Bronchiectasis in Older Adults: Distinctive Epidemiology, Etiology, Diagnosis, and Clinical Evolution Compared with Younger Populations.

Abstract

Non-cystic fibrosis bronchiectasis is increasingly recognized as a major cause of chronic respiratory morbidity, particularly among older adults. Its rising prevalence is largely attributable to improved diagnostic imaging and heightened clinical awareness, with epidemiological data consistently demonstrating a marked age-related increase in disease burden. Older patients represent the majority of contemporary cases and exhibit a distinct clinical phenotype characterized by multimorbidity, frailty, and worse outcomes. Pathophysiologically, bronchiectasis is driven by a 'vicious vortex' of airway inflammation, impaired mucociliary clearance, chronic infection, and structural lung damage. In older individuals, this process is amplified by immunosenescence, inflammaging, and age-related structural and functional lung changes, which together promote persistent infection and progressive airway injury. Additional contributors, such as microaspiration, cumulative environmental exposures, and coexisting conditions, including chronic obstructive pulmonary disease and gastroesophageal reflux disease, further exacerbate disease progression. Diagnosis in older adults with bronchiectasis is frequently delayed due to atypical presentations and clinical overlap with other chronic conditions, resulting in more advanced disease at the time of recognition. Microbiologically, older patients show a shift toward more virulent and resistant pathogens, particularly Pseudomonas aeruginosa and Enterobacteriaceae, with important implications for management. Prognosis is poorer in this population, with higher mortality, increased healthcare utilization, and reduced quality of life, largely driven by frailty and comorbidities rather than by disease severity alone. These findings highlight the need for a comprehensive, geriatric-informed approach integrating respiratory care with systematic assessment of functional status, comorbidities, and patient-centered outcomes to optimize management in older patients with bronchiectasis.