REFERAT

Diagnostic Procedures and Treatment Of

PNEUMONIA IN ELDERLY

Lecturer :dr. Alex Ginting S. Sp.P

Created by :Athieqah Asy –Syahidah

110. 2007. 051FK - YARSI

INTERNAL MEDICINE DEPARTMENTRUMAH SAKIT PUSAT ANGKATAN DARAT GATOT SOEBROTO

JAKARTA2012

1

Foreword

All praise be to Allah SWT, the Cherisher and Sustainer of the world; God whohas been giving His blessing to the writer to complete this referat entitled ”Diagnostic Procedures and Treatment of Pneumonia in Elderly”. This referat is submitted to fulfill one of the requirements of internship at Internal Medicine Department, RSPAD Gatot Soebroto.

In finishing this referat, the writer really gives his regards and thanks for people who has given guidance and help, especially for dr. Alex Ginting, Sp. P as the supervisor who has given his best guidance to write a quality content of this referat. Another great thanks also send to writer’s parent who always give their best supports.

Finally the writer realizes there are unintended errors in writing this referat. The writer really allows all readers to give their suggestions to improve its content in order to be made as one of the good examples for the next referat. Hopefully this referat is useful for the wirter and all the readers.

Jakarta, Desember 2012

Writer

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RATIFICATION SHEET

REFERAT

Diagnostic Procedures and Treatment of Pneumonia in Elderly

Created by :Athieqah Asy-Syahidah

(110.2007.051)UNIVERSITAS YARSI

Corrected and Confirmed by :

________________________________ Pembimbing : dr. Alex Ginting, Sp.P Tanggal : Desember 2012

INTERNAL MEDICINE DEPARTMENTRUMAH SAKIT PUSAT ANGKATAN DARAT GATOT SOEBROTO

JAKARTA2012

3

Table of Contents

Cover i

Foreword ii

Ratification Sheet iii

Table of Contents iv

Chapter I 1

Introduction 1

Chapter II 2

Review of the Literature 2

I. Geriatric 2

II.Pneumonia in Elderly 7

a. Definition 7

b. Epidemiology 7

c. Classification 10

d. Etiology 12

e. Symptoms and Findings of Pneumonia in Elderly 14

f. Diagnostic Procedures 16

g. Severity Assessment 20

h. Treatment of Pneumonia Among the Elderly 23

i. Prevention 32

j. Conclusion 34

References

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CHAPTER 1

Introduction

The world's population has increased significantly from year to year, it

directly increase the number of elderly (geriatric). The same thing also

happened in Indonesia, according to the International Demographic Data from

the Bureau of the Census USA, the enhancement number of elderly in

Indonesia is the highest in the world (41,4%), with an estimated length of time

between 1990-2025. However, the enhancement number of elderly in

Indonesia is inversely proportional to life expectancy of Indonesia’s

population.

That will be followed by greater number of elderly patients who may

demand health care services as they are more vulnerable to various

conditions of acute illness. One of the diseases that become a main focus in

elderly is pneumonia, in which morbidity and mortality in elderly patients due

to pneumonia is still high.

In elderly, their health status is determined by several comorbidities

factors, such as diabetes mellitus, renal insufficiency, hepatic insufficiency,

Alzheimer's and etc. Thus the special health care needs for elderly, it requires

an holistic approach and a total care.

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CHAPTER 2

Review of the Literature

I. GERIATRIC

Geriatric is a term consisting of the word Geros (elderly) and iatreia (care

/ merumat), geriatrics itself refers to the branch of medicine that focuses on

providing health care for seniors. (Ignas Vascher Leo, 1909). Someone said

elderly, if it has reached the age of 60. (1)

a. DEP.KES RI

1. 60 – 69 y’o : elderly

2. ≥ 70 y’o : high risk elderly

b. WHO

1. Middle age = 45 – 59 y’o

2. Elderly = 60 – 74 y’o

3. Old = 75 – 90 y’o

4. Very old = > 90 y’o

To deal with geriatric diseases requires an holistic approach and a total

care to patients in an integrated way by considering the state of the

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environment, socio-economic, lifestyle, diagnosis and therapy in treating

patients with the disease.

Total care is when a resident or patient requires a caregiver in order to

have all their survival needs met, including ambulation, respiration, bathing,

dressing, feeding, and toileting. The term "total care" is sometimes incorrectly

used in nursing homes and other similar facilities to refer to a patient who

simply needs diaper changes, but is able to provide other care on his/her own.

