Pneumonia in the Elderly by mikesanye

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									                               Pneumonia in the Elderly
                                    [Respiratory Infections]

                        Zalacain, Rafael MD*; Torres, Antoni MD†

From the *Pneumology Service, Hospital de Cruces, Cruces-Baracaldo, Spain; and †Clinical Institute of
Pneumology and Thoracic Surgery, Hospital Clinic, Barcelona, Spain.
Address correspondence to: Rafael Zalacain, MD, Pneumology Service, Hospital de Cruces, Plaza de
Cruces s/n, 48903 Cruces-Baracaldo, Spain. E-mail: rzalacain@hcru.osakidetza.net or rzalacai@separ.es.




Abstract:
Pneumonia is a frequent condition in the elderly (>=65 years of age), a population
group that is constantly increasing in number, and is characterized by high
morbidity and mortality rates, being the first infectious cause of death in this group.
This condition has specific features different from those found among younger
patients. Its incidence is higher, with around 25 to 40 cases per 1000 inhabitants per
year, and this figure increases in more elderly patients. Age as an isolated factor is
not of great importance to suffer pneumonia, and the increased risk would be due to
interaction of factors such as immune competence, concurrent illnesses, and
nutritional factors. Aspiration is the main mechanism that causes pneumonia in the
elderly. Although the lack of characteristic clinical data has been a constant feature,
it has been recently shown that a very large number of these patients present clinical
data suggestive of pneumonia. The main characteristic is altered mental status,
accounting for 20% to 50% of the cases. The most common etiologic agent is
Streptococcus pneumoniae, followed by Haemophilus influenzae, while the number
of cases of gram-negative enteric pathogens and Pseudomonas aeruginosa is lower
than what has been previously described. Treatment, both in outpatient clinics and
in hospital, would involve the combination of a [beta]-lactam and a macrolide agent,
or an antipneumococcal fluoroquinolone alone. Mortality rates are higher in this
group, more than 10%, but age is not a related prognostic factor. As preventive
measures, influenza and pneumococcal vaccinations are recommended.




Pneumonia in the elderly is and has been a frequent condition and is characterized
by high morbidity and mortality rates. Pneumonia was described more than hundred
years ago as the “old man's friend” because the patient would die due to a sharp,
acute, and frequently painless illness and thus did not suffer progressive
deterioration, so distressing for him and people around. Nowadays, the situation is
not as dramatic, but pneumonia still remains the first infectious cause of death and
the fourth general cause of death among the elderly.1–3




Epidemiology

When facing this problem, the first thing to be done is define when a subject can be
considered “elderly.” It is obvious that many times biologic age has no relation to
chronological age, and thus, individual assessment would be the best way to
determine when a patient is elderly. From a practical point of view, the limit has
been established at 65 years of age, and most population studies consider subjects of
this age and above.

Lately and due to the increase in life expectancy, there has been a demographic
growth of people over 65 years, a group frequently suffering from respiratory
infections, especially pneumonia, a condition which in this age group has features
different from those found among young patients.1–5

In terms of the place where the disease was acquired, pneumonia in the elderly can
be classified into 2 groups, leaving nosocomial pneumonia aside. These 2 groups
are community-acquired pneumonia (CAP) in patients who live in their own home
and CAP in patients who live in nursing homes. The former are more common
because most of the elderly live in their own homes, but the latter are becoming
increasingly relevant, as the number of patients living in nursing homes is
increasing as well. These patients suffer general deterioration and present higher
pneumonia and mortality rates.6 As a consequence, recent guidelines on CAP
consider nursing home pneumonia a condition with different characteristics.7,8

