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The specificities of pneumonia in elderly patients

Defense Thèse de privat-docent : Univ. Genève, 2018
Abstract The incidence of pneumonia increases with age. Making an accurate clinical diagnosis of pneumonia is difficult in very elderly adults because of certain clinical specificities, the presence of cognitive and behavioural disorders, and the decompensation of concomitant comorbidities. Roles for computed tomography (CT) and thoracic ultrasound look promising, especially in helping to diminish false-positive diagnoses of pneumonia, but evidence for the use of these imaging techniques will require reinforcement via pragmatic studies. Progress in the field of aetiological diagnosis has revealed evidence of the non-negligible roles played by viruses and bacterial–viral co-infections. A new concept of the physiopathology of pneumonias is emerging according to which the disease is a consequence of a homeostatic disequilibrium that affects the microbiota in the airways. Whether the changes in the microbiome are a cause or consequence of the development of pneumonia is a question for the future. Although the Pneumonia Severity Index (PSI) and CURB65 (confusion, uraemia, respiratory rate, blood pressure, age ≥ 65 years) remain the most frequently used pneumonia severity scores, it is important to remember that they are not a substitute for clinical judgment. With regards to treatments using antibiotics, few therapeutic trials have been carried out involving very elderly subjects, despite changes in numerous parameters, such as creatinine clearance, in this population. Indeed, most international guidelines are based on studies carried out on younger adults. Following the recommended guidelines for the management of pneumonia remains an important issue, notably with regard to the correct choice of antibiotic, in order to avoid the emergence of bacterial resistance. Some experts have drawn attention to the increased risk of Clostridium difficile-associated infection when treating bacteria using macrolides and they instead propose doxycycline for patients managed in outpatient units. Nevertheless, therapeutic trials to validate this proposition are eagerly awaited. Corticosteroids have a beneficial effect on the sub-group of patients with very significant inflammation. Using a procalcitonin (PCT) test or the C-reactive protein (CRP) marker may also help to guide treatment. Meta-analyses have shown that the treatment duration can be inferior to seven days in cases involving non-severe pneumonia. It is important that any decompensating organs accompanying the pneumonia are also treated. Finally, recent studies have shown increases in cardiovascular morbidity and mortality extending numerous years after the episode of pneumonia, and this should be remembered in the patient's long-term follow-up. Hospital discharge cannot be prescribed until the patient has met all the criteria for clinical stability, yet to the best of our knowledge, these have never been studied in very elderly populations of ≥ 85 years old. Age alone should not be a reason to refuse intensive care, and numerous other parameters should be evaluated, such as the patient's nutritional, functional and cognitive status, as well as his or her advance directives. It is imperative to discuss treatment plans with patients immediately they are admitted to hospital. Although vaccination is one of the quality criteria for pneumonia management, the possible preventive measures of good oral hygiene and attentiveness to swallowing disorders should not be forgotten.
Keywords PneumoniaElderly patientsDiagnosis
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PRENDKI, Virginie. The specificities of pneumonia in elderly patients. Université de Genève. Thèse de privat-docent, 2018. doi: 10.13097/archive-ouverte/unige:106349 https://archive-ouverte.unige.ch/unige:106349

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Deposited on : 2018-07-10

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