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January 18, 2018 | Author: Anonymous | Category: , Science, Health Science, Geriatrics
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Aspiration pneumonia in older people David J Stott David Cargill Professor of Geriatric Medicine

Aspiration pneumonia in older people • •

Epidemiology Causes of aspiration pneumonia – Oropharyngeal dysphagia • Cerebrovascular and degenerative neurological disease

– Oropharyngeal bacterial colonisation / poor oral health



Issues of older age – – – – –

• •

‘Physiology’ of ageing Multimorbidity Undernutrition Reduced functional and cognitive reserve Non-specific presentation of disease

Prevention Management

Conflict of interest Research funding from pharmaceutical industry – Trials of statins, antithrombotics, nutritional supplements Consultancy – Nestle Nutrition, Pfizer, Astra Zeneca

Epidemiology • Incidence of pneumonia increases with aging and frailty – RR=6 if age > 75 compared to < 60 years – hospitalisations per year for pneumonia 1.1 / 1000 community-dwelling elderly adults 33 / 1,000 nursing home residents per year

• Morbidity and mortality from pneumonia increases with aging Marik, Chest 2003

Definitions and mechanisms • Aspiration is the misdirection of oropharyngeal or gastric contents into the larynx and lower respiratory tract • Aspiration pneumonia develops after aspiration of bacterially colonized oropharyngeal contents • Aspiration of bacteria from oropharynx is the primary pathway by which bacteria gain entrance to the lungs

Bacterial cause of communityacquired pneumonia (CAP) • Diagnosis of the bacterial cause of CAP is made in 65 years • Dysarthria or aphasia • Severe disability – modified Rankin > 4

• Cognitive impairment – Abbreviated Mental Test < 8

• Failed water swallow test Sellars, Stott et al, Stroke 2007; 38: 2284

Swallowing assessment and investigation after stroke Routine assessment • Look in the mouth! No impaired consciousness • Water swallow test • Bedside swallow assessment Selected patients • Nasendoscopy • Modified Barium swallow (video-fluoroscopy)

Key concepts in illness in later life • Reduced homeostatic reserve with ageing • Multiple diseases – Frailty – Undernutrition – Iatrogenesis, adverse drug reactions

• Non-specific presentation of disease – Geriatric giants

• Multiple problems, requiring complex solutions

FVC and FEV1 and ageing

Knudson, Am Rev Resp Dis 1976

Healthy ageing and the swallow • Older people swallow more slowly – – – –

Laryngeal vestibule closure delayed Maximal hyolaryngeal excursion delayed Upper esophageal sphincter opening delayed Oral bolus transport time prolonged

• Safety of oropharyngeal swallowing is not compromised – No increase in the frequency of aspiration in radiographic studies that compare older to younger adults – However reduced physiological reserve

Cough reflex –respiratory defence • No apparent effect of healthy ageing on the cough reflex • The cough threshold concentration for inhaled citric acid – 2.6 ± 4.0 mg/mL in control subjects – 37.1 ± 16.7 mg/mL in patients with dementia – > 360 mg/mL in survivors of aspiration pneumonia

Geriatric Giants – non-specific presentation of disease • Intellectual impairment – Delirium and dementia

• Immobility – ‘Off feet’

• Instability – Falls

• Incontinence • Loss of swallow

Fernandez-Sabe et al Medicine 2003; 82:159 • 1,474 patients hospitalized with CAP – nursing home residents excluded

• 305 (21%) over 80 years versus under 80s – – – – –

pleuritic chest pain reduced (37 versus 45%) headache (7 versus 21%) myalgias (8% versus 23%) absence of fever (32% versus 22%) ‘altered mental status’ (21 versus 11%)

Cumulative incidence of delirium in hospitalised patients Age > 65 years

15-20%

‘Frail’ elderly

40-60%

Prior chronic cognitive impairment

30-45%

Cochrane Database of Systematic Reviews

Causes of delirium Disturbance Infection Cardio-respiratory Fluid / electrolyte Metabolic Intracranial Drug toxicity/withdrawal

% of cases 35 32 30 13 12 20

O'Keefe & Lavan, Age Ageing 1999;28: 115

Outcome of delirium • • • • •

Prolonged hospital stay Increased mortality Increased costs of health care Residual cognitive impairment Increased risk of progression to dementia

Management strategies to reduce the risk of aspiration pneumonia • Assistance with regular oral hygiene • Screening / investigation for dysphagia – High risk subgroups e.g. stroke, dementia, pneumonia, witnessed aspiration

• • • • •

Nil-by-mouth during high risk periods Postural interventions / swallowing manoeuvres for dysphagia Hand-feeding Small amounts frequently Modified diet / thickened fluids / food supplements

Conclusions • • • • •

Aspiration is the main cause of pneumonia in later life Oropharyngeal dysphagia plus bacterial colonisation Frailty, cognitive impairment and multi-morbidity Non-specific presentation Potential for prevention – multi-modal / multi-disciplinary strategies

Acknowledgements Collaborators • Petrina Sweeney • Jeremy Bagg • Gillian Kerr • Marian Brady • Cameron Sellars • Lindsay Bowie • Peter Langhorne

Funders • CSO Scottish Executive • Chest Heart and Stroke Scotland

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