Pneumonia in the elderly

Pneumonia in the elderly is an acute infectious disease, predominantly of a bacterial etiology, characterized by focal lesions of the respiratory parts of the lungs, the presence of intraalveolar exudation revealed by physical or instrumental examination, expressed in varying degrees by a febrile reaction and intoxication.

[1], [2], [3], [4]

Epidemiology

Pneumonia in the elderly is one of the most common diseases: in Ukraine, the average incidence rates are 10-15%. The risk of developing pneumonia increases with age. The prevalence of community-acquired pneumonia among elderly and senile people in the United States is 20-40%. Mortality in pneumonia among patients over 60 years is 10 times higher than in other age groups, and reaches 10-15% in pneumococcal pneumonia.

[5], [6], [7], [8], [9], [10], [11], [12],

Symptoms of the pneumonia in the elderly

Clinical manifestations of pneumonia are made up of pulmonary and extrapulmonary symptoms.

Pulmonary manifestations

Cough, unproductive or with the separation of sputum, is a frequent manifestation of pneumonia. However, in attenuated patients with oppression of the cough reflex (stroke, Alzheimer's disease), it is often absent.

A characteristic sign of pneumonia is shortness of breath, which can be one of the main (and sometimes the only) of its manifestations in the elderly.

The inflammatory process in the lung tissue, spreading to the pleura, causes in patients a feeling of heaviness and pain in the chest. In these cases, a pleural friction noise is heard.

With pneumonia in elderly patients, such classical signs as dullness of percussion sound, crepitation are not always clearly expressed, and sometimes - absent. This can be explained by the fact that the phenomenon of compaction of pulmonary tissue in pneumonia in the elderly does not always reach the degree that would be sufficient to form these features. Often the dehydration in elderly patients due to various causes (gastrointestinal tract damage, tumor process, diuretic treatment), limits exudation to the alveoli, making it difficult to form a pulmonary infiltrate.

In elderly patients it is difficult to unambiguously interpret the signs of pulmonary tissue damage revealed during percussion and auscultation due to the presence of! Background pathology - heart failure, lung tumor, chronic obstructive pulmonary disease - COPD. Thus, percussion dullness with pneumonia is difficult to distinguish from atelectasis, bronchial breathing with the presence of wheezing may be a consequence of the presence of a pneumosclerotic site, wet small-bubbling rales can be heard at left ventricular failure. The erroneous interpretation of auscultatory data is the most common cause of clinical overdiagnosis of pneumonia in the elderly.

Extrapulmonary symptoms

Fever in pneumonia in the elderly and old age is observed quite often (75-80%), although compared with patients of other age groups, the disease often occurs with a normal or even low temperature, which is a prognostically less favorable sign. Frequent manifestations of pneumonia in the elderly are violations of the central nervous system in the form of apathy, drowsiness, inhibition, loss of appetite, confusion, until the development of a co-morbid condition.

In some cases, the first manifestations of pneumonia are a sudden disruption of physical activity, loss of interest in the environment, refusal to eat, urinary incontinence. Such situations are sometimes mistakenly interpreted as a manifestation of senile dementia.

From the clinical symptoms of pneumonia in the elderly, the decompensation of background diseases may come to the fore. Thus, in patients with COPD, the clinical manifestations of pneumonia may be characterized by increased cough, the appearance of respiratory failure, which can be mistakenly regarded as an exacerbation of chronic bronchitis. With the development of pneumonia in a patient with congestive heart failure, the latter can progress and become refractory (resistant) to treatment.

Markers of pneumonia can be, decompensation of diabetes mellitus with the development of ketoacidosis (in elderly patients with diabetes mellitus); the appearance of signs of liver failure in patients with liver cirrhosis; development or progression of renal failure in patients with chronic pyelonephritis.

Leukocytosis may be absent in a third of patients with pneumonia, which is an unfavorable prognostic sign, especially in the presence of a neutrophil shift. These laboratory changes have no age-specific features.

[13]

Treatment of the pneumonia in the elderly

Classification, most fully reflecting the characteristics of the course of community-acquired pneumonia and allowing to substantiate etiotropic therapy, is based on the definition of the causative agent of the disease. However, in practice, the clarification of the etiology of pneumonia is unrealistic because of the lack of information and the considerable duration of traditional microbiological studies. In addition, the elderly in 50% of cases there is no productive cough in the early period of the disease.

At the same time, the treatment of pneumonia should be started urgently when establishing a clinical diagnosis.

In a number of cases (20-45%), even if there are adequate sputum samples, it is not possible to identify the pathogen.

Therefore, in practice, the most often used empirical approach to the selection of etiotropic therapy. Treatment of patients older than 60 years can be performed on an outpatient basis. For this purpose it is recommended to use protected aminopenicillins or cephalosporins of the second generation. Due to the high risk of Legionella or chlamydial etiology of pneumonia, it is advisable to combine preparations of the above mentioned groups with macrolide antibiotics (erythromycin, rovamycin), increasing the duration of therapy to 14-21 days (with legionellosis).

