Pneumonia in elderly

Pneumonia in elderly: An overview

Pneumonia in elderly
Image courtesy of: National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC)

Pneumonia in elderly patients can present with very little warning signs and the diagnosis can be easily missed even by healthcare providers.

Important note: This article only focuses on Pneumonia in elderly. If you want to understand what pneumonia is and what causes it, click here: “Pneumonia symptoms in adults”.

As a practicing internal medicine physician, I admit several patients with pneumonia to the ICU every week. Many of these patients are elderly. Some of  them are over 90 years old. Pneumonia in elderly is very common and these patients constitute about 25% of my practice. The symptoms of pneumonia in elderly depend upon their overall health and functional status. The symptoms of pneumonia in active and outgoing patients are different from those in patients with decreased mobility. I will be describing several real stories of pneumonia in elderly patients to teach you how they present in real life. I will be changing the names, professions and other details to protect the identities of those patients.

Pneumonia in elderly: the mechanism of symptoms

Pneumonia is a disease of the lungs. When our lungs get infected, they develop inflammation and injury and cause the symptoms of pneumonia. To understand how pneumonia symptoms develop, you have to look at it from two different levels: the organ level and the body level. In medical terms, they are also called local systems and systemic systems. The local symptoms or the organ level symptoms develop from the changes that occur in the lungs as a result of pneumonia. The infected lungs can cause several problems. They can cause irritation of the nerves that result in cough. They can cause problem with oxygen exchange and can cause shortness of breath. They can cause friction from inflammation and result in pain with breathing. In younger patients, they simply express as cough, shortness of breath and pain with breathing. In elderly patients, things will be slightly different. The lungs and nerve tissue in the lungs are not very reactive and responsive in the elderly. They are not always able to cough strongly when they have pneumonia. They are not always able to express the feeling of shortness of breath. They may not always feel the pain when breathing.

In elderly patients, you will notice that they are trying to cough but it may not come out as cough. It may just come out as a grunting noise when breathing. They may not be able to tell if they feel short of breath but they may have some uncomfortable feeling on their chest. They may not have pain when breathing but may develop a fast or shallow breathing pattern.The exact symptom in each patient will be different but if you can imagine a weak lung with less sensitive nerves and try to see if the symptoms of a particular elderly patient would fit in that picture, you can link that symptom to possible pneumonia.

At the body level or the systemic level, pneumonia behaves like a typical infection. When your body detects infection, it activates the immune system to try to fight that infection. In doing so, the body releases certain chemicals, special proteins and specialized cells that cause inflammation of the whole body. The body temperature goes up and the heart beats faster. In elderly patients, all these responses are usually blunted. The immune system of the elderly is usually not strong enough to react this strongly. But, you will find that their body will be trying very hard to produce these changes. The individual patient’s immune system will decide how much response it will create. Some patients may be able to produce a mild fever while others do not even have a fever. Some patients may end up having a lower than normal body temperature instead of the fever. Others may just have chills and shaking with an unsuccessful attempt to produce fever. Some may just feel drowsy, sleepy and lethargic while others can get confused or irritable. Overall, you will be able to detect signs of struggle and stress in their body. This struggle and stress is something that will be common in all elderly patients with pneumonia but how they express will completely depend on the individual patient.

Pneumonia in elderly: 85 year old female in nursing home

Mrs. B is an 85 year old female who has been living in the nursing home for the last 2 years. She has three sons and a total of nine grandchildren who visit her frequently. She is always excited when the grandchildren visit her and she is always looking forward to hearing their wiggles and giggles. She does have some problems with remembering things and sometimes looses track of what day it is but she always remembers the names of all her grandchildren. She also does not forget about the good old days when she was at home with her husband. He died from a stomach cancer 3 years ago.

On a Friday afternoon, one of the nurses went into her room to give her medications. She noticed that Mrs. B was not quite herself that day. The nurse knew her very well. She always had a very friendly and cheerful manner. But that day, she seemed very sleepy and tired. The nurse asked her if anything was wrong with her but she could not pin point any specific symptom. She just said that she was feeling very tired that day and wanted to sleep early. The nurse checked her temperature and took her blood pressure and pulse. She did not have a fever. Everything seemed to be within normal limits but something did not appear quite right.

