A Study of Community-Acquired Pneumonias in Elderly Individuals in Bijapur , India

Community-acquired pneumonia (CAP) in elderly has different clinical presentation and higher mortality than CAP in other age group. Clinical presentation may vary from mere presence of fever to altered sensorium. The incomplete clinical picture of CAP in the elderly may be associated with a delay in establishing the diagnosis and, consequently, in starting adequate antibiotic therapy. Delay in diagnosis and treatment may contribute to the higher observed death rate in the elderly population with CAP. Hence the following study was undertaken to study the clinical, radiological, and bacteriological profile of community-acquired pneumonia in elderly. A total of 50 patients were studied. Age group varied from 66 years to 88 years. Presentation varied from typical symptoms to altered sensorium. Smoking and COPD were most common predisposing conditions. Most common organisms responsible were Streptococcus pneumonia, Klebsiella pneumonia, Pseudomonas, H. influenza, and Staphylococcus aureus. Etiological agents could not be identified in many cases because of difficulty in collecting sputum in elderly patients, lower yield of culture, and various atypical and difficult to isolate causative organisms. Hence there is need for an empirical therapy covering both typical and atypical organisms. Better understanding of these aspects may help a long way in managing elderly patients with pneumonia.


Introduction
Pneumonia "the captain of men of death," "The friend of the aged, allowing them a merciful relief from those cold gradations of decay, that make the last state of all so distressing" as described by William osler, is one of the most common infectious disease encountered in the clinical practice [1].
Pneumonia is the sixth leading cause of death in the United States [2].About 600,000 persons with pneumonia are hospitalized each year, and there are 64 million days of restricted activity due to this illness [3].The reported incidence rates of radiologically confirmed community acquired pneumonia in different populations varied between 1.3 and 11.6 cases per 1000 inhabitant-year with highest rates in elderly adults that is 13-15 cases per 1000 inhabitant-year.In developed countries almost one half of total hospitalization for pneumonia occur in patients over 65 years, and pneumonia is a leading cause of death in this age group [4].
Managing pneumonia in an elderly patient requires an appreciation of many aspects of geriatric medicine, including the demographics of our aging population [5].The effect of pneumonia on the general health of an elderly person, and knowledge of how pneumonia in this population is different than inyounger populations.As stated by Sir William Osler, "In old age, pneumonia may be latent, coming on without chill, the cough and expectoration are slight, the physical signs ill defined and changeable, and the constitutional symptoms out of all proportion." Most patients who require hospitalization for the treatment of community-acquired pneumonia (CAP) are elderly.The elderly have impaired function of many organs by virtue of the aging process and as a result of comorbidity [6].There are structural and functional alterations in old age which impair the host's defense against pulmonary infection [7,8].
Elderly patients hospitalized because of CAP constitute a special population and since they commonly have underlying illnesses, prior neurologic disturbances, nutritional and immunologic deficits.CAP in this population has peculiar clinical characteristics.For instance, not all the signs and symptoms of pneumonia are present in all cases.The clinical presentation may consist only of an alteration of the patient's general condition, confusion, or decompensation of underlying disease.The incomplete clinical picture of CAP in the elderly may be associated with a delay in establishing the diagnosis and, consequently, in starting adequate antibiotic therapy.Delay in diagnosis and treatment may contribute to the higher observed death rate in the elderly population with CAP [9,10].Hence the following study was undertaken to study the clinical, radiological, and bacteriological profile of community-acquired pneumonia in elderly.

Material and Methods
The present study was conducted at Al-Ameen Medical College hospital and District hospital, Bijapur (affiliated to Al-Ameen Medical College) between December 2008 and June 2010.This study is a prospective study carried out on 50 cases of community-acquired pneumonia of patients aged >65 years.Prior to the study, the protocol was approved by the institutional ethical committee, and all patients gave their informed consent to participate.

