Acute dyspnoea is a common presenting symptom in older adults and, in contrast to the younger patient, is usually multifactorial in aetiology. Dyspnoea in older patients can be mistakenly attributed to normal ageing, which may result in a delay in presentation and diagnosis (1).

This chapter will provide guidance on the challenges that older age can pose for clinicians managing emergency presentations of obstructive airways disease, end-stage lung disease and cardiac failure. Management of pulmonary embolism and pneumonia are covered in Chapters 5 and 7 respectively.

Dyspnoea is defined by the American Thoracic Society as a ‘subjective experience of breathing discomfort, often derived from the interplay between physiological, psychological, social and environmental factors’ (2). Pathological dyspnoea occurs when increased effort in the act of breathing is experienced at rest, or with physical activity that is usually well-tolerated (3). Dyspnoea can be a frightening and distressing symptom.

The sensation of dyspnoea is mediated by detection of hypoxaemia, hypercapnia, irritation and inflammation in the bronchi by chemoreceptors, mechanoreceptors and lung receptors. Age-related changes in the respiratory system (Box 6.1) lead to a functional deterioration, even in the absence of respiratory disease. The consequences of these changes include an increased susceptibility to infection, less capacity of the respiratory system to compensate for increased tissue oxygen demands and a higher likelihood of developing respiratory failure.

Despite these changes, the age-related changes in the cardiovascular system generally contribute a greater amount to reduced physiological reserve than do changes in the pulmonary system.

The patient may present in extremis, requiring urgent intervention. Here, conduct a rapid primary survey to assess severity and call for senior or critical care help early.

Given the extensive differential diagnosis for dyspnoea in the older adult (Box 6.3), a detailed patient history is vital to exploring and excluding different contributory factors. However, many patients with dyspnoea are unable to provide a comprehensive history until their symptoms are urgently addressed. Bear in mind that older adults often have multiple pathologies contributing to dyspnoea and it is less common for symptoms to fit into one single diagnosis.

Older age onset asthma more closely resembles COPD. It is rarely IgE-mediated, is less likely to have atopic triggers and demonstrates less reversibility with bronchodilators. It tends to be associated with gradually progressive irreversible airways obstruction (4).

Older adults with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may present with a disturbance in daily function and mental status rather than the classical triad of increased dyspnoea and sputum volume and a change in sputum purulence seen in younger patients. Weight loss in COPD may be primarily due to the metabolic demands of an increased respiratory effort, combined with poor nutrition. Patients with COPD, however, are at increased risk of lung malignancy, and symptoms such as chest pain or haemoptysis may necessitate further investigation. Malignancy is the most common cause of death in patients with mild COPD.

Symptoms found to correlate most frequently with acute heart failure include paroxysmal nocturnal dyspnoea, orthopnoea and exertional dyspnoea. Other non-specific symptoms may include ankle swelling, bloating, syncope, nocturnal cough, weight gain, fatigue and low mood.