Modified pneumonia in geriatric population

PNEUMONIA IN THE GERIATRIC POPULATION

DR.PV PRABHAKAR RAO

PROFESSOR,

Dept of Pulmonology,

MNR Medical College and

Hospital

INTRODUCTION

Elderly 65 years

Organ

functional

decline

Comorbid

conditions

DEFINITIONPneumonia

Infection

InflammationConsolidation

Clinical symptoms

EPIDEMIOLOGY

14 per 1000 persons >60 years of age

75% of these cases were CAP

18 to 44 per 1000 in india

RISK FACTORS

IMMUNOCOMPROMISED

Autoimmune diseases

Cancer

Organ transplantation

Splenic dysfunction,

Primary immunedefeciences,

HIV

IMMUNOCOMPETENT

Age,

Life style factors

Prior Pneumonia

Aspiration

Concomitent treatment

Comorbid conditions

IMMUNOCOMPETENT

1. Profound disability

2. Bedridden

3. Urinary incontinence or deteriorating health status

4. Old age

5. Male sex

6. Difficulty in swallowing

7. Inability to take oral medications

RISK FACTORS FOR NURSING HOME ACQUIRED

PNEUMONIA

56%

10%

6%

6%

5%

4%

4%

9%

S.pneumoniae

H.influenza

Chlamydia

Legionella spp

S.aureus

Mycoplasma

Gram Neg bacilli

Viruses

ETIOLOGY

S.Pneumonia

CAP

S. Pneumoniae

H.influenzae

HAP

C. pneumoniae

Viral infectionS

20% of cases of TB

Nursing Homes

CLINICAL PRESENTATION

Atypical Presentations in Elderly

Fewer SymptomsConfusion, Mental

status changes Renal Dysfunction

In patients, with multiple comorbidities, it may present

with general weakness, decreased appetite, altered

mental status, incontinence, or decompensation due to

underlying disease

Fever is absent in 30% to 40% of older patients.

Due to the lack of specific symptoms, the diagnosis of

CAP is frequently delayed in older adults.

MANAGEMENT OF PNEUMONIA IN THE

ELDERLY

Includes

1) Severity assessment and criteria for ICU admission

2) Diagnostic workup

3) Therapeutic approach

Severity assessment and criteria for ICU

admission

Severity assessment and site-of-care decisions are critical

when managing elderly patients who present with pneumonia

Severity assessment tools can help predict mortality and

determine the optimal setting in which to provide care for

patients with pneumonia.

The PSI score and the CURB-65 are the most extensively studied

and widely recommended scores for assessing patients who

present with pneumonia.

PSI is based on 20 parameters that are evaluated at the time

of clinical presentation .

The primary purpose of the PSI score is to distinguish

between patients that could be safely treated in an outpatient

setting versus those inpatient observation and treatment.

The CURB-65 score places similar importance on age when

assessing severity of illness. The CURB-65, a less complex

scoring system, only requires six variables to be evaluated at

presentation

CURB-65

C-Confusion --- 1 point

U- Urea >19mmol-- 1

R- Resp rate> 30/min-- 1

B- Blood pressure <90/60-- 1

Age >65 yrs-- 1

Score 0- 1

Low SeverityScore 2- 3

Mod sev

Score 4- 5

High sev

OP based

treatmentWard treatment ICU admission

Variables in PSI

Patient Characteristics Points

Demographic factors

Age

Men

Women

Nursing home resident

Age in years

Age in years minus 10

Age plus 10

Coexisting illnesses

Neoplastic disease

Liver disease

Congestive heart failure

Cerebrovascular disease

Renal disease

30

20

10

Cont’dPhysical examination findings

Altered mental status

RR >30/min

SBP <90 mmHg

Temperature < 95◦F or > 104◦F

PR > 125/min

20

15

10

Lab and CXR findings

Arterial pH <7.35

BUN > 30 mg/Dl

Na+ <130 mmol/L

Glucose >250 mg/dL

Hematocrit <30%

Pa O2 < 60 mmHg

Pleural effusion

30

20

10

PORT

Classcriteria

Mortality

%Treatment Strategy

Class IAge<50yrsN

o RF

OP IP

0 0.5%Out patient

Class II 70 points 0.4 0.9 Out patient

Class III71 – 90

points0 1.25 Brief hospitalization

Class IV91 – 130

points12.5 9 Inpatient

Class V > 131 points NA 27.1 IP - ICU

CAP – Management based on PSI Score

The profound influence of age on PSI, CURB-65 and

CRB-65 scores highlights the fact that elderly patients

with CAP are at risk for higher severity of disease and

therefore poorer clinical outcomes.