Total care is where long term care facilities for residents are responsible for

meeting all the needs of a resident. While some residents receiving so-called

total care may be able to independently meet all or some of their needs for

their activities of daily living without the assistance of a caregiver, the facility

and its staff have the duty of monitoring the resident to be sure s/he is having

those needs met.

The term "total care" is also used within long term care facilities to refer

to residents who need actual assistance in meeting all their needs in their

activities of daily living. Those who need little or no assistance are referred to

as "self care." Some facilities have special units reserved for those dependent

on total care. Others specialize specifically in residents in need of total care.

Some facilities cannot handle total care residents, and when one becomes

needy of such care, the facility will transfer the resident to another facility.

Holistic health is a concept in medical practice upholding that all

aspects of people’s needs including : psychological, physical, social and

spiritual should be taken into account and seen as whole. As defined before,

holistic approach is widely accepted in medicine.

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Many elderly suffering from diseases that can lead to complications if

not handled properly, such as bone fractures that can lead to osteoporosis, or

if someone has high cholesterol numbers during aging, it may become

coronary heart disease (CHD), hypertension, heart failure and myocardia

infarc, diabetes mellitus, and kidney or liver dysfunction.

Some of the problems that often arise in old age called as a series of

I's, ie immobility, instability, incontinence, intellectual impairment, infection,

impairment of vision and hearing, isolation, Inanition, insomnia and immune

deficiency. (Kane and Ouslander)

Disease Characteristics of the Elderly in Indonesia `

- Joint and bone diseases, such as rheumatic, and osteoporosis.

- Cardiovascular diseases, such as hypertension, cholesterolemia,

angina, cardiac attack, stroke, high triglycerides, anemia, and CHD.

- Digestive diseases such as gastritis and ulcer pepticum.

- Urogenital Diseases, such as Urinary Tract Infection (UTI), Acute

Kidney Injury/ Chronic and Benigna Prostate Hyperplasia.

- Disease Metabolic / Endocrine, such as diabetes mellitus, and obesity.

- Respiratory diseases, such as pneumonia, influenza, asthma, and

pulmonary tuberculosis.

- Disease malignancies, such as carcinoma or cancer.

- Other diseases, such as senility / dementia, Alzheimer, and Parkinson's

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The growth of the number of elderly in Indonesia was recorded as the

most rapid in the world in the period 1990-2025. In 2005 there were

17,767,709 people or 7.97% of the total population, and it will become 25.5

million in 2020, or around 11.37 percent of the total population. That means

the number of elderly in Indonesia will be ranked fourth in the world, under

China, India, and the United States. (2)

While in Jakarta, based on data from a national health survey of 2001,

there were 641,124 elderly or around 8.64% of the total population of Jakarta,

amounting to 7,423,379 people. (3)

According to the international demographic data from the Bureau of the

Census USA (1993), the increase in the number of elderly Indonesia between

the years 1990-2025 reached 41.4%, the highest in the world. The rapid

increase is related to the life expectancy of Indonesia's population. From

Badan Pusat Statistik (BPS) 1998, the life expectancy of Indonesia’s

population approximately is 63 years for men and 67 years for women. But

according to the WHO study (1999) the life expectancy of Indonesia’s

population is 59.7 years, ranked the world 103. Number one is Japan (74.5

years).

Increasing number of the elderly will be followed by greater number of

geriatric patients who may demand health care services as they are more

vulnerable to various conditions of acute illness. One of illnesses includes

respiratory tract infection, which is the leading cause of death and the most

significant cause that impairs quality of life the elderly. The elderly is more

9

vulnerable to infection as they own impaired physiological immune system

and reduced lung function, i.e. suppression of the cough reflex and decreased

function of mucocilliary epithelial in the respiratory tract, therefore, the risk of

pneumonia in the elderly increases. Decreased cell-mediated immunity as

shown by increasing annergic reaction, slower response of lymphocyte

proliferation, as well as reduced function of helper T-cells and B- lymphocytes

in the elderly will cause lower immune response against infections. (3)

Upper respiratory tract infections and influenza are common in the

elderly and may develop into pneumonia. The prevalence of influenza may

reach 5-20% of population each year along with high mortality rate, especially

among neonates and the elderly population. (4)

In 2003, the mortality rate related to pneumonia is still as high as

30.3% of all hospitalized elderly patients. In 2000, a proportion of 54%

hospitalization and 90% of death in the elderly over 65 years in the United

States were caused by pneumonia. Until 2002, many elderly patients have

died from pneumonia (200 out of 100,000 elderly) .(5,6)

Considering the high morbidity and mortality rates related to

pneumonia in the elderly, it’s important to diagnose early and to treat the

elderly patients carefully.

