Pneumonia in the elderly

Pneumonia in the elderly is an acute infectious disease, predominantly of bacterial etiology, characterized by focal lesions of the respiratory parts of the lungs, the presence of intra-alveolar exudation detected during physical or instrumental examination, expressed to varying degrees by a febrile reaction and intoxication.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Epidemiology

Pneumonia in the elderly is one of the most common diseases: in Ukraine, the average incidence rate is 10-15%. The risk of developing pneumonia increases with age. The prevalence of community-acquired pneumonia among the elderly and senile in the United States is 20-40%. Mortality from pneumonia among patients over 60 years of age is 10 times higher than in other age groups, and reaches 10-15% for pneumococcal pneumonia.

[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ]

Symptoms pneumonia in the elderly

Clinical manifestations of pneumonia consist of pulmonary and extrapulmonary symptoms.

Pulmonary manifestations

Cough, unproductive or with sputum production, is a common manifestation of pneumonia. However, in weakened patients with suppressed cough reflex (stroke, Alzheimer's disease), it is often absent.

A characteristic sign of pneumonia is shortness of breath, which can be one of the main (and sometimes the only) of its manifestations in the elderly.

The inflammatory process in the lung tissue, spreading to the pleura, causes patients to feel heaviness and pain in the chest. In these cases, pleural friction noise is heard.

In elderly patients with pneumonia, such classic signs as dullness of percussion sound, crepitation are not always clearly expressed, and sometimes are absent. This can be explained by the fact that the phenomenon of compaction of lung tissue in pneumonia in the elderly does not always reach the degree that would be sufficient for the formation of the above signs. Dehydration, often present in elderly patients, caused by various reasons (lesion of the gastrointestinal tract, tumor process, diuretic use), limits the processes of exudation into the alveoli, complicating the formation of pulmonary infiltrate.

In elderly patients, it is difficult to unambiguously interpret the signs of lung tissue damage revealed by percussion and auscultation due to the presence of! Background pathology - heart failure, lung tumor, chronic obstructive pulmonary diseases - COPD. Thus, percussion dullness in pneumonia is difficult to distinguish from atelectasis, bronchial breathing with wheezing may be a consequence of the presence of a pneumosclerotic area, wet fine-bubble wheezing can be heard in left ventricular failure. Erroneous interpretation of auscultatory data is the most common cause of clinical overdiagnosis of pneumonia in the elderly.

Extrapulmonary symptoms

Fever in pneumonia in the elderly and senile age is observed quite often (75-80%), although compared to patients of other age groups, the disease often occurs with normal or even low temperature, which is a prognostically less favorable sign. Frequent manifestations of pneumonia in the elderly are disorders of the central nervous system in the form of apathy, drowsiness, lethargy, loss of appetite, confusion, up to the development of a soporous state.

In some cases, the first manifestations of pneumonia are a sudden loss of physical activity, loss of interest in the surroundings, refusal to eat, and urinary incontinence. Such situations are sometimes mistakenly interpreted as a manifestation of senile dementia.

Among the clinical symptoms of pneumonia in the elderly, decompensation of underlying diseases may come to the fore. Thus, in patients with COPD, clinical manifestations of pneumonia may be characterized by increased cough, the appearance of respiratory failure, which may be mistakenly assessed as an exacerbation of chronic bronchitis. When pneumonia develops in a patient with congestive heart failure, the latter may progress and become refractory (resistant) to treatment.

Markers of pneumonia may include decompensation of diabetes mellitus with the development of ketoacidosis (in elderly patients with diabetes mellitus); the appearance of signs of liver failure in patients with liver cirrhosis; the development or progression of renal failure in patients with chronic pyelonephritis.

Leukocytosis may be absent in one third of patients with pneumonia, which is an unfavorable prognostic sign, especially in the presence of a neutrophilic shift. These laboratory changes have no age-related characteristics.

[ 13 ]

Treatment pneumonia in the elderly

The classification that most fully reflects the features of the course of community-acquired pneumonia and allows justifying etiotropic therapy is based on determining the causative agent of the disease. However, in practice, clarifying the etiology of pneumonia is unrealistic due to insufficient information and the significant duration of traditional microbiological studies. In addition, in 50% of cases, the elderly do not have a productive cough in the early stages of the disease.

At the same time, treatment of pneumonia should be started immediately upon establishing a clinical diagnosis.

In a number of cases (20-45%), even with adequate sputum samples, it is not possible to identify the pathogen.

Therefore, in practice, an empirical approach to the choice of etiotropic therapy is most often used. Treatment of patients over 60 years of age can be carried out on an outpatient basis. For this purpose, it is recommended to use protected aminopenicillins or second-generation cephalosporins. Due to the high risk of legionellosis or chlamydial etiology of pneumonia, it is advisable to combine drugs of the above groups with macrolide antibiotics (erythromycin, rovamycin), increasing the duration of therapy to 14-21 days (for legionellosis).

