Vol. 12 •Issue 5 • Page 29
Confronting the Threat of Pneumonia in Nursing Homes
Pneumonia preys on weakened immune systems and wavering health, a big reason why health care practitioners need to be constantly wary for its harmful presence in nursing homes.
“It is a very serious issue when you consider the close living quarters and the patients’ frail conditions and comorbidities,” said Ellen Pond, CRT, staff therapist at Christopher House, a subacute and skilled nursing facility located in Worcester, Mass. “Often, an upper respiratory virus will spread throughout a floor and three or four patients will end up with secondary pneumonia, which for many of these patients can be life threatening.”
The prevalence of pneumonia among the elderly is becoming more common as the general population ages. Pneumonia and influenza are already the seventh-leading cause of death overall in the United States and the fifth-leading cause for Americans over the age of 65. Pneumonia resulting from aspirated materials, which occurs frequently in the elderly, recently moved into the 14th spot on the overall list, replacing homicides.1
“We’re going to see more frail people who are going to get pneumonia and who are going to die of pneumonia,” said David R. Mehr, MD, MS, a geriatrician and associate professor of family and community medicine, University of Missouri-Columbia, Columbia, Mo.
But while pneumonia in the elderly presents a challenge to health care practitioners, their solid clinical assessment skills can go a long way toward lessening the risk of the disease.
For many reasons, the elderly can be more vulnerable to getting pneumonia, said Joseph M. Mylotte, MD, professor of medicine at the University of Buffalo. Their immune systems are weaker, and they may have other underlying conditions, such as heart and lung ailments.
Additionally, nursing home risk factors for pneumonia include a host of issues: old age, swallowing difficulties, being male, being bedridden, urinary incontinence and an inability to take oral medications.2
Unfortunately, recognizing pneumonia in these patients isn’t easy. For one thing, seniors aren’t as vocal about their health problems. “As we get older, we don’t complain as much,” said T.J. Marrie, MD, department of medicine, University of Alberta, Edmonton, Canada. “It’s like looking after babies.”
Some elderly may have mental difficulties that prevent them from helping the doctor in his examination. “The diagnosis is not as straightforward as it can be in a young person who can give you a history,” said Dr. Mylotte, who’s also chief of .infectious diseases and director of acute geriatrics services at Erie County Medical Center, Buffalo.
Many times, though, a senior’s lack of articulation goes beyond communication problems or the fact that they might not want to admit they’re sick. Because of changes in their immune system, they might not even feel sick. Irving Gomolin, MD, FRCPC, FACP, estimated that while 99 out of 100 young people will present with classic pneumonia symptoms, only 90 out of 100 older people will.
“The classic symptoms will be less pronounced, and sometimes they present in ways that aren’t typical,” said Dr. Gomolin, chief of the divisions of geriatric medicine and clinical pharmacology, Winthrop University Hospital, Mineola, N.Y. “You have to keep a high level of suspicion.”
Fever, an important indicator for pneumonia, might not even be noticed because the elderly have normal body temperatures that run lower than those younger. Pneumonia patients also may present with disorientation, but clinicians could jump to the conclusion that it’s a signal of stroke or medication problems, said Robert A. Bonomo, MD, a specialist in infectious disease and geriatrics at Louis Stokes Veterans Affairs Medical Center, Cleveland.
Further complicating matters is the fact that a doctor often isn’t present in the .nursing home. Nurses many times do evaluations, later informing the doctor of their observations, Dr. Mylotte said
“If the physician doesn’t ask the right .questions, and the nurse doesn’t provide the right info, any diagnosis can be missed,” Dr. Mylotte said. Nurses, respiratory therapists and others need to keep their eyes open for anything abnormal in patients, and then pass along their concerns in a clear and accurate fashion.
“You have to let the doctor know, but don’t play doctor,” Pond said. “Let them diagnose.”
If pneumonia is suspected, the gold standard for diagnosis is a chest X-ray. “You have to have a low threshold for doing chest X-ray,” said Dr. Mylotte, pointing out that many nursing homes have access to portable X-ray machines.
One thing to keep in mind with X-rays is that if the patient is dehydrated, which is a frequent issue because of rapid respiratory rate and fever, you might not be able to see an infiltrate right away, Dr. Gomolin said. As a result, it’s important to monitor for dehydration, and the best way to do that is by measuring the blood urea nitrogen, Dr. Mylotte said.