Patients with clinically severe pneumonia are required to be hospitalized, the signs of which are: cyanosis and shortness of breath for more than 30 breaths per minute, confused consciousness, high fever, tachycardia not corresponding to the degree of fever, arterial hypotension (systolic blood pressure below 100 mmHg and (or) diastolic blood pressure below 60 mm Hg). In severe community-acquired pneumonia, it is recommended to use cephalosporins of the third generation (claforan) in combination with parenteral macrolides. Recently, it has been proposed to use stepwise antibacterial therapy with the stabilization or improvement of the inflammatory process in the lungs. The optimal variant of this technique is the consistent use of two dosage forms (for parenteral administration and for oral administration) of the same antibiotic, which ensures continuity of treatment. The transition to oral administration of the drug becomes possible 2-3 days after the start of treatment. For this type of therapy can be used: ampicillin sodium and ampicillin trihydrate, sulbactam and ampicillin, amoxicillin / clavunate, ofloxacin, cefuroxime sodium and cefuroxime acetyl, erythromycin.

Antibiotics for the treatment of pneumonia in the elderly

[14], [15], [16], [17], [18], [19], [20]

Benzippeicidulin

Is highly active against the most common causative agent of community-acquired pneumonia - S. Pneumoniae. In recent years there has been an increase in the resistance of pneumococci to penicillin, and in some countries its level reaches 40%, which limits the use of this drug.

[21], [22], [23]

Aminopenicillins (ampicillin, amoxicillin)

Characterized by a broader spectrum of activity than benzylpenicillins, but unstable to beta-lactamases of staphylococci and Gram-negative bacteria. Amoxicillin has an advantage over ampicillin, since it is better absorbed in the gastrointestinal tract, less dosed and better tolerated. Amoxicillin can be used with a mild pneumonia in outpatient practice in elderly patients without concomitant pathology.

[24], [25], [26], [27], [28], [29]

Protected aminopenicillins - amoxicilav / kpavulanate

Unlike ampicillin and amoxicillin, the drug is active against strains of B-lactamase producing bacteria that are inhibited by clavulanate, which is part of it. Amoxicillin / clavulanate is highly active against most pathogens of community-acquired pneumonia in the elderly, including anaerobes. Currently considered as a leading drug in the treatment of community-acquired infections of the respiratory tract.

The presence of the parenteral form allows the use of the drug in hospitalized patients with severe pneumonia.

Cefuroxime

Refers to cephalosporins of the second generation. The spectrum of action is close to amoxicillin / clavulanate, with the exception of anaerobic microorganisms. Strains of pneumococcus, resistant to penicillin, can be resistant to cefuroxime. This drug is considered as a first-line agent in the treatment of community-acquired pneumonia in geriatric patients.

[30], [31], [32]

Cefotaxime and ceftriaxone

Relate to parenteral cephalosporins of the third generation. They are highly active against most Gram-negative bacteria and pneumococci, including strains resistant to penicillin. They are the drugs of choice in the treatment of severe pneumonia in the elderly. Ceftriaxone is the optimal drug for parenteral treatment of elderly patients with pneumonia at home because of the convenience of administration - once a day.

[33], [34], [35], [36], [37]

Macrolides

In elderly patients, the importance of macrolides is limited due to the characteristics of the spectrum of pathogens. In addition, in recent years, there has been an increase in the resistance of pneumococci and hemophilic rods to macrolides. Macrolides of the elderly should be administered in combination with third-generation cephalosporins in severe pneumonia.

Other treatment of pneumonia in the elderly

The effect of therapy largely depends on the correct use of cardiac agents affecting the function of respiration (camphor, cardiamine), cardiac glycosides, coronarolytics and, if necessary, antiarrhythmic agents.

As antitussive agents with persistent dry cough used drugs that do not have a negative effect on the drainage function of the bronchi (balticks, intussin).

The appointment of expectorant and mucolytic agents is an important link in complex therapy. Usually used: bromhexine, ambroxol, mucaltin, 1-3% aqueous solution of potassium iodide, infusion of thermopsis, alteynic root, leaves of mother-and-stepmother, plantain, breast-collecting.

Great attention should be paid to the organization of treatment, care and monitoring of patients with pneumonia. B feverish period requires bed rest and individual fasting or stay in the intensive care unit, control of hemodynamic parameters and the degree of respiratory failure. Important psychological support, early activation of the patient, because people of the elderly and senile are very sensitive to hypodynamia.

Food should be easily digestible, rich in vitamins (especially vitamins C). It should be given often (up to 6 times a day). Abundant drink (about 2 liters) in the form of green tea, mors, compote, broth.

When bed rest, constipation is often observed, caused mainly by intestinal atony. When inclined to constipation shows the inclusion in the diet of fruit juices, apples, beets and other vegetables and fruits that stimulate peristalsis of the intestine.

Reception of light laxatives of plant origin (preparations of buckthorn, Senna), slightly alkaline mineral waters. Without special indications, it is not necessary to limit the intake of liquid (less than 1-1.5 liters per day), as this can contribute to the increase of constipation.

Pneumonia in the elderly lasts about 4 weeks before the normalization of the main clinical and laboratory indicators. However, the restoration of the structure of the lung tissue can be delayed up to 6 months. Therefore, it is extremely important to conduct a complex of medical and recreational activities in outpatient settings. He must! Include clinical and laboratory and roentgenological examination after 1-3-5 months, the use of vitamins and antioxidants, bronchodilators and expectorants, sanitation of the oral cavity and upper respiratory tract, cessation of smoking, physical therapy, exercise therapy, and, if possible, a sanatorium treatment.