High incidence of silent aspiration in elderly patients with community-acquired pneumonia

Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly

Silent aspiration of oral microorganisms is a major cause of aspiration pneumonia. To establish oral hygiene criteria for the prevention of aspiration pneumonia in edentulous elderly persons, we investigated the relationship between presence of tongue-coating and number of oral bacteria in saliva and episodes of pneumonia. A total of 71 edentulous Japanese people aged 65 years or older living in nursing homes were enrolled in the study. A tongue plaque index (TPI) was used to evaluate quantity of tongue-coating, with TPI0 signifying no tongue-coating and TPI1 signifying presence of tongue-coating. Edentate elderly with TPI1 demonstrated significantly higher salivary bacterial counts than those with TPI0 (p<0.05). The number of elderly patients developing aspiration pneumonia was larger (p<0.005) in patients with TPI-based poor scores (average TPI>0.5) than in those with TPI-based good scores. The relative risk of developing pneumonia in the good tongue hygiene group compared with in the poor tongue hygiene group was 0.12, 95% confidence interval (CI): 0.02-0.9. The results demonstrate that tongue-coating is associated with number of viable salivary bacterial cells and development of aspiration pneumonia, suggesting that tongue-coating is a risk indicator of aspiration pneumonia in edentate subjects.

Bacterial community-acquired pneumonia in older patients

Pneumonia in the elderly remains a major source of morbidity and mortality in an age group that is growing in numbers. It remains unclear whether the propensity of older adults to develop community-acquired pneumonia represents an aging of host defenses, secondary effects of comorbid disease, or both. The signs and symptoms of pneumonia in the elderly are more subtle than in younger populations, which may lead to a delay in diagnosis. Although therapy for community-acquired pneumonia in the elderly is the same as for younger populations, mortality is higher, leading to an important role for prevention.

Evaluation of chewing and swallowing disorders among frail community-dwelling elderly individuals

The purpose of the present study was to develop a new assessment scale to evaluate the risk of chewing and swallowing disorders among frail community-dwelling elderly individuals. Subjects were 85 frail elderly individuals (29 men and 56 women) living in southern Japan. First, we pooled 18 subjectively evaluated variables identified by previous studies as being related to chewing and swallowing disorders. Secondly, using factor analysis, we extracted 12 variables as the 'dysphagia risk assessment for the community-dwelling elderly' (DRACE) and examined its reliability using Cronbach's alpha coefficient. Thirdly, we examined the validity of the DRACE by comparing it with an existing method for evaluating dysphagia. Cronbach's alpha coefficient of the DRACE was 0.88, indicating satisfactory reliability. Dysphagia risk assessment for the community-dwelling elderly scores were significantly related to the results of the 3-oz water test (P < 0.01). Furthermore, DRACE scores were closely associated with activities of daily living as evaluated by the Barthel index, a tendency that was consistent with previous studies. These findings suggest that the DRACE is a useful tool with sufficient reliability and validity to detect latent risk of chewing and swallowing disorders among frail community-dwelling elderly individuals.

Aspiration pneumonias: under-diagnosed and under-treated

PURPOSE OF REVIEW

To examine recent advancements of the epidemiology, risk factors, bacteriology, diagnostic measures, and treatment for aspiration pneumonia.

RECENT FINDINGS

In a large prospective study, 10.3% of community-acquired pneumonia requiring hospitalization was associated with aspiration pneumonia, as opposed to 30% when patients were admitted from long-term facilities. A murine stroke model showed increased apoptosis of cell-mediated immune cells due to overactivation of the sympathetic nervous system. Subsequent nasal inoculum of low-dose Streptococcus pneumoniae caused severe pneumonia. Another murine study showed intratracheal administration of hydrochloric acid-primed lungs more susceptible to infection with Klebsiella pneumoniae. Tracheal pH monitoring demonstrated acidification of trachea in 28% of patients with acute stroke deemed to be safe for oral feeding. Various antimicrobial agents used to treat aspiration pneumonia have comparable success rates. However, clindamycin was the only agent that did not propagate emergence of methicillin-resistant Staphylococcus aureus.

SUMMARY

Aspiration pneumonia is prevalent in community-acquired pneumonia. Further studies are needed to elucidate the effects of sympathetic nervous system and aspiration pneumonitis as primers for lung infection. Predicting aspiration risk is difficult and newer diagnostic tools are necessary. Antimicrobials used in aspiration pneumonia have similar success rates although the development of resistant organisms must be monitored.

Oral flora in independent over 80-year-olds with more than 20 teeth

The purpose of this study was to investigate oral flora in independent persons aged over 80 years with more than 20 remaining teeth. The subjects were 22 participants of the 8020 campaign (6 males and 16 females) with a mean age of 81.3+/-1.6 years and an average of 24.7 teeth (Independent 8020 group). This group was compared with a group of 38 elderly people residing in nursing homes (10 males and 28 females) who had a mean age of 81.3+/-8.5 years and an average of 4.2 teeth (Nursing group with fewer teeth). Saliva samples were collected from the vestibular areas of the maxilla and mandible using cotton swabs. Cell numbers of microorganisms were expressed as colony forming units/ml (CFUs/ml) and compared between the two groups. The average number of Staphylococcus species was 65.2+/-74.4 CFUs/ml in the Independent 8020 group and 400.3+/-352.1 CFUs/ml in the group with fewer teeth (p<0.01); that of Candida albicans was 18.0+/-37.7 CFUs/ml in the Independent 8020 group and 152.9+/-211.9 CFUs/ml in the Nursing group with fewer teeth (p<0.05). Both species showed statistically significant differences between the two groups. This suggests that the Independent 8020 achiever group had better oral hygiene and that the presence of many teeth may be associated with an increased awareness of dental health.

Coordination of swallowing and respiration in normal sequential cup swallows

OBJECTIVES

To establish normative data on laryngeal vestibular closure patterns and respiratory phase patterns during sequential cup swallows in healthy adults.

STUDY DESIGN

Cross-sectional study.

