Background Chronic breathlessness is a debilitating symptom with major adverse impact on those involved. Little is known about prevalence and impact of breathlessness in community-dwelling older, frail adults.

Methods Mixed-methods study. Cross-sectional survey of 249 adults at risk of severe frailty (living in own homes; ≥65 years, eFrailty Index >0.36) to determine i) prevalence (self-reported breathlessness most days/past month), ii) impact of chronic breathlessness (questions about mental health, activities, care from healthcare practitioners (HCPs), and iii) associated clinical factors. Qualitative interviews explored psychological impact and experiences of breathlessness care in primary care for: patients (n=20), carers (n=5), and HCPs (n=10). Quantitative analysis used descriptive and inferential statistics (odds ratios); qualitative data were subjected to thematic analysis. Findings were synthesised using modified Critical Interpretative Synthesis.

Results 99/249 (40%) participants (median age 80 years, 61% women) reported chronic breathlessness. Breathlessness was associated with worse psychological outcomes: higher odds of anxiety (OR 2.2; 95%CI 1.29–3.85), family anxiety (OR 2.0; 95%CI 1.20–3.41), and depression (OR 1.9; 95%CI 1.12–3.39) (measured on Integrated Palliative care Outcome Scale), and poorer quality of life (QoL): higher odds of significant problems with usual activities (OR 1.78; 95%CI 1.06–2.96) (measured on EQ-5D-5L). People with chronic breathlessness give up activities because of their breathlessness which they conflate with underlying disease. Breathlessness is ‘one of many’ symptoms and in context of ‘one appointment, one problem’, is not recognised as therapeutic target by patients or HCPs, remaining invisible and unmanaged. HCPs can feel helpless and do not routinely ask about impact of breathlessness.

Conclusions Over one-third of older, frail adults live with chronic breathlessness with major detrimental impact. Lack of routine assessment in primary care means they may not access evidence-based symptom-targeted interventions. Systematic identification, assessment, and management in primary care may help improve psychological health, QoL, and overall wellbeing.