Pneumonia occurs with a higher incidence in the elderly than in the young, and
although it is difficult to define precisely as most of the population studies refer to
hospitalized cases, it can be estimated that there are 25 to 40 cases per 1000
inhabitants per year. This number increases among patients of older age.9 For
instance, in a study carried out in the United States, with data of elderly patients
hospitalized due to CAP obtained from the Medicare system, it was shown that the
incidence was over 5 times higher when comparing patients of 65 to 69 years of age
(8.4 cases per 1000 inhabitants) to those aged 90 or more (48.5 cases per 1000
inhabitants).10 The incidence is even higher among patients from nursing homes,
reaching almost 70 to 120 cases per 1000 inhabitants and year.11 Regarding the
proportion of hospitalizations due to pneumonia, more than two thirds correspond to
patients aged >=65.
Age has been traditionally considered a factor related to a higher incidence of
pneumonia but this relation is quite complex. Previous studies to identify risk
factors among patients with CAP have shown that although age (70 or more years
of age) is an independent risk factor for pneumonia, it was the least important, with
the highest risk rates related to underlying diseases.12 In another study with elderly
patients with CAP,13 age by itself did not appear to be a significant factor related to
the development of pneumonia. In this study, aspiration and low serum albumin
(<30 mg/dL) were independent risk factors associated with the development of the
disease.

Regarding risk factors for pneumonia in elderly patients living in nursing homes,
age also seems to have a less important role compared with factors such as
deterioration of functional status, difficulties swallowing, presence of a nasogastric
tube and neurologic disorders.14,15

Although there is no unanimity, it seems that age by itself does not play an
important role as an independent risk factor to develop pneumonia. The risk to
develop this illness is due to interactions between the competence of the immune
system, underlying diseases, and nutritional factors.1,5

Age is associated with many alterations in host defense mechanisms, which can be
classified into mechanical changes and those originating in the immune system.16–
18 Decrease in secretion elimination, impaired cough reflex, altered bronchial
elasticity, and changes in mucociliary motility are among the mechanical or
physiological changes and are factors that can have a great impact on pulmonary
defenses. Among the immunologic changes due to age, there is an important
deterioration of cell-mediated immunity, a less pronounced alteration of humoral
immunity, and, regarding neutrophils, although their absolute numbers are the same
as in younger subjects, their functions do not seem to be the same.

The presence of underlying diseases plays an important role in the development of
CAP in elderly patients. These 2 factors seem to complement each other, as
comorbidity increases immune dysfunction.16,19 More than two thirds of the elderly
patients hospitalized due to CAP have at least 1 comorbidity.13,20–22

Malnutrition is also an associated feature of CAP in this population and represents
one of the most serious problems due both to its frequency and to its implication in
nutritional deficits in different organs and systems. Nutritional deficits have been
found in 35% to 40% of the elderly population 23 and reached 86% in a study of
elderly patients with CAP.24 Malnutrition could be a cause of the relative anergy
present at this age, as well as of the increased susceptibility to infections, the
decrease in the lymphocyte responses, and the increase in mortality rates.25
Pathogenesis

Among the possible mechanisms causing pneumonia, aspiration of oropharyngeal
flora is the main cause in the elderly. In these patients, and especially in those living
in nursing homes, there are a number of factors, such as underlying diseases, bed
confinement, urinary incontinence, or prior antibiotic usage, that may cause an
oropharyngeal colonization by more aggressive bacteria, normally gram-negative,
increasing the risk of pneumonia due to these microorganisms.3,6,26 In this
population, oral hygiene is usually poor, and this is an important factor for
oropharyngeal colonization and a risk factor for pneumonia.

The importance of silent aspiration in elderly patients with CAP has been shown in
a study where 71% of the patients with pneumonia had silent aspirations versus
10% in the control group of similar age but with no pneumonia.27

Nevertheless, to develop pneumonia the aspirated inoculum must be large, the
bacteria particularly virulent, and the respiratory defense mechanisms very
deteriorated.1,26 When aspiration occurs, there is an inflammatory response, which
may produce symptomatology that resembles bacterial pneumonia, although at the
first stages there is no bacterial infection, as this occurs later on. It is very difficult
to distinguish between bacterial pneumonia and chemical aspiration pneumonitis,
and consequently the latter are always treated with antibiotics. From a theoretical
point of view, the presence of emesis or cough while eating, followed by fever and
respiratory difficulty within a few hours, could suggest aspiration pneumonitis.28
However, this would not be of great importance from a practical point of view,
since the patient is likely to develop bacterial infection at the time of (or some hours
after) aspiration in cases with fever and impaired breathing, so they are always
treated with antibiotics.