Inclusion Criteria.
They are following: (a) age >65 years, (b) clinical symptoms like fever, cough with or without expectoration, pleuritic chest pain, dyspnea, and altered sensorium and (c) clinical signs like tachypnea, reduced chest movements, dull percussion note, bronchial breath sounds, increased vocal fremitus, and vocal resonance and crepitations.(d) Radiological evidence of pneumonia without any clinical evidence of pneumonia will also be included.Patient demographic features were recorded according to a standard questionnaire.A detailed clinical history was taken.History for comorbid illness and habits like smoking and alcoholism were taken.Comorbid illnesses were defined as the presence of coexisting cardiac failure, ischemic heart disease, chronic lung disease (copd), chronic liver disease (cirrhosis of liver), chronic kidney disease (diabetic nephropathy), malignancies (multiple myeloma), neurological diseases (old h/o strokes) and diabetes mellitus.A detailed clinical examination was carried out including general physical examination, vital signs, and respiratory system examination, mainly for signs of consolidation and other systemic examination for the comorbid illness.Routine investigations like hemoglobin, total leucocytes count, differential count, ESR, random blood sugar, blood urea, serum creatinine, liver function tests, and serum electrolytes

Results
The present study was conducted at Al-Ameen Medical College hospital and District hospital, Bijapur (affiliated to Al-Ameen Medical College) between December 2008 and June 2010.This study is a prospective study carried out on 50 cases of hospitalized community-acquired pneumonia patients aged >65 years.A detailed history was taken, clinical parameters on admission were noted, routine investigations, chest Xray, and sputum examination were carried out on all patients.The results and observations of the study are as follows.1.

Symptomatology.
In this study patients presented with both typical and atypical symptoms.Among the typical respiratory symptoms, cough was present in 37 (74%) patients, expectoration in 32 (64%) patients, 23 had mucopurulent sputum, and 9 patients had mucoid sputum, fever in 28  had pulse rate of 120-130/min), hypotension defined as systolic blood pressure <90 mmHg was noted in 8 (16%) patients (6 patients had SBP of 60-80 mm Hg and SBP was not recordable in 2 patients) and hypothermia defined as temperature <35 • C was noted in 1 (2%) patients (34.6c).This is shown in Table 5.

Findings on Respiratory System
Examination.In this study, crepitation was the most common respiratory system examination findings, which was noted in 47 (94%) patients.
Other findings were reduced chest movements, impaired note on percussion, bronchial breathing, increased vocal fremitus and vocal resonance, and pleural rub.The details of these are shown in Table 6.

Analysis of Prognostic Factors of Community Acquired Pneumonia in Elderly
Analysis of clinical characters shows that age distribution above 65 years had no association with mortality.Among the clinical presentation altered sensorium had statistically highly significant association with increased mortality.Presence of associated diseases had statistically significant association with mortality.This is shown in Table 13.Analysis of vital signs shows statistically significant association of temperature >38 • C and <35 • C, pulse rate >100/min, and systolic blood pressure <90 mmHg with mortality.This is shown in Table 14.
Analysis of laboratory parameters shows statistically significant association of total leucocyte count >11,000 and <4000 cells/cumm, raised urea and hyponatremia with mortality, whereas raised serum creatinine, and hypoalbuminemia did not show significant association.This is shown in Table 15.
Analysis of complications shows highly significant association of ARDS and septic shock with mortality.This is shown in Table 16.

Discussion
Community-acquired pneumonia (CAP) is a frequent cause of hospital admission and mortality in elderly patients worldwide.The clinical presentation, etiology, and outcome of community-acquired pneumonia in elderly differs from that of other population.In the present study, 50 patients of community-acquired pneumonia >65 years of age were included.The results of study which has been presented in previously are discussed below.
6.1.Age.Pneumonia is common in the extremes of age.In this study, the age group of patients presenting with community-acquired pneumonia ranged from 66 to 88 years.Of these patients 32 (64%) were aged 65-74 years, 14 (28%) were aged 75-84 years, and 4 (8%) were aged ≥85 years.In a study conducted by Riquelme et al. 14,069 Medicare patients age >65 years who required hospitalization for CAP were studied.They noted that 30.3% were aged 65-74 years, 41.8% were aged 75-84 years, and 27.8% were aged >85 years [11].
In another study by Torres et al., the mean age of elderly patients presenting with community-acquired pneumonia was 78 ± 8 yr (mean ± SD) [12].These differences may be due to differences in the rate of hospitalization and access to health care of the elderly in the different populations studied.
The increased incidence of pneumonia in elderly patients is due to the defects in mechanical clearance of airways, loss of elastic recoil of lungs, decreased strength of respiratory muscle causing decreased effectiveness of coughing, agerelated decline in mucociliary clearance, defects in humoral and cell-mediated immunity, and cumulative effects of comorbid chronic diseases and their treatments.

