Bronchiectasis in the Elderly—a Disease That Has Not Gone Away

In the early twentieth century, bronchiectasis (BE) was not a disease seen in the elderly population as life expectancy was usually < 40 years. A century on, however, and this is now a disease much more prevalent in the elderly and as patients live longer, this trend will almost certainly continue. Why is this so? (1) BE is irreversible and often worsens with advancing years and (2) aetiologies associated with new-onset BE in the elderly are strongly related to the ageing process itself—namely gastro-oesophageal reflux disease (GORD), immunosenescence, cancer and inflammatory diseases, oral sepsis, aspiration of food and liquid into the respiratory tract and development of pulmonary fibrosis. BE can also complicate chronic airway diseases such as COPD, which becomes more prevalent with age, and is associated with more rapid disease progression and a higher mortality. In both the BSI and FACED BE mortality prediction scores, age is an independent risk factor for death. At present, GORD and aspiration are considered to be the primary cause of few cases of BE. There is however a lot of data supporting the role of GORD and the severity of BE and its prognosis. Similarly, the data implicating aspiration in elderly patients as a major risk factor for the development of community-acquired pneumonia is overwhelming yet it is rarely looked for and the subsequent bronchiectasis is usually labelled as post-infective rather than due to aspiration. In older patients with recurrent chest infections and/or chronic cough and sputum, it is, therefore, critical to think of BE and investigate appropriately including testing for GORD and aspiration. Treatment involves attenuation of risk wherever possible and the twin pillars of sputum clearance and judicious use of antibiotics.