In case an X-ray machine isn’t available on the nursing home premises, Dr. Mehr and colleagues have developed an alternative clinical diagnosing system for patients in whom pneumonia is being actively considered as a diagnosis.3 The system scores eight signs and symptoms associated with pneumonia: respiratory rate ³ 30, temperature ³ 38 degrees Celsius, elevated pulse, somnolence or diminished alertness, presence of acute confusion, absence of wheezes, lung crackles on auscultation, and increased white blood count.
By using this system, nursing homes without X-rays, or without a doctor regularly on site, can better weigh whether to send patients to emergency rooms for evaluation. When handling older patients, nursing homes must be continually balancing risks and benefits of taking such an action. The initial temptation may be to ship a patient to a hospital for diagnosis or treatment, but that aggressiveness may not be in the patient’s best interest.
“If the person is at relatively low risk (for dying) — they’re probably a candidate for oral antibiotics and not putting them in the hospital,” Dr. Mehr said. “Even if they are at a high risk of dying, there may come a time when comfort care becomes more important than survival.”
Pneumonia treatment begins with antibiotics, though they should be administered carefully because resistant bacteria may be created inadvertently. “In general, if you think they aspirated during feeding, wait to see if they get better,” Dr. Marrie said. “It might not be an infection, so it’ll settle down.”
Chest physiotherapy, deep breathing .exercises and coughing can help expectorate sputum, though some patients may be too weak to effectively do this. Positive expiratory pressure with high-frequency oscillations at the airway opening also can be used. “It’s very effective, if you have the right patient —someone who can take deep breaths and cooperate,” said Diane Perkins, CRT, respiratory manager at Christopher House.
Bronchodilators can loosen secretions, but Perkins usually avoids inhalers for an elderly population. “They have such poor technique,” she said, estimating that 95 percent of the patients she treats use an inhaler improperly.
Drinking water can clear up secretions, and it’s a good idea anyway, because patients are sick and probably aren’t drinking as much as they need. Also, try exercise. “Often what helps most is getting the patient up and about,” Pond said. “It helps to mobilize the secretions.”
Frequently, elderly pneumonia patients will have high respiratory rates, so Pond uses a pulse oximeter to assess the oxygen saturation. If they’re shown to have hypoxemia, they’ll need supplemental oxygen, which can involve a lot of monitoring, she said. While they’re sick, RTs need to ensure they’re receiving enough oxygen, and once they get better, RTs need to ensure they’re weaned off slowly and properly.
The administration of supplemental oxygen can be difficult because the patient may be delirious and pull at the mask or nasal cannula, Dr. Gomolin said. Another thing to keep in mind is that because of a lack of Medicare reimbursement, RTs are often a rarity in nursing homes, so that leaves overburdened nurses to handle oxygen.
“We all assume nurses can do it, and nurses can, but they’re busy doing other things,” Pond said. “What happens if there is no RT around is they get one good reading and then take them off (oxygen).”
TIPS FOR PREVENTION
In terms of preventive measures, nursing home personnel can consider a few simple interventions. For starters, keep the head of beds elevated so patients don’t aspirate.
And make sure patients brush their teeth. In one Japanese study, researchers discovered that if nursing home staff performed oral care on patients after every meal for a month, the patients gained improved swallowing reflux and overall functioning, which in turn, may reduce the risk of pneumonia.4
Another measure for reducing pneumonia is staff hand washing. “If the whole floor gets sick, you know the hand-washing technique isn’t up to par,” Perkins said.
Vaccinations also are important. Every year, patients should receive the vaccine for influenza, a complication of which is pneumonia, Dr. Gomolin said. Patients should get the pneumococcal vaccine as well, despite the fact its benefit to older populations hasn’t been positively shown.
“It’s cheap and safe,” Dr. Mylotte said. “Most of us doing geriatrics highly recommend it.” n
1. Minino AM, Smith BL. Deaths: preliminary data for 2000. National vital statistics reports; vol 49 no 12. Hyattsville, Md: National Center for Health Statistics. 2001.
2. Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect Dis. 2000 Oct;31(4):1066-78.
3. Mehr DR, Binder EF, Kruse RL, Zweig SC, Madsen RW, D’Agostino RB. Clinical findings associated with radiographic pneumonia in nursing home residents. J Fam Pract. 2001 Nov;50(11):931-7.
4. Yoshino A, Ebihara T, Ebihara S, Fuji H, Sasaki H. Daily oral care and risk factors for pneumonia among elderly nursing home patients. JAMA. 2001 Nov;286(18):2235-6.
John Crawford is assistant editor of ADVANCE.