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  • Diagnosing infections in older adults can be challenging because they may present with atypical symptoms and frequently do so in patients with cognitive impairment.

  • Atypical symptoms include delirium, falls, or functional decline. Fever and other localizing symptoms may be subtle, absent, or difficult to elicit.

  • Hospitalization and death as a consequence of pneumonia, influenza, and other respiratory tract infections are common.

  • Urinary tract infection remains the most common overdiagnosed bacterial infection. Asymptomatic bacteriuria is common in older adults and requires no treatment.

  • Optimal management of chronic diseases, immunizations, prevention of pressure ulcers, oral hygiene, judicious antibiotic use, and attention to infection prevention practices, including hand hygiene and appropriate gown and glove use, are key preventive measures to reduce infections and enhance quality of care in older adults in skilled nursing facilities.


Infections remain a major cause of mortality and morbidity in older adults across all health care settings. Atypical presentations, immunologic changes related to aging, and multiple chronic conditions continue to make diagnosis of infections in older adults challenging. Infections are associated with higher rates of rehospitalization as well as functional decline and increased mortality among older adults. When infections lead to hospitalizations, older adults can be exposed to nosocomial pathogens and resultant complications, such as functional disability, delirium, and pressure ulcers. Pneumonia and influenza are still among the top 10 causes of death in older adults. Infections common to older adults include the following: urinary tract infections (UTI), upper and lower respiratory tract infections, gastroenteritis including Clostridioides (formerly Clostridium) difficile infection, skin and soft-tissue infections including surgical site infections, osteomyelitis, and prosthetic device–associated infections. HIV/AIDS in aging populations is also a growing concern because those infected as younger adults now have an increasing life expectancy because of the effectiveness of antiretroviral therapy and because the number of new infections in older adults is also on the rise (see Chapter 55).

There are an estimated 1.13 to 2.68 million infections in nursing home residents each year, suggesting a downward trend from previous estimates, particularly for UTIs, wound infections, and infections due to multidrug-resistant organisms. Even so, infections continue to be a major concern. Moreover, about 25% of the short-stay older adults admitted to skilled nursing facilities return to a hospital for treatment of an infection within 30 days, accounting for 325,000 hospital transfers and over $4 billion in additional health care costs annually.


The risk of developing an infection and its resultant morbidity and mortality depend on the virulence of the pathogen, its inoculum, and the host’s defense system. The ability of a pathogen to attach and replicate in a host environment determines its virulence. Age-related changes in the immune system, known as immunosenescence, result in increased susceptibility to infections, such as influenza and bacterial pneumonia, and in decreased effectiveness of vaccines, such as ...

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