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II. PNEUMONIA IN ELDERLY

a. Definition

Pneumonia can be generally defined as inflammation of the lung

parenchyma, in which consolidation of the affected part and a filling of the

alveolar air spaces with exudate, inflammatory cells, and fibrin is

characteristic.(7) It may be caused by bacteria, viruses, or parasites. Clinically

pneumonia is characterized by a variety of symptoms and signs. Cough

(which may be productive of purulent, mucopurulent, or “rust-colored”

sputum), fever, chills, and pleuritic chest pain are among its manifestations.

Extra- pulmonary symptoms such as nausea, vomiting, or diarrhea may occur.

There is a spectrum of physical findings, the most common of which is

crackles or rales in the lungs. Other findings in the lungs may include dullness

to percussion, increased tactile and vocal fremitus, bronchial breathing, and a

pleural friction rub.

b. Epidemiology

Until now, pneumonia is the leading cause of death in hospitalized

geriatric patient. The prevalence of pneumonia at acute geriatric ward of Cipto

Mangunkusumo Hospital in 2000 was 54.8% with mortality rate reached

32.5%. In2001, the prevalence increased to 61.6% with mortality rate of

32.9%. In 2003, the prevalence of pneumonia in geriatric patients decreased

into 52.2%, with mortality rate that remained high of 30.3%. (5,6)

In terms of patient statistics in Japan, as indicated by the figures in

Table 1 which were excerpted from “Kokumin Eisei no doukou (Trends in

National Public Health in Japan),” both the physician treatment rate and the

11

mortality rate show an abrupt and accelerating increase among pneumonia

patients over 65. It can be stated that pneumonia is a disease of the eld- erly

rather than a disease frequently observed among them.

Pneumococcal resistance to antibiotic is one of the other important

issues. Parsons (2002) reported that the incidence of pneumococcal

resistance to penicillin varied from country to country: Spain 65.6% (1999-

2000), United States 23% (1998), England 9% (1998), and Australia 9%

(1994). (8)

The resistance contributes to high mortality rate and the development of

complications related to pneumonia such as meningitis and sepsis (invasive

pneumococcal pneumonia = IPD). In Europe and United States, the incidence

of invasive pneumococcal disease ranges between 25 and 100 per 100,000

cases with the highest age- specific incidence rate in the elderly. Mortality

rate related to IPD may reach 40% in patients aged >85 years and 20% in

patients aged >65 years. The issue of antimicrobial resistance apparently may

12

not only restricted to penicillin, but also macrolides, chloramphenicol,

trimetoprim-sulfametoxazol, and cephalosporin. (9)

The transmission of pneumonia in the elderly patients is similar to the

young adults. It is important to remember that pneumonia in the elderly may

present with few respiratory symptoms and signs (data given below) and

instead may be manifest as delirium, worsening of chronic confusion, and

falls. Delirium or acute confusion was found in 45 [44.5%] of 101 elderly

patients with pneumonia studied by Riqueleme et al.(10), compared with 29

(28.7%) of 101 age- and sex-matched control subjects. Falls are usually an

indication that the person is ill. Among the healthy elderly, rough or slippery

ground accounted for 54% of falls, but in the sick elderly this factor accounted

for only 14% of falls (11). Dizziness, syncope, cardiac and neurological disease,

poor health status, and functional disability are more likely to account for falls

among the sick elderly (11)

However, several aspects need to be concerned. First, oropharynx is the

common site of microbial colonization that may increase the risk for

pneumonia. Malnutrition, poor oral and dental hygiene also contribute as risk

factors for recurrent pneumonia. (6)

Pneumonia is a major medical problem in the elderly. The increased

frequency and severity of pneumonia in the elderly is largely explained by the

ageing of organ systems (in particular the respiratory tract, immune system,

and digestive tract) and the presence of comorbidities due to age-associated

diseases. The most striking characteristic of pneumonia in the very old is its

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clinical presentation: falls and confusion are frequently encountered, while

classic symptoms of pneumonia are often absent. Community acquired

pneumonia (CAP) and nursing-home acquired pneumonia (NHAP) have to be

distinguished. Although there are no fundamental differences in

pathophysiology and microbiology of the two entities, NHAP tends to be much

more severe, because milder cases are not referred to the hospital, and

residents of nursing homes often suffer from dementia, multiple comorbidities,

and decreased functional status.

c. Classification

Classification of anatomy

Based on the anatomical part of the lung parenchyma involved, traditionally,

pneumonia are classified into following three types:

1. Lobar pneumonia:

Occurs due to acute bacterial infection of part of a lobe or complete

lobe. Whole lobe is often affected as the inflammation spreads through

the pores of Khon and Lambert channels. Commonly Streptococcus

pneumoniae, Staphylococcus aureus, beta Haemolytic streptococci

and less commonly Haemophilus influenzae, Klebsiella pneumoniae

are responsible for lobar pneumonia.