Mandatory hospitalization is required for patients with clinically severe pneumonia, the signs of which are: cyanosis and dyspnea over 30 breaths per minute, confusion, high fever, tachycardia that does not correspond to the degree of fever, arterial hypotension (systolic blood pressure below 100 mm Hg and (or) diastolic blood pressure below 60 mm Hg). In severe community-acquired pneumonia, it is recommended to use third-generation cephalosporins (claforan) in combination with parenteral macrolides. Recently, it has been proposed to use stepwise antibacterial therapy when stabilizing or improving the inflammatory process in the lungs. The optimal version of this technique is the sequential use of two dosage forms (for parenteral administration and for oral administration) of the same antibiotic, which ensures continuity of treatment. The transition to oral administration of the drug becomes possible on the 2-3 day after the start of treatment. For this type of therapy the following can be used: ampicillin sodium and ampicillin trihydrate, sulbactam and ampicillin, amoxicillin/clavulanate, ofloxacin, cefuroxime sodium and cefuroxime acetyl, erythromycin.

Antibiotics for the treatment of pneumonia in the elderly

[ 14 ], [ 15 ], [ 16 ], [ 17 ], [ 18 ], [ 19 ], [ 20 ]

Benzippeeitsiplin

It exhibits high activity against the most common pathogen of community-acquired pneumonia - S. pneumoniae. In recent years, an increase in pneumococcal resistance to penicillin has been noted, and in some countries its level reaches 40%, which limits the use of this drug.

[ 21 ], [ 22 ], [ 23 ]

Aminopenicillins (ampicillin, amoxicillin)

They are characterized by a broader spectrum of activity compared to benzylpenicillins, but are unstable to beta-lactamases of staphylococci and gram-negative bacteria. Amoxicillin has an advantage over ampicillin, as it is better absorbed in the gastrointestinal tract, is dosed less frequently and is better tolerated. Amoxicillin can be used for mild pneumonia in outpatient practice in elderly patients without concomitant pathology.

[ 24 ], [ 25 ], [ 26 ], [ 27 ], [ 28 ], [ 29 ]

Protected aminopenicillins - amoxicillin/cpavulanate

Unlike ampicillin and amoxicillin, the drug is active against bacterial strains producing B-lactamases, which are inhibited by clavulanate, which is part of its composition. Amoxicillin/clavulanate exhibits high activity against most pathogens causing community-acquired pneumonia in the elderly, including anaerobes. It is currently considered the leading drug in the treatment of community-acquired respiratory tract infections.

The presence of a parenteral form allows the drug to be used in hospitalized patients with severe pneumonia.

Cefuroxime

Belongs to the second generation cephalosporins. The spectrum of action is similar to amoxicillin / clavulanate, with the exception of anaerobic microorganisms. Strains of pneumococcus resistant to penicillin may also be resistant to cefuroxime. This drug is considered as a first-line agent in the treatment of community-acquired pneumonia in geriatric patients.

[ 30 ], [ 31 ], [ 32 ]

Cefotaxime and ceftriaxone

They are third-generation parenteral cephalosporins. They have high activity against most gram-negative bacteria and pneumococci, including strains resistant to penicillin. They are the drugs of choice in the treatment of severe pneumonia in the elderly. Ceftriaxone is the optimal drug for parenteral treatment of elderly patients with pneumonia at home due to the ease of administration - once a day.

[ 33 ], [ 34 ], [ 35 ], [ 36 ], [ 37 ]

Macrolides

In elderly patients, the value of macrolides is limited due to the characteristics of the spectrum of pathogens. In addition, in recent years, an increase in the resistance of pneumococci and Haemophilus influenzae to macrolides has been noted. Macrolides should be prescribed to the elderly in combination with third-generation cephalosporins for severe pneumonia.

Other Treatments for Pneumonia in the Elderly

The effect of therapy largely depends on the correct use of cardiac agents that affect respiratory function (camphor, cardiamine), cardiac glycosides, coronary blockers and, if necessary, antiarrhythmic agents.

As antitussives for persistent dry cough, drugs that do not have a negative effect on the drainage function of the bronchi (Baltix, Intussin) are used.

Prescribing expectorants and mucolytics is an important part of complex therapy. The following are commonly used: bromhexine, ambroxol, mucaltin, 1-3% aqueous solution of potassium iodide, infusion of thermopsis, marshmallow root, coltsfoot leaves, plantain, and breast collection.

Much attention should be paid to the organization of treatment, care and monitoring of patients with pneumonia. During the febrile period, bed rest and individual fasting or stay in the intensive care unit are necessary, monitoring of hemodynamic parameters and the degree of respiratory failure. Psychological support and early activation of the patient are important, since elderly and old people are very sensitive to hypodynamia.

Food should be easily digestible, rich in vitamins (especially vitamin C). It should be given often (up to 6 times a day). Plenty of fluids (about 2 liters) in the form of green tea, fruit drinks, compotes, broths.

Constipation is often observed during bed rest, mainly due to intestinal atony. If you are prone to constipation, it is recommended to include fruit juices, apples, beets and other vegetables and fruits in your diet, which stimulate intestinal peristalsis.

Taking mild laxatives of plant origin (buckthorn, senna), weakly alkaline mineral waters. Without special indications, do not limit fluid intake (less than 1-1.5 liters per day), as this may contribute to increased constipation.

Pneumonia in the elderly lasts about 4 weeks until the main clinical and laboratory parameters are normalized. However, the restoration of the lung tissue structure can take up to 6 months. Therefore, it is extremely important to carry out a set of therapeutic and health-improving measures in an outpatient setting. It should! Include a clinical, laboratory and X-ray examination after 1-3-5 months, the use of vitamins and antioxidants, bronchodilators and expectorants, sanitation of the oral cavity and upper respiratory tract, smoking cessation, physiotherapy, exercise therapy and, if possible, spa treatment.