Could geriatric comprehensive assessment predict the outcome of pneumonia in the very old?
SIR—Patients over the age of 65 years develop pneumonia twice as often as younger patients. Risk factors include poor nutrition, endotracheal intubation and neuromuscular disease. Aspiration was felt to be particularly frequent in the elderly [1]. Interestingly, mortality in the intensive care unit amongst patients with respiratory disease is not predictable on the basis of age alone, but requires examination of co-morbid conditions [2].Health services for the elderly are becoming increasingly important in industrialised nations, and comprehensive geriatric assessment (CGA) is one of the procedures designed to improve the health of this part of the population [3]. CGA determines an elderly person's medical, psychosocial, functional, environmental resources and problems, and comes up with an overall plan for treatment and follow-up [3–5].
This survey of patients under cefepime treatment aims: (i) to analyse the characteristics of patients presenting with pneumonia among Belgian acute geriatrics units using a CGA; and (ii) to assess the risk factors associated with outcomes for these patients.
Patients
Two hundred seventy-seven patients (74% females) admitted to Belgian geriatrics units and presenting with pneumonia, and which the physician decided to treat with cefepime alone or in combination, were followed between January and June 2001.
Patients underwent routine CGA, performed in the units participating in the project. Usually, these evaluations included medical, psychiatric, therapeutic, social, functional and nutritional status.
Patients with a clinically diagnosed pneumonia (signs, symptoms and chest X-ray) and treated by cefepime for at least 3 days, were included in this survey.
- Social evaluation including determination of age, sex, home (private versus institution), marital status for each patient.
- The severity of the pneumonia was scored using the ATS criteria [6].
- If available, creatinine clearance was calculated using the Cockcroft formula [7].
- The severity of the medical problems was scored using a co-morbidity index adapted from Greenfield et al. [8] (annex 1).
- If possible, the geriatric depression scale (GDS) was used to assess the probability of a depressed state [9]. A score higher than three suggests the presence of depression.
- The assessment of activities of daily living (ADL) was made while using the Katz scale [10].
- If applicable, cognitive function was assessed while using the Mini Mental State Examination [11].
- If applicable, the ‘Mini Nutritional Assessment test’ (MNA) [12] was used for the nutritional assessment.
- Clinical evaluation.
- Recording of length (in days) of antimicrobial therapy (cefepime and amikacin).
Recording of the total amount of each antibiotic used (in g or mg).
Biochemical markers
When available, data on serum prealbumin, albumin and serum c-reactive protein (CRP) were collected. CRP was used to assess the inflammatory process and the possible endogenous component of malnutrition. Both these measurements were recorded if performed at the beginning and the end of the treatment.
Evaluation of the infection
Clinical
All patients with a clinically diagnosed pneumonia, and who received at least 3 days of a cefepime (± amikacin) regimen, were evaluated for clinical efficacy in view of the following definitions:
- Clinical success
Disappearance of all clinical signs and symptoms of pneumonia and improvement or lack of progression of all abnormalities on the chest X-ray or a significant clinical improvement which precludes, at the treating clinician's discretion, any further antimicrobial treatment.
- Clinical failure
Persistence and/or worsening of clinical signs and/or symptoms (with no negativation of a previously positive Rx thorax.
- Death
Attributed to initial respiratory infection.
- Unable to determine
No post-treatment evaluation made, or death due to other causes.
Data was collected in a database, using the Microsoft Access software, statistical analyses were performed with the Statistica 5 Microsoft software. Results from patient groups are presented as mean ± SD. A non-paired Student's t-test was used to compare means of the parameters. Z-score with Yates' correction was used to assess the differences between proportions of conditions. Univariate and multivariate logistic regression analyses were performed to identify variables associated with high-risk factors. For all statistical analyses, P < 0.05 was considered to be statistically significant.
Comprehensive geriatric assessment
Characteristics of the patients are illustrated in Appendix 1 (please see journal website). Fifty-five per cent of the patients were living in an institution and 46% were married. Their mean age was 84.4 years (ranged from 43 to 102 years). Half of the patients presented a creatinine clearance lower than 49 ml/min (median). More than half the patients presented a GDS higher than three suggesting the presence of depression. More than half the patients presented severe malnutrition in view of their MNA values (median 15). Malnutrition was also confirmed by low serum albumin and prealbumin levels. As expected, the mean serum CRP was 17 mg/100 ml, reflecting an inflammatory syndrome.
Clinical outcomes
Seventy-one per cent of the patients presented a clinical resolution of the disease, 10% failed to improve, 16% did not survive and the clinical outcome could not be determined for 3% of the patients.
Table 1 shows the characteristics of the patients according to their clinical outcome.
