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ELDERLY
DR. DOHA RASHEEDY
LECTURER OF GERIATRIC MEDICINE
DEPARTMENT OF GERIATRIC AND GERONTOLOGY
INTRODUCTION
Waning immunity and the physiologic changes that come with aging make
the elderly especially prone to infectious diseases such as pneumonia,
urinary tract infection (UTI), and skin and soft tissue infections.
EXAMPLES ON NONSPECIFIC
SYMPTOMS:
Generalized malaise
Falls
Changes in mental status or cognitive impairment
Anorexia
comorbid illnesses.
increased exposure to pathogens in institutions.
complications of medical treatment.
AGEING IMMUNITY
Immunosenescence increases vulnerability of the elderly to
infection.
Alterations in the barriers posed by the skin, lungs, and gastrointestinal tract
(and other mucosal linings), permitting invasion by pathogenic organisms
SKIN:
poor perfusion,
increase the risk of damage to the skin and the subsequent development of soft
tissue infection such as cellulitis and infected decubitus ulcers.
Mucosal surfaces :
also adversely affected by age, disease, and lifestyle (e.g., cigarette smoking) with loss
of the ciliary action of the epithelial cells of the upper respiratory tract and possibly
reduction of secretory immunoglobulins).
PRIMARY IMMUNITY
Consists of phagocytosis, complement, and natural killer cells.
ACQUIRED IMMUNITY
With advancing age,
COMPLICATION OF TREATMENT
Invasive devices, which include indwelling urinary
catheters, intravenous catheters, feeding tubes, and
tracheostomies, are more common in the elderly.
These devices compromise host defenses enabling
bacteria to enter the body and cause infection.
the older adult with altered cognitive function may not be able to
perceive symptoms of infection or communicate them to their health
care provider.
USEFUL INDICATORS
OF INFECTION
Functional status: is a sensitive indicator of infection in nursing home
residents.
Acute infection in the elderly often is heralded by a decline in mental or
physical function. Difficulty ambulating, frequent falls, incontinence, and
delirium
FEVER
PNEUMONIA
RISK FACTORS:
1. Chronic obstructive pulmonary disease and smoking are the most
pervasive risk factors for CAP. Smoking cessation for 5 years may
reduce excess risk of CAP by almost half.
2. Congestive heart failure
3. diabetes
4. lung cancer
5. immunosuppression
6. Previous pneumonia
7. other malignancies
ORGANISMS
CAP:
Streptococcus pneumoniae, Haemophilus influenzae Staphylococcus
aureus, Moraxella catarrhalis, Pseudomonas aeruginosa, Escherichia
coli, Klebsiella pneumoniae ,
Atypical: Legionella pneumophilia, Chlamydia pneumoniae, Coxiella
burnetti, Mycoplasma pneumoniae
Viruses: Influenza A, Parainfluenza .
NHAP:
Streptococcus pneumoniae, haemophilus influenzae,Moraxella
catarrhalis
SEVERITY OF PNEUMONIA.
There are a variety of assessment tools that can assist in determining
the severity of pneumonia.
CURB-65
The modified American Thoracic Society (ATS) guidelines.
Pneumonia severity index scoring system
PSI
Class I (age 50,no coexisting illness, and no adverse clinical findings)
And II (PSI 70) are considered for outpatient treatment,
and class III (70-90) may be managed either as an inpatient or
outpatient
Class IV (PSI 91130) and V (PSI score >130) for inpatient
management,
the index heavily weights age, assigning men over the age of 70 and
women over 80 into risk class III even if there are no other risk factors.
It neglects other areas such as social circumstances which are
important in deciding whether or not to admit elderly patients.
The authors suggest that the CURB-65 score can stratify patients
into 3 different management options:
group 1 (score 0 or 1) was found to have a low mortality of 1.5%
and can be considered for outpatient management
group 2 (score of 2, mortality intermediate 9.2%, can be considered
for hospital supervised treatment;
group 3 (score 3 or more, mortality high at 22%,) should be
considered for intensive care management if appropriate.
