Pneumonia in Long Term Care
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Pneumonia in Long Term Care

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Pneumonia in dependent adults is pervasive. Many are suffering needlessly because their oral health is contributing to all respiratory diseases. ...

Pneumonia in dependent adults is pervasive. Many are suffering needlessly because their oral health is contributing to all respiratory diseases.
Dental hygienists in most states are unable to care for these people without a prescription from a dentist. It's an unnecessary hurdle.

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  • http://www.sciencedirect.com/science/article/pii/S0149291898801446This is a lot of money and can put a strain on the savings people may have or the government, or the facility. Simple efforts like vaccines can help save money, however vaccines aren’t perfect either.
  • Clin Infect Dis. 2004 Dec 1;39(11):1642-50. Epub 2004 Nov 8.The burden of community-acquired pneumonia in seniors: results of a population-based study.Jackson ML, Neuzil KM, Thompson WW, Shay DK, Yu O, Hanson CA, Jackson LA.SourceCenter for Health Studies, Group Health Cooperative, University of Washington, Seattle, USA. jackson.ml@ghc.org AbstractBACKGROUND:Pneumonia is recognized as a leading cause of morbidity in seniors. However, the overall burden of this disease--and, in particular, the contribution of ambulatory cases to that burden--is not well defined. To estimate rates of community-acquired pneumonia and to identify risk factors for this disease, we conducted a large, population-based cohort study of persons aged >or=65 years that included both hospitalizations and outpatient visits for pneumonia.METHODS:The study population consisted of 46,237 seniors enrolled at Group Health Cooperative who were observed over a 3-year period. Pneumonia episodes presumptively identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes assigned to medical encounters were validated by medical record review. Characteristics of participants were defined by administrative data sources.RESULTS:The overall rate of community-acquired pneumonia ranged from 18.2 cases per 1000 person-years among persons aged 65-69 years to 52.3 cases per 1000 person-years among those aged >or=85 years. In this population, 59.3% of all pneumonia episodes were treated on an outpatient basis. In multivariate analysis, risk factors for community-acquired pneumonia included age, male sex, chronic obstructive pulmonary disease, asthma, diabetes mellitus, congestive heart failure, and smoking.CONCLUSIONS:On the basis of these data, we estimate that roughly 915,900 cases of community-acquired pneumonia occur annually among seniors in the United States and that approximately 1 of every 20 persons aged >or=85 years will have a new episode of community-acquired pneumonia each year.http://cid.oxfordjournals.org/content/39/11/1642.long
  • Clin Infect Dis. 2004 Dec 1;39(11):1642-50. Epub 2004 Nov 8.The burden of community-acquired pneumonia in seniors: results of a population-based study.Jackson ML, Neuzil KM, Thompson WW, Shay DK, Yu O, Hanson CA, Jackson LA.SourceCenter for Health Studies, Group Health Cooperative, University of Washington, Seattle, USA. jackson.ml@ghc.org AbstractBACKGROUND:Pneumonia is recognized as a leading cause of morbidity in seniors. However, the overall burden of this disease--and, in particular, the contribution of ambulatory cases to that burden--is not well defined. To estimate rates of community-acquired pneumonia and to identify risk factors for this disease, we conducted a large, population-based cohort study of persons aged >or=65 years that included both hospitalizations and outpatient visits for pneumonia.METHODS:The study population consisted of 46,237 seniors enrolled at Group Health Cooperative who were observed over a 3-year period. Pneumonia episodes presumptively identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes assigned to medical encounters were validated by medical record review. Characteristics of participants were defined by administrative data sources.RESULTS:The overall rate of community-acquired pneumonia ranged from 18.2 cases per 1000 person-years among persons aged 65-69 years to 52.3 cases per 1000 person-years among those aged >or=85 years. In this population, 59.3% of all pneumonia episodes were treated on an outpatient basis. In multivariate analysis, risk factors for community-acquired pneumonia included age, male sex, chronic obstructive pulmonary disease, asthma, diabetes mellitus, congestive heart failure, and smoking.CONCLUSIONS:On the basis of these data, we estimate that roughly 915,900 cases of community-acquired pneumonia occur annually among seniors in the United States and that approximately 1 of every 20 persons aged >or=85 years will have a new episode of community-acquired pneumonia each year.http://cid.oxfordjournals.org/content/39/11/1642.long