2. Lobular pneumonia:

Acute bacterial infection of the terminal bronchioles characterized by

purulent exudates which extends into surrounding alveoli through

endobronchial route resulting into patchy consolidation. It is usually

seen in extremes of age and in association with chronic debilitating

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conditions.Commonly Streptococci, Staphylococcus aureus, beta

Haemolytic streptococci, Haemophilus influenzae, Klebsiella

pneumonia and Pseudomonas are responsible for Bronchopneumonia.

3. Interstitial pneumonia:

Patchy inflammatory changes, caused by Viral or mycoplasma

infection, mostly confined to the interstitial tissue of the lung without

alveolar exudates. It is characterised by alveolar septal oedema and

mononuclear infiltrates. Commonly Mycoplasma pneumoniae,

Respiratory syncytial virus, Influenza virus, adenoviruses,

cytomegaloviruses and uncommonly Chlamydia and Coxiella are

responsible for Interstitial pneumonia.

Classification of pathogen

Pathogen classification is the most useful to treat the patients by choosing

effective antimicrobial agents :

1. Bacterial Pneumonia

(a) Aerobic Gram-positive bacteria,such as streptococcus

pneumoniae, staphylococcus aureus, Group A hemolytic

streptococci

(b) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae,

Hemophilus influenzae, Escherichia coli

(c) Anaerobic bacteria

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2. Atypical Pneumonia

Including Legionnaies pneumonia, Mycoplasmal pneumonia, chlamydia

pneumonia. Usually show the systemic manifestations such as

cephalgia, myalgia and confusion in elderly.

3. Fungal Pneumonia

Commonly caused by candid sp. and aspergilosis. Fungal pneumonia

is also caused by Pneumocystis Jiroveci

4. Viral Pneumonia

May be caused by adenoviruses, respiratory syncytial virus, influenza,

cytomegaloviruses

5. Pneumonia caused by other pathogen

Rickettsias, parasites, protozoa

Classification of acquired environment

a. Community acquired pneumonia (CAP)

b. Hospital acquired pneumonia (HAP)

c. Nursing home acquired pneumonia (NHAP)

d. Immuno compromised host pneumonia (ICAP)

d. Etiology

The main pathogens causing pneumonia in the elderly is a bacteria.

Pathogenic microbes for pneumonia may differ between the elderly and the

16

younger population. Mycoplasma pneumonia is found overwhelmingly among

the younger population, but rarely seen among the elderly. Bacterial

pneumonia, on the other hand, is a kind of pneu- monia frequently observed

among the elderly. Chlamydia pneumonia has been reported to be much

more common among the elderly than the younger population.(12). However,

chlamydia pneumonia has also been reported to be fre- quently seen in the

younger population, and the disease, including mixed infection with bacterial

pneumonia, needs to be further examined.

Figure 1 shows comparisons of pathogenic microbes for pneumonia

between the elderly and the younger population.(13) Overall, no major

differences seem to exist regarding pathogenic microbes, and there are at

least no critical differences.

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e. Symptoms and Findings of Pneumonia in the Elderly

Since the contrast between the elderly and the younger population can

be ascribed to the difference in abilities of the infected host to fend off

infections, differences in symptoms and findings are presumed to exist, which

draws the most attention. Table 2 shows the comparisons of symptoms and

findings in community-acquired respiratory infections between the elderly and

adults complied by Suga.(14)

Although the elderly with community-acquired respiratory infections are

likely to exhibit mild symptoms, atypical physical findings, and mild laboratory

findings, their dis- ease is resistant to treatment and is often intractable. On

the other hand, the diseases develop abruptly in adults with severe symptoms

and severe abnormal laboratory findings, but they respond well to treatment.

While these are classical examples that are generally observed, not all cases

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present such trends, and that is what makes clinical medicine complicated.

In a period of five years between April 1985 and March 1990, there

was a research about 406 cases of pneumonia at Kawasaki Medical School,

Kawasaki Hospital, Okayama, Japan. Fifty-seven cases were found among

patients aged 80 and above, and 51 cases among patients under 50 years of

age.

Table 3 shows the comparisons of their cardinal symptoms (at most up to the top three chief complaints) and laboratory findings.

Although chest pain and bloody sputum seem to be more common

among the younger population, and disturbed consciousness, dehydration,

loss of appetite, and general malaise among the elderly, no obvious

differences are seen in cardinal symptoms of pneumonia such as fever,

cough, and sputum.

