation, glucose level, (end-tidal CO 2 , if available) |
| General work of breathing | Respiratory rate, muscle use, overall patient comfort |
| Airway patency | Voice changes, secretions, edema, foreign body |
| Lung | Breath sounds, wheezing, crackles, rhonchi, rales, generalized vs focal |
| Heart | S3, murmur, rub, gallop, decreased, click |
| Abdominal | Abdominal muscle use during respiration, distention, fluid wave, tympani, tenderness, acute increase in girth, mass, rigidity |
| Extremity | Bilateral or unilateral edema, pain, wounds, splinter emboli, clubbing of digits |
| Skin | Rashes, wounds, lesions, scars, blisters |
Adjuncts to Physical Examination
Many adjunct measures can help narrow the differential diagnosis and guide appropriate treatment during the evaluation of patients with dyspnea. These adjuncts are discussed here in order of importance and ease of obtaining. The importance of each test may change with particular disease etiologies. Additionally, availability will certainly vary based on the resources in a particular practice setting. Electrocardiogram (EKG) and chest radiograph are fast, readily available adjuncts that provide pertinent information; these should be done on most elderly patients with dyspnea. The EKG aids in the evaluation of an arrhythmia or myocardial infarction (ST elevation or non-ST elevation, ST-segment elevation myocardial infarction or non–ST-segment elevation myocardial infarction, respectively). The provider must pay close attention to the EKG result, as this can show subtle evidence of myocardial ischemia, signs of new or progressive cardiopulmonary diseases (such as congestive heart failure, pulmonary embolism, pericarditis, pulmonary hypertension, or valve disease) The chest radiograph will give information as to heart size, cardiac/aortic silhouette, pulmonary infiltrate, masses, effusion, pneumothorax, hemothorax, or bony abnormalities.
End-tidal CO 2 monitoring is becoming increasingly available and should be used if available. Moment-to-moment information on the ventilation status of the patient and the perfusion dynamics can be interpreted from the end-tidal CO 2 waveform, and changes in that measurement can also provide clues to impending changes in hemodynamic status.
Ultrasound scan (point of care) is also becoming more widely available and can provide immediate and potentially life-saving information. Of particular importance are the cardiac and lung examinations. The cardiac examination can provide information about the presence of a pericardial effusion and potential tamponade physiology, basic evaluation of cardiac output based on heart chamber squeeze, and evidence of cardiac hypertrophy. The lung examination can identify the presence of a pneumothorax or hemothorax based on the absence of pleural sliding and the presence of pulmonary edema based on the presence of b-lines. Additionally, the rapid ultrasound in shock and hypotension or RUSH examination is easy and fast to perform and gives additional information as to cardiopulmonary status (including the information noted above). It also gives further information about volume status and the potential presence of deep vein thrombosis in the lower extremities. Although this information may not be required on stable patients, it should be kept in mind if there is any change in status of the patient or in the elderly patient with undifferentiated dyspnea and shock.
Laboratory data can readily assist in the evaluation and treatment of the stable patient with dyspnea; however, unless point-of-care testing is available, it is of limited utility in the unstable or metastable patient. A basic metabolic panel provides information on electrolyte abnormalities, kidney function, anion gap, and glucose level. These results also provide information on the acid-base status of the patient, particularly if used in conjunction with an arterial or venous blood gas. A complete blood count provides information about anemia, shows possible volume contraction, and indicates infection through the white blood cell count. A troponin (serial or single, as appropriate) is a marker for myocardial damage and an indicator of systemic organ damage. A creatine phosphokinase (CPK) evaluates for muscle breakdown and rhabdomyolysis. A D-dimer can be used as a marker for potential deep vein thrombosis or pulmonary embolism in low-risk patients, bearing in mind that there are suggestions that D-dimer cutoff levels need to be adjusted as patients age older than 50 to maintain sensitivity. Liver function test evaluates albumin and protein and can give information of vascular oncotic pressure, generalized nutritional status, and acute hepatocyte damage. An arterial or venous blood gas test provides useful information as to the acid/base status, evaluation of oxygenation, and ventilation of the patient.