METHODS

Combined videofluoroscopic and respiratory phase recordings were analyzed in 70 healthy adults during 50 mL sequential liquid cup swallows. The following dependent variables were measured offline from the digitized recordings: 1) number of swallows, 2) number of ingestion cycles (IC) (period of sustained apnea including 1 or more swallows), 3) opening of the laryngeal vestibule after each swallow, and 4) respiratory phase surrounding each IC. Patients were grouped according to the position of the larynx after each swallow.

RESULTS

The mean number of swallows was 4.35, and the mean number of ICs was 3.28. Laryngeal vestibular opening after swallows was categorized into three groups: Always Open = 67.1%, Mixed (Open and Closed) = 31.4%, Always Closed = 1.4%. Statistical differences were not found in laryngeal opening pattern by age or sex, but the Always Open group had fewer swallows (4.02 vs. 5.23, P = .008) and a greater number of ICs (3.62 vs. 2.41, P = .001) than the Mixed Group. Respiratory phase after IC was expiration in 79% and inspiration in 21%.

CONCLUSIONS

Normal patterns of laryngeal vestibular closure and respiratory phase coordination during sequential swallowing have been described for the first time. The high occurrence of inspiration and laryngeal vestibular opening that surrounds sequential liquid cup swallows when compared with previous findings in single, discrete swallows may place patients with swallowing disorders at greater risk during this task.

Factores pronósticos de la neumonía adquirida en la comunidad en ancianos

BACKGROUND AND OBJECTIVE

To determine whether there are differences between the prognostic factors associated with 30-days mortality in patients 65-84 year-old and patients over 84 years hospitalized for community-acquired pneumonia (CAP).

PATIENTS AND METHOD

An observational study with retrospective data collection was carried out in a representative sample of all CAP in-patients of 27 general hospitals. Data regarding comorbidities, signs and symptoms on admission, radiological and laboratory examinations, and complications during hospitalization were recorded.

RESULTS

1,191 CAP patients were studied, 80.1% in the 65-84 age group and 19.9% in the over 84 age group. Mortality during the first 30 days was 11.9% in the younger group and 20.7% in the older (p < 0.001). In the younger group, the multivariate analysis showed the following independent prognostic factors: general discomfort (odds ratio [OR] = 3.93), respiratory rate > 30/min (OR = 5.02), atrial fibrillation (OR = 3.57), dementia (OR = 9.18), and hospitalization during the previous year (OR = 3.74). In the older group, independent prognostic factors were cancer (OR = 8.4) and renal failure (3.32). Age significantly modified the effect of altered mental state, tachypnea, tachycardia, hyperglycemia, and dementia on mortality.

CONCLUSIONS

In people over 84 years, except cancer and renal failure, classic CAP prognostic factors used in severity indexes do not distinguish those who will die from those who will not. Therefore, these factors must be interpreted with caution.

Oral hygiene evaluation for effective oral care in preventing pneumonia in dentate elderly

The purpose of this study was to establish criteria for the visual evaluation of oral hygiene by analyzing the relationship between status of oral hygiene and number of oral bacteria in saliva for use in predicting the development of pneumonia. A total of 145 Japanese people of advanced age living in nursing homes were enrolled in the study. We evaluated the Dental Plaque Index (DPI) and Tongue Plaque Index (TPI) as simple measures of status of oral hygiene. We also determined the number of viable microorganisms in the saliva of each subject. The relationship between the status of oral hygiene and episodes of pneumonia was investigated over a period of one year. Dentate patients with poor oral hygiene as indicated by their DPI and TPI scores demonstrated significantly higher salivary bacterial counts than those with a good score for oral hygiene (p<0.01 and p<0.05, respectively). Both the number of febrile days was significantly higher (p=0.0012), and number of patients developing pneumonia larger (p<0.01) in dentate patients with DPI-based poor scores than those with DPI-based good scores. These results demonstrate a significant positive correlation between salivary bacteria and visual evaluation of oral hygiene in dentate patients according to number of febrile days and development of pneumonia.

Differences in the Features of Aspiration Pneumonia According to Site of Acquisition: Community or Continuing Care Facility

OBJECTIVES

To determine the prevalence of aspiration pneumonia and to compare the features and risk factors for this entity in patients from continuing care facilities (CCFs) and the community who were admitted to the hospital with pneumonia.

DESIGN

Prospective population-based study.

SETTING

Six hospitals in Capital Health Region (Edmonton), Alberta, Canada.

PARTICIPANTS

One thousand nine hundred forty-six adults admitted with pneumonia. Patients were stratified by their residence as community or CCF.

MEASUREMENTS

Aspiration pneumonia prevalence; risk factors; and outcomes such as mortality, length of stay, and intensive care unit admission rates.

RESULTS

Ten percent of those with community-acquired pneumonia (CAP) had aspirated, compared with 30% of those with CCF-acquired pneumonia. Those with community-acquired aspiration pneumonia (CAAP) and those with CCF-acquired aspiration pneumonia (CCF-AP) were younger, more likely to go to ICU, and more likely to require mechanical ventilation and had a longer length of stay and a higher mortality rate than nonaspirators. The risk factors for aspiration differed; for those with CAAP, impaired consciousness due to alcohol, drugs, or hepatic failure predominated, whereas 72% of those with CCF-AP had neurological disease that resulted in dysphagia. Eighty percent were treated with antibiotics effective against anaerobic bacteria.

CONCLUSION

Aspiration pneumonia is common in patients with both CAP and CCF-acquired pneumonia. The risk factors differ, and there is a high mortality rate. Neurological disease dominates as the predisposing factor toward aspiration pneumonia in people in CCFs.

