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Got P.I.E.?

"Pneumonia in Elderly"
By: Marc Evans Abat, MD, FPCP, FPCGMGot P.I.E.?

Almost everybody loves pies.  Savory or sweet, pies occupy a special place in many people’s hearts.  I know a doctor who is a sucker for a fast food joint’s tuna pie.  A trip to Tagaytay will not be complete without passing by this particular restaurant and buying a box or two of their buko pies.  And of course, who can forget the quintessential pizza, from the ones bought cheaply from the neighborhood corner to the artisan do-it-yourself varieties.

There is one pie though that I am sure our senior citizens will dread, and may possibly “leave them breathless”.  This is P.I.E or pneumonia in elderly. 

Pneumonia is basically an infection of the lung substance, particularly the air sacs.  In the Philippines, as of 2013, pneumonia is the 7th leading cause of death, at about 10% of registered deaths.  It is also the 9th leading cause of morbidity or sickness. 

Elderly are particularly at risk for pneumonia and its complications due to many reasons:

  1. Changes in the immunity of the older person, particularly immunosenescence, may increase susceptibility to infections, even under mild stress
  2. Co-existing diseases like chronic obstructive pulmonary disease, heart failure, liver disease, kidney disease, malnutrition, cancer and diabetes may also lower immunity and cause structural changes in the lungs that makes them more susceptible to infection or impair response to treatment. 
  3. The same co-existing diseases also make the elderly more susceptible to complications and deterioration from pneumonia. These conditions can also exacerbate because of pneumonia.  Bronchial asthma may worsen, the heart may decompensate and fail, and the kidneys may become acutely injured.
  4. Certain conditions or diseases also predispose the elderly to ease of entry of infectious agents.  For example, more frail, older elderly experience swallowing problems that may lead to aspiration, or entry of foreign particles into the lungs
  5. Polypharmacy, or the use of more than 10 drugs, some of which may be inappropriate, may adversely affect how an older person protects itself from entry of organisms.  Drugs that obtund consciousness may increase the risk of aspiration.  Cough suppressing medications like opiods, may reduce the strength of the cough reflex, increasing aspiration risk.
  6. Dementia, which occurs in older patients, may eventually lead to complications like swallowing disorders and malnutrition
  7. Health-seeking behaviors, like having vaccinations and regular health consultations, may become drastically reduced, due to many complicated reasons


So how does the elderly get pneumonia? 

As was previously mentioned, the organism can come from the community setting or in the healthcare setting.  Usually those microorganisms contracted from the healthcare setting (e.g. while confined in the hospital for another reason) tend to cause more severe infections, and are more difficult to treat due to possibility of antibiotic resistance.  The entry of organisms into the lungs is usually through microaspiration of infected particles from the mouth, or inhaled from the air (as droplets or aerosols from an infected person). 

A prior infection, like influenza, may impair the defenses along the respiratory tract, which may make bacterial penetration easier.   Some patients suffer from gross aspiration of oral or gastric contents, introducing a chemical damage to the lungs (making infection easier) and a larger amount of infected material.  As was again mentioned, a variety of infectious agents can cause pneumonia:

  1. Bacteria. Streptococcus pneumoniae is the most common organism in all spectra of disease severity.  A variety of other bacteria can also cause pneumonia (some of which may also be responsible for infections in other parts of the body).
  2. Viruses.  Influenza, parainfluenza, and respiratory syncytial viruses are common causes of viral pneumonia.  More unusually causes are to related to SARS and MERS-Cov.
  3. Fungi.Candida species and Aspergillus can cause pneumonia in susceptible patients, like those with cancer, or other patients with very weak immunity

What are the signs and symptoms of pneumonia? 

The classic symptoms of fever, cough with phlegm production, and difficulty breathing are sometimes not seen at onset of disease in older patients.   More commonly, it’s either just one of these three.  Other findings initially seen in older patients include:

  1. Sudden loss of appetite
  2. Sudden loss of interest in doing activities
  3. Increased sleeping time
  4. Sudden or increased incidence of falling (“nadadapa”, “natutumba”)
  5. Abdominal pain
  6. Chest pain
  7. Delirium or acute confusion
  8. Difficulty sleeping

How is pneumonia treated? 

Antibiotics are given, depending on the perceived severity of the pneumonia.  Those assessed to have mild pneumonia may still take oral antibiotics as an outpatient.  Those with more severe symptoms may need hospitalization and either intravenous antibiotics alone or combined with oral agents.  Especially in the more severe patients, other medications will be given either to treat the concomitant diseases that are worsened or exacerbated, or to tide over the acute problems while the infection is improving.  Medications to soften phlegm and loosen the airways, and oxygen support may also be given by doctors as adjuncts in the treatment.  

Hopefully this helps in understanding and preventing P.I.E.  Personally, I’d rather have that slice of pizza.




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