Several tools have also been designed to predict the

need for ICU admission and the risk of death in patients

presenting with severe CAP. Examples include the

PS-CURXO80, SMART-COP and PIRO-CAP score.

DIAGNOSTIC WORKUP

The extent of the diagnostic workup for patients with

pneumonia depends upon the severity of the pneumonia.

For otherwise healthy patients who are going to be treated on

an ambulatory basis, a chest radiograph to confirm the clinical

diagnosis is all that is necessary; however, for elderly patients,

who often have comorbidities for which they are receiving

medication, a complete blood cell count and measurements

of electrolytes and serum creatinine are usually indicated.

DIA

GN

OS

TIC

WO

RK

UP

Lab evaluation

Radiologic

Microbiologic

LABORATORY EVALUATION

Laboratory studies should include blood cell counts, serum glucose and

electrolyte measurements, and pulse oximetry or arterial blood gas

assays.

The serum level of C-reactive protein and the erythrocyte sedimentation

rate are increased to higher values with bacterial than with viral

pneumonias.

Procalcitonin (PCT), a precursor of calcitonin, is present at increased

concentrations in the blood of persons with bacterial infections, and PCT

assays have been used to evaluate the severity, prognosis, and

evolution of pneumonia

RADIOGRAPHIC EVALUATION

Radiographic evaluation is necessary to establish the presence of

pneumonia

The presence of air bronchograms and a lobar or segmental pattern is more

characteristic of typical than atypical causes of pneumonia. In contrast, a

mixed pattern (alveolar and interstitial disease is more frequently observed

with atypical pneumonias.

Pneumonia complicating aspiration most often involves the superior

segment of the right lower lobe or posterior segment of the right upper lobe

MICROBIOLOGIC EVALUATION

It includes

1) Sputum Examination

2) Blood and Pleural Fluid Cultures

3) Antigen Detection

4) Nucleic Acid Amplification Tests

5) Serologic Evaluation

Identification of the infecting microorganism facilitates the use

of specific therapy instead of unnecessarily broad spectrum

antimicrobial agents

INVASIVE DIAGNOSTIC TECHNIQUES

Bronchoscopic Samples Transthoracic Lung Aspiration

DIFFERENTIAL DIAGNOSIS

1. Tuberculosis

2. Malignancy

3. Systemic vasculitis/connective tissue disease

4. COPD, Bronchial Asthma

5. Eosinophilic pneumonia

6. Pulmonary alveolar proteinosis

7. ILD’S

8. Sarcoidosis

9. Pulmonary embolism

10. Pulmonary edema

THERAPEUTIC APPROACH TO PNEUMONIA

Antibiotic therapies

Clinical practice guidelines do not recommend different

treatments for elderly patients, who are included in the general

treatment recommendations for CAP.

The treatment approach should be stratified according to the

location of therapy as out patient or in the hospital, whether in

the ward service or the ICU setting

OUT PATIENT BASIS

previously healthy pt

No antibiotic usage any comorbidity

in last 3m or antibiotics usage

in last 3m

MACROLIDE RESP FQ or

or doxycycline MACROLIDE +

BETALACTAM

IN PATIENT WARD(NON ICU)