Further imaging, such as computed tomography (CT) imaging or a bedside formal echocardiogram or lower extremity deep vein thrombosis examination can be used, if available and appropriate. The necessary information for emergency diagnosis and disposition can be readily obtained from these studies alone. This evaluation includes testing for malignancy, pulmonary embolism (in high risk patients), pneumonia, and cardiac abnormalities.
Evaluation of the unstable patient
In the unstable patient, the evaluation (specifically, the history and physical examination) is done in conjunction with management and treatment of symptoms and underlying causes. The information noted above about the stable patient is of importance and should eventually be obtained once feasible. In the unstable elderly patient, it is recommended to use a similar approach to adult advanced cardiac life support (ACLS) protocols with first evaluation and stabilization of airway, breathing, and circulation before moving on to additional history and evaluation of the patient.
Evaluation
The initial evaluation for any elderly patient with a complaint of dyspnea should begin while walking into the examination room and looking at and listening to the patient. Inability of the patient to talk and increased work of breathing (including tachypnea, using supraclavicular or abdominal muscles, retractions, audible wheezing, crackles, grunting, stridor, or gasping), are all signs of impending respiratory compromise and may require emergent airway or ventilatory management before continuing the overall assessment. Breath sounds can give the provider clues to the underlying cause of dyspnea and guide management of the patient. Concurrently or immediately after assessment of airway and breathing, members of the treatment team should establish vascular access. Whether peripheral venous, central venous, or intraosseous access is required depends on the specific needs and ability to obtain based on the patient’s anatomy and pathology. Once airway and ventilation status are controlled in the unstable dyspneic patient, the provider can move forward to further evaluation.
History
Although history may be difficult to obtain in the unstable or nonverbal elderly patient, it is important to obtain a focused history including onset, duration, attempted therapy, previous causes of dyspnea, cardiac and respiratory history, a list of medications/compliance, and potential allergies. Often this information is limited in the acute setting or unobtainable from the patient. If immediately available, history from family members, emergency medical services report, chart review, nursing home chart review, or medication list review can be important and help guide appropriate management of the patient.
Physical Examination
As mentioned above, the physical examination in an unstable elderly patient should be done in a similar approach to the advanced cardiac life supportprotocol. First, is the evaluation of airway, looking for airway patency, obstruction, edema, voice changes, and the ability to manage secretions. Next is the evaluation of breathing, including breath sounds, respiratory rate, and extrarespiratory muscle use. Cardiovascular examination, particularly evaluation of heart sounds/murmurs, pulses, and extremity edema should follow. Patients should be fully undressed and the skin examined, followed by the rest of the physical examination. Vital signs are of paramount importance and should be immediately available to the provider during initial examination.
Adjuncts
In addition to the adjuncts in stable dyspnea discussed above, particularly useful in the unstable patient is the use of point-of-care ultrasound scan (particularly the RUSH examination) and end-tidal CO 2 capnography.
Treatment
Oxygen
Oxygen should be given to all patients with hypoxia (O 2 saturation <90%), and these patients should be titrated using nasal cannula, venturi mask, or nonrebreather as appropriate for the patient’s condition with a goal saturation of 94%. Additional use of humidified air may make high-flow oxygen therapy more tolerable, particularly for the elderly patient. Patients with a diagnosis of chronic obstructive pulmonary disease (COPD), especially those older than 70 are at risk of hypercapnic respiratory failure, and oxygen therapy should be used with caution. In these cases, it is recommended that the goal saturation be reduced to 88% to 92% with frequent blood gas monitoring to reduce precipitating hypercapnea.
Noninvasive positive pressure ventilation
Noninvasive positive pressure ventilation (NIPPV) is an important treatment modality that provides ventilation assistance without invasive endotracheal intubation (bi-pap is the most commonly used form of NIPPV). Bi-pap provides ventilation assistance by providing 2 separate levels of positive airway pressure: a higher level with inspiratory breath and a lower level with expiratory breath.
Some patients may begin to feel anxious or claustrophobic with NIPPV. Some providers advocate using small doses of a benzodiazepine to allay this feeling; however, particular caution should be used, as the patient can become overly sedated (a decreased mental status is a contraindication to using NIPPV) or paradoxically increasingly agitated ( Box 1 ).
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