Involvement of periodontopathic anaerobes in aspiration pneumonia

Increasing evidence has linked the anaerobic bacteria forming periodontopathic biofilms with aspiration pneumonia in elderly persons. In experiments designed to eliminate the potent respiratory pathogens forming biofilms in the oral cavity, we have shown that the mechanical and chemical oral cleansing using povidone-iodine effectively reduced the detection rates and numbers of methicillin-sensitive Staphylococcus species, Streptococcus pneumoniae, and Haemophilus influenzae in patients scheduled to undergo oral surgery requiring endotracheal intubation. We confirmed the pathogenicity of periodontopathic anaerobic bacteria for aspiration pneumonia in an experimental mouse model. Based upon the finding of the coexistence of Porphyromonas gingivalis with Treponema denticola in chronic periodontitis lesions, we innoculated a mixed culture of P. gingivalis and T. denticola into the mouse trachea; the resulting infection induced inflammatory cytokine production and caused pneumonia. In another series of investigations, professional oral health care (POHC), mainly cleansing administered by dental hygienists once a week for 24 months to elderly persons requiring daily care, resulted in the reduction of the number of total anaerobes, Candida albicans, and Staphylococcus species and in the number of cases of fatal aspiration pneumonia. We also found that the POHC treatment of elderly persons for 6 months in the winter season reduced the salivary levels of protease, trypsin-like activity, and neuraminidase and also decreased the frequency of influenza cases.

Nosocomial pneumonia and oral health

This article will critically review the evidence linking pneumonia to the aspiration of microbe-laden oropharyngeal secretions and tie that to the predisposition for these processes to affect dependent, medically compromised individuals. The goal of this review is to alert the reader to the role that oral disease and oral health play in fostering and preventing, respectively, widespread and potentially fatal pulmonary disease among high-risk individuals.

Silent Aspiration: What Do We Know?

Although clinically evident aspiration is common in subjects with dysphagia, a significant proportion may aspirate silently, i.e., without any outward signs of swallowing difficulty. This article reviews the literature on the prevalence, etiology, and prognostic significance of silent aspiration. An electronic database search was performed using silent aspiration, aspiration, dysphagia, and stroke as search terms, together with hand-searching of articles. Silent aspiration has been described in many conditions and subgroups of patients (including normal individuals), using a number of detection methods, making comparisons a challenge. The best data are for acute stroke, in which 2%-25% of patients may aspirate silently. Mechanisms associated with silent aspiration may include central or local weakness/incoordination of the pharyngeal musculature, reduced laryngopharyngeal sensation, impaired ability to produce a reflexive cough, and low substance P or dopamine levels. In terms of prognosis, silent aspiration has been associated with increased morbidity and mortality in many but not all studies. However, some degree of silent aspiration at night may be normal in healthy individuals. The phenomenon of silent aspiration is poorly understood and further research is needed to improve methods of detection and thereby better define its prevalence and prognostic significance.

Professional oral care reduces influenza infection in elderly

Influenza is a major cause of respiratory infection and has a high mortality rate in the elderly. Neuraminidase (NA) on the surface of the influenza virus and bacterial trypsin-like proteases (TLP) play key roles in influenza virus infections. We investigated the effects of oral care on influenza, evaluating in particular the activities of NA and TLP in saliva, as they may contribute to an increased risk of infection with influenza. One hundred ninety elderly patients who visited day care service facilities once a week were randomly assigned to either a professional oral care group or to an own oral care group as the control group. Nine individuals in the control group and one person in the professional oral care group were diagnosed with influenza during the follow-up period. The relative risk of developing influenza while under professional oral care compared to that in the control group was 0.1 (95% CI 0.01-0.81, p=0.008). Significant decreases in numbers of salivary anaerobic bacterial CFUs, and NA and TLP levels were observed in the professional oral care group compared to that in the control group (p<0.01). This study suggests that maintenance of oral hygiene is effective in the prevention of influenza in the elderly.

Aspiration and infection in the elderly : epidemiology, diagnosis and management

Aspiration of the oropharyngeal or gastric contents by elderly persons often leads to lower respiratory tract infections, such as aspiration pneumonia or pneumonitis. The existence of dysphagia and aspiration in elderly patients are important factors in the occurrence of aspiration pneumonia, but are not sufficient to cause aspiration pneumonia in the absence of other risk factors. Salivary flow and swallowing can eliminate Gram-negative bacilli from the oropharynx in healthy persons. However, elderly persons may have diminished production of saliva as a result of medications and oral/dental disease, leading to poor oral hygiene and oropharyngeal colonisation with pathogenic organisms. When dysphagic patients aspirate pathogenic bacteria while swallowing food or liquids, they must also have decreased defences, such as impaired immunity or pulmonary clearance, in order to develop aspiration pneumonia.Elderly patients with cerebrovascular disease often have dysphagia that leads to an increased incidence of aspiration. It was previously reported that patients with silent cerebral infarction affecting the basal ganglia were more likely to experience subclinical aspiration and an increased incidence of pneumonia. Basal ganglia infarction leads to the impairment of dopamine metabolism and, as a consequence, a decrease of substance P in the glossopharyngeal nerve and sensory vagal nerves. Therefore, dysphagia and a decreased cough reflex may be induced by the impairment of dopamine metabolism in some elderly patients with cerebrovascular disease, suggesting that pharmaceutical agents which modulate dopamine metabolism may be able to improve swallowing and the cough reflex in patients with basal ganglia infarction. The main strategy for controlling aspiration and aspiration-related pulmonary infection in the elderly is to prevent aspiration of pathogenic bacteria along with the oropharyngeal or gastric contents. Because aspiration pneumonia in the elderly is related to certain risk factors, including dysphagia and aspiration, effective preventive measures involve various approaches, such as pharmacological therapy, swallowing training, dietary management, oral hygiene and positioning.

DNA identification of the pathogen of candidal aspiration pneumonia induced in the course of oral cancer therapy

Aspiration of oropharyngeal bacteria and fungi is occasionally suspected in patients with pneumonia. A patient with oral carcinoma underwent chemoradioimmunotherapy and, about 4 weeks from the start of the therapy, the patient suffered from severe oral mucositis induced by chemoradiotherapy, and candidal pneumonia was subsequently induced. The candidal pneumonia was insufficiently improved by potent antifungal drugs, taking a lethal course. Randomly amplified polymorphic DNA analysis and DNA sequence examination of strains isolated from the oral cavity 1 week before the onset of pneumonia and autopsied lung revealed the identity of both strains as Candida albicans, and the DNA analysis supported aspiration of oral Candida. These results indicate that the pathogen of the pneumonia, C. albicans, was aspirated from the oral cavity and that oral Candida is easily aspirated and becomes the pathogen of pneumonia.