2.
3.
4.
5.
Uncontrolled comorbidity
6.
New Somnolence
New or increased agitation
Facility unable to care for patient
7.
INVESTIGATIONS
Leucocytosis and increase in band forms develop less frequently in
elderly patients and are thus less sensitive in the detection of
pneumonia.
a normal CRP value virtually excludes pneumonia, even in the very
old.
Blood gas analysis
Microbiology: the question of whether sputum analysis should be
done is controversial (recommended by the Infectious Diseases
Society of America, but not by the American Thoracic Society).
Indeed, the elderly are often too weak to provide an adequate
sputum specimen, or too confused to cooperate and the diagnostic
yield of sputum analysis is relatively low.
Blood cultures twice
TEST for urinary legionella antigen ,PCR testing for Chlamydia spp,
M pneumoniae, and common respiratory viruses are now available,
but their clinical usefulness has not yet been established.
BUN, electrolytes, glucose prognostic value
MANAGEMENT:
Supportive ttt:
1. Chest percussion
2. Rehydration
3. Bronchodilators
4. Oxygen therapy or mechanical ventilation
INSTITUTIONALLY ACQUIRED
PNEUMONIA
Initial regimens should be broadly inclusive, followed by step-down
therapy to narrower coverage if the causative agent is identified
For MRSA-colonized patients or patients in units with high rates of
MRSA, initial regimens should include vancomycin or linezolid until
MRSA is excluded.
PATHOGENESIS OF HCAP
Colonization of the pharynx with bacteria is the most important step in the
pathogenesis of hospital-acquired pneumonia.
Pharyngeal colonization is promoted by:
exogenous factors (instrumentation of the upper airway with nasogastric
and endotracheal tubes, contamination by dirty hands and equipment)
treatment with broad-spectrum antibiotics that promote the emergence of
drug-resistant organisms)
patient factors (malnutrition, advanced age, altered consciousness,
swallowing disorders, and underlying pulmonary and systemic diseases).
Aspiration of infected pharyngeal or gastric secretions delivers bacteria
directly to the lower airway.
+ Impaired cellular and mechanical defense mechanisms in the lungs of
hospitalized patients raise the risk of infection after aspiration has
occurred.
CLINICAL FINDINGS
SYMPTOMS AND SIGNS
The symptoms and signs associated with hospital-acquired pneumonia are
nonspecific; however, one or more clinical findings (fever, leukocytosis,
purulent sputum, and a new or progressive pulmonary infiltrate on chest
radiograph) are present in most patients.
Other findings associated with hospital-acquired pneumonia include those
listed above for community-acquired pneumonia.
The differential diagnosis of new lower respiratory tract symptoms and signs in
hospitalized patients includes
1.
2.
3.
4.
5.
6.
7.
INFLUENZA
VIRAL INFECTIONS OF
RESPIRATORY TRACT
Influenza types A and B, parainfluenza, coronavirus, and rhinovirus are
the cause of most common viral respiratory infections.
Influenza type A and respiratory syncytial virus (RSV) cause the
greatest morbidity and mortality.
Influenza types A and B cause epidemics of disease almost every
winter.
SYMPTOMS & SIGNS:
Classic influenza presents with abrupt onset of fever, chills, headache,
and myalgia, which are accompanied by pharyngitis, nonproductive
cough, and clear, watery nasal congestion. The fever accompanying
influenza infection can last from 4-8 days.
Common symptoms of RSV infection include rhinorrhea, cough,
sputum production, shortness of breath, and wheezing
LABORATORY TESTS
Viral culture for influenza using nasopharyngeal swab, is useful in
making an etiological diagnosis because the symptoms of influenza
may be similar to those of other viruses such as RSV.
Rapid antigenic tests, with 80-90% sensitivity and specificity
(depending on sample quality), are commercially available to detect
influenza types A and B.