19

In view of laboratory findings, no obvious differences are observed in

variables important in pneumonia patients including body temperature (fever),

white blood cell count (WBC) in peripheral blood, and C-reactive protein

(CRP). Differences exist in serum protein and a tuberculin skin test, though it

is unknown if they are the result of or basis of pneumonia.

One of the characteristics of pneumonia among the elderly that is

frequently noted is that they do not often run a fever. However, despite

normothermia at the first consultation or hospital admission, all of the above-

mentioned pneumonia patients, except those in shock, showed body

temperatures of 37 °C or greater when a careful thermometry was performed

after admission.

As these examples suggest, despite the fact that there are certain

severity patterns in symptoms and findings of pneumonia among the elderly,

no definitive differences exist between the elderly and the younger population.

Furthermore, since there are individual differences among pneumonia

patients, the regular treatment approach should be applied even to the

elderly.

f. Diagnostic Procedures

(a) Radiology

Although often difficult to perform in optimum conditions, plain chest

radiographs are important for confirming the clinical suspicion of pneumonia,

assessing extension of the disease, detecting potential complications such as

cavitation, parapneumonic effusion, or empyema, and documenting signs of

pre-existing pulmonary disorders such as COPD, sequelae of tuberculosis,

20

interstitial lung disease, bronchiectasis, or possible carcinoma. Computed

tomography scan is helpful when seeking an underlying cause such as airway

obstruction by a proximal tumour, documenting location and extension of a

pleural effusion, or when considering alternative diagnoses

(b) Laboratory data

Leucocyte count and inflammatory parameters

Leucocytosis and increase in band forms develop less frequently in

elderly patients and are thus less sensitive in the detection of pneumonia.

Fortunately, CRP, although not specific for bacterial infection, is highly

sensitive for detecting pneumonia: a normal CRP value virtually excludes

pneumonia, even in the very old. A persistent increase in CRP concentrations

under antibiotherapy is an adverse prognostic factor and suggests inadequate

antibiotic coverage, parapneumonic effusion, or empyema.(15,16,17) Procalcitonin

has a much lower sensitivity for the detection of pneumonia (54% in patients

aged 50–85).(18) Increased white-blood-cell counts, a higher percentage of

band forms, leucopenia, and lymphopenia have been described as adverse

prognostic factors.

Blood gas analysis

American Thoracic Society guidelines recommend that arterial blood

gases (ABG) be obtained on admission in patients who are hospitalised with

severe illness, or in any patient with chronic lung disease, not only for

detection of hypoxaemia (for which pulse oximetry is sufficient), but also for

that of hypercapnia, which occurs at a much higher frequency in the elderly

21

because of a lesser functional reserve.(19) This recommendation also pertains

to HAP. A reasonable limit is to suggest measuring ABG when pulse oximetry

readings for pulse oximetry are below 94%. For patients who are not admitted

to an ICU or intermediate- care unit, pulse oximetry is adequate for

subsequent monitoring of oxygenation with CAP, NHAP, or HAP.

Blood chemistry

Hyponatraemia and elevations of hepatic enzymes (alanine

aminotransferase and aspartate aminotransferase) are frequent, non-specific,

and are not reported as adverse prognostic factors. Conversely, low serum

albumine, and renal failure are associated with an increased mortality

( c) Microbiology

Although there is no doubt that a causative diagnosis of pneumonia in

the elderly is desirable, the question of whether sputum analysis should be

done is controversial (recommended by the Infectious Diseases Society of

America, but not by the American Thoracic Society).(20,21) Indeed, the elderly

are often too weak to provide an adequate sputum specimen, or too confused

to cooperate and the diagnostic yield of sputum analysis is relatively low.

Blood cultures and test for urinary legionella antigen are unanimously

recommended in elderly patients hospitalized for CAP or NHAP.(20,21) PCR

testing for Chlamydia spp, M pneumoniae, and common respiratory viruses

are now available, but their clinical usefulness has not yet been established.

Recent studies suggest that a search for urinary S pneumoniae

capsular antigen (common to all serotypes) may be useful in the diagnosis of

22

pneumococcal pneumonia. For non-bacteraemic pneumonia, reported

sensitivity ranges from 64–69%; and from 77–100% for bacteraemic

pneumococcal pneumonia.(22) Specificity of urinary S pneumoniae capsular

antigen is 82–97%. Potential drawbacks of the method are its rather low

sensitivity for non-bacteraemic pneumococcal pneumonia, and a high

positivity rate 1 month after an acute pneumococcal infection. (22)

(d) Bronchoscopy

Bronchoscopy is well tolerated in the very old(23-25),and should be done

when pneumonia responds poorly to treatment, or in immunocompromised

patients. In severe pneumonia, complications of bronchoscopy consist mainly

of transient worsening hypoxaemia (11%), postbronchoscopy fever (5%), and

transient cardiac arrhythmia (2%). In one study, about two-thirds of

bronchoalveolar lavage (BAL) yielded significant microbiological results,

leading to a change of therapy in 55% of the patients. Bronchoscopy may also

contribute to a diagnosis of unsuspected mycobacterial disease or unusual

organisms, as well as non-infectious causes of pulmonary infiltrates.