Drug treatment of pneumococcal pneumonia in the elderly

Streptococcus pneumoniae has been recognised as a major cause of pneumonia since the time of Sir William Osler. Drug-resistant S. pneumoniae (DRSP), which have gradually become resistant to penicillins as well as more recently developed macrolides and fluoroquinolones, have emerged as a consequence of indiscriminate use of antibacterials coupled with the ability of the pneumococcus to adapt to a changing antibacterial milieu. Pneumococci use cell wall choline components to bind platelet-activating factor receptors, colonise mucosal surfaces and evade innate immune defenses. Numerous virulence factors that include hyaluronidase, neuraminidase, iron-binding proteins, pneumolysin and autolysin then facilitate cytolysis of host cells and allow tissue invasion and bloodstream dissemination. Changes in pneumococcal cell wall penicillin-binding proteins account for resistance to penicillins, mutations in the ermB gene cause high-level macrolide resistance and mutations in topoisomerase IV genes coupled with GyrA gene mutations alter DNA gyrase and lead to high-level fluoroquinolone resistance. Risk factors for lower respiratory tract infections in the elderly include age-associated changes in oral clearance, mucociliary clearance and immune function. Other risks for developing pneumonia include poor nutrition, hypoalbuminaemia, bedridden status, aspiration, recent viral infection, the presence of chronic organ dysfunction syndromes including parenchymal lung disease and recent antibacterial therapy. Although the incidence of infections caused by DRSP is rising, the effect of an increase in the prevalence of resistant pneumococci on mortality is not clear. When respiratory infections occur, rapid diagnosis and prompt, empirical administration of appropriate antibacterial therapy that ensures adequate coverage of DRSP is likely to increase the probability of a successful outcome when treating community-acquired pneumonia in elderly patients, particularly those with multiple risk factors for DRSP. A chest x-ray is recommended for all patients, but other testing such as obtaining a sputum Gram's smear is not necessary and should not prolong the time gap between clinical suspicion of pneumonia and antibacterial administration. The selection of antibacterials should be based upon local resistance patterns of suspected organisms and the bactericidal efficacy of the chosen drugs. If time-dependent agents are chosen and DRSP are possible pathogens, dosing should keep drug concentrations above the minimal inhibitory concentration that is effective for DRSP. Treatment guidelines and recent studies suggest that combination therapy with a beta-lactam and macrolide may be associated with a better outcome in hospitalised patients, and overuse of fluoroquinolones as a single agent may promote quinolone resistance. The ketolides represent a new class of macrolide-like antibacterials that are highly effective in vitro against macrolide- and azalide-resistant pneumococci. Pneumococcal vaccination with the currently available polysaccharide vaccine is thought to confer some preventive benefit (preventing invasive pneumococcal disease), but more effective vaccines, such as nonconjugate protein vaccines, need to be developed that provide broad protection against pneumococcal infection.

Medical Treatments and Cares for Geriatric Syndrome: New Strategies Learned from Frail Elderly

In Japan, there are 21 million older people above 65 years, and about 8% of them are frail elderly. Geriatrics is to study the frail elderly as to why they become frail elderly, and to treat patients properly or the remaining 92% older people not to become frail elderly. In order to promote health of the older people, geriatricians have to take deep insights for cares as well as medical treatments. With such a will, we find the way to prevent diseases in the older people. In this review, we describe medical treatments and cares for promoting successful aging.

Preventive Strategies for Aspiration Pneumonia in Elderly Disabled Persons

Pneumonia is the fourth leading cause of death despite the availability of potent new antimicrobials in Japan. Aspiration of oropharyngeal bacterial pathogens to the lower respiratory tract is one of the most important risk factors for pneumonia. Impairments in swallowing and cough reflexes among disabled older persons, e.g., related to cerebrovascular disease, increase the risk of pneumonia. Thus, strategies to reduce the volumes and pathogenicity of aspirated material should be pursued. Since both swallowing and cough reflexes are mediated by endogenous substance P contained in the vagal and glossopharyngeal nerves, pharmacologic therapy using angiotensin-converting enzyme inhibitors, which decrease substance P catabolism, can improve both reflexes and result in the lowering of the risk of pneumonia. Similarly, since the production of substance P is regulated by dopaminergic neurons in the cerebral basal ganglia, treatment with dopamine analogs or potentiating drugs such as amantadine can reduce the incidence of pneumonia. Furthermore, since mortality from infections correlates with cutaneous anergy, interventions that reverse these age-associated changes in the immune system are also effective. The main theme of this review is to discuss how pneumonia develops in disabled older people and to suggest preventive strategies that may reduce the incidence of pneumonia among these subjects.

Healthcare-associated pneumonia in adults: management principles to improve outcomes

Guidelines for Management of HAP were developed jointly by the ATS and IDSA in 2004. These guidelines were designed to improve patient outcomes and to decrease the emergence of MDR pathogens (see Fig. 1).Principles include early initiation of appropriate and adequate antibiotic therapy after cultures of blood and sputum are obtained. Quantitative distal airway sampling by bronchoscopy provides greater diagnostic specificity for VAP: in one randomized study, improved outcomes were noted, compared with clinical diagnosis with qualitative endotracheal aspirates. Higher doses of initial, empiric antibiotics also are recommended. Assessment of the patient's clinical response to empiric antibiotics should be correlated with microbiologic results to streamline, de-escalate, or stop unnecessary anti-biotic treatment. Duration of therapy for uncomplicated HAP should be limited to 7 days followed by close monitoring for relapse after cessation of antibiotics. The authors suggest that prevention strategies target modifiable short- and long-term risk factors. They also advocate the use of a multidisciplinary team that is dedicated to the treatment and prevention of HCAP and the basic principle of the modern Hippocratic Oath: "I will prevent disease whenever I can, for prevention is preferable to cure."

A pilot study of quantitative aspiration in patients with symptoms of obstructive sleep apnea: comparison to a historic control group

OBJECTIVE

It has been shown that many healthy people aspirate secretions at night. Patients with obstructive sleep apnea (OSA) have frequent episodes of gasping at night that may predispose them to aspiration. The purpose of this study was to determine whether patients with symptoms of OSA are predisposed to pharyngeal aspiration.

