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Correspondence |

Pneumonia and Mortality Beyond Hospital Discharge in Elderly Patients FREE TO VIEW

Renzo Rozzini, MD; Marco Trabucchi, MD
Author and Funding Information

From the Department of Internal Medicine and Geriatrics (Dr Rozzini), Poliambulanza Hospital; and the Geriatric Research Group (Dr Trabucchi), Second University of Rome.

Correspondence to: Renzo Rozzini, MD, Poliambulanza Hospital, Via Bissolati 57, Brescia 25154, Italy; e-mail: renzo.rozzini@iol.it


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(2):473-474. doi:10.1378/chest.10-2057
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Published online

To the Editor:

We read with interest the article by Bordon et al in CHEST (August 2010)1 on the effect of pneumonia on survival, and we would like to contribute to the topic with data obtained from a large group of elderly patients admitted to our geriatric ward (Poliambulanza Hospital, Brescia, Italy) during a 36-month period. Patients underwent a multidimensional evaluation after admission, which included the gathering of information on demographics, mental and physical health, and functional abilities, using a standard protocol.2,3 Pneumonia was diagnosed by clinical signs and chest radiography, and treatment was carried out according to the American Thoracic Society/Infectious Diseases Society of America guidelines.4

During the observed period, 3,365 elderly patients were admitted to our ward, and 382 were diagnosed with pneumonia (265 community-acquired pneumonia [CAP], 74 health-care-associated pneumonia, and 43 hospital-acquired pneumonia); 236 died in hospital (187, no pneumonia; 25, CAP; 14, health-care-acquired pneumonia; and 10, hospital-acquired pneumonia). Patients with nonrespiratory infectious diseases were excluded (n =45). Only the group of patients discharged alive were considered; thus, the number of included patients with CAP was 240. Three months’ mortality was the outcome measure of the analysis.

The characteristics and the survival rate at 3 months of patients with pneumonia and those with acute noninfectious conditions (ie, heart failure, stroke, dehydration, delirium, and so forth) are shown in Table 1. Severity of somatic, biologic, psychic, and functional conditions was higher in patients affected by pneumonia than in those with acute noninfectious diseases. In particular, those disabled 2 weeks before admission were nearly doubled in the CAP group. Three-month mortality was significantly higher in patients with pneumonia (19.2%) than in other patients (10.3%).

Table Graphic Jump Location
Table 1 —Characteristics and 3-Month Mortality Rate of 2,948 Elderly Hospitalized Patients With and Without CAP

Data are presented as mean ± SD or No. (%). APACHE II-APS = Acute Physiology and Chronic Health Evaluation II-Acute Physiologic Subscore; CAP(+) = with community-acquired pneumonia; CAP(-) = without community-acquired pneumonia; CRP = C-reactive protein; CURB-65 = confusion or dementia, urea nitrogen, respiratory rate, BP, and age ≥65 y; NYHA = New York Heart Association.

a 

Significant differences between groups were assessed using the independent t test and the χ2 test for continuous and categorical variables, respectively.

Table 2 gives the crude and adjusted associations of different variables and 3-month mortality in the hospitalized elderly patients. After controlling for variables significantly associated with 3-month mortality in crude analyses (ie, male, ≥90 years old, smoking habit, Acute Physiology and Chronic Health Evaluation II-Acute Physiology Subscore [APACHE II-APS] subscore ≥12, urea/creatinine ratio >60, disabled 2 weeks before admission, delirium, dementia, COPD, malnutrition, renal failure, metastatic cancer, stroke, a Charlson index score ≥5, and a drugs numbering ≥7), being very old (≥90 years); having a smoking habit; having an APACHE II-APS subscore ≥12; having a urea/creatinine ratio >60; being disabled 2 weeks before admission; having delirium, dementia, COPD, malnutrition, metastatic cancer, a Charlson index score ≥5, and drugs numbering ≥7 held an independent association.

Table Graphic Jump Location
Table 2 —Three-Month Mortality Risk in 2,948 Elderly Hospitalized Patients

Cox proportional hazard ratio was used to model the time-of-death data to identify possible predictors of mortality. Variables significantly associated with mortality in crude analysis were included as potential confounders in a final Cox proportional hazards regression model, with CAP admission status as the main predictor and time to death as the outcome. RR = relative risk. See Table 1 for expansion of other abbreviations.

a 

Crude analysis.

b 

Final Cox proportional hazards regression model.

