Aging Begins at 30

Pneumonia Is Not the Old Man's Best Friend

Pneumonia in the elderly is frequently deadly. In old-fashioned lobar pneumonia, now called pneumococcal, 17% die. In hospital or nursing home acquired pneumonia, 70% die despite treatment. Pneumococcal is Gram positive and nursing home pneumonia is Gram negative. The whole bacterial kingdom is divided into those that dye purple, called Gram positive, and those that dye pink, called Gram negative. The stain we still use today was invented in 1878 by a young Dane called Hans Christian Gram. It is like tie-dying. The first dye is crystal violet, which is fixed or mordanted in Gram positive bacteria by iodine (in tie-dying the mordant is alum). The dye washes out of the Gram negative bacteria with alcohol and a pink counter stain, safranin, is added to color them so they can be easily seen. Gram positive bacteria are usually sensitive to penicillin. The Gram negative ones, the ones that pick up the pink stain, are not. The latter require complex and newer antibiotics, often difficult to choose.

A bigger problem than finding the right causative baceteria in the eldely, is to know that pneumonia is present. Some doctors still expect a sudden onset with a shaking chill, sharp stabbing pleurisy chest pain on coughing or deep breathing, and a quick rise in temperature to 102° or higher. This happens when you are thirty or forty and perhaps when you are fifty, but rarely if you are sixty-five or older. Pneumonia in the young occurs frequently in alcoholics and smokers, but the elderly do not need these risk factors. There are one-sixth less patients with shaking chills and a third less with pleurisy than in the younger age groups. In addition, ten times more elderly have underlying heart disease and many have kidney complications. This makes treatment so much more difficult and the death rate therefore is seventeen times or more higher in the elderly than in the young. A doctor has to look for pneumonia in the confused elderly who are breathing fast. Anyone with more than 26 respirations per minute deserves a chest x-ray. The normal rate is 18 per minute.

Osler in the 1890's said that pneumonia was the old man's best friend carrying him off relatively rapidly after he had reached his three score years and ten. Nowadays, many people live a good and useful life after pneumonia, especially elderly women as they live longer with an average survival to 83 instead of 78 in men.

How do the elderly usually get pneumonia? Most often they initially have the common pneumococcal bacteria carried in the throat. It takes some secondary happening to make it travel down into the lungs. The most common happening is a common cold or influenza causing the bacteria to multiply to much higher numbers than usual and then migrate to the lung. Very important are situations that make you live in closer contact with others. There you more and more often pick up Gram negative organisms whose normal residence is in the colon. Gram negative organisms are found in the throat in eight percent of normal young people and the same percentage of the active normal elderly. Once you get into a nursing home, your chances of having these bacteria in your throat rise to 12% and in a skilled nursing home to 37%. In the acute care hospital, 60% of the elderly carry these potentially dangerous bacteria in their throat. When this happens, a heavy dose of sleeping pills or a stroke allows you to breathe these potentially deadly organisms into your lungs.

About 75% of pneumonias in the elderly are caused by the pneumococcus, or the old-fashioned lobar type of disease. About 20% are due to Gram negative organisms and about 5% due to a special sub-group of these Gram negative organisms called Legionnaires organisms in "honor" of the outbreak that occurred in Philadelphia where the American Legion was meeting in 1976. There are "new" organisms called Brahamella (now Moraxella) and also others called TWAR, which are very hard to diagnose and treat, but they make up a relatively small percentage of the total group of pneumonias.

Aspiration pneumonia occurs when we vomit and inhale the vomitus. This is deadly and difficult to treat.

The good news is that 75% of pneumonias, that is those caused by pneumococci are potentially preventable by vaccine given once in your lifetime. Even if you get one of the more lethal organisms, there is every chance that modern diagnosis and antibiotic treatment will save you for more years of happy, healthy elder living.

Section Top | Title Page

See related Patient Topics Infections, Lungs and Breathing or Pneumonia.

See related Provider Topics Infections, Lungs and Breathing or Pneumonia.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

http://www.vh.org/adult/patient/internalmedicine/aba30/1992/pneumo.html