STUDY DESIGN

A prospective study in which patients with symptoms of OSA were compared with a historic group of normal controls by using the same methodology.

METHODS

The study was offered to patients with symptoms of OSA undergoing a sleep study. The radiotracer Technicium was infused through a plastic tube placed in the nasopharynx after the patient achieved stage II sleep. A chest radionuclide scan determined the amount of material aspirated. The Wilcoxon-rank sum test was used to compare the mean amount aspirated between the experimental and historic control groups.

RESULTS

Fourteen patients successfully completed the study. One normal volunteer in our study aspirated a quantity similar to the historic normal control group. The amount of aspirated material in the study group ranged from 0.152 to 3.648 mL, with a mean of 1.24 mL +/- 0.905 (SD). When compared with the historic normal control group, the patients with symptoms of OSA aspirated significantly more radio-tracer (P <.01). There was a lack of association between respiratory disturbance index and amount aspirated.

CONCLUSIONS

The results suggest there is an apparent risk of increased pharyngeal aspiration in patients with symptoms of OSA.

Pneumonia in the very old

Pneumonia is a major medical problem in the very old. 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 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. The immune response decays with age, yet pneumococcal and influenza vaccines have their place for the prevention of pneumonia in the very old. Pneumonia in older individuals without terminal disease has to be distinguished from end-of-life pneumonia. In the latter setting, the attributable mortality of pneumonia is low and antibiotics have little effect on life expectancy and should be used only if they provide the best means to alleviate suffering. In this review, we focus on recent publications relative to CAP and NHAP in the very old, and discuss predisposing factors, microorganisms, diagnostic procedures, specific aspects of treatment, prevention, and ethical issues concerning end-of-life pneumonia.

Lung infections and aging

Respiratory tract infections are the leading cause of death due to infectious disease in the elderly. Many factors, especially waning immune responses and the onset of age-associated organ dysfunction, likely account for an increase in susceptibility to respiratory tract infection in the elderly, and morbidity and mortality rates are substantially greater for the elderly when outcomes are compared to that of younger individuals. The presence of underlying disease states such as chronic obstructive pulmonary disease (COPD) or other organ system disease further increases the likelihood of developing severe pneumonia in the elderly population, and the frail elderly, particularly when institutionalized in chronic care facilities, are at high risk for developing severe and recurrent pneumonia. This article will discuss various factors associated with advanced age that predispose the elderly to respiratory infections and summarize current approaches to treatment and prevention.

Ertapenem Therapy for Community-Acquired Pneumonia in the Elderly

OBJECTIVES

To compare the efficacy and safety of ertapenem, 1 g once a day, with ceftriaxone, 1 g once a day, for treatment of the subgroup of patients aged 65 and older with community-acquired pneumonia (CAP) requiring parenteral therapy.

DESIGN

Combined data from patients aged 65 and older in two randomized, double-blind clinical trials.

SETTING

Eighty international centers.

PARTICIPANTS

Eight hundred fifty-seven treated patients, of whom 351 were aged 65 and older.

INTERVENTIONS

Intravenous or intramuscular ertapenem or ceftriaxone with the option to switch to oral amoxicillin-clavulanate after at least 3 days of parenteral therapy.

MEASUREMENTS

Clinical efficacy was assessed at completion of parenteral therapy and 7 to 14 days after all therapy had been completed (test of cure (TOC) assessment). Bacterial eradication was assessed at the TOC visit. Safety was assessed daily during study therapy and for 14 days thereafter.

RESULTS

One hundred forty-eight clinically evaluable patients aged 65 and older were treated with ertapenem and 125 with ceftriaxone. Pathogens were identified in 157 (57.5%) patients (the most common being Streptococcus pneumoniae), most of which were penicillin-susceptible. Clinical cure rates were 95.9% for patients in the ertapenem group and 92.7% for patients in the ceftriaxone group at completion of parenteral therapy and 93.9% and 90.4%, respectively, at the TOC assessment. Overall bacterial eradication rates were 92.8% (77 of 83) for patients treated with ertapenem and 93.2% (69 of 74) for those treated with ceftriaxone. The most common drug-related adverse experiences in both treatment groups were diarrhea and mild to moderate elevation of serum aminotransferase levels.

CONCLUSION

Ertapenem 1 g once a day was highly effective for treatment of elderly patients with CAP requiring parenteral therapy and was as effective as ceftriaxone. Ertapenem was generally well tolerated, with an overall safety profile similar to ceftriaxone.

Aspiration pneumonia and dysphagia in the elderly

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in the elderly, and the leading cause of death among residents of nursing homes. Oropharyngeal aspiration is an important etiologic factor leading to pneumonia in the elderly. The incidence of cerebrovascular and degenerative neurologic diseases increase with aging, and these disorders are associated with dysphagia and an impaired cough reflex with the increased likelihood of oropharyngeal aspiration. Elderly patients with clinical signs suggestive of dysphagia and/or who have CAP should be referred for a swallow evaluation. Patients with dysphagia require a multidisciplinary approach to swallowing management. This may include swallow therapy, dietary modification, aggressive oral care, and consideration for treatment with an angiotensin-converting enzyme inhibitor.

Community-acquired pneumonia in very elderly patients: causative organisms, clinical characteristics, and outcomes

We performed an observational analysis of prospectively collected data on 1,474 adult patients who were hospitalized for community-acquired pneumonia; 1,169 patients were under 80 years of age and 305 (21%) patients were over 80 years ("very elderly"). Mean patient ages were 60 years in the former group and 85 years in the latter group. Severely immunosuppressed patients and nursing-home residents were not included. Comorbidities significantly associated with older age were chronic obstructive pulmonary disease, chronic heart disease, and dementia. The most common causative organism was Streptococcus pneumoniae (23% in both groups). Aspiration pneumonia was more frequent in the very elderly (5% in younger patients versus 10% in the very elderly); Legionella pneumophila (8% in younger patients versus 1% in the very elderly) and atypical agents (7% in younger patients versus 1% in the very elderly) were rarely recorded in the very elderly. While very elderly patients complained less frequently of pleuritic chest pain, headache, and myalgias, they were more likely to have absence of fever and altered mental status on admission. No significant differences were observed between groups as regards incidence of classic bacterial pneumonia syndrome (60% versus 59%) in 343 patients with pneumococcal pneumonia. The development of inhospital complications (26% in younger versus 32% in very elderly patients) as well as early mortality (2% in younger versus 7% in very elderly patients) and overall mortality (6% in younger versus 15% very elderly patients) were significantly higher in very elderly patients. Acute respiratory failure and shock/multiorgan failure were the most frequent causes of death, especially of early mortality. Factors independently associated with 30-day mortality in the very elderly were altered mental status on admission (odds ratio, 3.69), shock (odds ratio, 10.69), respiratory failure (odds ratio, 3.50), renal insufficiency (odds ratio, 5.83), and Gram-negative pneumonia (odds ratio, 20.27).

