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LEARNING OBJECTIVES

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Learning Objectives

  • Identify the critical differences in presentation, etiology, and management of pneumonia in older adults versus young adults.

  • Determine risk factors for infection due to antibiotic-resistant organisms.

  • Integrate pneumonia prevention measures into routine care of older adults.

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Key Clinical Points

  1. The diagnosis of pneumonia in older adults may be more complex due to the physiologic changes which occur with age and accumulation of comorbidity. Both promote subtle and/or atypical clinical presentations with fever, productive cough, and other classic signs being less common in older adults.

  2. It is important to categorize older patients with pneumonia based on functional status, which predicts severity of illness and changes the likelihood of specific pathogens, including multidrug resistant organisms.

  3. Known risk factors for infection due to resistant pathogens include functional impairment, recent hospitalization, previous antibiotic treatment, the presence of indwelling devices, and severe illness. It is important to know local resistance rates to adapt antibiotic treatment choices.

  4. An interdisciplinary approach to management is critical with a goal of preserving and/or recovering function.

  5. Prevention measures, which diminish the incidence and severity of pneumonia in older adults, should be employed; these include immunization versus influenza and pneumococcal disease and optimized management of comorbidities.

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INTRODUCTION

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In developed countries, pneumonia is a major cause of mortality and the most frequent cause of infectious death, as well as the leading cause of severe sepsis and septic shock. The incidence of pneumonia increases with age and is associated with high morbidity, mortality, and health care costs. Pneumonia in older adults affects a heterogeneous spectrum of patients; the assessment of clinical, cognitive, functional, and social issues is key to achieving correct ascertainment of most likely pathogens and thus initial antibiotic management, clinical decision making, and subsequent care planning.

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DEFINITION

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Pneumonia can be defined from three different points of view: the clinician, researcher, and pathologist. Pneumonia is clinically defined as the combination of symptoms (fever, chills, cough, pleuritic chest pain) and signs (hyper- or hypothermia, increased respiratory rate, dullness upon percussion, crackles, wheezing, pleural rub) associated with an opacity (or opacities) on a chest x-ray. In epidemiological or clinical trials, the presence of two or more of these symptoms, one or more of the physical signs, and a new opacity on the chest x-ray not due to other conditions (such as congestive heart failure, vasculitis, pulmonary infarction, drug reactions or atelectasis) is typically required for a diagnosis of pneumonia. From the pathologist point of view, pneumonia is an acute inflammatory process of the lung parenchyma in response to an infectious agent that affects the structures of the distal airways. The pneumonic process can predominantly develop in the alveoli (alveolar pneumonia), the interstitial space (interstitial pneumonia), or both (mixed pneumonia or diffuse alveolar damage). Alveolar pneumonia is predominantly exudative inflammation. Interstitial pneumonia is normally referred to as proliferative or productive, with inflammation in the stromal space and ...

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