respiratory inspections are common in elderly people and often times,that tickles into the lungs.More often than not they have comorbiidites,like Diabetes,hypertension etc.Hence,the treatment has to be different and some times the prognosis is guarded

1. PNEUMONIA IN THE GERIATRIC POPULATION
DR.PV PRABHAKAR RAO
PROFESSOR,
Dept of Pulmonology,
MNR Medical College and
Hospital

2. INTRODUCTION
Elderly 65 years
Organ
functional
decline
Comorbid
conditions

3. DEFINITION
Pneumonia
Infection
InflammationConsolidation
Clinical symptoms

4. EPIDEMIOLOGY
14 per 1000 persons >60 years of age
75% of these cases were CAP
18 to 44 per 1000 in india

5. RISK FACTORS
IMMUNOCOMPROMISED
Autoimmune diseases
Cancer
Organ transplantation
Splenic dysfunction,
Primary immunedefeciences,
HIV
IMMUNOCOMPETENT

6. Age,
Life style factors
Prior Pneumonia
Aspiration
Concomitent treatment
Comorbid conditions
IMMUNOCOMPETENT

7. 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

8. 56%
10%
6%
6%
5%
4%
4%
9%
S.pneumoniae
H.influenza
Chlamydia
Legionella spp
S.aureus
Mycoplasma
Gram Neg bacilli
Viruses
ETIOLOGY

9. S.Pneumonia
CAP
S. Pneumoniae
H.influenzae
HAP
C. pneumoniae
Viral infectionS
20% of cases of TB
Nursing Homes

10. CLINICAL PRESENTATION

11. Atypical Presentations in Elderly
Fewer Symptoms
Confusion, Mental
status changes
Renal Dysfunction

12.  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.

13. MANAGEMENT OF PNEUMONIA IN THE
ELDERLY
 Includes
1) Severity assessment and criteria for ICU admission
2) Diagnostic workup
3) Therapeutic approach

14. 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.

15.  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

16. 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 Severity
Score 2- 3
Mod sev
Score 4- 5
High sev
OP based
treatment
Ward treatment ICU admission

17. 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

18. Cont’d
Physical 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

19. PORT
Class
criteria
Mortality
%
Treatment Strategy
Class I
Age<50yrsN
o RF
OP IP
0 0.5%
Out patient
Class II  70 points 0.4 0.9 Out patient
Class III
71 – 90
points
0 1.25 Brief hospitalization
Class IV
91 – 130
points
12.5 9 Inpatient
Class V > 131 points NA 27.1 IP - ICU
CAP – Management based on PSI Score

20.  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.

21. 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.

22. DIAGNOSTICWORKUP
Lab evaluation
Radiologic
Microbiologic

23. 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

24. 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

26. 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

27. INVASIVE DIAGNOSTIC TECHNIQUES
Bronchoscopic Samples Transthoracic Lung Aspiration

28. 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

29. 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

30. 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

31. IN PATIENT WARD(NON ICU)
RESP FQ
OR
adv MACROLIDE + BETA LACTAM

32. ICU TREATMENT
no risk factors for pseudomonas
BETA LACTAM + AZITHROMYCIN or
RESP FQ
For pencillin allergy AZTREONAM + RESP FQ are
recommended

33. ICU TREATMENT
risk factors for pseudomonas present
Antipseudomonal β-lactam + Antipseudomonal FQ

34. Antibiotic Recommendations for
Nosocomial Pneumonia
Pneumonia 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41.  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.

42.  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.

43. 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

44.  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.

45. 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.