(e) Serological studies

Serological studies are not recommended initially on a routine basis in

available guidelines but may be contributive either in poorly responsive

patients, for retrospective confirmation of a suspected diagnosis, or in

epidemiological studies.

However, if certain etiologic agents such as Coxiella burnetii, M. pneu-

moniae, C. pneumoniae, or a virus are suspected, serological tests of acute

23

and convalescent serum samples can aid in the diagnosis. Unfortunately, the

results of these studies are not available for 3–4 weeks, by which time the

clinical situation has been resolved.

These studies are helpful for public health purposes and should always

be performed in workups during an outbreak of pneumonia. A urine specimen

for detection of Legionella antigen is useful in all cases of severe pneumonia.

Currently available tests detect only Legionella pneumophila serogroup 1

antigen (which accounts for ∼80% of cases of legionnaires disease) (26-27)

g. Severity Assessment

Severity assessment and site-of-care decisions are critical when

managing elderly patients who present with CAP. Severity assessment tools

can help predict mortality and determine the optimal setting in which to

provide care for patients with CAP. Nowadays, we can use PSI (Pneumonia

Severity Index) or CURB-65 for severity assessment test.

PSI is a prediction rule to calculate the severity of a person with CAP. It

is based on data that are commonly available upon presentation and divide

patients into 5 different classes, according to the severity of the disease.

Higher scores mean higher risk of death, admission to ICU and longer length

of stay in the hospital. The patient may need to be treated as an inpatient.

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Patients in risk classes 1, 2 and 3 are regarded as at low risk of death

and are mostly treated as outpatients unless there are other risk factors. The

low risk patients in class 3 who look sick or needed further care can stay in

the hospital for another 23 hours and monitored for deterioration. After the

patient’s condition is better, patient will be allowed to leave the hospital.

As for patients grouped in class 4 (moderate risk) and 5 (high risk),

they should be hospitalized due to their higher risks of death and

complications.

25

There is an exception for patients with hypoxemia or PaO2 of >60mm

Hg. These patients must be hospitalized regardless of their PSI score. This

also applies to patients with metastatic disease (endocarditis, meningitis,

osteomyelitis) or those infected with high risk pathogens such as Staph.

aureus.

For all patients, clinical judgement supported by the CRB65 score

should be applied when deciding whether to treat at home or refer to hospital.

Patients who have a CRB65 score of 0 are at low risk of death and do

not normally require hospitalisation for clinical reasons. Patients who have a

CRB65 score of 1 or 2 are at increased risk of death (moderate risk of death),

particularly with a score of 2, and hospital referral and assessment should be

considered. Patients who have a CRB65 score of 3 or more are at high risk of

death and require urgent hospital admission. These patients should be

reviewed by a senior physician at the earliest opportunity to refine disease

severity assessment and should usually be managed as having high severity

pneumonia. Patients with CURB65 scores of 4 and 5 should be assessed with

specific consideration to the need for transfer to a critical care unit (high

dependency unit or intensive care unit).

26

Although severity assessment criteria (CURB-65) are useful to help

identify patients who may need hospitalization in the ward service or ICU, they

are not meant to replace clinical judgment.

h. Treatment of Pneumonia Among the Elderly

The most important treatment of pneumonia is antibiotic chemotherapy.

Although there are no specific choice regarding the selection of drugs

according to pathogenic bacteria, careful attention should be given to

administration and dosage. Table 4 lists precautions in introducing antibiotic

therapy on elderly pneumonia patients.(28-29) They are well summarized and

provide sufficient information.

Of these precautions, the most important point to notice is underlying

renal dysfunction in the elderly. Table 5 shows the dosage and administration

27

for using antibacterial agents in such a case.Treatment should be planned on

the basis of this table.

As the therapies other than chemotherapy, managements of

dehydration, diet, or body temperature are needed. Also, expectoration of

bronchial secretion are required to subside pneumonia.