Next morning, the nurse went in her room to wake her up but she was very weak and was unable to get out of the bed. She seemed somewhat confused and was asking the nurse where her husband was. She seemed to have forgotten about his death. At that point, the nurse was really concerned and made a few phone calls. Later, they decided to take her to the local hospital.

In the ER, she was still unable to tell what was bothering her. She just seemed confused and lethargic. They ran a series of tests on her. They did some blood work, a head CT and a chest x-ray. When the ER doctor looked at the chest x-ray, he discovered that the patient had pneumonia. He then called me to admit the patient and start the treatment as I was the on-call doctor that day.

The patient did not have the usual text book signs and symptoms of pneumonia but I was not surprised at all. In fact, this is the most common way pneumonia in elderly patients who are in nursing homes present.

I talked to the family and explained about the diagnosis of pneumonia in elderly. They were surprised that she did not have the actual symptoms of pneumonia but were happy that we got the diagnosis right. I admitted her to the ICU and gave her antibiotics and supplemental oxygen. I also gave her some fluids through her veins as she appeared somewhat dehydrated. Dehydration is common in patients with pneumonia in elderly. Next morning, she was more alert and was able to have a more normal conversation. It took four days of treatment to get her back to how she felt before she got sick but everyone was happy at the end.

Pneumonia in elderly survival rates

Pneumonia in the very old patient population can be a deadly disease. Among elderly patients admitted to the hospital with pneumonia, those older than 85 years old have the worst survival rates. Based on latest estimates, more than 20% of 85 years old with pneumonia do not survive the hospitalization. Survival of elderly patients with pneumonia improve as the age bracket goes down. Among hospitalized elderly with pneumonia, those between ages of 80 and 84 have a mortality rate of about 15%. Similar patients between ages of 75 and 79 have a mortality rate of about 13%.

Can a 90 year old recover from pneumonia?

Despite the alarming survival rates of pneumonia in elderly, an individual 90 year old with pneumonia can certainly recover from it. In fact, I have personally admitted several 90 year olds with pneumonia and many of them survived the hospitalization and were discharged in stable conditions. The prognosis of pneumonia in the very old depends on their baseline health status. Some of you may have 90 year old father or mother who is very active. Some 90 year olds regularly get out of the house and exercise. Some 90 year olds are very active in the community and regularly participate in physical and mental exercise. The more active and outgoing a 90 year old is, the better the chances he/she will have of surviving and recovering from pneumonia.

Pneumonia in elderly with multiple existing medical problems have lower chance of surviving hospital admission than those who are otherwise healthy. Pneumonia in elderly with dementia can be hard to diagnose and hard to treat. It is difficult to recognize early signs of pneumonia in an elderly patient with dementia. Elderly with dementia are usually admitted very late when they already have sepsis and septic shock from pneumonia.
Pneumonia in elderly with COPD also have worse survival rates than those without COPD. Elderly with COPD have pre-existing lung damage. It is more difficult to get rid of pneumonia in elderly with COPD. Similarly, pneumonia in the elderly with congestive heart failure have worse survival rates than those without congestive heart failure.

How long can an elderly person live with pneumonia?

In theory, pneumonia is a treatable condition from which a patient can be expected to recover completely. However, some elderly with pneumonia suffer long term complications from pneumonia or its treatment. How long an individual elderly person live with pneumonia depends on the baseline health status. An active elderly person whose pneumonia was diagnosed early and treated appropriately can live to his/her expected natural lifespan. An elderly with poor baseline health and multiple medical issues may not even survive a month.

Pneumonia in elderly is a very common disease but there are so many different things you can learn about the disease from actually taking care of the patients with pneumonia in elderly. I hope this patient centered approach to educating my readers about pneumonia in elderly was helpful.

Please check back soon as I will be uploading more stories about different aspects of pneumonia in elderly and how different patients have different symptoms.