  • Ann Periodontol. 1998 Jul;3(1):251-6.Associations between oral conditions and respiratory disease in a national sample survey population.Scannapieco FA, Papandonatos GD, Dunford RG.SourceDepartment of Oral Biology, School of Dental Medicine, State University of New York at Buffalo, USA. Frank_Scannapieco@sdm.buffalo.eduAbstractRespiratory infectious diseases such as bacterial pneumonia and bronchitis are common and costly, especially in institutionalized and elderly inpatients. Respiratory infection is thought to rely in part on the aspiration of oropharyngeal flora into the lower respiratory tract and failure of host defense mechanisms to eliminate the contaminating bacteria, which then multiply to cause infection. It has been suggested that dental plaque may act as a reservoir of respiratory pathogens, especially in patients with periodontal disease. However, the impact of poor oral health on oral respiratory pathogen colonization and lung infection is uncertain, especially in ambulatory, non-institutionalized populations. To begin to assess potential associations between respiratory diseases and oral health, data from the National Health and Nutrition Examination Survey I (NHANES I) were analyzed. This database contains information on the general health status of 23,808 individual Of these, 386 individuals reported a suspected respiratory condition that was further assessed by a physician. These subjects were categorized as having a confirmed chronic respiratory disease (chronic bronchitis or emphysema) or an acute respiratory disease (influenza, pneumonia, acute bronchitis). They were compared to those not having a respiratory disease. Initial non-parametric analysis noted that individuals with a confirmed chronic respiratory disease (n = 41) had significantly greater oral hygiene index scores than subjects without respiratory disease (n = 193; P = 0.0441). Logistic regression analysis of data from these subjects, which considered age, race, gender, smoking status, and simplified oral hygiene index (OHI), suggested that subjects having the median OHI value were 1.3 times more likely to have a chronic respiratory disease relative to those with and OHI of O. Similarly, subjects with the maximum OHI value were 4.5 times more likely to have a chronic respiratory disease than those with an OHI of O. No evidence was found to support an association between the periodontal index and any respiratory disease. These results suggest OHI to have a residual effect on chronic respiratory disease of both practical and statistical significance.
  • When looking who is at risk for pneumonia, even those who are not immunocompromised are at higher risk if they have any of the following conditions. Most residents have at least one or two, putting them in a higher risk category than others.J Am Geriatr Soc. 2009 May;57(5):882-8. Epub 2009 Apr 21.Risk factors for community-acquired pneumonia in immunocompetent seniors.Jackson ML, Nelson JC, Jackson LA.SourceGroup Health Center for Health Studies, 1730 Minor Ave, Suite 1600, Seattle,WA, USA. jackson.ml@ghc.orgAbstractOBJECTIVES:To identify risk factors for developing community-acquired pneumonia (CAP) in seniors.DESIGN:Nested case-control study.SETTING:Group Health, a health maintenance organization in Washington state.PARTICIPANTS:One thousand one hundred seventy-three immunocompetent seniors with CAP and 2,346 age- and sex-matched controls, sampled during influenza seasons and pre-influenza periods of 2000/01 and 2002/03. CAP cases were presumptively identified according to diagnosis codes assigned to outpatient and inpatient encounters and validated according to review of chest radiograph reports or medical records.MEASUREMENTS:Medical records were used to assess body mass, the presence and severity of cardiopulmonary and other chronic diseases, and the presence of functional or cognitive impairments. Use of prescription medications and inpatient, outpatient, and home medical services were identified from administrative databases.RESULTS:Independent predictors of CAP include the presence and severity of cardiopulmonary disease, low weight and recent weight loss, and poor functional status; 42.0% of pneumonia cases can be attributed to underlying cardiopulmonary disease.CONCLUSION:Seniors with cardiopulmonary disease, poor functional status, low weight, or recent weight loss have a greater risk of developing CAP. Preventative efforts should be targeted toward these individuals.
