Aging Begins at 30

Diagnosing Pneumonia a Tough Call

Of those who contract old-fashioned lobar pneumonia, now called pneumococcal, 17 percent die. Of those who contract hospital or nursing home pneumonia, 70 percent die.

The bacterial kingdom is divided into those that dye purple called Gram positive, and those that dye pink, called Gram negative. (Pneumococcal is Gram positive and nursing home pneumonia is Gram negative.)

The stain we use was invented in 1878 by a young Dane named Hans Christian Gram. It is similar to tie-dying. The first dye is crystal violet and is fixed or mordanted in Gram positive bacteria by iodine. (In tie-dying the mordant is alum.)

The dye washed out of the Gram negative bacteria with alcohol and a pick counter stain, safranin, is added to color them so they can be easily seen.

Gram positive bacteria are usually sensitive to penicillin; gram negative bacteria are not. The latter require complex and new antibiotics that are often difficult to choose.

A bigger problem that finding the right causative bacteria in the elderly is to know that pneumonia is present.

Some doctors still expect a sudden onset with a shaking chill, sharp stabbing chest pain when coughing or breathing deep and a quick rise in temperature to 102 degrees or higher. This happens rarely to people older than 65.

Pneumonia in the young occurs frequently in alcoholics and smokers. There are one-sixth less patients with shaking chills and one-third less with pleurisy than in the younger age groups.

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 17 times or more higher in the elderly than in the young.

A doctor must look for pneumonia in the 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 said in the 1890s that pneumonia was the old man's best friend carrying him off relatively rapidly after he had reached his three score years and 10.

Nowadays, many people live a good and useful life after pneumonia, especially elderly women, as they live longer, with an average survival to age 83 compared to 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 the 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 are more likely to pick up Gram negative organisms that have normal residence in the colon. Gram negative organisms are found in the throat in 8 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 percent, and in a skilled nursing home to 37 percent. In the acute care hospital, 60 percent 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 percent of pneumonia in the elderly is caused by the pneumococcus, or the old-fashioned lobar-type of disease.

About 20 percent are due to Gram negative organisms and about 5 percent due to a special subgroup of these called legionnaires, organisms in "honor" of the outbreak that occurred in Philadelphia where the American Legion was meeting in 1976.

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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.

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