Scintigraphic method to detect silent aspiration during sleep in postsurgical patients with oral cancer

BACKGROUND

A simple method to detect silent aspiration during sleep has not been established in postsurgical oral cancer patients.

METHODS

Radioactive paste consisting of (99m)TcO(4) (-) and carboxylmethylcellulose was prepared and placed in a maxillary prosthesis with a cavity in the palatal space. The patient was requested to wear this appliance during sleep, and the following morning the patient was subjected to scintigraphic scanning. Both the anterior and posterior aspects of the thorax were scanned using a Shimazu Medical gamma camera with window settings adjusted to a low energy collimator at 500 kilocounts per image.

RESULTS

Silent aspiration that had not been detected by videofluoroscopic examination was clearly demonstrated by the scintigraphic method, showing aspiration of radioactive paste during sleep in the left thorax of the patient.

CONCLUSIONS

The method reported for establishing aspiration is simple and reliable to assess silent aspiration during sleep in patients with oral cancer.

Normative aging of the respiratory system

An absolute quantified normal rate of change and normal range of functions of the respiratory system applicable to all older adults as they age is elusive. Like life expectancy, which is dependent on a cohort effect, the norms of respiratory system function are related to the birth cohort to which a given individual belongs and the age at which the parameter is assessed. No single rate of change can express normal across all age ranges even for those individuals in apparently good health [29]. Analogous to defining risk factors for a disease, determining that a change in anatomy or physiology is not disease requires stringent prospective evaluation for the absence of occult disease and known risk factors for disease prior to concluding that the alteration is inevitable with the normal aging process [19,31]. Additional limitations in quantifying the norms of respiratory function with age are the lack of participation of the oldest adults in studies and the lack of precision and accuracy in these performance-based measurements. The data, although limited, do support a qualitative emphysematous change in lung histology and lung-thorax mechanics. This change plus altered lung volumes influence oxygenation and oxygen consumption. There is no evidence that the changes in the respiratory system with aging impact day-to-day function of older adults, but they may become evident under circumstances when physiologic demand reaches the limits of supply. Despite changes in cholinergic and adrenergic receptor functioning, there is no evidence to suggest altering prescribing these classes of medications for older people. Pioneer physiologists asked the original question "Is there a difference in this measurement for older people?" Researchers in pulmonary medicine, pathology, radiology, epidemiology, and public health have continued to revise the question toward the clinical implications while studying the aging process from their respective viewpoints. Clinicians who need to develop an integrated care plan should neither rely on formulas to "normalize" a measurement for age nor assume that a established predictive value of a diagnostic test done in young adults can be automatically applied to geriatric patients [4]. Rather, the clinical situation should consider that the variability in normal is greater with older age and that all diagnostic tests and care plans should be considered in the context of the patient's symptoms [5].

Community-acquired pneumonia in elderly patients

CAP in elderly patients carries a significant economic and clinical burden and will be more commonly encountered in the future as the US population ages. Diagnosis may be obscured by a nonclassic presentation in an elderly patient, and the clinician needs to be especially suspicious of pneumonia whenever the clinical status of an elderly patient deteriorates. The single most important clinical decision is the site of care; this determination is not always based on clinical factors but also on social factors. Severity assessment is key to stratifying appropriate therapy and to predicting outcome. Timely and appropriate empiric therapy enhances the likelihood of a good clinical outcome, although clinical resolution may be more delayed than in younger patients. Newly emerging patterns of antibiotic resistance have altered recent guidelines for CAP treatment; DRSP is now a consideration in elderly patients because an age older than 65 years is a well-described risk factor for infection with this organism. Prevention should always be implemented, with a focus on pneumococcal and influenza vaccination.

Acid aspiration induces bacterial pneumonia by enhanced bacterial adherence in mice

The issue of whether acid aspiration facilitates bacterial pneumonia caused by Pseudomonas aeruginosa by enhanced bacterial adherence was examined in mice. Survival or the number of bacteria in lung tissues was evaluated after an intratracheal challenge of hydrochloric acid (HCl), a sublethal dose of P. aeruginosa, or both in mice. Bacterial adherence to the tracheal epithelium after acid aspiration was also examined by scanning electron microscopy. A simultaneous intratracheal challenge of 50 microl of 10(-1) N HCl, but not 10(-2) to 10(-4) N HCl, combined with a sublethal dose of P. aeruginosa significantly increased the number of bacteria in the lung tissues and decreased survival, while all mice that received either HCl or P. aeruginosa survived. Significantly higher numbers of adherent bacteria on the tracheal epithelium were found in mice that received 10(-1)N HCl, compared with mice that received HCl (10(-2) to 10(-4) N) or saline. These data indicate that acid aspiration induced airway epithelial injury and enhanced P. aeruginosa adherence to the epithelium, and led to the subsequent development of bacterial pneumonia in mice. Enhanced bacterial adherence on the acid-injured epithelium may explain fatal bacterial pneumonias in patients with respiratory aspiration of gastric contents.

Aspiration-related illnesses: definitions and diagnosis

BACKGROUND

Aspiration is a leading cause of morbidity and mortality. It is the most common cause of pneumonia and one of the most serious adverse effects of enteral nutrition support. It is important to use standardized terminology to define and discuss aspiration-related illnesses.

METHODS

Review of the medical literature and extraction of definitions and descriptions of aspiration-related illnesses.

