|Year : 2020 | Volume
| Issue : 1 | Page : 20-23
Clinical profile and predictors of mortality in the elderly with community-acquired pneumonia at a tertiary care hospital in South India
Pranita Harshad Vanjare, Gopinath Kangogopal, Benny Paul Wilson, Surekha Viggeswarpu
Department of Geriatrics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
|Date of Submission||14-Feb-2019|
|Date of Decision||16-Apr-2019|
|Date of Acceptance||21-Jun-2019|
|Date of Web Publication||19-Jun-2020|
Benny Paul Wilson
Department of Geriatrics, Christian Medical College and Hospital, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Community-acquired pneumonia (CAP) is a common and the second-most common infectious cause of hospitalization and mortality in the elderly. There are limited data available on age-specific incidence, predictors, pattern of care, and mortality of CAP in the elderly in India. Materials and Methods: We performed a retrospective study of 108 patients over 60 years of age with CAP admitted to a tertiary care center. Death and discharge against medical advice were considered as poor outcomes. Risk factor for poor outcomes was assessed with multivariable variable logistic regression analysis. Results: The mean age of the study population was 70.4 ± 8.1 years. The overall inpatient mortality was 38%. Factors independently associated with mortality were the presence of delirium 5.4 (confidence interval 1.4–14.9;P= 0.009), mechanical ventilation (P ≤ 0.0001), and prolonged hospital stay (P ≤ 0.0001). Patients >75 years had a poor outcome as compared to <75 years (P = 0.09). Bacteremia was present only in 6.1% of patients. Conclusion: CAP in the elderly had a high risk of poor outcomes. Delirium at presentation and need for mechanical ventilation were important risk factors for mortality.
Keywords: Community-acquired pneumonia, delirium, elderly, mortality
|How to cite this article:|
Vanjare PH, Kangogopal G, Wilson BP, Viggeswarpu S. Clinical profile and predictors of mortality in the elderly with community-acquired pneumonia at a tertiary care hospital in South India. CHRISMED J Health Res 2020;7:20-3
|How to cite this URL:|
Vanjare PH, Kangogopal G, Wilson BP, Viggeswarpu S. Clinical profile and predictors of mortality in the elderly with community-acquired pneumonia at a tertiary care hospital in South India. CHRISMED J Health Res [serial online] 2020 [cited 2021 Mar 3];7:20-3. Available from: https://www.cjhr.org/text.asp?2020/7/1/20/286879
| Introduction|| |
Community-acquired pneumonia (CAP) is a common illness and leading cause of death among older adults. Incidence is the highest at the extreme of age. CAP remains a significant threat, especially to the elderly, and it is the most common infectious cause of hospitalization and mortality in them. The annual incidence of CAP in elderly patients is estimated to be 25–44 cases/1000 persons, and mortality rate in Asia is reported as 7.3%.
Studies have reported mortality rates of hospitalized older patients with CAP ranging from 9% to 33% and doubling as the age increased from 65 to 69 years. The high incidence of CAP in the older adults is due to the physiological changes associated with aging, the respiratory tract and immune system, and the presence of multiple comorbidities. It is important to remember that pneumonia in the elderly may present with few respiratory symptoms and instead may manifest as geriatric syndrome such as delirium.
The objective of the present study was to describe the clinical, etiological profile, and risk factors associated with poor outcomes in the elderly admitted with CAP.
| Materials And Methods|| |
This was a retrospective study carried out in the geriatric medicine department of a tertiary care center in South India from 2008 to 2012. One hundred and eight consecutive patients with CAP aged 60 years and older were analyzed. CAP was defined as a new infiltrate on a chest radiograph plus either 1 major or 2 min or criteria. Major criteria include cough, sputum production, fever, or hypothermia. Minor criteria include pleuritic chest pain, dyspnea, altered mental status, abnormal chest examination finding, leukocytosis, or left shift. Patients who had clinical features of other infections, immunodeficiency states, and hospital-acquired pneumonia were excluded from the study. The study protocol was approved by the Institutional Review Board.
The details were extracted from the electronic discharge records and inpatient case records. We collected sociodemographic data such as age, sex, and smoking, clinical data (sign and symptoms), comorbidities using the Charlson comorbidity index, and data on clinical course of the case (outcome, length of hospital stay, and mechanical ventilation). Delirium was diagnosed based on collateral history of recent change and fluctuation in sensorium along with the confusion assessment method. Laboratory investigations included total and differential white cell counts, serum albumin, inflammatory markers in the form of c-reactive protein or procalcitonin, and details of the organism grown in sputum or blood cultures.