Sex Distribution.
In this study males 35 (70%) were affected more than females 15 (30%).This sex distribution is similar to study conducted by Riquemele et al.where 67% were males and 33% were females, and this may be attributed to increased rates of alcoholism and smoking in males and also due to the increased association of comorbid conditions like COPD, congestive cardiac failure and others in males.This is shown in Table 17.

Predisposing Conditions.
The presence of chronic comorbidity in most of the CAP patients in our study is compatible with the contention that an important risk factor for pneumonia in elderly people is the prevalence of other illnesses [13].This is shown in Table 18.
Smoking was the most important risk factor (72%) in our study.The increased risk of pneumonia in smokers is due to alteration in respiratory flora, mechanical clearance, and cellular defenses.Bacterial colonization of lower respiratory tract is more prevalent in smokers than nonsmokers, mucociliary clearance is defective in smokers, owing to a reduction in ciliary beat frequency and changes in volume and viscoelastic properties of respiratory secretions.In a population-based case-control study, Nuorti et al. found that cigarette smoking was the strongest independent risk factor for invasive pneumococcal disease [15].
Alcoholism is also a risk factor as it interferes with various respiratory tract defenses such as alterations in normal flora, increased risk of aspiration, impaired mechanical clearance and deficient humoral and cellular immunity.
In our study COPD was most common associated comorbid condition (48%).Increased incidence and mortality of pneumonia have been described in COPD patients.This is explained due to defective mucociliary clearance, mucous plugging, airway collapse, respiratory muscle fatigue, and the effect of medications used [16].19.
In this study patients presented with atypical presentations like altered sensorium, nausea, vomiting, diarrhea, loss of appetite, and breathlessness in addition to typical symptoms of cough, expectoration, fever, and pleuritic chest pain.Cough was the most common respiratory symptom noted in 37 (74%) patients, which was productive in only 29 (58%) patients, due to decreased ability of elderly to bring out the sputum.
Harper and Newton found that the classical constellation of CAP in the elderly of cough, fever, and dyspnea was absent in 56% of patients [17].Fever was the presenting feature in 32 (64%) patients in our study.The frequency of fever in elderly patients with CAP according to various studies ranges from 33% to 60%.
Altered sensorium was the presenting feature in 8 (16%) of patients in our study.Venkatesan and coworkers [18] and Harper and associates found a prevalence of 47% and 15%, respectively, of mental alteration in elderly patients with CAP at admission.A practical conclusion of clinical interest is that an effort has to be made to take chest radiographs, upon arrival at the hospital, of all elderly patients with delirium.

General Physical Examination Findings.
In this study general physical examination of the patient showed pallor in 8 (16%) patients which may be secondary to infection, associated comorbid conditions, and malnutrition.Icterus was observed in 6 (12%) patients.Icterus is commonly described  20.
In our study tachypnea was the most common sign 42 (84%) patients, followed by tachycardia 35 (70%) patients.Fever the most frequently noted symptom of infection occurs less frequently in elderly.In our study fever was noted in 34 (68%) of patients.Poor febrile response was correlated to decrease release of IL-1 in elderly patients [19].Hypothermia is noted in 1 (2%) patient and is associated with poor prognosis.Septic shock secondary to pneumonia is commonly seen in elderly, and this may account for hypotension seen in 8 (16%) of patients.

