Siamak Moayedi, MD, Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
Mercedes Torres, MD, Instructor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.

Dyspnea is among the most frequent complaints among older adults. The prevalence of comorbid medical conditions combined with physiological changes of aging present significant challenges to the diagnosis. The initial approach to the older adult with dyspnea mandates consideration of a broad range of diagnoses. Failure to consider life-threatening medical conditions presenting with dyspnea, such as pulmonary embolism, acute coronary syndromes, congestive heart failure, asthma, obstructive pulmonary disease, pneumothorax, and pneumonia, can lead to significant morbidity and mortality. This review focuses on the rapid assessment and approach to the older adult with acute dyspnea.
Key words: dyspnea, shortness of breath, approach, geriatric, older adults.

David Fitchett, MD, FRCP(C), St Michael's Hospital, University of Toronto, Toronto, ON.

The incidence of coronary heart disease increases with advancing age. Although older patients may develop classical symptoms of ischemic heart disease, other symptoms such as dyspnea, syncope, and fatigue are often the dominant presenting features of angina and myocardial infarction. The present discussion aims to heighten awareness of the atypical nature of myocardial ischemic symptoms in the older adult and to suggest a structured approach to facilitate achieving a more accurate diagnosis.
Key words: chest pain, myocardial ischemia, dyspnea, coronary artery disease, infarction.

Pippa Hall, MD, CCFP, MEd, FCFP, Assistant Professor, Department of Family Medicine, Program Director, Palliative Medicine Residency Program, University of Ottawa, SCO Health Service, Ottawa, ON.

Dyspnea is experienced by patients with advanced lung and heart disease and cancer. When conventional therapy has been optimized, dyspnea can be managed in a systematic, evidence-based approach, involving an inter-professional team. The patient and family contribute to optimal care plan development. Non-pharmacological approaches are important. Compressed air, oxygen and steroids may be helpful. Strong evidence supports the use of opioids, while some evidence supports the use of neuroleptics and anxiolytics. Escalating distress in the last hours of life may necessitate interventions that improve dyspnea control at the price of deeper sedation. If upper airway congestion develops, anticholinergics are recommended.
Key words: dyspnea, terminal care, refractory symptom, palliation.

Introduction
Dyspnea, defined as a subjective sense of shortness of breath or uncomfortable breathing, is a common symptom in patients with advanced lung and heart disease, as well as in patients with cancer.^1,2 Dyspnea has been reported to be as distressing a symptom as pain, with patients often feeling they are about to die from suffocation or choking.

William J. Kostuk MD, FRCPC, FACC, FACP, Professor of Medicine, University of Western Ontario; Cardiologist, University Campus London Health Sciences Centre, London, ON.

Heart failure is the most rapidly rising cardiovascular condition in Canada. At times, the clinical presentation of heart failure may not make the diagnosis obvious. The diagnosis of heart failure should be considered when an older individual presents with complaints of exertional dyspnea or fatigue. In such individuals, the physician should not assume the symptoms are merely the result of age, obesity or chest disease. Physical examination and a few simple investigations,reviewed here, can be extremely helpful and may delay or even prevent the progression to symptomatic disease.
Key words: heart failure, diagnosis, dyspnea, fatigue, evaluation in older adults.

Lilia Malkin, BSc

The myriad of human physiological systems undergo change as the body grows older, and the respiratory system is no exception. For a more detailed look at the aging lungs, please see the Biology of Aging article, Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly. It is worth noting, however, that the evaluation of the geriatric patient presenting to the physician's office with respiratory symptoms such as cough and shortness of breath is quite similar to that of a younger adult. The following is a two-part review of diagnostic and treatment approaches to the geriatric patient presenting to the primary care physician for the first time with symptoms of dyspnea and cough, respectively.

Part I. Dyspnea
Dyspnea may be defined as "abnormal or uncomfortable breathing in the context of what is normal for a person according to his or her level of fitness and exertional threshold for breathlessness."¹ However, upon presenting to the physician, patients will usually refer to the alarming feeling of "shortness of breath," or "difficulty breathing." The complaint is fairly common, owing to the plethora of conditions that give rise to this symptom.