Patients who died and those discharged against medical advice were grouped as patients with poor outcome. Length of hospital stay was calculated from the time of admission to the ward till the time of discharge.
| Results|| |
One hundred and eight patients with CAP were included in the study. The mean age of the population was 70.4 ± 8.1 years and 76% of the patients were male.
Demographic and baseline characteristics are presented in [Table 1]. The mean duration of illness is 6.4 days. The most common underlying comorbidity for all patients was diabetes mellitus (71%), followed by hypertension in 50%, and chronic obstructive airway disease in 26% of the patients. Current and history of smoking was presented in 22% of patients. Blood culture yielded microorganism in six patients, out of these four had poor outcome (9.8%). Multi-organ dysfunction syndrome was seen in 30% of patients; however, only respiratory failure was seen in 10% of patients. Nearly 33% of patients required inotropic supports.
Although patients with poor outcome had more delirium (40%) and prolonged longer hospital stay (68%), bilateral pneumonia and pleural effusion did not show a significant difference between the two groups. CAP-related mortality was seen in 38% of patients. Simple logistic regression analysis [Table 2] showed that patients with poor outcome were more aged, had delirium (P = 0.01), had mechanical ventilation (P ≤ 0.001), and prolonged hospital stay (P ≤ 0.001). The patient who died had lower serum albumin (P = 0.26).
|Table 2: Association of risk factors on poor outcome using simple logistic regression|
Click here to view
In multivariate analysis, delirium, mechanical ventilation, and prolonged hospital stay were found to be associated with poor outcome (mortality) [Table 3].
|Table 3: Association of risk factors on poor outcome using multivariate logistic regression|
Click here to view
Descriptive statistics, including means and standard deviations, were used to summarize the age of the patients. For categorical data, the number and percentage were presented. For analysis of factors affecting outcome, we used the Pearson's coefficient, Chi-square test, and Fisher's-exact test to test for an association between the poor outcome (mortality) and the following binary variables: demographic and clinical features. Simple logistic regression analysis was used to assess the relation between poor outcome and each risk factor alone. Finally, multivariate logistic regression model was used to assess the impact of delirium, mechanical ventilation, and hospital stay on the poor outcome. All tests were two-sided at α = 0.05 level of significance. All analyses were performed using the Statistical Package for the Social Sciences software version 21.0 (Armonk, NY, USA: IBM Corp).
| Discussion|| |
Mortality associated with CAP in the elderly is still high. The overall mortality in this study was higher than prior studies from Malaysia, Indonesia, and the Philippines. In a population-based study in more than 65 years of age, the inpatient mortality was 12%. Most of the studies revealed mortality range 10%–30% in those >65 years of age. A study done in AIIMS in India showed similar results as per our study, with 35% mortality. Higher mortality in this study may be due to ours being tertiary care center with referral bias.
This study found that age >75 years is another important risk factor for mortality in pneumonia. Similar finding was observed in a study conducted by Han et al., in-hospital and 60 days mortality in age >85 years were three times more than 64–75 years.
This study also focuses on difficulty diagnosing pneumonia in the elderly because of atypical presentation. Delirium was seen in a large number of our patients and was also associated with the poor outcome. A study by Aliberti et al. also showed the high (44%) prevalence of delirium in patients who died of severe pneumonia. Elderly patients may not present with typical symptoms of pneumonia making difficult for physicians to diagnose. In this study, fever and cough were absent in 18% and 33%, respectively, of patients and did not showed significance with mortality. The absence of respiratory symptoms and fever is also mentioned in other studies. Our studies thus highlight the importance of nonrespiratory and neurological symptom like delirium as presenting complaints in elderly patients with CAP.
In our study, blood culture was positive in only 6.1% of patients. Studies have shown 7%–16% positivity of initial positive blood culture in patient admitted with pneumonia. Study in Japan showed only 4.4% of the positive rate of blood culture in patients admitted with CAP.
With the increase projected in elderly population by the year 2025, it is imperative. Strategies directed at improving the evaluation, diagnosis, and treatment and prevention of CAP are imperative and should be specifically focused on this population. Comorbidities are more common in the elderly.
