Respiratory Infections-A Hidden Killer of the Elderly-Part I
(4/14/01)-Because of the diagnosis of pneumonia given to our mother, we decided to increase our knowledge about the diagnosis and treatment nuances of dealing with respiratory infections in the elderly. We felt it could come in handy some time in our mother's lifetime or even our own. An informed consumer sets the tone for better service. We felt it would be important to use the proper medical terminology and know what the words mean. We believe this kind of diligence will pay off in subtle ways.
The first thing we learned was that chronic obstructive pulmonary disease, frequently complicated by respiratory infections, was the fourth leading cause of death in the elderly, with pneumonia and respiratory infections next in line.
The reason for the high morbidity (illness) and mortality (death) rate appears to be due to a variety of factors:
Proper diagnosis becomes essential. We should point out that confirming a diagnosis is a way to prolong a stay in a hospital. You do need facts to back up what you are saying. A dual diagnosis will prolong a stay in a hospital.
We further learned that the changes associated with aging include decrease in mucous production and changes in cell and humoral immunity that reduce the host's (the patient's) response to infection. Important in fighting off infections is a substance called immunoglobulin, produced in response to antigens or infectious agents. The elderly produce normal immunoglobulin to agents they have met before but lower levels of immunoglobulin to new antigens. Antigens are the bodies' natural way to fight off disease. At the same time, elderly are more likely to have underlying diseases, resistance to which is weakened by respiratory infections. Thus pulmonary disorders take a devastating toll in the elderly.
Diagnosis can prove tricky when dealing with pulmonary disorders. In order to make the diagnosis of both acute exacerbation of bronchitis and pneumonia you will need to produce a specimen satisfactory for bacteriological evaluation. With mucous reduction a natural process of aging, this becomes a difficult step. Secondly, in the elderly, pneumonia does not present the conventional symptoms. An elderly patient may have some acute change in mental or functional status. This may be a sign of an infectious cause, yet there may not be any fibrile response to this infection. Since fever is the cardinal sign of infection, its absence complicates diagnosis. (In our mothers case, if we knew the above, we may have caught the pneumonia at an earlier stage. We thought she may have had a stroke and had arranged for her to see a neurologist a few days before we discovered her prostate in her bed. This neurologist then arranged for her to get an MRI the next week. In between, our mother was hospitalized with pneumonia.)
According to our research, there is no current gold standard for the diagnosis of pneumonia. One has to distinguish between the normal bacteria present and the pathogenic bacteria such as Moraxella catarrhalis. It is hard to gather sputum that must pass through the mouth, where many bacteria are present, and also you must distinguish sputum from spit. A Gram stain test needs to be done, for without it no information gathered is reliable.You have to be able to distinguish whether it is from the mouth or the lungs. An ideal sputum specimen has greater than 25 % polymorphonuclear leukocytes and very fine epithelial cells. When the stain shows alveolar macrophages and you see bacteria, you have proof of causation. The absence of gram-positive cocci in clusters would provide sufficient evidence that the elderly person does not have staphylococcal pneumonia, a severe and often fatal illness in the elderly. The lack of large gram-negative rods would also speak against infection with gram-negative bacilli.
A rundown of the common pathogens responsible for pneumonia in the elderly living in a nursing home would include:
We learned that if a person is on antibiotics, it renders gram stain and sputum cultures as somewhat less useful, thus forcing the medical doctor to make a less precise diagnosis. (Older people are usually on some form of medication.) When an individual has a new infiltrate, the diagnosis is usually pneumonia. If they do not, it is called exacerbation of chronic bronchitis. The latter disorder is usually associated with sputum production. Exacerbation produces more sputum, which changes in color and slight fever and some dyspnea.
Pneumococcal pneumonia is most easily recognized via an X-ray. A blood count could be useful, for it defines whether the patient is anemic. The blood cell count, either less than 4000 or above 20,000, is a marker for an individual who has severe pneumonia. Pneumonia has a broad range of etiologies. Further complicating the situation in the elderly is the nutritional status. An elderly person may seem well nourished but may be loosing lean body weight, which can affect the T cell count. Research has shown that nutritional status must be aggressively maintained if one is to expect patient with pulmonary problems to recover.
Precautionary measures to be taken to prevent pneumonia include pneumococcal vaccination for everyone over 65 years of age. Influenza vaccination should be encouraged to prevent secondary bacterial disorders. This is especially true in nursing homes where the elderly come in contact with a lot of resistant organisms as well as other people. Many of the residents are on antimemetics and pain medications, which can increase the opportunity for aspiration. The main reason to take these vaccinations is to reduce the possibility of death, not to reduce the symptoms of the illness. They do prevent bacteremia and as a consequence probably prevent meningitis as well. They may also be a defense against antibiotic resistant pneumococci.
It should be noted that antiviral treatment takes about 2 weeks to develop antibody response. The Center for Disease Control seems to feel that the identification of a single case of influenza among nursing home residents is sufficient to initiate antiviral prophylaxis in all residents. Studies have indicated that this may prevent symptomatic illness in anywhere from 40% to 70% of the elderly who had the vaccination.
Respiratory Diseases Part II: Chronic Obstructive Pulmonary Disease
Pulmonary Rehabilitation for COPD-Part III
By Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated April 14, 2001
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