A multi-institutional study led by Cleveland Clinic experts revealed that patients with community-acquired pneumonia who are aged 85 and older have different comorbidities and disease etiologies than those who are between the ages of 65 and 75. According to findings recently published in theJournal of Investigative Medicine, this older patient population also receives less-intensive treatment and has a higher mortality rate.
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Building off of previous research, investigators set out to better understand this particularly vulnerable population. “We thought it would be interesting to evaluate how we treat the oldest geriatric patients, in whom clinical research is limited,” explains internist Michael B. Rothberg, MD, study coauthor and Vice Chair for Research in Cleveland Clinic’s Medicine Institute. “In most cases, ‘older’ patients are defined as over the age of 65; however, being 65 has very different implications than being 85. We wanted to examine how the care and outcomes of patients in the very elderly group differ from the experiences of those who are one or two decades younger.”
Demographic data from the retrospective cohort study revealed that patients 85 years and older were more likely to be white, female, and admitted with aspiration pneumonia. Additionally, the researchers observed that this older cohort suffered from higher rates of dementia but lower rates of diabetes and chronic obstructive pulmonary disease.
Data showed that Staphylococcus aureus was the most common pathogen across all age groups (33.4%); however, patients 85 years and older were more likely to have Escherichia coli pneumonia when compared with those ages 65 to 74 years (16.1% vs. 10.7%).
Although older patients in the study had a greater in-hospital mortality, Dr. Rothberg notes that they were also less likely to be admitted to the ICU and receive mechanical ventilation than their younger counterparts.
Rates of acute kidney injury and Clostridium difficile infections were also lower in the 85 and older age group. Additionally, data demonstrated that these patients had shorter lengths of stay and fewer medical costs, and were more likely to be discharged to a skilled nursing facility or hospice.
“These findings suggest that the care these older patients received was, on average, less intense than the care provided to their younger counterparts,” explains Dr. Rothberg. “Interestingly, the older the patient, the more pronounced this discrepancy. This raises critical questions and emphasizes the need to understand the driving force behind this trend. The data may indicate that older patients are potentially being under treated. On the other hand, older patients may be declining more aggressive care because they recognize the risks posed by their comorbidities.”
To better understand this patient population, Dr. Rothberg and his team are currently working on a follow-up study that examines do-not-resuscitate orders and the effect they have on the treatment and outcomes of geriatric patients.
“Advanced directives are essential, especially in patients with pneumonia, who typically present with a number of comorbidities. It is important we handle these cases with sensitivity. The oldest and sickest patients are regularly faced with life-and-death decisions, so they warrant careful consideration,” he adds, noting that doctors are seldom trained to have difficult end-of-life conversations.
“This is an opportunity to develop the tools necessary to help patients and families navigate these difficult issues,” Dr. Rothberg concludes.