Breathlessness in Older Adults

What We Know and What We Still Need to Know

Eralda Hegendörfer MD, PhD; Jean-Marie Degryse MD, PhD

J Am Geriatr Soc. 2023;71(7):2082-2095.

Abstract and Introduction

Abstract

Breathlessness is common among older adults, but it is often hidden as "normal aging "or considered narrowly as a symptom of cardio-respiratory diseases. Studies on breathlessness in older adults are mostly focused on specific diseases, whereas older adults are characterized by multimorbidity and multi-system age-related impairments. This article aims to provide an overview of what is known so far on breathlessness in the general population of older adults and identify areas for further research. Research shows that breathlessness in older adults is a multifactorial geriatric condition, crossing the borders of system-based impairments and diseases, and a valuable independent prognostic indicator for adverse outcomes. Further research needs to investigate (1) the multi-factorial mechanisms of breathlessness in community-dwelling older adults including the role of respiratory sarcopenia; (2) the influence of affective and cognitive changes of older age on the perception and report of breathlessness; (3) the best way to assess and use breathlessness for risk prediction of adverse outcomes in general geriatric assessments; and (4) the most appropriate multi-modal rehabilitation interventions and their outcomes. Clinicians need to shift their approach to dyspnea from a disease symptom to a multifactorial geriatric condition that should be proactively searched for, as it identifies higher risk for adverse outcomes, and can be addressed with evidence-based interventions that can improve the quality of life and may reduce the risk of adverse outcomes in older adults.

Introduction

In recent years, there has been increasing interest and calls for a systematic assessment of breathlessness in the general adult population as it is prevalent, provides valuable general prognostic information, its assessment requires minimal efforts and there are evidence-based interventions for its relief.^[1–4]

Community-dwelling older adults are a special population regarding breathlessness as its prevalence increases with age, yet it is commonly hidden and attributed to "normal aging".^[2,4] In addition, older adults are characterized by multimorbidity, age-related multi-system low physiological reserves, and reduced symptom perception and reporting.^[2,4,5]

This article aims to provide an overview of the current research findings on breathlessness in the general population of older adults and identify potential areas for future research about its underlying causes, prognostic role, assessment, and management in general geriatric care.

The terms breathlessness and dyspnea are both used in medical literature and in this article, we use them interchangeably. Dyspnea (literal meaning 'disordered breathing') is defined as a "subjective experience of breathing discomfort",^[6] but it is not a term used by patients, whereas breathlessness is more commonly used by patients and clinicians to describe breathing difficulty or discomfort.^[4,7]

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Table 1. Grades and descriptions of the MRC breathlessness scale.
Grade	Description
1	Not troubled by breathlessness except on strenuous exercise
2	Short of breath when hurrying on the level ground or walking up a slight hill
3	Walks slower than most people on the level, stops after a mile or so, or after 15 min walking on the level at own pace.
4	Stops for breath after walking about 100 yds (or after a few minutes) on the level
5	Too breathless to leave the house or breathless after undressing

Note: The modified version (mMRC) or the ATS dyspnea scale uses grading from 0 to 4 and modifies Grade 3 to:" Walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level."¹⁰

Table 2. Studies on factors associated with breathlessness in community-dwelling older adults.
Country & year of study	Participants	Prevalence of MRC ≥3	Associated factors^a
USA 2011–2013¹⁷	n = 4342 age ≥65 years	13.2%	• Restrictive spirometric pattern 2.11 (1.61–2.76) • Obstructive spirometric pattern 1.69 (1.33–2.14) • Pulmonary hypertension 1.47 (1.08–2.00) • LV hypertrophy 1.30 (1.01–1.67) • Lower extremity weakness 2.10 (1.53–2.88) • Upper extremity weakness 1.27 (0.98–1.64) • Depression symptoms 2.41 (1.59–3.66) • Obesity 2.22 (1.75–2.81) • Renal dysfunction 1.29 (1.01–1.65) • Anemia 1.59 (1.21–2.07)
Belgium 2008–2009⁹	n = 567 age ≥80 years	29.9%	• Low FEV1 3.19 (1.90–5.34) • Low physical performance 2.49 (1.50–4.12) • High NTproBNP 2.36 (1.45–3.85) • Overweight/obese 2.20 (1.29–3.75) • High GDS-15 score 1.87 (1.09–4.22)
USA 1989–1990¹⁶	n = 4413 age ≥65 years	17.5%^b	• Low FEV1 2.88 (2.37–3.49) • Respiratory muscle weakness 1.60 (1.20–2.14) • LV ejection fraction<45% 2.12 (1.43–3.16) • Diastolic dysfunction 1.32 (1.08–1.61) • Grip weakness 1.31 (1.06–1.61) • Single chair stand 2.10 (1.61–2.73) • Depressive symptoms 2.02 (1.26–3.23) • Anxiety symptoms 1.54 (1.22–1.93) • Cardiovascular medication 1.65 (1.35–2.01) • Psychoactive medication 1.71 (1.35–2.15) • Obesity 2.07 (1.67–2.55)
UK, year not reported¹³	n = 1169 age ≥70 years	32.3%	• Prevalence in participants with versus without dyspnea: • Reversible airway disease 19.3 versus 10.3% • COPD 19.3 versus 7% • LV systolic dysfunction 17.1 versus 6.04% • Obesity 33.9 versus 23.0% • High depression & anxiety score 62.4% versus 36.4%

