Journals of Gerontology: MEDICAL SCIENCES, 2015, 662 doi:10.1093/gerona/glu239 Letter to the Editor Advance Access publication January 23, 2015
Letter to the Editor Bacterial Pneumonia in Older People Aoife Fallon and Desmond O’Neill
Address correspondence to Desmond O’Neill, MD, FRCP, Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin 24, Ireland. Email: [email protected] Decision Editor: Stephen Kritchevsky, PhD
Dr Ruiz and colleagues found that age is an independent predictor of mortality in patients aged 65 and older with bacteremic pneumococcal pneumonia (1) with significantly poorer outcomes among those aged 80 and older. Although most recognized markers of disease severity and contributory factors were assessed by the authors, they did not consider the potential contribution of oropharyngeal dysphagia (OPD). OPD refers to the difficulty of initiating swallow and impaired transfer of food to the esophagus and is being increasingly recognized in older patients (2). The underlying causes of OPD include stroke, where OPD is seen in 30% of patients, and neurodegenerative disease (OPD in 60%–80%). The fact that such conditions are more common with age lead to an increasing prevalence of OPD in older patients admitted to hospital. Between 14% and 35% of community-dwelling older patients and as many as 50% of those in long-term care facilities are affected by OPD (2). OPD is a significant risk factor in the development of pneumonia. About 50% of patients with OPD will develop aspiration, which may be silent. It has been shown that OPD was present in up to 55% of those aged 70 and older admitted to hospital with pneumonia and is associated with increased disease severity (3). This is despite the fact that prior to assessment, the diagnosis was only suspected in half of this group (3). OPD has also been observed at higher rates in exacerbations of chronic OPD when compared with stable chronic OPD (4). Furthermore, it was found to be an independent risk factor in the readmission of elderly patients with both aspiration and nonaspiration pneumonia (5). It has been recommended that all older patients are assessed for OPD. In cases where it is identified, multidisciplinary involvement is warranted in order to reduce risk of further complications and poorer outcomes for this group of patients (2).
OPD may be a contributing factor to the poorer outcomes in the very elderly cohort in this study and is important to consider in clinical practice as a potentially modifiable risk factor for the development of pneumonia.
Funding None.
Conflict of Interest None.
References 1. Ruiz LA, Zalacain R, Capelastegui A, et al. Bacteremic pneumococcal pneumonia in elderly and very elderly patients: host- and pathogenrelated factors, process of care, and outcome. J Gerontol A Biol Sci Med Sci. 2014;69:1018–1024. doi:10.1093/gerona/glt288 2. O’Rourke F, Vickers K, Upton C, Chan D. Swallowing and oropharyngeal dysphagia. Clin Med. 2014;14:196–199. doi:10.7861/clinmedicine.14-2-196 3. Cabré M, Serra-Prat M, Force L, Almirall J, Palomera E, Clave P. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: observational prospective study. J Gerontol A Biol Sci Med Sci. 2014;69:330–337. doi:10.1093/gerona/glt099 4. Robinson DJ, Jerrard-Dunne P, Greene Z, Lawson S, Lane S, O’Neill D. Oropharyngeal dysphagia in exacerbations of chronic obstructive pulmonary disease. Eur Geriatr Med. 2011;2:201–203. doi:10.1016/j.eurger.2011.01.003 5. Cabre M, Serra-Prat M, Force L, Almirall J, Palomera E, Clave P. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010;39:39–45. doi:10.1093/ageing/afp100
© The Author 2015. Published by Oxford University Press on behalf of the Gerontological Society of America. All rights reserved. For permissions, please email: [email protected]
662
Downloaded from http://biomedgerontology.oxfordjournals.org/ at University of California, San Francisco on April 12, 2015
Centre for Ageing, Neuroscience and the Humanities, Trinity College Dublin, Dublin, Ireland.
Letter to the Editor Bacterial Pneumonia in Older People Aoife Fallon and Desmond O’Neill
Address correspondence to Desmond O’Neill, MD, FRCP, Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin 24, Ireland. Email: [email protected] Decision Editor: Stephen Kritchevsky, PhD
Dr Ruiz and colleagues found that age is an independent predictor of mortality in patients aged 65 and older with bacteremic pneumococcal pneumonia (1) with significantly poorer outcomes among those aged 80 and older. Although most recognized markers of disease severity and contributory factors were assessed by the authors, they did not consider the potential contribution of oropharyngeal dysphagia (OPD). OPD refers to the difficulty of initiating swallow and impaired transfer of food to the esophagus and is being increasingly recognized in older patients (2). The underlying causes of OPD include stroke, where OPD is seen in 30% of patients, and neurodegenerative disease (OPD in 60%–80%). The fact that such conditions are more common with age lead to an increasing prevalence of OPD in older patients admitted to hospital. Between 14% and 35% of community-dwelling older patients and as many as 50% of those in long-term care facilities are affected by OPD (2). OPD is a significant risk factor in the development of pneumonia. About 50% of patients with OPD will develop aspiration, which may be silent. It has been shown that OPD was present in up to 55% of those aged 70 and older admitted to hospital with pneumonia and is associated with increased disease severity (3). This is despite the fact that prior to assessment, the diagnosis was only suspected in half of this group (3). OPD has also been observed at higher rates in exacerbations of chronic OPD when compared with stable chronic OPD (4). Furthermore, it was found to be an independent risk factor in the readmission of elderly patients with both aspiration and nonaspiration pneumonia (5). It has been recommended that all older patients are assessed for OPD. In cases where it is identified, multidisciplinary involvement is warranted in order to reduce risk of further complications and poorer outcomes for this group of patients (2).
OPD may be a contributing factor to the poorer outcomes in the very elderly cohort in this study and is important to consider in clinical practice as a potentially modifiable risk factor for the development of pneumonia.
Funding None.
Conflict of Interest None.
References 1. Ruiz LA, Zalacain R, Capelastegui A, et al. Bacteremic pneumococcal pneumonia in elderly and very elderly patients: host- and pathogenrelated factors, process of care, and outcome. J Gerontol A Biol Sci Med Sci. 2014;69:1018–1024. doi:10.1093/gerona/glt288 2. O’Rourke F, Vickers K, Upton C, Chan D. Swallowing and oropharyngeal dysphagia. Clin Med. 2014;14:196–199. doi:10.7861/clinmedicine.14-2-196 3. Cabré M, Serra-Prat M, Force L, Almirall J, Palomera E, Clave P. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: observational prospective study. J Gerontol A Biol Sci Med Sci. 2014;69:330–337. doi:10.1093/gerona/glt099 4. Robinson DJ, Jerrard-Dunne P, Greene Z, Lawson S, Lane S, O’Neill D. Oropharyngeal dysphagia in exacerbations of chronic obstructive pulmonary disease. Eur Geriatr Med. 2011;2:201–203. doi:10.1016/j.eurger.2011.01.003 5. Cabre M, Serra-Prat M, Force L, Almirall J, Palomera E, Clave P. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010;39:39–45. doi:10.1093/ageing/afp100
© The Author 2015. Published by Oxford University Press on behalf of the Gerontological Society of America. All rights reserved. For permissions, please email: [email protected]
662
Downloaded from http://biomedgerontology.oxfordjournals.org/ at University of California, San Francisco on April 12, 2015
Centre for Ageing, Neuroscience and the Humanities, Trinity College Dublin, Dublin, Ireland.
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