Clinical Characteristics

Traditionally, there has been a description of the clinical presentation of CAP in the
elderly, being characterized by a lack of respiratory symptoms and fever (40% to
60% of the cases), and altered mental status appearing in 20% to 50% of these
patients.2,29–31 In elderly patients, specially those of older age and deteriorated by
other diseases, pneumonia presents with altered general condition of the patient,
confusion, or decompensation of underlying diseases. Due to the lack of specific
symptoms, CAP in these patients is underdiagnosed, and delaying its diagnosis
consequently delays its treatment. The absence of characteristic clinical findings
have been confirmed in a study by Metlay et al.32 In this study, of 1812 eligible
patients 581 were over 65, and the association between age and presenting clinical
symptoms was evaluated. Patients were categorized into 4 age groups: 18 to 44
years (43%), 45 to 64 years (25%), 65 to 74 years (17%), and 75 years or older
(15%), and 5 respiratory (cough, dyspnea, expectoration, pleuritic chest pain, and
hemoptysis) and 13 nonrespiratory symptoms were assessed. In a linear regression
analysis, patients from the 18- to 44-year-old group presented 3.3 more symptoms
than those aged 75 or more, 2.9 more symptoms than those between 65 and 74, and
1.4 more than those aged 45 to 64. Despite all these data, out of the 5 respiratory
symptoms, all except pleuritic chest pain, which was clearly lower in relation to age,
had a similar incidence in all age groups. As for nonrespiratory symptoms, fever,
chills, sweats, headache, and myalgias were decreased among elderly patients. The
authors suggest that the lower number of symptoms in elderly patients could be
caused by a decreasing tendency in elderly patients to report symptoms, although
the physiological basis for the symptom is present.

Although there is a tendency to recognize the lack of characteristic symptoms of
pneumonia, recent studies among elderly patients with CAP have shown that
clinical signs suggesting pneumonia do not appear in all cases but do appear more
frequently than previously reported. In 2 such studies, 56% of 73 cases and 77% out
of 101 cases presented clinical features which could be considered typical or
characteristic.20,24 Sample size is limited in both studies, and this could have led to
erroneous conclusions in relation to clinical aspects. Nevertheless, similar results
have been obtained in 2 more recent series with a much larger number of cases: in a
study with 343 patients,21 clinical presentation was considered typical in 75% of the
cases. In another report of 503 patients, out of which 169 (34%) were >=80 years of
age, 75% of the cases had fever and more than 60% of the patients presented with
the main respiratory symptoms.22 This study compared the main clinical data
(length of clinical manifestations, cough, expectoration, dyspnea, fever, chills, and
pleuritic chest pain) between patients of 65 to 79 years of age and those >=80, but
no differences were observed. It should be stressed that in all series of elderly
patients with CAP, one fourth of the cases or more presented alteration of mental
status. In a very recent study with very elderly (aged 80 years or older) patients with
CAP, clinical presentation was very similar between 305 patients over 80 years and
1.169 under 80, although the very elderly complained less frequently of pleuritic
chest pain, headache, and myalgias, and they were more likely to have absence of
fever and altered mental status on admission.33

Clinical presentation of CAP in elderly patients living in nursing homes tends to be
more atypical, with less characteristic clinical data and a higher frequency of
nonspecific characteristics, such as general weakness, decreased appetite, altered
mental status and incontinence.11 However, there are still few studies of elderly
patients from nursing homes, and in several reports including patients from both
places, no differences in clinical data have been observed, although the number of
cases from nursing homes was lower.22,34
Among physical findings, the presence of tachypnea is common in these patients,
and high respiratory rate might be the first sign suggesting pneumonia, 1 or 2 days
prior to any other clinical finding. In a recent study, tachypnea was the most
common physical sign in elderly patients, present in almost 70% of cases, even
more frequent than fever or pleuritic chest pain.32 Whenever these nonspecific data
appear in an elderly patient (altered mental status, general weakness, decreased
appetite), the respiratory rate should be measured, and if high, even in the absence
of any other suggestive data, a chest x-ray should be obtained to discover
pneumonia, achieving an early diagnosis and probably a better outcome.