RESULTS

Definitions, clinical features, diagnosis, and treatment of common aspiration-related illnesses are discussed.

CONCLUSIONS

Precisely defined terminology of aspiration-related illnesses adds consistency to this area of medicine and simplifies analysis and comparison of clinical studies.

Aspiration pneumonia: incidence, mortality, and at-risk populations

Pulmonary aspiration in the hospitalized patient can be devastating. Most aspiration events occur in patients with a swallowing disorder. Aspiration can be divided into 3 separate etiologies: oropharyngeal bacteria, particulate matter, and acidified gastric contents. Reported prevalence data are extremely variable, ranging from 10% to 70%. Mortality is related to the volume and content of the aspirate and is reported to be as high as 70%. Neurologic dysfunction, decreased consciousness, advancing age, gastroesophageal reflux, and tube feeding are all potential risk factors for the development of aspiration.

Future considerations in aspiration pneumonia in the critically ill patient: what is not known, areas for future research, and experimental methods

The medical literature supports the use of enteral feeding to provide nutrition and improve patient outcomes. A major complication of enteral feeding is aspiration and associated morbidity and mortality. Many knowledge gaps exist that inhibit our ability to define and diagnose aspiration, identify patients at risk, and develop prevention techniques. Several areas of inquiry should be explored to help us define and prevent the disorder--for instance, standardized criteria should be developed for diagnosing aspiration pneumonia and for differentiating it from other types of pneumonia, and accurate tests should be devised for detecting it. Research also is needed to evaluate the influence of (1) various enteral feeding sites on aspiration risk, (2) the effects of risk reduction techniques such as selective decontamination and use of promotility agents, and (3) potential benefits of immunonutrition. Current parameters used in decisions about when to initiate enteral feeding in critically ill patients are defined.

Impact of invasive strategy on management of antimicrobial treatment failure in institutionalized older people with severe pneumonia

The aim of the study was to investigate the etiology and the impact of invasive quantitative sampling on the management of severe pneumonia in institutionalized older people with antimicrobial treatment failure. Fifty-two institutionalized patients aged 70 years and older hospitalized with a presumptive diagnosis of severe pneumonia and failure to respond to treatment after 72 hours of initiation of outpatient antimicrobial therapy were enrolled. Microbial investigation included blood culture, serology, pleural fluid, and bronchoalveolar samples. A definite etiology could be established in 24 of 52 (46%) patients. Methicillin-resistant Staphylococcus aureus (33%), enteric Gram-negative bacilli (24%), and Pseudomonas aeruginosa (14%) accounted for most isolates. Atypical infections (2%) were uncommon. Invasive bronchial sampling directed a change of microbial therapy in 8 (40%) and discontinuation of antibiotics in 2 of 20 cases (10%) of definite pneumonia. Overall hospital mortality was 42%. There was no difference in mortality among definite or unverified cases or those who had invasive bronchial sampling-guided change in therapy. We conclude that antimicrobial therapy should be targeted toward "nosocomial" pathogens in those institutionalized patients who received prior antibiotic treatment. When combined with microbial investigation, direct visualization of the tracheobronchial tree might be useful in determining the presence of bacterial pneumonia.

Effect of professional oral health care on the elderly living in nursing homes

OBJECTIVE

We evaluated the effectiveness of professional oral health care (POHC) given by dental hygienists once a week for 24 months to 141 elderly persons needing daily care and living in 2 nursing homes.

STUDY DESIGN

Elderly subjects with POHC and without POHC living in 2 nursing homes were examined for 24 months to detect any fevers of 37.8 degrees C or more and the prevalence of fatal aspiration pneumonia. The numbers of Staphylococcus species and Candida albicans in swab samples from oral cavities were compared between the POHC group and the non-POHC group. The amounts of methylmercaptan exhaled in the POHC group were determined and compared with those in the non-POHC group.

RESULTS

The prevalence of fevers of 37.8 degrees C or more in the subjects receiving POHC was significantly lower than in the non-POHC group (P < .05). We found that the ratio of fatal aspiration pneumonia in the POHC group during the 24 months was significantly lower than in the non-POHC group (P < .05). Numbers of C albicans species in samples obtained from the oral cavity after 6 months of POHC were significantly lower than those in the non-POHC group (P < .01). POHC resulted in the reduction of the presence of Staphylococcus but not to a statistically significant extent. The amounts of methylmercaptan exhaled by the POHC group were significantly less than those of the non-POHC group (P <.05).

CONCLUSION

This study showed that POHC administered by dental hygienists to a group of elderly patients needing daily nursing care was associated with a reduction in prevalence of fever and fatal pneumonia.

Deterioration of previous acute lung injury during neutropenia recovery

DESIGN

Although neutropenia recovery is associated with a high risk of deterioration of respiratory condition, no studies designed to identify risk factors for acute respiratory distress syndrome (ARDS) in this situation have been published.

SETTING

Medical ICU in a French teaching hospital.

SUBJECTS

We conducted a study to describe critically ill cancer patients with ARDS during neutropenia recovery (defined as the 7-day period centered on the day the neutrophil count rose above 1000/mm3 [day 0]) and to compare them with critically ill cancer patients without ARDS during neutropenia recovery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During a 10-yr period, 62 critically ill cancer patients recovered from neutropenia, of whom 21 experienced ARDS during neutropenia recovery, with a median time of -1 days (-2.5-1) between day 0 and ARDS. In-ICU mortality in these 21 patients was 61.9%. As compared with non-ARDS patients, ARDS patients were less likely to have myeloma and more likely to have leukemia/lymphoma treated with adriamycin, a history of pneumonia before neutropenia, and a neutropenia duration >10 days; they had a shorter time since malignancy diagnosis and a longer time from chemotherapy to neutropenia. Neither the leukocyte counts on day 0 nor those during the 6-day neutropenia recovery period were predictive of ARDS.

CONCLUSIONS

Patients with acute respiratory failure after prolonged neutropenia complicated by pneumonia are at increased risk for ARDS.

Oral care reduces pneumonia in older patients in nursing homes

OBJECTIVES

Aspiration of oral secretions and their bacteria is increasingly being recognized as an important factor in pneumonia. We investigated whether oral care lowers the frequency of pneumonia in institutionalized older people.