These data confirm those of Bordon et al1 (ie, hospitalized CAP is associated with many deaths outside the time frame normally considered in this otherwise acute disease). This finding may support the hypothesis that pneumonia is an epiphenomenon of a preexisting condition (ie, of reduced vitality [as indicated by a higher prevalence of disability 2 weeks before admission]), whereas Bordon et al1 seem to endorse the possibility of an independent pathologic event induced by pneumonia itself. In the first case, it would be rather difficult to reduce the mortality hazard in older patients after pneumonia because of the frailty of the subjects, whereas in the second case, interventions, such as those indicated by Hurley5 in his editorial, could became the object of specific studies.

In conclusion, our data and those of Bordon et al1 indicate that clinicians must take into consideration the poor outcomes of older patients with pneumonia to choose the most appropriate care. At the same time, we are well aware that the instruments available to reduce mortality are very poor and that studies should be performed urgently to give a more precise direction to our therapeutic efforts. Improved understanding of the poor long-term prognosis associated with CAP is needed to modify the dismal outcome of this common disease in elderly patients.

Bordon J, Wiemken T, Peyrani P, et al; and the CAPO Study Group and the CAPO Study Group Decrease in long-term survival for hospitalized patients with community-acquired pneumonia. Chest. 2010;1382:279-283. [CrossRef] [PubMed]
 
Rozzini R, Sabatini T, Cassinadri A, et al. Relationship between functional loss before hospital admission and mortality in elderly persons with medical illness. J Gerontol A Biol Sci Med Sci. 2005;609:1180-1183. [CrossRef] [PubMed]
 
Rozzini R, Sleiman I, Barbisoni P, Trabucchi M. Pneumonia and mortality in elderly patients. J Am Med Dir Assoc. 2008;91:65-66. [CrossRef] [PubMed]
 
American Thoracic SocietyAmerican Thoracic Society Infectious Diseases Society of America Infectious Diseases Society of America Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;1714:388-416. [CrossRef] [PubMed]
 
Hurley JC. Bob Hope, pneumonia, and the counterfactual. Chest. 2010;1382:248-249. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Characteristics and 3-Month Mortality Rate of 2,948 Elderly Hospitalized Patients With and Without CAP

Data are presented as mean ± SD or No. (%). APACHE II-APS = Acute Physiology and Chronic Health Evaluation II-Acute Physiologic Subscore; CAP(+) = with community-acquired pneumonia; CAP(-) = without community-acquired pneumonia; CRP = C-reactive protein; CURB-65 = confusion or dementia, urea nitrogen, respiratory rate, BP, and age ≥65 y; NYHA = New York Heart Association.

a 

Significant differences between groups were assessed using the independent t test and the χ2 test for continuous and categorical variables, respectively.

Table Graphic Jump Location
Table 2 —Three-Month Mortality Risk in 2,948 Elderly Hospitalized Patients

Cox proportional hazard ratio was used to model the time-of-death data to identify possible predictors of mortality. Variables significantly associated with mortality in crude analysis were included as potential confounders in a final Cox proportional hazards regression model, with CAP admission status as the main predictor and time to death as the outcome. RR = relative risk. See Table 1 for expansion of other abbreviations.

a 

Crude analysis.

b 

Final Cox proportional hazards regression model.

References

Bordon J, Wiemken T, Peyrani P, et al; and the CAPO Study Group and the CAPO Study Group Decrease in long-term survival for hospitalized patients with community-acquired pneumonia. Chest. 2010;1382:279-283. [CrossRef] [PubMed]
 
Rozzini R, Sabatini T, Cassinadri A, et al. Relationship between functional loss before hospital admission and mortality in elderly persons with medical illness. J Gerontol A Biol Sci Med Sci. 2005;609:1180-1183. [CrossRef] [PubMed]
 
Rozzini R, Sleiman I, Barbisoni P, Trabucchi M. Pneumonia and mortality in elderly patients. J Am Med Dir Assoc. 2008;91:65-66. [CrossRef] [PubMed]
 
American Thoracic SocietyAmerican Thoracic Society Infectious Diseases Society of America Infectious Diseases Society of America Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;1714:388-416. [CrossRef] [PubMed]
 
Hurley JC. Bob Hope, pneumonia, and the counterfactual. Chest. 2010;1382:248-249. [CrossRef] [PubMed]
 
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