We read with interest the study by Martín-Salvador et al.,2 recently published in Archivos de Bronconeumología, analyzing age-dependent psychological, physical and functional deterioration in patients hospitalized for pneumonia. The authors highlight the impact of the episode on their quality of life, functional capacity and reserve, and their psychological and physical status. Numerous studies have been published recently on pneumonia in the elderly patient, evaluating prognostic factors and mortality in the short and middle term (30 days–1 year).2,3 These studies show that incidence is as high as 15–35 cases/1000 inhabitants/year, and that incidence, admission and mortality rates have increased in the last 10 years, and are much higher in the elderly than in patients under 75 years of age.2,3 Compared to individuals admitted for other causes, patients who are hospitalized for pneumonia have higher mortality during the subsequent year. This phenomenon is associated with the inflammatory response and impaired physical and functional capacity following pneumonia, which are more marked in elderly patients who have a lower functional reserve and capacity for recovering their baseline status.2 Pneumonia in the elderly is a challenge for emergency departments (ED), since mortality in the ED itself is almost the same as among hospitalized patients,4 and pneumonia, along with urinary tract infection, is the most common cause of admission, sepsis, severe sepsis, septic shock, and mortality among elderly patients seen in the ED.2,3 Although studies have been published on the impact of an episode of pneumonia on quality of life and on the functional, psychological and physical status of elderly individuals, scant data are available on the progress and mortality of these patients in the long term. It is estimated that almost half of elderly patients will have died within 5 years of presenting an episode of pneumonia.2 However, if this assertion is confirmed, it raises several questions: What are the causes of death? Do baseline comorbidity and age play a part? How does an episode of pneumonia impact on the life expectancy of the elderly individual? What are the long-term predictors of mortality?
To analyze the progress and mortality of elderly patients in the 5 years after presenting an episode of pneumonia, we used a database from a study of 400 patients seen in our ED between January 1, 2008 and August 1, 2009, in which 2 groups were compared: 286 patients <75 years of age versus 114 patients ≥75 years of age.5 Some of the results are shown in Table 1. The data show that over 40% of elderly patients die within 5 years of presenting an episode of pneumonia, compared to 14.3% of individuals <75 years of age (OR: 4.34; (95% CI: 2.64–7.14); P<.001). Our results confirm that 5-year mortality in these patients is very significant, although we could not establish if this was an end result of the pneumonia episode. We believe that the psychological, physical and functional impairment caused by pneumonia in the elderly patient,1 both in the short and long term, together with advanced age and the increased comorbidity burden reflected in the Charlson index, and in particular in the greater proportion of patients with COPD, are factors which contribute jointly to the fact that almost half of elderly patients will die within 5 years.
Characteristics and 5-Year Progress of Patients With Community-Acquired Pneumonia Seen in the Emergency Department.
| Patient Characteristics n=400 | Patients <75 Years n=286 | Patients ≥75 Years n=114 | P-value |
|---|---|---|---|
| Mean age in years±SD; (range) | 46.69±15.63 (18–74) | 84.33±6.65 (75–99) | <.001 |
| Sex, men, n (%) | 172 (60%) | 68 (59.6%) | .928 |
| Admitted from care home: n (%) | 3 (1%) | 36 (31.6%) | <.001 |
| Charlson index±SD | 0.93±1.14 | 3.23±1.43 | <.001 |
| COPD, n (%) | 34 (11.9%) | 34 (29.8%) | <.001 |
| Asthma, n (%) | 23 (8%) | 4 (3.5%) | .078 |
| DILD, n (%) | 7 (2.4%) | 7 (6.1%) | .074 |
| Clinical features and severity | |||
| Confusion-altered consciousness; n (%) | 22 (7.7%) | 28 (25.2%) | <.001 |
| Criteria for sepsis; n (%) | 204 (71.3%) | 63 (55.3%) | .002 |
| Criteria for severe sepsis; n (%) | 57 (19.9%) | 15 (13.2%) | .072 |
| Criteria for septic shock; n (%) | 18 (6.3%) | 1 (0.9%) | .02 |
| Discharge from the ED; n (%) | 149 (52.09%) | 13 (11.4%) | <.001 |
| Admission to ward-SSU/ICU; n (%) | 137 (47.9%) | 98 (86.5%) | <.001 |
| Number of days of stay±SD; n (%) | 7.43±4.99 | 9.2±4.25 | .004 |
| Positive microbiological diagnosis; n (%) | 93 (32.5%) | 12 (11.5%) | .02 |
| Streptococcus pneumoniae; n (%) | 55 (59%) | 4 (33%) | .08 |
| PSI prognostic evaluation | |||
| PSI score±SD | 82.69±43.32 | 132.94±43.74 | <.001 |
| Distribution by PSI; n (%) | <.001 | ||
| PSI I | 74 (25.9%) | 0 (0%) | NS |
| PSI II | 65 (22.7%) | 1 (0.9%) | NS |
| PSI III | 50 (17.5%) | 17 (14.9%) | NS |
| PSI IV | 51 (17.8%) | 44 (38.6%) | .003 |
| PSI V | 46 (16.1%) | 52 (45.6%) | .001 |
| Evaluation of mortality | |||
| Death in ED; n (%) | 0 (0%) | 3 (2.6%) | NS |
| Death in hospital; n (%) | 13 (11.6%) | 14 (14.9%) | .312 |
| Death in ICU; n (%) | 10 (34.5%) | 1 (14.3%) | .291 |
| Death among patients discharged after first ED visit; n (%) | 0 (0%) | 1 (7.7%) | NS |
| Overall death at 30 days; n (%) | 25 (8.7%) | 22 (19.3%) OR: 2.49 (95% CI: 1.34–4.64) | .003 |
| Overall death at 1 year; n (%) | 31 (10.8%) | 33 (28.9%) OR: 3.35 (95% CI: 1.93–5.81) | <.001 |
| Overall death at 5 years; n (%) | 41 (14.3%) | 48 (42.1%) OR: 4.34 (95% CI: 2.64–7.14) | <.001 |
CI: confidence interval; COPD: chronic obstructive pulmonary disease; DILD: diffuse interstitial lung disease; Dis: disease; ED: emergency department; ICU: intensive care unit; NS: not significant or insufficient sample; OR: odds ratio; PSI: Pneumonia Severity Index; SD: standard deviation; SSU: short stay unit.
Please cite this article as: Julián-Jiménez A, García Tercero E, García del Palacio JI. Mortalidad y neumonía adquirida en la comunidad en el paciente anciano. Arch Bronconeumol. 2016;52:450–451.