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As expected, a higher prevalence of severe pneumonia was observed amongst the patients who failed to improve (58% vs 39%, P < 0.01).
Patients who failed to improve, or died, presented with a lower serum albumin before treatment than those who presented a good clinical evolution. Poor evolution was associated with higher dose of cefepime administration and shorter treatment duration as compared with good clinical outcome. Patients with a poor outcome had low serum albumin concentrations. Serum CRP levels before treatment did not significantly differ between the groups. As expected, poor clinical outcome was associated with persistent high levels of CRP at the end of the treatment. In comparison to patients with a good clinical evolution, patients who failed to improve, or died, had a trend towards a higher degree of dependence in their daily activities.
Considering the severity of the diseases, we observed in the group of patients with poor outcome higher proportions of uncontrolled strokes and renal failure as compared with the group of patients presenting a good clinical outcome.
Results from univariate and multivariate logistic regression are presented in Table 2.
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A low MMSE value appeared to be the highest risk factor associated with a poor outcome.
Characteristics of the patients (n = 277) according to the origin of pneumonia acquisition (Community, Nosocomial, Institution)
As compared to patients with institution or nosocomial acquired pneumonia, CAP patients tend to present with higher nutritional, renal, cognitive and functional states. CAP-patients also presented with less severe pneumonia compared to institution or nosocomial pneumonia.
This survey confirms the frailty of elderly patients presenting with pneumonia: poor renal function, poor nutrition, high level of functional dependence, severe co-morbidity, with psychological and social problems, and cognitive impairment.
In this survey, poor clinical outcome was associated with low serum albumin level, high severity score and the presence of uncontrolled stroke and/or renal disease.
Co-morbidity is an important determinant for the risk of pulmonary infection and its prognosis: cancer, diabetes, chronic respiratory disorders, chronic renal failure and chronic heart failure, all increase the likelihood of lower respiratory tract infection (LRTI) [13].
Pneumonia mortality increases with age [14, 15] not exclusively due to age itself, but also to associated conditions such as presence of co-morbidities and malnutrition [13, 16]. Other factors associated with increased mortality from pneumonia in this age group include admission into a nursing home, bedridden status, delirium, absence of fever (<37°C), tachypnoea (respiratory rate >30/min), CRP greater than 100 mg/l, [17] hypoalbuminaemia, acute non-respiratory organ dysfunction, affection of several lobes, suspicion of aspiration and presence of swallowing disorders [13, 16, 18–21].
Fortunately, CRP, although not specific for bacterial infection, is highly sensitive for detecting pneumonia: a normal CRP value virtually excludes pneumonia, even in the very old [22]. A persistent increase in CRP-concentrations under antibiotic therapy is an adverse prognostic factor and suggests inadequate antibiotic coverage, parapneumonic effusion, or empyema [17, 23, 24].
Low serum albumin and renal failure are associated with an increased mortality [25, 26].
The treatment of pneumonia, due to aerobic Gram-positive and Gram-negative bacteria, particularly hospital-acquired infections, continues to be a primary challenge in geriatric medicine.
The choice of cefepim may be justified by the bacteriological results, which were documented for only 103 patients in this study (Appendix 2, please see journal website). Moreover, it was important to keep the same antibiotic treatment in order to exclude confounding factors associated with the diversity of antibiotic choice. Both Torres [27] and Celis [28] found that inappropriate antibiotic therapy was an independent risk factor for mortality from nosocomial pneumonia. Luna and co-workers [29] reported that, for patients with bacteriologically documented pneumonia by broncho-alveolar lavage, a change in the antibiotic regimen following bronchoscopy will no longer improve the mortality rate.
Pneumonia in the very old is a challenge for clinicians, because of non-typical symptoms, lower functional reserve and a high mortality rate. CGA may be helpful in detecting at-risk patients. Further studies are required to assess the effect of geriatric intervention on the outcome of these selected patients.
- Poor clinical outcome for old patients with CAP is associated with low serum albumin level, high severity score and the presence of uncontrolled stroke and/or renal disease.
- Pneumonia in the very old is a challenge for clinicians, because of non-typical symptoms, lower functional reserve and a high mortality rate.
- CGA may be helpful in detecting at-risk patients.
- Further studies are required to assess the effect of geriatric intervention on the outcome of these selected patients.
Conflicts of Interest
There is no conflict of interest in this work
Acknowledgements
We are indebted to Prof C Melot (Erasmus Hospital, Brussels) for his help in the statistical analysis of the data.
Pneumonia Elderly Risk Factors Project (P.E.R.F.), Geriatric Clinic, Erasme University Hospital, route de Lennik 808, 1070 Brussels, Belgium
* To whom correspondence should be addressed Email: tpepersa{at}ulb.ac.be
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