In addition, some nonantibiotic strategies may be important when

treating pneumonia in elderly populations. In older patients, the pneumonia

process often extends beyond the lung parenchyma, presenting as a systemic

disease with higher severity of illness. This is supported by the finding that

many elderly pneumonia patients present with primarily nonpulmonary

symptoms, such as mental status changes or renal dysfunction.

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1. Antibiotic therapy for CAP

For patients treated in the community, amoxicillin remains the preferred

agent at a dose of 500 mg three times daily. Either doxycycline or

clarithromycin are appropriate as an alternative choice, and for those patients

who are hypersensitive to penicillins. Those with features of moderate or high

severity infection should be admitted urgently to hospital.

For those patients referred to hospital with suspected CAP and where

the illness is considered to be life- threatening, general practitioners should

administer antibiotics in the community. Penicillin G 1.2 g intravenously or

amoxicillin 1 g orally are the preferred agents.

For those patients referred to hospital with suspected high severity

CAP and where there are likely to be delays of over 6 h in the patient being

admitted and treated in hospital, general practitioners should consider

administering antibiotics in the community. A diagnosis of CAP should be

confirmed by chest radiography before the commencement of antibiotics in

the majority of patients. Selected patients with life- threatening disease should

be treated based on a presumptive clinical diagnosis of CAP. In such

instances, an immediate chest radiograph to confirm the diagnosis or to

indicate an alternative diagnosis is indicated.

All patients should receive antibiotics as soon as the diagnosis of CAP

is confirmed. This should be before they leave the initial assessment area

(emergency department or medical assessment unit). The objective for any

service should be to confirm a diagnosis of pneumonia with chest radiography

and initiate antibiotic therapy for the majority of patients with CAP within 4 h of

presentation to hospital.

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Most patients with low severity CAP can be adequately treated with

oral antibiotics. Oral therapy with amoxicillin is preferred for patients with low

severity CAP who require hospital admission for other reasons such as

unstable comorbid illnesses or social needs. When oral therapy is

contraindicated, recommended parenteral choices include intravenous

amoxicillin or benzylpenicillin, or clarithromycin.

Most patients with moderate severity CAP can be adequately treated

with oral antibiotics. Oral therapy with amoxicillin and a macrolide is preferred

for patients with moderate severity CAP who require hospital admission.

Mono therapy with a macrolide may be suitable for patients who have

failed to respond to an adequate course of amoxicillin prior to admission.

Deciding on the adequacy of prior therapy is difficult and is a matter of

individual clinical judgement. It is therefore recommended that combination

antibiotic therapy is the preferred choice in this situation and that the decision

to adopt mono therapy is reviewed on the ‘‘post take’’ round within the first 24

h of admission.

When oral therapy is contraindicated, the preferred parenteral choices

include intravenous amoxicillin or benzylpenicillin, together with

clarithromycin. For those intolerant of penicillins or macrolides, oral doxycyline

is the main alternative agent. Oral levo- floxacin and oral moxifloxacin are

other alternative choices.

When oral therapy is contraindicated in those intolerant of penicillins,

recommended parenteral choices include levofloxacin mono therapy or a

second-generation (eg, cefuroxime) or third-generation (eg, cefotaxime or

ceftriaxone) cephalosporin together with clarithromycin.

30

Patients with high severity pneumonia should be treated immediately

after diagnosis with parenteral antibiotics. An intravenous combination of a

broad-spectrum b- lactamase stable antibiotic such as co-amoxiclav together

with a macrolide such as clarithromycin is preferred. In patients allergic to

penicillin, a second-generation (eg, cefuroxime) or third-generation (eg,

cefotaxime or ceftriaxone) cephalosporin can be used instead of co-

amoxiclav, together with clarithromycin.

Table 6. Initial empirical treatment regimens for pneumonia

source : British Thoracic Society : Guidelines for the management of community acquired

pneumonia, update 2009

The oral route is recommended in those with low and moderate

severity CAP admitted to hospital provided there are no contraindications to

31

oral therapy. Patients treated initially with parenteral antibiotics should be

transferred to an oral regimen as soon as clinical improvement occurs and the

temperature has been normal for 24 h, providing there is no contraindication

to the oral route.

For community managed and for most patients admitted to hospital

with low or moderate severity and uncomplicated pneumonia, 7 days of

appropriate antibiotics is recommended.

For those with high severity microbiologically-undefined pneumonia, 7–

10 days treatment is proposed. This may need to be extended to 14 or 21

days according to clinical judgment; for example, where S aureus or Gram-

negative enteric bacilli pneumonia is suspected or confirmed.

