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Editor's Correspondence
June 23, 2003

Is Pneumonia Still the Old Man's Friend?

Arch Intern Med. 2003;163(12):1491-1492. doi:10.1001/archinte.163.12.1491

Yes, it is. We read with great interest the article by Kaplan et al1 on pneumonia in elderly patients, and we would like to present data that allow one to conclude, 100 years after William Osler, that pneumonia is really the old man's friend.1-3

We present data obtained on 1803 elderly patients consecutively admitted to our Acute Care for the Elderly Medical Unit (ACE-MU) in Brescia, Italy, during a 15-month period. Admission to the ACE-MU is mainly through the emergency department (82%). We have compared the characteristics and the survival at 6 months of inpatients admitted with pneumonia and inpatients with acute noninfectious conditions (eg, gastroenteric bleeding, dehydration, delirium, heart failure, and stroke).

A multidimensional evaluation, including information on demographics (ie, age, sex, education, living site prior to admission and after discharge, living conditions, and caregiver or formal support availability), cognitive and affective status, physical health, functional abilities, and social support was performed on the first day after admission using a standard protocol by a trained staff of geriatricians. Cognitive status was evaluated by the Mini-Mental State Examination (MMSE)4 and depressive symptoms by the Geriatric Depression Scale (GDS).5 An MMSE score less than 21 and a GDS score higher than 5 indicate poor cognition and depression, respectively.

Self-reported disability was assessed by the Barthel Index (the lower the score, the higher the degree of disability)6 and the Instrumental Activities of Daily Living scale by Lawton and Brody.7 A premorbid Barthel Index score (2 weeks before admission) of less than 90 was considered a marker of disability.

Somatic health was evaluated by the detection of single symptomatic diseases uncontrolled by therapy, comorbidity (computed by the Charlson Index),8 and the evaluation of physiologic severity (computed by the Acute Physiology Score–Acute Physiology and Chronic Health Evaluation II [APS-APACHE] subscore [the higher the score, the higher the severity]).9 The number of currently administered drugs was also recorded. Pneumonia was diagnosed by clinical signs and chest radiography, and treatment was performed according to the American Thoracic Society guidelines.10 Six-month mortality was the outcome measure of our analysis.

Table 1 gives the sociodemographic, functional, and clinical characteristics of the population affected by pneumonia and other acute noninfectious diseases. Severity of somatic, biological, psychologic, and functional conditions was higher in patients affected by pneumonia than in those with acute noninfectious diseases. According to the clinical conditions, 6-month mortality was significantly higher in patients with pneumonia (27.4%) than in other patients (20.0%).

Table 1. 
Characteristics and 6-Month Mortality Rate of 1803 Inpatients Consecutively Admitted in a Geriatric Ward for Pneumonia or Other Acute Noninfectious Diseases*
Characteristics and 6-Month Mortality Rate of 1803 Inpatients Consecutively Admitted in a Geriatric Ward for Pneumonia or Other Acute Noninfectious Diseases*

Table 2 gives the crude and adjusted associations of clinical variables and 6-month mortality in the 1803 hospitalized elderly patients; variables associated with mortality in bivariate analysis were age (≥80 years), male sex, pneumonia, cancer, anemia, congestive heart failure, cor pulmonale, chronic obstructive pulmonary disease, stroke, diabetes mellitus, liver diseases, dementia, depression, Charlson Index score of 4 or higher, disability, APS-APACHE II subscore of 4 or higher, serum creatinine level greater than 3 mg/dL [265.2 µmol/L], and serum albumin level less than 3.5 g/dL. In adjusted analysis cancer, anemia, dementia, Charlson Index score of 4 or higher, and APS-APACHE II subscore of 4 or higher hold their association with 6-month mortality, while pneumonia looses statistical significance.

Table 2. 
Six-Month Mortality Risk in 1803 Hospitalized Elderly Patients (Cox Regression Analysis)
Six-Month Mortality Risk in 1803 Hospitalized Elderly Patients (Cox Regression Analysis)

In conclusion, our data on a different sample confirm those by Kaplan et al1 and Osler's notion on the high risk of death after pneumonia infection in the elderly. However, our parameters indicate that pneumonia occurs in particularly frail patients (see Table 1 for comparison of clinical, functional, and biological data), while in a multivariate analysis the disease itself loses relevance as an independent risk factor of death (Table 2). Thus, we agree with Kaplan et al1 that in hospitalized patients pneumonia "strikes a population that is at higher risk of death compared with general population." With all of these points taken into consideration, we conclude that pneumonia is really the old man's friend, since it is a nonpainful lethal event undergone in elderly patients hampered by negative clinical conditions.

References
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