Another frequent physical sign is tachycardia, although it is less frequent than
tachypnea and less specific. Patients who at admission had higher respiratory and
heart rates, as well as high fever, were diagnosed sooner and thus received antibiotic
therapy earlier.35 Crepitations are not very significant, because many elderly people
without pneumonia may have similar noises while around 20% to 30% of patients
with CAP do not.16

Blood leukocyte counts are frequently high, and even when normal there is usually
a shift towards the left. In some cases in which clinical presentation is insidious,
leukocyte count is the only objective data which could point towards an infectious
etiology such as pneumonia.3,29

Chest x-ray may sometimes make a minor infiltrate evident, which might be
mistaken with accompanying underlying diseases. Elderly people normally present
with a progression of infiltrates, and although this is generally a sign of bad
prognosis, in these patients, who are normally dehydrated, this increase might be
due to rehydration.1–3 A chest x-ray should be taken not only when patients present
typical symptoms but also when they have acute confusional symptoms, as well as
in those cases with insidious clinical signs, which include tachypnea, leukocytosis,
or a shift towards the left.




Etiology

The main etiologic agent found in different CAP series has been Streptococcus
pneumoniae, as shown in Table 1. 13,20–22,33,34,36 Regarding other microorganisms, it
has been traditionally considered that these patients frequently have Gram-negative
enteric bacilli (GNB), while atypical microorganisms (Mycoplasma pneumoniae,
Chlamydia pneumoniae, Coxiella burnetii) and virus were unusual. However, more
recent reports show that the differences are not so great in relation to
microorganisms found in studies with younger patients.
                        TABLE 1. Microbial Agents Implicated in the Etiologic Diagnosis of
[                       Community-Acquired Pneumonia in the Elderly




A study of 395 cases of CAP in which the impact of age on etiology was studied, an
age over 60 years, in the absence of accompanying comorbidity, was not associated
with any particular etiologic agent. On the contrary, patients younger than 60 years
of age had significantly more cases due to atypical bacterial microorganisms,
mainly M. pneumoniae.37

With regard to GNB, it has been described that they could account for 10% to 30%
of the cases of pneumonia in this population,30,38 but these findings have not been
confirmed in more recently published series. In studies by Venkatesan et al 20 and
Riquelme et al,13 the frequencies of GNB were 0% and 2%, respectively. In a study
by García-Ordóñez et al,21 these microorganisms accounted for 6%, and in a study
by our group 22 out of 503 cases, GNB only accounted for 5%. In 2 reports on
severe CAP in elderly patients, in which high levels of GNB might be expected due
to the aggressiveness of these bacteria, frequencies were 14% and 16%
respectively.34,36 The low prevalence of GNB in all these groups has been recently
confirmed in a study on CAP caused by Gram-negative bacteria and Pseudomonas
aeruginosa,39 in which age >=65 years was not among the factors associated with
pneumonia by these microorganisms. For GNB, associated factors were aspiration,
previous hospital admission, prior treatment with antibiotics, and presence of a
pulmonary comorbidity. For P. aeruginosa, factors were the presence of a
pulmonary comorbidity and previous hospital admission.

The increased prevalence of atypical microorganisms in these patients is also
common, although it could probably be due to the systematic use of serology in
these studies. Legionella pneumophila must not be forgotten, as this pathogen was
the third etiologic agent after S. pneumoniae and H. influenzae in our series 22 and is
of great significance because age is a risk factor.40

In a very recent report with patients aged 80 years or older, 305 cases of CAP were
studied, and S. pneumoniae was the most frequent causative agent followed by
aspiration pneumonia and Gram-negative bacilli caused 3% of cases. There were
very few cases of atypical microorganisms and L. pneumophila.33
As for the etiology of patients from nursing homes, S. pneumoniae is also the most
frequent agent, followed by H. influenzae. Regarding GNB, they were also
traditionally considered to be frequent in this patient group, even more than among
patients from their own houses. Nowadays, the frequencies have been established
around 10% to 12%, in fact higher than among patients from their own homes,
reaching 20% in more severe cases.11,14 Nevertheless, the study of pneumonia due
to Gram-negative bacteria mentioned above, living in a nursing home was not an
independent risk factor to develop pneumonia caused by these microorganisms.39
Atypical microorganisms are not frequent in these patients.41