  • Pneumonia is scary visitor. Hiding behind the door of health. We’ll see that oral hygiene is a also a contributing factor to pneumonia. More studies are looking at how important dental biofilm disruption is to decreasing the risk for pneumonia. J Am Geriatr Soc. 2009 May;57(5):882-8. Epub 2009 Apr 21.Risk factors for community-acquired pneumonia in immunocompetent seniors.Jackson ML, Nelson JC, Jackson LA.SourceGroup Health Center for Health Studies, 1730 Minor Ave, Suite 1600, Seattle,WA, USA. jackson.ml@ghc.orgAbstractOBJECTIVES:To identify risk factors for developing community-acquired pneumonia (CAP) in seniors.DESIGN:Nested case-control study.SETTING:Group Health, a health maintenance organization in Washington state.PARTICIPANTS:One thousand one hundred seventy-three immunocompetent seniors with CAP and 2,346 age- and sex-matched controls, sampled during influenza seasons and pre-influenza periods of 2000/01 and 2002/03. CAP cases were presumptively identified according to diagnosis codes assigned to outpatient and inpatient encounters and validated according to review of chest radiograph reports or medical records.MEASUREMENTS:Medical records were used to assess body mass, the presence and severity of cardiopulmonary and other chronic diseases, and the presence of functional or cognitive impairments. Use of prescription medications and inpatient, outpatient, and home medical services were identified from administrative databases.RESULTS:Independent predictors of CAP include the presence and severity of cardiopulmonary disease, low weight and recent weight loss, and poor functional status; 42.0% of pneumonia cases can be attributed to underlying cardiopulmonary disease.CONCLUSION:Seniors with cardiopulmonary disease, poor functional status, low weight, or recent weight loss have a greater risk of developing CAP. Preventative efforts should be targeted toward these individuals.
  • Treatment of Nursing Home–Acquired PneumoniaKYLE MILLS, PharmD, BCPS, and A. CHRISTIE NELSON, PharmD, University of Wyoming School of Pharmacy, Laramie, WyomingBRADFORD T. WINSLOW, MD, FAAFP, Swedish Family Medicine Residency Program, Littleton, ColoradoKATHRYN LEE SPRINGER, MD, Greater Denver Infectious Diseases, Denver, ColoradoAm Fam Physician. 2009 Jun 1;79(11):976-982.  Related EditorialPneumonia is an important cause of morbidity and mortality in nursing home residents, with 30-day mortality rates ranging from 10 to 30 percent. Streptococcus pneumoniae is the most common cause of nursing home–acquired pneumonia, although Staphylococcus aureus and gram-negative organisms may be more common in severe cases. Antibiotic therapy for nursing home–acquired pneumonia should target a broad range of organisms, and drug-resistant microbes should be considered when making treatment decisions. In the nursing home setting, treatment should consist of an antipneumococcalfluoroquinolone alone or either a high-dose beta-lactam/beta-lactamase inhibitor or a second- or third-generation cephalosporin, in combination with azithromycin. Treatment of hospitalized patients with nursing home–acquired pneumonia requires broad-spectrum antibiotics with coverage of many gram-negative and gram-positive organisms, including methicillin-resistant S. aureus. Appropriate dosing of antibiotics for nursing home–acquired pneumonia is important to optimize effectiveness and avoid adverse effects. Because many nursing home residents take multiple medications, it is important to consider possible drug interactions.