DESIGN

Survey.

SETTING

Eleven nursing homes in Japan.

PARTICIPANTS

Four hundred seventeen patients randomly assigned to an oral care group or a no oral care group.

INTERVENTION

Nurses or caregivers cleaned the patients' teeth by toothbrush after each meal. Swabbing with povidone iodine was additionally used in some cases. Dentists or dental hygienists provided professional care once a week.

MEASUREMENTS

Pneumonia, febrile days, death from pneumonia, activities of daily living, and cognitive functions.

RESULTS

During follow-up, pneumonia, febrile days, and death from pneumonia decreased significantly in patients with oral care. Oral care was beneficial in edentate and dentate patients. Activities of daily living and cognitive functions showed a tendency to improve with oral care.

CONCLUSION

We suggest that oral care may be useful in preventing pneumonia in older patients in nursing homes.

Deletion allele of the angiotensin-converting enzyme gene as a risk factor for pneumonia in elderly patients

PURPOSE

Aspiration due to an age-related reduction in cough is a major cause of pneumonia in elderly persons. Because the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene (ACE) has been associated with the cough reflex, we studied whether this genetic polymorphism was also associated with the risk of pneumonia.

SUBJECTS AND METHODS

We studied 1011 elderly inpatients (221 men and 790 women, mean [+/- SD] age of 82 +/- 7 years) in a long-term care hospital. The association between the ACE I/D polymorphism and the incidence of pneumonia (defined using specific criteria that included radiographic abnormalities) was assessed during an 8-month period that excluded the winter. Data were analyzed using proportional hazards models, with adjustment for age, sex, and other potential confounders.

RESULTS

During follow-up, 87 cases (9%) of pneumonia occurred, 38 of which were fatal. The ACE DD allele (vs. ID + II) was associated with an increased risk of pneumonia (relative risk [RR] = 2.9; 95% confidence interval [CI]: 1.7 to 4.8, P < 0.001) and fatal pneumonia [RR = 4.4; 95% CI: 2.1 to 9.0; P < 0.0001).

CONCLUSIONS

The ACE D allele is an independent risk factor for pneumonia in elderly persons.

Acid stimulation reduces bactericidal activity of surface liquid in cultured human airway epithelial cells

To examine the effects of acid exposure with moderate acidity (pH 3.0-5.0) on bactericidal activity of airway surface liquid (ASL), ASL was collected by washing the surface of primary cultures of human tracheal epithelial cells 24 h after treatment with phosphate-buffered saline (PBS) adjusted to a pH of 3.0, 4.0, or 5.0. In all ASL, bactericidal activity was sensitive to sodium concentration. Escherichia coli (500 colony forming units [CFU]) was incubated in ASL, and the number of surviving bacteria was examined. The number of surviving bacteria in ASL from cultured cells with acid exposure at pH 3.0-5.0 was significantly higher than that in control ASL. The minimum inhibitory dilution ratio of ASL against 500 CFU of E. coli was also examined by microdilution assays. According to this assay, the bactericidal activity in ASL with acid challenge at a pH of 3.0 was less than half of that in control ASL. Reverse transcription-polymerase chain reaction and Western blot analysis showed that the production of mRNA and protein of human beta-defensin (HBD)-1 were significantly decreased by acid exposure at pH 3.0-5.0. In contrast, acid exposure did not change the production of mRNA and protein of HBD-2 and beta-actin mRNA. These results indicate that acid exposure, even with moderate acidity, may inhibit the production of bactericidal molecules, including HBD-1, in airway epithelial cells. Acid exposure may reduce bactericidal activity of ASL in human airway epithelial cells and may increase susceptibility of the airway to bacterial infection.

Inhibiting bacteria and skin pH in hemiplegia: effects of washing hands with acidic mineral water

OBJECTIVE

To evaluate bacterial flora in hemiplegic hands as a possible pathogen of endogenous infection in a rehabilitation unit and to examine the effect of cleansing hands with acidic mineral water on the flora.

DESIGN

Case-control study in a university affiliated hospital. Seventy-two patients with hemiplegia caused by cerebrovascular diseases were included in this study. Bacterial flora by the swab method, bacterial frequency on the palm by the stamp method, and skin surface pH were examined before and after single cleansing by immersion in plain or acidic mineral water.

RESULTS

The bacterial frequencies of patients with hemiplegia and diabetes were higher than those of normal healthy subjects. After cleansing with acidic mineral water, skin surface pH was decreased and bacterial frequency was markedly decreased. A prolonged decrease in skin surface pH was observed in patients with hemiplegia in contrast to normal healthy subjects who presented a short-term decrease.

CONCLUSION

Increased bacterial frequencies were associated with a high skin surface pH caused by disordered skin systems in patients with hemiplegia. Acidic mineral water may be useful for inhibiting bacterial growth in patients with hemiplegia.

Introduction of simple swallowing ability test for prevention of aspiration pneumonia in the elderly and investigation of factors of swallowing disorders

Aspiration pneumonia is a major cause of death in the elderly. In this study, a water swallowing test was introduced as a method of evaluating the swallowing ability of patients, and a swallowing ability evaluation team investigated an appropriate procedure and evaluation method for the situation of our hospital. We also investigated the relationship between the swallowing ability of patients examined by the water swallowing test and underlying diseases, complications, and medicated drugs. In the water swallowing test, the water-drinking method was fixed, and evaluation was made based on the time required for drinking, profile, and episodes, by which patients suspected of swallowing disorder were detected, confirming the usefulness of this method. The frequency of developing swallowing disorder was significantly higher in patients with cerebrovascular disorders, Parkinson's syndrome (p < 0.01, respectively) and symptomatic epilepsy, hypertension (p < 0.05, respectively) as underlying disease/complication. Regarding medicated drugs, H2 blockers were related to swallowing disorder (p < 0.05). It was confirmed that patients who were judged as having swallowing disorder (including suspected cases) by the water swallowing test, and patients with underlying diseases and complication that may cause the disorder, and patients medicated with drugs that may affect the swallowing ability require appropriate management by medical care staff.