Treatment

Antibiotic treatment of patients with CAP must cover S. pneumoniae, H. influenzae,
GNB, and L. pneumophila, as well as atypical microorganisms. This fact causes the
different guidelines for management of CAP to pay special attention to these
patients. For example, the American Thoracic Society guidelines 7 consider an age
>=65 as a modifying factor which increases the risk of infection by S. pneumoniae
resistant to penicillin and other drugs, while residence in a nursing home increases
the risk for enteric GNB. Moreover, it is reported that age would not be an
independent criteria for hospital admission, as this would be conditional on the
presence of underlying diseases and a series of data suggesting severity due to
altered laboratory findings and physical examination. In the guidelines by the
Infectious Diseases Society of America,8 the decision for hospitalization was
conditional on a severity index calculated according to the method developed by the
Pneumonia Patient Outcomes Research Team.42 Using this method, patients were
stratified with respect to a high or low risk of death, and data extrapolated to define
the need for hospitalization. According to this classification, most of the elderly
patients would belong to classes III to V, mainly IV and V, because they normally
have underlying diseases and abnormal physical and laboratory findings.

Regardless of the place of treatment, hospital or outpatients clinic, all admitted
patients should receive an early dose of antibiotic therapy, since it has been shown
that lower 30-day mortality rates are reduced with antibiotic administration within 8
hours of hospital arrival, accounting for a 15% reduction.43

For outpatients or inpatients, antibiotic therapy should consist of either a [beta]-
lactam/macrolide combination or an antipneumococcal fluoroquinolone alone.7,8 In
this way, almost all causal microorganisms would be covered, because, as has been
shown in several different reports, the incidence of P. aeruginosa is not high in
these patients, and the specific therapy for this pathogen should not be normally
administered as an initial choice, unless the patient presents predisposing factors for
this bacteria, such as bronchiectasis, corticosteroid therapy (>10 mg per day),
lengthy broad-spectrum antibiotic therapy (>7 days in the past month), and
malnutrition.7

In the case of outpatients, therapy could involve amoxicillin/clavulanate or
cefuroxime plus a macrolide, or monotherapy with an antipneumococcal
fluoroquinolone (moxifloxacin, levofloxacin, gatifloxacin). From a practical point
of view, the latter alternative seems more convenient, as only 1 antibiotic is
administered. In the hospital, intravenous therapy with a third-generation
cephalosporin with no anti-P. aeruginosa activity (ceftriaxone or cefotaxime) or
amoxicillin/clavulanate (or ampicillin/sulbactam), associated with a macrolide, or
monotherapy with antipneumococcal fluoroquinolone can be used. In patients
admitted to the intensive care unit (ICU) without pseudomonal risks, an intravenous
third-generation cephalosporin with no anti-P. aeruginosa activity (ceftriaxone or
cefotaxime) or, for those with risks, fourth-generation cephalosporin (cefepime)
associated with a fluoroquinolone (ciprofloxacin, moxifloxacin, levofloxacin,
gatifloxacin) or a macrolide (azithromycin, clarithromycin) should be used.

As for patients from nursing homes, both outpatients and inpatients, antibiotic
therapy would be similar, putting special emphasis on risk factors for P.
aeruginosa.6 When pneumonia due to this organism is strongly suspected,
administration should involve intravenous antipseudomonal [beta]-lactam
(cefepime, piperacillin/tazobactam, imipenem, or meropenem) plus an
antipseudomonal quinolone, such as ciprofloxacin, or an aminoglycoside.