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 s; GDS-15, 15 items geriatric depression scale; LV, left ventricle; MRC, Medical Research Council breathlessness scale; n, number.
^aThe studies from USA and Belgium applied a multivariable logistic regression including all impairments. Only those with statistically significant adjusted odds ratio and their 95% confidence intervals (in brackets) are reported here. The study from UK compared population prevalence of clinically diagnosed conditions between those with and without dyspnea. Only conditions with statistically significant differences (p value >0.05) are reported here.
^bThe ATS scale grade ≥2 "Do you have to walk slower than people of your age on the level because of breathlessness?" (equivalent to MRC ≥3).

Table 3. Age -related physiological changes that might (co-) contribute to exertional dyspnea in older adults.
Location	Changes and the mechanisms leading to exertional dyspnea (→)
LUNGS	Reduced lung compliance (due to reduced elastic recoil) • Reduced forced expiratory volume in 1 s • Reduced vital capacity • Increased functional residual capacity Increased airway resistance • Increased functional residual capacity • Increased residual volume • Lung hyperinflation ➔ Increased mechanical loading of respiratory muscles Reduced gas exchange efficiency due to: – Increased dead space & ventilation/perfusion mismatch – Reduced DLCO (diffusion capacity for carbon monoxide) ➔ Increased ventilatory demand during exercise
CHEST WALL	Reduced chest wall compliance (stiffening of the chest wall) Changes in the shape of thorax (dorsal kyphosis) ➔ Increased mechanical loading of respiratory muscles
RESPIRATORY MUSCLES	Reduced inspiratory and expiratory muscles' strength due to: – Increased mechanical loading from changes in lung & chest wall – Age-related sarcopenia ➔ Decreased ventilatory capacity
LOCOMOTOR MUSCLES	Reduced mass and strength (age-related sarcopenia, deconditioning) • Reduced anaerobic threshold and mechanical efficiency ➔ Increased ventilatory demand during exertion
CARDIO-VASCULAR	Reduced compliance of myocardium, arteries, and veins (stiffening) Calcification of valves; Atherosclerosis. • Hypertension • Reduced end-diastolic and stroke volume • Reduced cardiac output Reduced response of beta receptor stimulation and reduced function of atrial pacemakers' cell • Reduced heart rate and contractile response to exertion ➔ Increased ventilatory demand during exertion & decreased ventilatory capacity (through restrictive lung changes)

Table 4. Studies on association of breathlessness with adverse outcomes in community-dwelling older adults.
Country, cohort, year	Participants	Dyspnea grade	Adverse outcomes
Belgium, BELFRAIL cohort, 2008–2009⁹	n = 567 age ≥80 years	MRC 3–5	All-cause mortality at 5 years HR 2.85 (95% CI 1.93–4.20) First unplanned hospitalization at 3 years HR 1.72 (1.35–2.19) New/worsened ADL disability at 2 years OR 2.49 (1.54–4.04) adjusted for age, sex & smoking status.
USA, Health and Retirement Study, 2008⁴	n = 3671 age ≥70 years	Non-exertional^a	ADL decline at 5 years HR 1.43 (95%CI 1.22–1.68) Mortality at 5 years HR 1.63 (1.32–2.02) adjusted for age, sex, race and education
Australia, Australian Longitudinal Study of Aging, 1992³⁴	n = 798 Mean age 76.4 years SD 5.8	MRC ≥2	Worse self-rated health at baseline OR 2.02 (95% CI 1.53–2.67) and at 2 years OR 1.72 (95% CI 1.28–2.33), adjusted for age, sex, living arrangement, smoking status, and co-morbidities
France, PAQUID cohort, 1988³⁵	n = 2792 age ≥65 years	MRC 3–5	Mortality at 8 years MRC 3: HR 1.4 (95% CI 1.2–1.7); MRC 4: HR 2.01 (1.6–2.5); MRC 5: HR 6.0 (3.7–9.7) versus MRC grade 1, adjusted for age, sex, smoking status, profession
UK, year not reported²⁸	n = 500 age ≥70 years	MRC 3–5	Mortality at 10 years OR 1.94 (95%CI 1.11–3.38) adjusted for age, sex, and dyspnea-related morbidities (left ventricular dysfunction and COPD)
France, PAQUID cohort, 1988–1989³⁶	n = 3646 Mean age = 75.3 years SD 6.8	MRC 3–5	Mortality at 13 years MRC 3: HR 1.42 (95% CI 1.25–1.63); MRC 4–5: HR 1.90 (1.61–2.25) versus MRC 1 adjusted for age, sex, BMI, previous ischemic heart disease, stroke, hypertension, smoking and diabetes

Abbreviations: ADL, activities of daily living; BMI, body mass index; CI, confidence interval; COPD, chronic obstructive pulmonary disease; HR, hazard ratio; MRC, Medical Research Council breathlessness scale; n: number; OR, odds ratio; SD, standard deviation.
^a"How often do you become short of breath while awake?" Often or sometimes → nonexertional breathlessness.