Management of community-acquired pneumonia in older adults

Abstract

Community-acquired pneumonia (CAP) is an increasing problem among the elderly. Multiple factors related to ageing, such as comorbidities, nutritional status and swallowing dysfunction have been implicated in the increased incidence of CAP in the older population. Moreover, mortality in patients with CAP rises dramatically with increasing age. Streptococcus pneumoniae is still the most common pathogen among the elderly, although CAP may also be caused by drug-resistant microorganisms and aspiration pneumonia. Furthermore, in the elderly CAP has a different clinical presentation, often lacking the typical acute symptoms observed in younger adults, due to the lower local and systemic inflammatory response. Several independent prognostic factors for mortality in the elderly have been identified, including factors related to pneumonia severity, inadequate response to infection, and low functional status. CAP scores and biomarkers have lower prognostic value in the elderly, and so there is a need to find new scales or to set new cut-off points for current scores in this population. Adherence to the current guidelines for CAP has a significant beneficial impact on clinical outcomes in elderly patients. Particular attention should also be paid to nutritional status, fluid administration, functional status, and comorbidity stabilizing therapy in this group of frail patients. This article presents an up-to-date review of the main aspects of CAP in elderly patients, including epidemiology, causative organisms, clinical features, and prognosis, and assesses key points for best practices for the management of the disease.

Keywords: clinical features; community-acquired pneumonia; elderly; etiology; management; prognosis; treatment.

Figure 1.

Frequency of older patients among 4534 hospitalized CAP cases from 1995 to 2012 in a tertiary teaching hospital in Barcelona, Spain.

Figure 2.

Area under receiver operating characteristic curve (95% confidence interval) for predicting mortality of PSI and CURB-65 scores by age group in 4534 hospitalized cases with community-acquired pneumonia in a tertiary teaching hospital in Barcelona, Spain. PSI, Pneumonia Severity Index; CURB-65, Confusion, Urea >7 mmol/l, Respiratory rate ≥30/min, Blood pressure (systolic blood pressure <90 or diastolic blood pressure ≤60 mmHg) and age ≥65 years.