Recognising Heart, Lung and Other Causes of Breathlessness in Elderly

As winter approaches, I am seeing a noticeable increase in elderly patients who come to me with worsening breathlessness, often assumed to be caused by chest or respiratory issues. Upon evaluation, however, many of these cases reveal underlying heart problems as the true source of their symptoms. Breathlessness, or dyspnea, in older adults can stem from a variety of health concerns, with both cardiac and respiratory systems playing significant roles. Recognizing the cause is essential for effective treatment, as heart-related breathlessness often requires different management than respiratory-related issues.

Common Causes of Breathlessness in Elderly Patients

1. Heart-Related Causes

Symptoms: Heart-related breathlessness often worsens when lying flat or during physical activity. Other symptoms may include chest discomfort, palpitations, fatigue and swelling in the legs or ankles. Following conditions are some of the most common heart issues that lead to breathlessness.

Heart Failure: In heart failure, the heart fails to pump blood efficiently, resulting in fluid buildup in the lungs and difficulty breathing. Patients often feel more breathless when lying down or even after minimal exertion.

Arrhythmias: Abnormal heart rhythms can lead to inadequate blood flow and oxygen delivery to the body, causing breathlessness, especially with exertion. Patients may experience palpitations or a racing heart along with breathlessness.

Coronary Artery Disease (CAD): This occurs when the coronary arteries are narrowed or blocked, reducing blood flow to the heart muscle. This can cause angina (chest pain), and shortness of breath, especially during physical activity. Severe blockages can lead to heart attacks, which can have breathlessness as an early symptom.

Prevention: Preventive steps include adopting a heart-healthy lifestyle, managing stress, controlling blood pressure and quitting smoking. Regular physical activity, a balanced diet rich in fruits, vegetables, whole grains and lean proteins, and reducing salt intake are also beneficial. Routine heart check-ups and managing conditions like diabetes and hypertension can reduce the risk of heart-related breathlessness.

Treatment: Treatment for heart-related breathlessness often involves medications, such as beta blockers, angiotensin receptor-neprilysin inhibitors (ARNIs), mineralocorticoid receptor antagonists (MRAs) and sodium-glucose co-transporter 2 Inhibitors (SGLT2i).  MRAs and SGLT2is help reduce fluid buildup, improving breathing, while beta-blockers and ARNIs support heart function. Severe cases may require surgical interventions like angioplasty or the placement of a pacemaker, depending on the specific condition.

2. Lung-Related Causes

Symptoms: Breathlessness originating from lung problems is often accompanied by wheezing, coughing or chest tightness, especially during exertion. Common lung issues causing breathlessness in seniors include:

Chronic Obstructive Pulmonary Disease (COPD): A condition that includes chronic bronchitis and emphysema, COPD often results from long-term smoking and causes chronic breathlessness. Patients experience difficulty breathing, persistent cough and frequent respiratory infections.

Asthma: Seniors can develop asthma even if they didn’t have it when they were younger. This late-onset asthma can lead to breathlessness, especially during physical activities or in cold weather. Symptoms include wheezing, tightness in the chest, and breathlessness.

Pneumonia: A lung infection often triggered by bacteria, viruses or fungi, pneumonia is particularly severe in seniors. Symptoms include sharp chest pain, fever, chills, and a productive cough, alongside breathlessness that worsens as the infection progresses.

Prevention: Preventive measures for lung issues include avoiding smoking and secondhand smoke exposure, receiving vaccines for flu and pneumonia, and maintaining good hygiene to avoid respiratory infections. Wearing a mask during flu season and avoiding cold air exposure can help reduce asthma triggers.

Treatment: For lung conditions, bronchodilators, inhaled corticosteroids and supplemental oxygen may be prescribed. Pulmonary rehabilitation programs are highly beneficial, as they help strengthen the lungs and improve breathing capacity through structured exercises. Infections like pneumonia are treated with antibiotics, antiviral medications, or supportive care depending on the cause.

3. Other Causes of Breathlessness in Seniors

Breathlessness in seniors isn’t limited to just heart and lung issues. Here are other common conditions that may lead to breathlessness:

Anemia: Low red blood cell count leads to decreased oxygen delivery to the body, causing breathlessness, weakness, and pallor. This condition is common in older adults, especially those with dietary deficiencies or chronic illnesses.

Pulmonary Embolism (PE): A blood clot in the lungs blocks blood flow, causing sudden, severe breathlessness. Pulmonary embolism is a medical emergency with additional symptoms like chest pain, rapid heart rate and sometimes coughing up blood.

Kidney Disease: Chronic kidney disease can lead to fluid overload and anemia, both of which cause breathlessness. Swelling and fatigue often accompany the symptoms.

Obesity and Deconditioning: Excess body weight and lack of physical fitness can place strain on both the heart and lungs, making simple activities feel challenging. Deconditioned muscles also require more oxygen, increasing breathlessness.

Gastroesophageal Reflux Disease (GERD): Acid reflux can cause irritation of the airways, leading to difficulty breathing and symptoms that may mimic asthma.

Anxiety and Panic Disorders: Psychological factors can lead to episodes of hyperventilation, causing a feeling of breathlessness and chest discomfort.

Diagnosis and Evaluation

Accurate diagnosis requires a combination of medical history, physical exams, and tests, such as:

Electrocardiogram (ECG) and echocardiogram: These are used to assess heart rhythm, size and function to diagnose heart-related causes.

Pulmonary function tests (PFTs): Used to measure lung capacity and airflow, often indicating COPD or asthma.

Blood tests: These can detect anemia, infections and heart failure markers like NTproBNP.

Imaging: Chest X-rays and CT scans help detect pneumonia, lung clots and fluid buildup due to heart failure.

For any elderly person experiencing persistent or worsening breathlessness, a thorough medical assessment is essential to determine the most appropriate course of action.