Our study had some limitations. First, our study was a retrospective study based on electronic records performed in single center. Second, functional status of the patients was not available. Third, confusion, urea nitrogen, respiratory rate, and blood pressure 65 score was not calculated for most of the patients, and vaccination data were also not available.
| Conclusion|| |
CAP in the elderly has different clinical presentation and higher mortality. Elderly patient with pneumonia may present with atypical presentation like delirium rather than typical presentation of pneumonia. This may lead to delay in the diagnosis and initiation of treatment. The following prognostic factors shown to have associated with mortality, delirium, mechanical ventilation, and prolonged hospital stay. However, prospective study on larger number of patients is required to substantiate these findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al.
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the global burden of disease study 2010. Lancet 2012;380:2095-128.
Jokinen C, Heiskanen L, Juvonen H, Kallinen S, Karkola K, Korppi M, et al.
Incidence of community-acquired pneumonia in the population of four municipalities in Eastern Finland. Am J Epidemiol 1993;137:977-88.
Janssens JP, Krause KH. Pneumonia in the very old. Lancet Infect Dis 2004;4:112-24.
Song JH, Oh WS, Kang CI, Chung DR, Peck KR, Ko KS, et al.
Epidemiology and clinical outcomes of community-acquired pneumonia in adult patients in Asian countries: A prospective study by the Asian network for surveillance of resistant pathogens. Int J Antimicrob Agents 2008;31:107-14.
Kaplan V, Angus DC, Griffin MF, Clermont G, Scott Watson R, Linde-Zwirble WT. Hospitalized community-acquired pneumonia in the elderly: Age- and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med 2002;165:766-72.
Sharma G, Goodwin J. Effect of aging on respiratory system physiology and immunology. Clin Interv Aging 2006;1:253-60.
Lipsky BA, Boyko EJ, Inui TS, Koepsell TD. Risk factors for acquiring pneumococcal infections. Arch Intern Med 1986;146:2179-85.
Yoshikawa TT, Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect Dis 2000;31:1066-78.
Park DR, Sherbin VL, Goodman MS, Pacifico AD, Rubenfeld GD, Polissar NL, et al.
The etiology of community-acquired pneumonia at an urban public hospital: Influence of human immunodeficiency virus infection and initial severity of illness. J Infect Dis 2001;184:268-77.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941-8.
Azmi S, Aljunid SM, Maimaiti N, Ali AA, Muhammad Nur A, De Rosas-Valera M, et al.
Assessing the burden of pneumonia using administrative data from Malaysia, Indonesia, and the Philippines. Int J Infect Dis 2016;49:87-93.
Ochoa-Gondar O, Vila-Corcoles A, Rodriguez-Blanco T, Ramos F, de Diego C, Salsench E, et al.
Comparison of three predictive rules for assessing severity in elderly patients with CAP. Int J Clin Pract 2011;65:1165-72.
Kothe H, Bauer T, Marre R, Suttorp N, Welte T, Dalhoff K, et al.
Outcome of community-acquired pneumonia: Influence of age, residence status and antimicrobial treatment. Eur Respir J 2008;32:139-46.
Dey AB, Nagarkar KM, Kumar V. Clinical presentation and predictors of outcome in adult patients with community-acquired pneumonia. Natl Med J India 1997;10:169-72.
Han X, Zhou F, Li H, Xing X, Chen L, Wang Y, et al.
Effects of age, comorbidity and adherence to current antimicrobial guidelines on mortality in hospitalized elderly patients with community-acquired pneumonia. BMC Infect Dis 2018;18:192.
Aliberti S, Bellelli G, Belotti M, Morandi A, Messinesi G, Annoni G, et al.
Delirium symptoms during hospitalization predict long-term mortality in patients with severe pneumonia. Aging Clin Exp Res 2015;27:523-31.
Metlay JP, Schulz R, Li YH, Singer DE, Marrie TJ, Coley CM, et al.
Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med 1997;157:1453-9.
van der Eerden MM, Vlaspolder F, de Graaff CS, Groot T, Jansen HM, Boersma WG, et al.
Value of intensive diagnostic microbiological investigation in low- and high-risk patients with community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2005;24:241-9.
Ramanujam P, Rathlev NK. Blood cultures do not change management in hospitalized patients with community-acquired pneumonia. Acad Emerg Med 2006;13:740-5.
[Table 1], [Table 2], [Table 3]