  • All of this trouble, and drama comes from a complex organism called a biofilm. Treating just one organism in the biofilm won’t help. A biofilm protects its inhabitants that include bacteria, as well as virus and fungus. Dental scientists are looking at the amount of yeast in the oral biofilm and how that yeast contributes to the decay in teeth.
  • Although the three typical bacterial pathogens are listed, they don’t do this alone.Streptococcus cranks out the matrix that benefits all other pathogens by protecting them from antibiotics and antibodies, and the bacteria, yeast, and virus live together in harmony.They grow into a biofilm.
  • The pneumonia causing biofilm has many more than just any of these three components, or all three of these pathogensIf these three live in a dental biofilm, then they are easily inhaled, as either part of a biofilm that has broken free or as part of a planktonic shower. The planktonic shower occurs when a biofilm becomes filled with too many of a certain type of pathogen, and spews forth a shower of non-adherent pathogens. Planktonic means they are free floating. http://emedicine.medscape.com/article/234916-overview
  • This is a picture of a typical resident in a nursing home. The blue plaque is over 24 hours old. The light blue is plaque that is so massive that the stain didn’t penetrate. The sticky mass contains all the components of a pneumococcal infection of the lungs. The condition of the gingivae is a tell tale sign that this biomass has not been attended to in many days. The CNA at this facility love their residents, they are long term employees of this facility and care very deeply what happens to the residents.It’s hard to get in there to clean. This resident knew we were going to take a picture but still his lips had to be pried and he could not co operate fully with the attempts. This is not a reason to give up. It’s a reason to try another way to access the mouth.
  • Breathing or respiration bring the pathogens into the lungs.
  • Nearly 50% of Nursing Home Acquired Pneumonia contain Strep pneumonia in the system. Step pneumonia is a well known inhabitant of dental biofilm.Point out how easy it is to either inhale the planktonic bacteria or to inhale microscopic chunks of dental biofilm.This picture originally showed the symptoms of the lung infection; pneumonia. The mouth is indicated here because it is a graphic depiction of how little medicine values the health of the mouth and their focus on treating symptoms, not preventing disease. The mouth is the starting place for community acquired; hospital-aquired; nursing home-acquired and aspiration pneumonia.
  • In this graphic from Montana State University Bozeman, the biggest biofilm school in the USA, we see how biofilm grows in the alveoli and is protected by the slime. This slime protects against the antibodies like neutrophils (the ball in the center is depicting the neutrophil). And antibiotics that look like blue pills and other antibodies look like the little Y symbols.
  • http://cid.oxfordjournals.org/content/37/1/148.full.pdf+html?sid=855e5d02-79a6-4d00-8553-b8d61e054270This article reflects that treatment with pneumonia and flu vaccine increased risk substantially but it may raise too many questions, if you’re game, go for it.
  • http://cid.oxfordjournals.org/content/37/1/148.full.pdf+html?sid=855e5d02-79a6-4d00-8553-b8d61e054270Out of all of these contributing factors Oral Hygiene is the easiest to modify. Swallowing difficulty can be managed by an orofacial myologist, which is a specially trained dental hygienist. These people can help increase facial muscle tone, decrease snoring and other things as well.
  • Not only does oral care save lives, it can contribute to monetary savings. you can help by providing daily oral cares. Dietary adjustments can help, like using xylitol and fresh foods but teeth still need to be brushed as often as possible. Find a good time per resident. If they’re always crabby in the morning, do it in the afternoon. If it wasn’t done yesterday make sure it gets done today. Ask us we’re here to help you help the residents.
  • http://www.cdc.gov/nchs/fastats/pneumonia.htm10 – 30 percent of people in LTC get pneumoniaPopulation studies show that out of a population of 100000 elders, 17% will die from pneumoniaThe cost in today’s dollars is between $15 to 20,000 per case and about 7-9 days in the hospitalEstimates show that about 21% of NHAN can be avoided with better oral care.