Findings of Respiratory System
Examination.Among the respiratory signs noted in our study crepitations was the most frequent finding noted in most of the patients 47 (94%).In a study by Zalcain et al., crepitations were the most common respiratory finding noted in 79% of patients [20].Other characteristics respiratory signs like bronchial breathing, increased vocal fremitus and vocal resonance, and impaired note on percussion were present in less than one third of the patients.This shows the paucity of characteristic clinical signs in elderly patients with pneumonia and the need to diagnose pneumonia in elderly patients with atypical presentations and minimal signs and symptoms.6.7.Laboratory Data.Among the laboratory investigations in our study, leucocytosis was the most consistent finding noted in 42 (84%) patients where as leucopenia was seen in 4 (8%) patient and was associated with poor prognosis.In study by Torres et al., seventy-six (76%) patients had a leukocyte count >10.000/mm3.Elevated white blood cell counts in elderly people may be caused by the increased rate of pneumococcal infection in old age.
In our study raised blood urea was noted in 20 (40%) patients.Raised bilirubin in 6 (12%) and raised liver enzymes in 8 (16%) was noted.The hepatic impairment and the impaired renal function were more severe in the elderly age group compared to the younger groups in various studies.This may suggest a more severe systemic infection in this age group [21].Hyponatremia was seen in 8 (16%) of patients.Hyponatraemia due to inappropriate antidiuretic hormone (ADH) secretion may occur in any pneumonia and is notably more common in Legionella infection.
In our study, serum albumin level was low in 14 (28%) patients.Serum albumin level is commonly cited as a marker of nutritional status, and it has been correlated independently with a higher case-fatality rate among persons with CAP [22].Although serum albumin level is an indicator of nutritional status, experimental and clinical data indicate that in inflammatory disorders the synthesis of acute-phase proteins occurs at the expense of albumin, and thus a low serum albumin level can be caused by both malnutrition and the acute inflammatory response.
In a study conducted by Kobashi et al., the main laboratory data at admission were as follows: the white blood cell count was above 10,000/cumm in 58%, the ESR was over 20 mm in one hour in 95%, the, serum protein was under 6.5 g/dL in 30%, serum albumin was under 3.5 g/dL in 35%, and blood urea nitrogen (BUN) was over 20 mg/dL in 23%.
6.8.Sputum Microscopy and Culture.In this study bacteriological positivity on gram staining of sputum was seen in 26 (52%) of patients.Cultures were positive in only 18 (32%) patients.Streptococcus pneumonia was the most common etiological agent isolated, 8 (16%) patients, followed by gram-negative bacilli like Klebsiella pneumonia 3 (6%), Pseudomonas aeruginosa 2 (4%), E. coli 1 (2%), Hemophilus influenza 2 (4%) and Staphylococcus aureus 1 (2%) patient.This is almost similar to study conducted by Torres et  Woodhead et al. reviewed 11 studies that reported on the etiology of pneumonia in the elderly and compared them to 3 studies of pneumonia in younger populations.The proportion of cases due to H. influenzae, S. aureus, and gram-negative bacilli was higher among the elderly, and the proportion due to Legionella and other atypical pathogens was higher among the younger patients [23].
Colonization of the oropharyngeal mucosa with aerobic gram negative Bacilli like Escherichia coli, Klebsiella species, Proteus species, Enterobacter species, and Pseudomonas aeruginosa increases with increasing age, predisposing to increased incidence of gram-negative bacilli in aged [24].
In various studies in Western counties undertaken to investigate the causes of community-acquired pneumonia in the elderly, the distribution of causative pathogens appeared to differ from that in younger adults, S. pneumoniae, was the most common causing about 50% of infections, respiratory viruses, H. influenzae, gram-negative bacilli, C. pneumoniae and L. pneumophila were others commonly noted [25].
The cause of CAP is often difficult to establish.The most effective methods are often invasive and cannot always be justified, and serological diagnosis is too late to be of any therapeutic use.Despite the progress made in the diagnosis of pneumonia, it takes a few days to identify the causative microorganism in the blood or sputum samples, and the etiology of half of all patients with CAP remains uncertain [26].Physicians need reliable data on the relative prevalence of different etiological agents in the patients' area of residence, in addition to the clinical, laboratory, and radiological findings in order to initiate antibiotic treatment empirically.The relative frequency of etiological agents varies among different geographical areas [27].
6.9.Radiological Presentation.The radiological data in our study showed a predominance of lobar pneumonia in 39 (78%) patients followed by bronchopneumonia in 9 (18%) patients.Radiological data of our study compared with that due to Torres et al. is shown in Table 21.
Riquelme et al. found the chest-radiographic infiltrate pattern on admission as alveolar in 82% cases interstitial in 6% and mixed in 13% and unilateral in 71%.
Zalacain et al. noted pleural effusion in 60 (12%), septic shock in 41 (8%), lung abscess in 2 (4%), and emphysema in 14 (3%) as common complications in their study.6.11.Mortality.In this study, 8(16%) patients had mortality.Mortality rates for elderly patients hospitalized with CAP in previous reports range from 6 to 40% [28].Along with asso-ciated comorbidities and malnutrition, increased age itself is a independent risk factor for increased mortality for CAP in elderly.Kaplan et al. reported a mortality of 11% in elderly patients with community-acquired pneumonia [29].
Conte et al. developed a prognostic rule for elderly patients admitted with CAP.They found five predictors of bad prognosis as follows: presence of comorbidity, abnormal vital signs axillary temperature >38 • C, cardiac frequency >110 beats/min and systolic arterial pressure <90 mmHg, age >85 yrs, alteration in mental state, and plasma creatinine >1.5 mg/dL [30].