This following algorithm made by IDSA (Infectious Diseases Society of

America) and ATS (American Thoracic Society) for the steps of CAP

treatment :

32

Table 7. Antibiotic therapy (choices in order of preference) for community-acquired pneumonia when the etiology is unknown

source: American Thoracic Society and the Infectious Diseases Society of America

From PDPI (Perhimpunan Dokter Paru Indonesia) 2004, treatment for

CAP is divided into three categories by where the patient treated, the

ambulatory basis patients (without modification factors, with modification

factors, atypical pneumonia suspected), hospital ward patient (without

modification factors, with modification factors, atypical pneumonia suspected),

and intensive care unit patients (risk factors for pseudomonas infections +/-).

33

The ambulatory basis patients without modification factors could be

treated by β-lactam or β-lactam +anti β-lactamase. The ambulatory basis

patients with modification factors treated by β-lactam or β-lactam +anti β-

lactamase or respiratory fluoroquinolone (levofloxacin, moxifloxacin), and

atypical pneumonia patiens treated by macrolide (azithromycin).

For patients to be treated in hospital ward without modification factors :

β-lactam or β-lactam +anti β-lactamase iv, or, cephalosporin 3rd generation iv,

or, flouroquinolone iv. If modification factors detected, we can choose

cephalosporin 3rd generation iv, or, respiratory flouroquinolone. Atypical

pneumonia patients treated by macrolide (azithromycin).

Intensive care unit-patients divided by the risk of pseudomonas

infections. If the risk is high, we can give cephalosporin 3rd generation iv and

macrolide or fluoroquinolon.

Table 8. Recommended treatment of microbiologically documented

pneumonia and

34

source : British Thoracic Society : Guidelines for the management of community acquired

pneumonia, update 2009

2. Antibiotic Therapy for HAP

Table 9. Initial Empiric AB therapy for HAP or VAP in patients with no known risk factors for multidrug-resistant pathogens, early onset, and any disease

severity.

Source : American Journal of Respiratory and Critical Care Medicine Vol 171

35

Table 10. Initial IV, adult doses of antibiotics for empiric therapy of HAP or

VAP in patients with late onset disease or risk factors for multidrug-resistant

pathogens

Source : American Journal of Respiratory and Critical Care Medicine Vol 171

i. Prevention

Vaccination is the mainstay for prevention of CAP. All persons aged

65 years and over should receive the pneumococcal polysaccharides vaccine.

The efficacy of revaccination is unknown. All persons aged 50 years and over

should receive inactivated influenza vaccine during the autumn and winter.

Chemoprophylaxis for influenza infection with oseltamivir or zanamivir for

those who have household exposure or are at high risk for influenza

36

complications in the setting of an outbreak. A smoking cessation plan should

be offered to all elderly smoker patients, since nearly a third of pneumonia

episodes could be attributed to smoking.

Table 11. Pneumonia vaccination

37

j. Conclusion

The growth of the number of elderly in Indonesia was recorded as the

most rapid in the world in the period 1990-2025, and it made the number of

elderly in Indonesia will be ranked fourth in the world, under China, India, and

the United States. While in Jakarta, based on data from a national health

survey of 2001, there were 641,124 elderly or around 8.64% of the total

population of Jakarta, amounting to 7,423,379 people.

Increasing number of the elderly will be followed by greater number of

geriatric patients who may demand health care services. To deal with geriatric

diseases requires an holistic approach and a total care to patients in an

integrated way. Total care is when a patient requires a caregiver in order to

have all their survival needs met, including ambulation, respiration, bathing,

dressing, feeding, and toileting. Holistic health is a concept in medical practice

upholding that all aspects of people’s needs including : psychological,

physical, social and spiritual should be taken into account and seen as whole.

Until now, pneumonia is the leading cause of death in hospitalized

geriatric patient. Pneumonia can be generally defined as inflammation of the

lung parenchyma, in which consolidation of the affected part and a filling of

the alveolar air spaces with exudate, inflammatory cells, and fibrin is

characteristic, caused by bacteria, viruses, or parasites. There are no critical

differences in pneumonia between the elderly and the younger population.

The most striking characteristic of pneumonia in the very old is its clinical

presentation: falls and confusion are frequently encountered, while classic

symptoms of pneumonia are often absent. Severity assessment tools can

help predict mortality and determine the optimal setting in which to provide

38

care for patients with CAP. Empiric antimicrobial regiment should cover

S.Pneumoniae with β-lactam medications or new respiratory flouroquinolones,

and atypical pathogens should be treated with macrolides or respiratory

fouroquinolones.

Vaccination is the mainstay for prevention of CAP. All elderly should

receive the pneumococcal polysaccharides vaccine. The efficacy of

revaccination is unknown.

39

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