Preventing pneumonia and its complications in the elderly requires close monitoring and timely support
neumonia, an infection in the lung tissue, is a common infection. In the elderly, it can become a serious illness. It is usually classified into two broad types: community-acquired pneumonia, which is treated at home or in a nursing home, and nosocomial pneumonia, or hospital-acquired pneumonia. This article describes the family physician’s role in cases of community-acquired pneumonia in the elderly, the latter is not dealt here.
With the ageing process, there is an increased susceptibility to fatal diseases. Most review articles on elderly pneumonia have taken 60-70 years of age as a cut-off.
Moreover, frequent pneumonia hospitalisations in the elderly are reported due to associated diseases such as dementia, physical disability, diabetes and hypertension. Having these co-morbidities weakens one’s immune system. Chronic diseases such as chronic obstructive pulmonary disease (COPD) and asthma, which require the use of medications containing steroids, affect the immune system. Likewise, cardiovascular diseases put one at risk of not returning to one’s full health and function.
In cases where pneumonia remains untreated, for example, in elderly people living alone at home, it can lead to complications like confusion and organ failure, and most importantly, a higher mortality rate. It has been reported that one out of 20 people who contract pneumonia dies. In 2019 alone, 2,500,000 people lost their lives due to pneumonia across the world, most of them elderly.
In a developed country, for example, the United States, pneumonia is the eighth leading cause of death. Increased rates of hospitalisation and length of stay in elderly patients accounted for $4.8 billion of the total $8.4 billion spent for the care of pneumonia.
As winter approaches, more cases in the elderly will be reported in hospitals across the country. In a low-middle income country like Pakistan, where limited funds are allocated at government-funded hospitals, can the burden of pneumonia cases be handled adequately? How can a physician in a family health clinic help?
The recognition and initial treatment of community-acquired pneumonia is of crucial importance. The symptoms of pneumonia vary from case to case, as it’s caused by 30 different strains of micro-organisms. These are mostly bacteria; in some cases, viruses and fungi are also involved. Patients are treated depending on which organism has triggered the disease. Common symptoms caused by these organisms are cough, yellow to green sputum, usually fever and chills, malaise and weakness.
The recognition and initial treatment of community-acquired pneumonia is of crucial importance. The symptoms vary from case to case, as it’s caused by 30 different strains of micro-organisms.
In the elderly, especially diabetics, more prominent symptoms are non-specific as they present with lethargy, breathlessness and inability to eat and sleep, and in more serious cases, confusion. A high index of suspicion must be kept in such cases. It is important that such patients go to their family physician for proper temperature charting. A family physician then checks the lungs by listening to the chest with a stethoscope and checking the oxygen saturation with a pulse oximeter. They can then order a chest X-ray to help in the diagnosis of pneumonia.
In addition, a blood test can be requested, which may show an elevated white cell count. The CRB 65 score (C- confusion, R- raised respiratory/ breathing rate and B- low blood pressure) to assess the severity of pneumonia in patients over 65 years of age can help family physicians based in the community in differentiating patients who can be treated in a family health clinic or need hospital-based treatment. Based on the clinical assessments, patients are either treated at home or sent to a hospital for further evaluation or possible admission.
Studies have reported higher mortality in those with raised CRB scores. Bacterial pneumonia is treated with antibiotics, whereas viral pneumonia resolves in its own time. The average treatment takes approximately 7 to 14 days. The usual advice is to frequently drink fluids and take bed rest, but in most elderly patients, the amount of fluid intake needs to be advised with caution due to associated illnesses like heart or kidney diseases.
A family physician based in the community is the one who establishes relationships with local residents through their consultations. Patients place their trust in their physicians. As family physicians are front-line caregivers, their focus is on empowering patients through education about multiple preventive measures along with any danger signs that they can develop. Hence, improving patients’ awareness improves their health.
Preventive measures such as frequent hand washing, wearing a mask, avoiding crowded places during flu season and infrequent touching of the face can help. Vaccinations for pneumonia and influenza can prevent severe complications. Cigarette smoke is toxic to the respiratory tract and prevents bacteria from getting out of the respiratory tract, so smokers are at higher risk of getting pneumonia. Since smokers take weeks to recover from pneumonia as compared to non-smokers, patient education is imperative.
Since the outbreak of the Covid-19 pandemic, lack of access to healthcare has led to an excessive death toll in the elderly due to pneumonia. Public advocacy campaigns, including educational materials in local languages, advertisements and social media posts, can encourage healthy lifestyles. Non-governmental organisations, in association with family physicians, can run mobile and pop-up clinics that offer awareness-raising programmes in the older populations.
To extend preventive measures for the elderly, health workers can partner with local political systems, social work agencies and schools. Family physicians can serve as a bridge to promote improved health behaviours between at-risk older populations and policymakers.
The writer is a family physician