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Respiratory Diseases in the Elderly: Pneumonia Prevention and Treatment

This module focuses on the age-related and disease-related predisposing factors of pneumonia in the elderly. It covers interventions to prevent pneumonia, as well as the diagnosis and treatment for bacterial pneumonia. The module also discusses the common causes of community-acquired and hospital-acquired pneumonia.

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Respiratory Diseases in the Elderly: Pneumonia Prevention and Treatment

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  1. Infectious Disease in the Elderly in Community and Long Term Care Facilitiesmodule 2Respiratory diseases:Pneumonia Unit two UNMC Section of Infectious Diseases Brandi L. Lesiak, PA-C, MPAS Kim Meyer, PA-C, MPAS Claudia Chaperon APRN, Phd Ed Vandenberg MD CMD Updated 11-23-06

  2. PROCESS A series of modules and questions Step #1: Power-point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

  3. Objectives Upon completion the learner will be able to: • Describe the age-related and disease-related predisposing factors of pneumonia • List interventions to prevent pneumonia • Describe diagnosis and treatment for pneumonia in the elderly

  4. Bacterial pneumonia (1, 2, 3) • Pneumonia is the leading infectious cause of death in the USA and the world • Common source of morbidity and mortality in older adults • Broadly classified into • Altered host defenses • Increased exposure to bacteria

  5. Reduced barrier function of Respiratory tracts due to: Altered mucous increases bacterial adherence Alteredrespiratory cilia function (slower/less organized) Leads to; Greater colonization with Gm neg. bacteria Chest wall is less compliant Dependent on abdominal breathing for lung expansion Lungs are more compliant Leading to: Increase in residual volume Decline FEV1 Pulmonary System:Why pneumonia is so common in old age?

  6. FEV-1 Versus Age 100% % of Value at 20-25 years 50% 25% • 50 70 80 • Age in Years

  7. Why pneumonia is so common in old age? • Decline in PaO2 PaO2 = 100-(age/3) • By age 40 yrs, full expansion does not occur supine • By age 65 yrs, full expansion does not occur sitting

  8. pO2 Lower Limit of Normal for Age 100 90 pO2 mmHg 80 70 60 AGE 20 40 60 80 Effect of Age on p02 Seated and Supine

  9. Pulmonary System:(4, 5)Why pneumonia is so common in old age? • Increased silent aspiration of gastric and oropharyngeal contents • Decreased protective reflexes with disease (CVAs, swallowing disorders. • Decreased clearance of aspirate • Increased GERD • Increased dental disease

  10. PREVENTION (6, 7, 8) Improve host defenses: • Pneumococcal vaccine • Improve cough reflex ( especially during sleep) -avoid sedatives, hypnotics, narcotics • Reminders to: deep breath, increase upright activity and incentive respirometers

  11. PREVENTION- continued (9, 10) Improve host defenses: • Improve clearance of secretions -humidify, -reduce drying ( meds: anticholinerigcs) -mucolytics - smoking cessation

  12. PREVENTION- continued ( 11, 12, 13, 14) Decrease exposure to bacteria. • Hand washing, contact precautions • Avoidance of antibiotics • Reduce frequency and severity of aspirations • Control reflux: ( upright after meals) • Avoid NG tubes • Oral hygiene • Screen for and treat dysphagia (Speech therapy, diet consistency)

  13. Bacterial pneumonia (15) • Community Acquired Pneumonia ( CAP) • S. pneumoniae is the most common cause • Other caused H.flu, M. catarrhalis, viral, atypicals • Hospital-acquired pneumonia • Gram-negative rods (Pseudomonas, Acinetobacter, Enterobacter) followed by Staphylococcus aureus and Legionella are more common • Aspiration pneumonia -anaerobes Pitfall: No specific etiologic organism can be determined for 30 – 50% of patients Medina-Wadpole AM, JAGS 47:1005-1015,1999

  14. Bacterial pneumonia • Symptoms: • Fever, chills • Mental status changes • Weakness, arthralgias, myalgias • Shortness of breath, tachycardia • Cough, sputum production • Pleurisy, tightness • Exam findings: • Elevated temperature • Crackles/rales, dullness to percussion • Increased respiratory rate, retractions • Lab/xray: • Leukocytosis, increased PMNs, elevated temp, CXR findings, decreased O2 sat

  15. Typical/ lobar pneumonia

  16. Atypical/interstitial pneumonia

  17. Bacterial pneumonia (16) • Sputum culture: • Should be <25 epi cells, moderate to many WBCs • Gram stain • Color or characteristic may aid in preliminary dx • Rusty colored: Strep pneumonia • Currant jelly: Klebsiella pneumonia • Blood tinged: Tuberculosis • Blood culture: • Many organisms can spread hematogenously, and blood cultures should be obtained (i.e. Strep pneumonia, Staph Aureus)