RESP FQ

OR

adv MACROLIDE + BETA LACTAM

ICU TREATMENT

no risk factors for pseudomonas

BETA LACTAM + AZITHROMYCIN or

RESP FQ

For pencillin allergy AZTREONAM + RESP FQ are

recommended

ICU TREATMENT

risk factors for pseudomonas present

Antipseudomonal β-lactam + Antipseudomonal FQ

Antibiotic Recommendations for

Nosocomial PneumoniaPneumonia category microorganisms Empiric therapy

1)HCAP/ HAP/ VAP

No risk for MDR

pathogens

and

Hospitalised < 5 days

S.pneumonia

H.influenzae

MRSA

Klebsiella

Ceftriaxone

Ampicillin +

Sulbactum

Respiratory FQ ‘S

Ertapenam

Azithromycin for

atypical

coverage

Cont’d

Pneumonia category microorganisms Empiric therapy

2) HCAP/ HAP/ VAP

At risk for MDR

pathogens

and

Hospitalised > 5 days

Pseudomonas

Klebsiella

Acinetobacter

Legionella

Antipseudomonal

Cephalosporins

Carbapenams

piptaz + Resp FQ

Switch from intravenous to oral therapy

Patients should be switched from intravenous to oral

therapy when they are hemodynamically stable and

improving clinically, are able to ingest medications, and

have a normally functioning gastrointestinal tract.

Duration of therapy

should be treated for a minimum of 5 days .

A longer duration of therapy may be needed if initial therapy

was not active against the identified pathogen or if it was

complicated by extra pulmonary infection, such as meningitis

or endocarditis

CRITERIA FOR CLINICAL STABILITY

1

.

Temperature≤37.8C

2

.

Heart rate ≤100 beats/min

3

.

Respiratory rate ≤24 breaths/min

4

.

Systolic blood pressure ≥90 mm Hg

5

.

Arterial oxygen saturation ≥90% or pO2 ≥ 60 mm Hg on

room air

6

.

Ability to maintain oral intake

7

.

Normal mental status

Non antibiotic therapies

Recommended in severely ill patients with CAP, usually those in the

ICU setting.

It includes

1) Systemic corticosteroid therapy

2) Recombinant human activated protein C

3) Use of lung protective-ventilation strategy

4) Immunomodulatory agents such as statins and ACE inhibitors

Issues that Are Especially Significant When Treating

Elderly Patients with Pneumonia

1) Functional assessment

2) Referral to geriatric assessment team and restorative care

3) Do-not-resuscitate status

4) Nutritional assessment

5) Impaired renal and hepatic function

PREVENTIVE ASPECTS

1) Prevention of the next episode of pneumonia

Those who are at risk for aspiration should be positioned

at a 450angle when eating and should receive pureed

foods.

All tobacco smokers should be given advice and help to

stop smoking.

► 2) Vaccination

Both influenza and pneumococcal vaccinations have been

shown to be beneficial in the prevention of pneumonia in the

elderly

Two types of pneumococcal vaccines are approved for use in

the United States:

●Pneumococcal polysaccharide vaccine (PPSV23)

consists of capsular material from 23 pneumococcal

types

●Pneumococcal conjugate vaccine (PCV) consists of

capsular polysaccharides from the 13 most common

types that cause disease,covalently linked to a nontoxic

protein that is nearly identical to diphtheria toxin.

In 2014, the the United States Advisory Committee on

Immunization Practices (ACIP) began recommending

sequential administration of both PCV13 and PPSV23 for

all adults ≥65 years of age who have not previously

received a pneumococcal vaccine.

ACIP also recommends influenza vaccination annually in

the elderly patients.

Summary

Pneumonia represents one of the most frequent hospital

diagnosis among elderly patients

Elderly patients treated for pneumonia are at high risk of

subsequent mortality for several years after the episode.

Due to its high incidence and significant mortality, it has

become a major public health problem

Investigating strategies to reduce mortality in these patients

should be a major issue for future research.

In this population an etiologic diagnosis is rarely available

when antimicrobial therapy must be instituted.

Use of the guidelines for treatment of pneumonia issued by

the Infectious Diseases Society of America, with modification

for treatment in the nursing home setting, is recommended.

BEST TEACHER AWARD by Andhra Pradesh State Council of Higher

Education, Hyderabad. From the Chief Minister of Andhra Pradesh,

His Excellency Dr Y. S. Rajashekhar Reddy on 5th October 2005 on the

Occasion of International Teacher’s day.