Severe Pneumonia in the Elderly: Risks, Treatment, and Prevention

, Winthrop University Hospital, Mineola, NY

Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Abstract and Introduction

Abstract

The elderly are more susceptible to pneumonia than younger populations. The prevalence of both disability and comorbid diseases increase with age and are associated with increased risk of pneumonia. Therefore, the elderly constitute a growing proportion of those at risk. The known independent risk factors for pneumonia include alcoholism, asthma, immunosuppression, heart disease, institutionalization, and age greater than 70. The strongest predictors of mortality, at least in community-acquired pneumonia, are BUN greater than 20mg/dL, respiratory rate greater than 30 per breaths minute, and diastolic blood pressure less than 60mmHg. The American Thoracic Society has published practice guidelines for the management of both community-acquired and hospital-acquired pneumonia. These guidelines suggest evaluation, therapy, and work-up of pneumonia patients based upon patient- specific risk factors, age and site of treatment. Pneumococcal species are the most common causative pathogens for pneumonia in the elderly, and the development and utilization of the pneumococcal vaccine was a major public health milestone. However, too few individuals are being vaccinated, perhaps, because pneumococcal pneumonia is more likely to be prevented in low-risk patients who receive the vaccine, (those without risk factors for pneumonia), than in high-risk patients. It appears that overall health status is the most significant factor in determining the risk of morbidity and mortality associated with onset of pneumonia in the elderly.

Introduction

A number of studies have confirmed that there is a high rate of morbidity and mortality associated with pneumonia in the elderly (Fig. 1).[1,2,3,4,5] These high rates have continued to impede the efforts of healthcare professionals, despite significant improvements in therapeutic options and public health practices. One-sixth of the six million pneumonia cases that are reported each year occur primarily in those individuals 65 years and older requiring hospitalization for pneumonia.[6] Over 90% of all deaths from pneumonia occur in this older population.[7] Currently, individuals over 65 comprise 12% of the population, and by the year 2050 this will increase to 25 percent. By 2020, there will be 65 million individuals over the age of 65 years, all at high risk for pneumonia.

Among 590 residents of Franklin County, the mortality from pneumococcal bacteremia was higher in patients at least 65 years old compared with younger adults. Adapted from Plouffe JF, Breiman RF, Facklam RR: Bacteremia with Streptococcus pneumoniae. Implications for therapy and prevention. Franklin County Pneumonia Study Group. JAMA 275:194-198, 1996.

Over the last several years, a number of advances have been made in understanding the pathogenesis and treatment of pneumonia, as well as in the development of effective practice guidelines. This article will examine the impact of pneumonia in the elderly, identify potential solutions to the prevailing problems that prevent improved outcomes and review the preventive strategies that are currently recommended.

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