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Vol. 52. Issue 8.
Pages 450-451 (August 2016)
Vol. 52. Issue 8.
Pages 450-451 (August 2016)
Letter to the Editor
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Mortality in Elderly Patients With Community-Acquired Pneumonia
Mortalidad y neumonía adquirida en la comunidad en el paciente anciano
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Agustín Julián-Jiméneza,
Corresponding author
agustinj@sescam.jccm.es

Corresponding author.
, Elisa García Tercerob, José Ignacio García del Palacioc
a Servicio de Urgencias/Medicina Interna, Complejo Hospitalario de Toledo, Toledo, Spain
b Servicio de Geriatría, Complejo Hospitalario de Toledo, Toledo, Spain
c Servicio de Neumología, Complejo Hospitalario de Toledo, Toledo, Spain
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Tables (1)
Table 1. Characteristics and 5-Year Progress of Patients With Community-Acquired Pneumonia Seen in the Emergency Department.
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To the Editor:

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.

Table 1.

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.

References
[1]
A. Martín-Salvador, I. Torres-Sánchez, G. Sáez-Roca, I. López-Torres, E. Rodríguez-Alzueta, M.C. Valenza.
Estudio del deterioro psicofísico y funcional en pacientes ingresados con neumonía. Análisis por grupos de edad.
Arch Bronconeumol, 51 (2015), pp. 496-501
[2]
J. González-Castillo, F.J. Martín-Sánchez, P. Llinares, R. Menéndez, A. Mujal, E. Navas, et al.
Guidelines for the management of community-acquired pneumonia in the elderly patient.
Rev Esp Quimioter, 27 (2014), pp. 69-86
[3]
A. Julián-Jiménez, J. González del Castillo, M. Martínez Ortiz de Zárate, F.J. Candel González, P. Piñera Salmerón, M.S. Moya Mir.
Características y cambios epidemiológicos de los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias hospitalarios.
An Sist Sanit Navar, 36 (2013), pp. 387-395
[4]
M. Ruiz-Ramos, F.J. García-León, J.L. López-Campos.
Características demográficas de la mortalidad en los servicios de urgencias hospitalarios de Andalucía.
Emergencias, 26 (2014), pp. 109-113
[5]
A. Julián-Jiménez, M.J. Palomo, R. Parejo, N. Laín-Terés, R. Cuena-Boy, A. Lozano-Ancín.
Mejora del manejo de la neumonía adquirida en la comunidad en el servicio de urgencias.
Arch Bronconeumol, 49 (2013), pp. 230-240

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.

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