  • This course is copyrighted by Exploring Transitions, LLC and is available for use by PrevMed. Only a small number of copies are allowed due to restrictions on the photographs. Contact Shirley Gutkowski if this is past year 2018. crosslinkpresent@aol.com.

Pneumonia in Long Term Care Presentation Transcript

  • 1. Pneumonia
    Oral biofilm management for health
  • 2. 1998
    Average cost for people over age 65 with community acquired pneumonia is $7166.
    ClinTher. 1998 Jul-Aug;20(4):820-37.
    The cost of treating community-acquired pneumonia.
  • 3. 2004
    Roughly 915,900 cases of community-acquired pneumonia occur annually among seniors in the United States.
  • 4. 2004
    Approximately 1 of every 20 persons aged 85 years or over will have a new episode of community-acquired pneumonia each year
  • 5. 2006
    There is good evidence to show that improved oral hygiene and frequent professional oral health care reduces the progression or occurrence of respiratory diseases among high-risk elderly adults living in nursing homes… 
    J Periodontol. 2006 Sep;77(9):1465-82.
    Systematic review of the association between respiratory diseases and oral health.
  • 6. Immunocompetent Seniors
  • 7. Higher risk for Community-Acquired Pneumonia
  • 8. Nursing Home Acquired Pneumonia
     30-day mortality rates ranging from
    10 to 30%
  • 9. A study looking at the charts of 528 persons with NHAP transferred to acute hospitals for treatment found that advance directives were present only 6.4% of the time.
  • 10. Given the high 1-year mortality rate for
    NHAP, clinicians caring for nursing home residents should make it a priority to ensure that advance directives are in place. These should be readily available to help with the decision on whether or not the resident
    should be transferred to a hospital, and must also accompany the patient to the acute care facility.
  • 11. You know
    when you
    hear it.
  • 12. All Due to Biofilm
  • 13. Typical bacterial pathogens
    Streptococcus pneumoniae (penicillin-sensitive and-resistant strains)
    Haemophilus influenzae (ampicillin-sensitive and -resistant strains) 
    Moraxella catarrhalis (all strains penicillin-resistant).
  • 14. Typical bacterial pathogens attributed to pneumonia
  • 15.
  • 16. The airway is very close to the mouth – ahem.
  • 17. Mouth
    Lungs
  • 18. Montana State University Center for Biofilm Engineering used with permission
  • 19. 2005
    Calculation of population-based attributable fractions showed that 21% of all cases of pneumonia in our cohort could have been avoided if inadequate oral care and swallowing difficulty were not present.
  • 20. ~ $15,000Per person with NHAP
  • 21. Contributing to Nursing Home Acquired Pneumonia
  • 22. Contributing to NHAPThese two can be addressed by a licensed dental hygienist
  • 23. A dental hygienist
    assisting with oral care can save thousandsof dollars.
  • 24. To Summarize
  • 25. Conclusion
    Pneumonia is expensive
    Oral care can decrease incidence by 20%
    Nursing home acquired pneumonia leads to death.
  • 26. Conclusion
    Dental hygienists cannot work in Long Term Care facilities unless there is also a dentist there to “oversee” them.
    Dental hygienists risk their license if they brush someone’s teeth without a prescription by a dentist to do so.
  • 27. Call to Action
    Find out the limitations of dental hygienists in your state.
    Strive for a mandate that all Long Term Care Facilities funded by Medicaid have an independent dental hygienist as the Director of Dental Hygiene, a DDH.
  • 28. Credits
    PowerPoint designed by
    Cross Link Presentations, LLC
    Presentation design
    Shirley Gutkowski, RDH, BSDH, FACE
    ScriptShirley Gutkowski, RDH, BSDH, FACE
    Photos: Dreamstime, Gutkowski, Stone
    Images: Montana State University Center for Biofilm EngineeringCharacters: PresenterMedia
    Copyright 2011 Exploring Transitions, LLC