There have been attempts to determine the association between different antibiotic
therapies and outcome. For instance, there has been a retrospective study which
reviewed 12,945 hospital records of elderly patients with CAP, of which 24.7%
came from a nursing home, using different antibiotic therapy, preferably different
[beta]-lactams, in monotherapy or in combination with macrolides. This study
showed that initial treatment with a second-generation cephalosporin plus
macrolide, a nonpseudomonal third-generation cephalosporin plus macrolide, or a
fluoroquinolone alone were independently associated with lower 30-day mortality.
Strangely enough, a [beta]-lactam/[beta]-lactamase inhibitor plus a macrolide was
associated with higher mortality rates, with no justifying reasons.44

In these patients, apart from antibiotic therapy, some supportive care (including
hydration and nutritional intake) is needed because of the large number of patients
with nutritional deficits. Moreover, severe cases should be admitted to a ICU and
undergo mechanical ventilation, as it is inappropriate to withhold this care on the
basis of age alone.34




Resolution
Elderly patients with CAP present a slower resolution with more complications,
which mean a longer hospital stay.1–3 The radiographic resolution is slower as well
and is inversely correlated with age.45

Mortality rates are also higher than in young patients, and according to data from
different reports on CAP, they range from 11% to 33%.13,20–22 These figures are
higher in cases from nursing homes, where they range from 13% to 41%.11,14 They
can even be higher in patients in ICU, where mortality rates can reach 40% to
55%.34,36 In a recent study with very elderly patients (>=80 years of age) mortality
rate was 15% versus 6% in younger patients (<80 years)33; this figure in the very
elderly was very similar to those found in studies of older patients.13,20–22 Two
studies carried out in the United States, using the Medicare database, have
addressed the issue of patient outcome. In one of them,44 in which 12,945 elderly
patients with CAP were reviewed, mortality rate was 15.3%, 11.2% in patients from
their own houses and 27.5% in those from a nursing home. In the second study,10
with 623,718 cases, mortality rate was 10.6%, 10.3% in patients from their own
homes and 17.6% in those from a nursing home. The latter study also showed that
mortality doubled between age groups 65 and 69 and more than 90 (7.8% versus
15.4%) and was also higher in patients with an underlying illness (11.9% versus
7.6%).

Several studies have attempted to define the most relevant risk factors for outcome
of CAP in the elderly, putting special emphasis on the role of age. A first study by
Fine et al 46 analyzing the factors which would predict a complicated course of
pneumonia—including death, as well as several medical complications—showed
that out of 5 predisposing factors for a complicated course (a high-risk etiology,
immunosuppression, body temperature above 38.3°C, comorbidity, age more than
65 years), age had the lowest impact. In several studies on prognostic factors related
to mortality, the role of age as a risk factor associated with mortality is controversial
(Table 2). 13,21,22,33,34,36,47–52 For instance, in previous studies 49–51 on hospitalized
patients with CAP, age was a risk factor associated with mortality. However, in
more recent reports 52 where hospitalized cases of CAP were analyzed, as well as in
those carried out exclusively with elderly patients,13,21,22 age did not appear as a
prognostic factor associated with mortality. Similar results have been found among
patients older than 75 years of age 47 or older than 80 years of age,33 as well as in
series of patients admitted to the ICU.34,36 With all these data and with the increase
in life expectancy, it is possible we have to modify the limit of age for considering a
subject as “elderly.”




                         TABLE 2. Studies on Community-Acquired Pneumonia and Risk Factors for
[                        Death
The different risk factors associated with mortality in these studies are shown in
Table 2. In view of these reasons and literature experience from recent years, it is
increasingly evident that the importance of age as an independent risk factor for
morbidity and mortality is small. This confirms the results obtained in a meta-
analysis by Fine et al 53 about factors that influence the prognosis and outcome of
patients with CAP, which included 33,148 cases, with mortality of 13.7%, where
age does not appear as a factor associated with mortality (Table 3). In this analysis,
the authors concluded that age had a direct association with mortality, but it was not
a prognostic variable or a statistically significant factor.




                        TABLE 3. Prognostic Factors Associated With Mortality (Fine et al 53)
[




Regarding patients from nursing homes, age has not been considered a prognostic
factor in published studies, in contrast to previous functional status, dementia,
changes in mental status, high respiratory rate, sedative medication, suspected
aspiration, and comorbidity, which were all associated with poor prognosis.54