  18. Aspiration Pneumonia (17, 18, 19, 20) • Aspiration of bacterial of oropharyngeal or gastric secretions • Common in elderly population, especially with altered mental status & dysphagia • Risk factor in both community and nosocomial acquired pneumonia • Caused by mixed anaerobic flora and viridans streptococci in community-acquired • Gram-negatives more important in nosocomial aspiration penumonia • Dependant portions of the lung: superior segment and RLL most common site

  19. The End of Module Two on Respiratory infectious diseases in the Elderly

  20. Post-test A 75-year-old man who had onset of temperatures to 39°C (102.2°F), myalgia, fatigue, headache, cough, and rhinorrhea 7 days ago has recurrence of fever and worsening of cough. The fever, myalgia, and headache gradually resolved over the first four days but the respiratory symptoms persisted. A radiograph of the chest shows a right lower lobe pneumonia. Which of the following organisms is the most likely cause of the worsening symptoms? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

  21. Which of the following organisms is the most likely cause of the worsening symptoms? • Influenza virus • Klebsiella pneumoniae • Mycoplasma pneumoniae. • Staphylococcus aureus. • Streptococcus pneumoniae

  22. Answer: E. Streptococcus pneumoniae • Pneumonia is the major complication of influenza and other viral respiratory infections. Unlike other forms of influenza-related pneumonia, the systemic symptoms of primary influenza pneumonia do not resolve 2 to 4 days after onset of the illness, and the patient is rapidly overcome by the viral illness. Alternatively, influenza may be complicated by a bacterial superinfection that often occurs 7 to 10 days after the onset of symptoms. By this time in the course of the illness, there is a relatively small viral load, but host defenses are decreased because of damage caused to the respiratory epithelium by the viral illness. This may result in a bacterial pneumonia. The most frequently implicated bacterial agent responsible for bacterial superinfections in this setting is Streptococcus pneumoniae. Staphylococcus aureus, although reported in outbreaks during severe influenza A seasons, is considerably less common than Streptococcus pneumoniae. Mycoplasma pneumoniae is an uncommon superinfecting organism. Gram-negative bacilli are common only in patients who are either hospitalized or are residents of chronic-care facilities. end

  23. Readings and resources (1)Niederman MS. Nosocomial pneumonia in the elderly patient. Chronic care facility and hospital considerations.Clin Chest Med 1993;14:479-490. (2) Pennington JE. Respiratory tract infections: intrinsic risk factors.Am J Med 1994;76:34-41. (3) Yamaya M, et. al. Interventions to prevent pneumonia among older adults. JAGS 49:85-90, 2001 (4) Barish CF. Respiratory complications of gastroesophageal reflux. Arch Intern Med 1985;145:1882-1888. (5) Yamaya M, et. al. Interventions to prevent pneumonia among older adults.JAGS 49:85-90, 2001 (6) Sims RV, Steinmann WC, McConville JH et al.The clinical effectiveness of pneumococcal vaccine in the elderly.Ann Intern Med. 1988 May;108(5):653-7. Erratum in: Ann Intern Med 1988 Nov 1;109(9):762-3. (7) Terpenning MS. et al..Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc. 2001 May;49(5):557-63. (8) Yoneyama T,et. al. Oral care and pneumonia. Oral Care Working Group.Lancet. 1999 Aug 7;354(9177):515.

  24. (9) Huxley EJ, Viroslav J, Gray WR Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med. 1978 Apr;64(4):564-8. (10) Sims RV, Steinmann WC, McConville JH The clinical effectiveness of pneumococcal vaccine in the elderly.Ann Intern Med. 1988 May;108(5):653-7. Erratum in: Ann Intern Med 1988 Nov 1;109(9):762-3. (11) Barish CF Respiratory complications of gastroesophageal reflux.Arch Intern Med. 1985 Oct;145(10):1882-8. Review. (12) Craven DE Preventing nosocomial pneumonia: state of the art and perspectives for the 1990s. Am J Med. 1991 Sep 16;91(3B):44S-53S. Review (13) Meguro K Prevention of respiratory infections in elderly bed-bound nursing home patients.Tohoku J Exp Med. 1992 Jun;167(2):135-42. (14) Barza M Effect of broad-spectrum parenteral antibiotics on "colonization resistance" of intestinal microflora of humans. Antimicrob Agents Chemother. 1987 May;31(5):723-7 (15) Hutt E. Evidence-based guidelines for management of nursing home-acquired pneumonia. J Fam Pract. 2002 Aug;51(8):709-16.

  25. 16) Medina-Walpole AM, Katz PR. Nursing home-acquired pneumonia. J Am Geriatr Soc. 1999 Aug;47(8):1005-15. Review. (17) Johanson WG. Aspiration pneumonia, anaerobic infections, and lung abscess.Med Clin North Am. 1980 May;64(3):385-94. Review. (18) Feinberg MJ, Aspiration and the elderly.Dysphagia. 1990;5(2):61-71. Review. (19) Kikuchi R, High incidence of silent aspiration in elderly patients with community-acquired pneumonia.Am J Respir Crit Care Med. 1994 Jul;150(1):251-3. . (20) Johanson WG, Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med. 1972 Nov;77(5):701-6. No abstract available

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