Compared with community dwelling older adults, RACF residents acquire pneumonia at a rate of 10 times higher, and are admitted to hospital 30 times more often. Pneumonia is the leading cause of death among aged care home residents, accounting for one-third to one half of all deaths. Survivors have high rates of re-hospitalisation, long term morbidity and mortality.
Pneumonia can be hospital acquired or community acquired. Aged care home acquired pneumonia is a recognised variant of community acquired pneumonia. In aged care homes, compared to the general community, Streptococcus pneumoniae remains the commonest cause, and there are higher rates of gram negative bacilli, Staphylococcus aureus and respiratory viruses, and lower rates of atypical pathogens (legionella, chlamydia and mycoplasma).
Aspiration may lead to either pneumonia or noninfectious chemical pneumonitis (which does not require antibiotics). However differentiating between the two can be difficult.239 Aspiration pneumonia may be caused by a wider range of organisms than community acquired pneumonia, including Staphylococcus aureus, Haemophilus influenzae, Gram negative aerobes and anaerobes. Recommended antibiotic treatment of moderately severe illness is 10 days of oral clindamycin (450 mg 3 times per day), or amoxicillin with clavulanic acid (500 mg/125 mg 3 times per day). Severe aspiration pneumonia requires hospital admission for intravenous therapy240 (see Dysphagia and Aspiration).
It is important to identify 'end of life' pneumonia that has little attributable mortality, and where antibiotics have little impact on life expectancy. However, antibiotics may be appropriate for the relief of symptoms within a palliative care context.
Pneumococcal vaccination with 23vPPV is recommended for adults 65 years and over, and Aboriginal and Torres Straight Islander peoples 50 years and over, with a single re-vaccination 5 years later. Vaccination can be done concurrently with influenza vaccination or at any other time of the year. Vaccination is not recommended for residents who have been vaccinated within the past 3 years because of increased risk of local adverse reactions; or for individuals who have recently had immunosuppressants or radiation of lymph nodes.241
Risk of pneumonia can be reduced by optimal management of predisposing factors such as dysphagia, asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart failure, cerebral vascular disease, immobility, debility, oral hygiene and feeding problems; and by minimising the use of corticosteroids. Prophylactic antibiotics have not been shown to reduce risk, and may lead to resistant organisms.
Common presenting symptoms of pneumonia are: a new cough, sputum, fever, rigors, breathlessness, wheezing, pleuritic chest pain, sore throat and head cold symptoms. However, classic symptoms are often absent in the elderly. Symptoms are often nonspecific, and include tachypnoea, lethargy, functional decline, incontinence (new onset), alteration in sleep-wake cycles, loss of appetite, increased confusion or agitation.
Common differential diagnoses are pulmonary embolism, pulmonary oedema, malignancy, and aspiration pneumonitis.
Investigations to confirm diagnosis, assess severity and guide treatment include chest X-ray, pulse oximetry (oxygen saturation of less than 90% predicts short term mortality), full blood count (FBC), urea and electrolytes (U&E) and glucose. Sputum cultures are useful if a deep cough specimen can be obtained before antibiotic therapy and processed in the laboratory within 1-2 hours of collection. General practitioners may also consider culture for mycobacterium tuberculosis for residents with an identified risk of tuberculosis, urinary antigen test for Legionella pneumophila type 1, or blood cultures in patients with severe pneumonia.
- antimicrobial therapy
- paracetamol for pain relief and antipyretic action
- supportive nursing care and monitoring
- decision on whether the patient can be safely managed in the RACF.
Initial antibiotic therapy is based on the severity of clinical presentation, expected microbial patterns, and antibiotic resistance. Several validated risk scoring systems have been developed such as the pneumonia severity index (PSI)242 but these require laboratory testing which may be difficult to perform in many RACFs. In the following clinical assessment scale, patients displaying two or more features are defined as having severe pneumonia with high risk of mortality (>30%):
- respiratory rate >30/min
- pulse >125/min
- acute change in mental state
- hypotension (systolic <90 mmHg and/or diastolic <60 mmHg and/or 20 mmHg less than patient's baseline
- history of dementia, cardiovascular disease, liver disease or renal failure
- requiring oxygen at a rate >3 L/min.
Patients with mild to moderate pneumonia and good functional status seem to do better with treatment in the RACF. Patients with severe pneumonia may have lower acute mortality if hospitalised initially, although longer term mortality may not be improved. Minor aspiration may not require antibiotic treatment, and aspiration pneumonia will require coverage for anaerobic organisms. (See guidelines for recommended treatment regimens).243, 244
Assess the resident's response to treatment daily and seek specialist advice if there is no improvement within 48 hours, if the patient is immunosuppressed or may have tropical cause of pneumonia. Inform public health authorities if a notifiable disease is suspected, ie. tuberculosis or legionella.
One-third of older adults presenting with pneumonia are found to have asthma or COPD within 3 years of the pneumonia episode. It is recommended that spirometry be performed in the convalescence period to diagnosis any underlying asthma or COPD, particularly if the resident exhibited diffuse wheeze and crackles on auscultation during the pneumonia episode.