Several studies commenting on different prognostic rules for elderly patients with
CAP have also been published. For instance Ahkee et al 55 assessed the presence of
fever and leukocytosis and observed that those who had CAP without fever and
leukocytosis were 7 times more likely to die than those who presented with both
symptoms. Seppa et al 56 studied 950 elderly patients with pneumonia and found 3
risk factors independently associated with 30-day mortality: acute aggravation of an
underlying disease, respiratory rate (>=25/min), and serum C-reactive protein
concentration (>=100 mg/L). Thirty-day mortality rate was 20% if patients had all 3
risk factors and 2.2% if the patients had none or only 1 of them. Moreover, Conte et
al 57 retrospectively analyzed 1356 elderly patients with CAP, where they identified
several prognostic factors which were subsequently validated retrospectively in
another group of 1000 cases. The analysis proved that the presence of a comorbid
disease and an abnormal vital sign (temperature less than 36.1°C, heart rate >110
beats/min, and systolic blood pressure <90 mm Hg) at admission were the main
predictors of bad prognosis. Furthermore, they assigned mortality risk scores
according to prognostic variables: age >=85 years, altered mental status, and
creatinine level >=1.5 mg/dL scored 1, whereas the presence of a vital sign
abnormality or a comorbid disease scored 2. These variables stratified patients into
4 distinct groups with increasing scores and the increased mortality in the validation
cohort was statistically significant from group 1 to 4.

In patients from nursing homes, Naughton et al 58 developed a prediction model
associated with 30-day mortality. The included variables were respiratory rate >30
breaths/min, heart rate >125 beats/min, altered mental status, and a history of
dementia. The death rate among patients with 2 or more of these variables at
diagnosis was higher than 30%. All these prognostic rules need further validation by
prospective studies in elderly patients with CAP.

Other studies have assessed the importance of having previously suffered from
pneumonia as a mortality risk factor in the following months, which in turn is
variable in relation to age. The results are, however, still contradictory. For instance,
Brancati et al,59 monitored admitted patients with CAP for 2 years and saw that the
predictors of mortality were comorbidity and hematocrit below 35%, while age was
not associated with a significant increase in mortality during that period of time. On
the other hand, Hedlund et al 60 monitored patients with CAP for 32 months after
discharge and saw that age was an independent factor associated with mortality.




Prevention

In these patients, recommendations include general measures, such as correct oral
hygiene, as well as control of gastroesophageal reflux.2,6 Oral hygiene is normally
poor in this population, especially in patients from nursing homes, thus facilitating
colonization by potential respiratory pathogens, which subsequently are aspirated
and can cause pneumonia. Gastroesophageal reflux is also frequent in these patients
and can cause aspiration. As it has not been proven that antireflux medication can
effectively reduce aspiration or incidence of pneumonia, postural measures such as
raising the bed board are advised.

Regarding preventive intervention, the most important measures would be influenza
and pneumococcal vaccinations. Influenza virus may cause serious problems in
elderly patients and predispose to infections due to other microorganisms, mainly S.
pneumoniae. There have been several studies that have shown that the influenza
vaccine has proven its efficacy in reducing complications due to influenza,
including pneumonia in 50% to 80% of the patients. Influenza immunization is an
indispensable factor of the care of patients 65 years of age and older, and thus
annual vaccine should be administered to all patients, regardless of whether they
have underlying diseases or not or whether they live in their own homes or in a
nursing home.61

Concerning pneumococcal vaccination, there is more controversy and results are
more contradictory.62–64 It seems that this vaccine is protective in 50% to 80% of
cases against invasive pneumococcal illness in elderly patients and people with
comorbidity. However, its efficacy in preventing nonbacteremic pneumococcal
pneumonia is not clear. These data have been confirmed in a recent study with
patients aged 65 or more, in which the receipt of the pneumococcal vaccine was
associated with a significant reduction in the risk of pneumococcal bacteremia but
did not alter the risk of nonbacteremic pneumonia, which is a more common
manifestation of pneumococcal infection in elderly persons.65 Moreover, the
efficacy of the vaccine decreases with age, and in elderly patients its effects also
diminish after 3 years following administration, so revaccination is recommended in
5 years. Despite these limitations, pneumococcal vaccination should be
administered to all patients aged 65 or more, both those who live in their own
houses and those who live in an elderly home, because it is safe and inexpensive
and has a good cost-effectiveness ratio.66




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Key Words: elderly; community-acquired pneumonia; nursing home pneumonia

								
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