Conclusion
Community-acquired pneumonia in elderly patients is a common and serious problem encountered in clinical practice.Elderly patients with community-acquired pneumonia have different clinical presentation and higher mortality.Elderly patients may present with atypical symptoms like altered sensorium and gastrointestinal symptoms, other than the typical respiratory symptoms of pneumonia.They may not have all the classical signs of consolidation and may present with only few signs like tachypnea, tachycardia, and crepitations.The atypical presentations may lead to delay in diagnosis and initiation of treatment and may be responsible for higher observed mortality in elderly patients with pneumonia.
Etiological agents cannot be identified in many cases because of difficulty in collecting sputum in elderly patients, lower yield of culture, and various atypical and difficult to isolate causative organisms.Hence the need for an empirical therapy covering both typical and atypical organisms.
The following prognostic factors shown to have statistically significant association with mortality; altered sensorium, presence of associated diseases, temperature >38 • C or <35 • C, pulse rate >100/min, systolic blood pressure <90 mmHg, leucocytosis >11,000 cells/cumm, leucopenia <4000 cells/cumm, raised urea >40 mg/dL, hyponatremia, ARDS and septic shock.Prospective studies on larger number of patients are required to substantiate these findings.
Criteria.(a) Hospital acquired pneumonia that is patient hospitalized in the previous 14 days.(b) HIVpositive status.(c) Tuberculosis.(d) Lung malignancies.

Table 1 :
Age and sex distribution.
2.3.Statistical Analysis.The data was analyzed by Mean ± SD (standard deviation), percentage, and Chi-square test (P value <0.05 was considered significant).

Table 6 :
Respiratory system examination findings.

Table 9 :
Showing bacteria isolated on culture.

Sputum Gram Staining and Culture Demonstrated Correlation in 18 of 26 Patients (with Both Gram Staining and Culture Positivity and 8 Patients Had Sterile Cultures)
were congestive cardiac failure, ARDS, lung abscess, and emphysema.Details of this are shown in Table11.4.3.Mortality.In this study, out of 50 patients, 42 (84%) patients improved and 8 (16%) patients had mortality.This is shown in Table12.

Table 13 :
Association of clinical characteristics with mortality.

Table 14 :
Association of vital signs with mortality.

Table 15 :
Association of laboratory data with mortality.

Table 16 :
Association of complications with mortality.

Table 17 :
Sex distribution in study conducted by us and Riquemele et al.

Table 18 :
Predisposing factors seen in our study and another study conducted by Torres et al. is as follows.
6.4.Presenting Complaints.Elderly patient may present with typical as well as atypical symptoms.Atypical symptoms are commonly described in elderly than in younger patients.The clinical presentation may consist of only an alteration of the patient's general condition, confusion, or decompensation of underlying disease.Clinical presentation according to our study as well as studies conducted by Torres et al. and Kobashi et al. is shown in Table

Table 19 :
Clinical presentation according to our study as well as studies conducted by Torres et al. and Kobashi et al.Presenting symptoms Our study Torres et al.Kobashi et al. 8%) patients.Central cyanosis is explained due to shunting of blood through consolidated lung.Vital signs noted in our study as well as in study conducted by Kobashi et al. is shown in Table

Table 20 :
Vital signs noted in our study as well as in study conducted byKobashi et al.

Table 21 :
Radiological findings in our study and study by Torres et al.