Unfortunately, the sensitivity of culture for RSV is extremely poor
because the shedding of RSV in the oropharynx is low. In addition,
RSV is thermo-labile and does not survive long in transit.
PREVENTION
Hospitalization and mortality in both community-dwelling elderly and
nursing home residents are reduced when vaccine is administered
before the influenza season.
Side effects of the influenza vaccine are the same for the elderly as for
younger individuals: local soreness, low-grade fever, and muscle
aches.
When influenza occurs in a nursing home, the CDC recommends
antiviral prophylaxis for all residents to prevent an epidemic.
Prophylaxis should be continued for at least 2 weeks or, if cases
continue to occur, until 1 week after the outbreak has ended.
TREATMENT
Treatment of the common cold is symptomatic with
acetaminophen, decongestants, and antihistamines. However, many
cold remedies contain medications that can cause adverse effects in
the elderly or interact with prescription medications.
Laninamivir:
TUBERCULOSIS
interferon- assays
TREATMENT
latent disease :
If the chest x-ray film does not reveal evidence of active disease in a
person with a positive skin test
UTI
2.
5. Diabetes.
Asymptomatic bacteriuria
Asymptomatic bacteriuria (> 100,000 colonies/mL on 2 consecutive
specimens in an asymptomatic patient)
affect 1-6% of men and 10-20% of women over age 60 in the community
and 15-35% of men and 25-50% of women in nursing homes.
There is no clinical benefit when asymptomatic bacteriuria is
treated.
TREATMENT
2.
3.
4.
Once culture results are available, the empiric antibiotic regimen should
be changed to an appropriate antibiotic with the narrowest spectrum.
GASTROENTERITIS
Causative organisms:
In outpatients with diarrhea, viral pathogens are most common
The principal bacterial pathogens causing diarrhea in the elderly are C.
difficile, Campylobacter species, Escherichia coli, Salmonella species,
and Shigella species. When onset of symptoms is within 12 h of ingestion
of contaminated food, the toxins of Clostridium perfringens, Bacillus
cereus, or S. aureus may be responsible.
Antibiotic-associated diarrhea caused by C. difficile is common in the
elderly because of more hospitalizations, nursing home stays, and
antibiotic use. Up to 50% of patients older than 65 will develop C. difficileassociated diarrhea after hospitalization and antibiotic use. Much of the
problem with C. difficile is due to poor infection control practices.
PSUEDOMEMBRANOS COLITIS
Clinical ranges from mild diarrhoea to life-threatening colitis
Occurs 1/7 to 6/52 after antibiotic exposure
The patient experiencing diarrhea may have crampy lower
abdominal pain, anorexia, fever, malaise, and watery or bloody
diarrhea. In general, symptoms are not specific enough to
identify the causative pathogen
C. difficile can cause severe diarrhea, fever and systemic toxicity
Severely ill may have no diarrhoea due to toxic megacolon
Complications: perforation, peritonitis high mortality
LABORATORY TESTS
TREATMENT
Treatment
focuses
replacement.
on
rehydration
and
electrolyte
INFECTED
PRESSURE
ULCERS
2.
INFECTIVE
ENDOCARDITIS
ORGANISMS
Most cases of NVE are caused by Streptococcus viridans (50%)
and Staphylococcus aureus,
intraoperative
in particular
DIAGNOSIS
The major Duke criteria are:
1.
2.
2.
Fever
3.
4.
5.
TREATMENT
Antimicrobial therapy must be bactericidal and prolonged.
Pts with acute endocarditis require antibiotic treatment as soon as three
sets of blood culture samples are obtained, but stable pts with subacute
disease should have antibiotics withheld until a diagnosis is made.
Streptococci:
Penicillin G (23 mU IV q4h for 4 weeks)
Ceftriaxone (2 g/d IV as a single dose for 4 weeks)
Enterococcih
Penicillin G (45 mU IV q4h) plus gentamicind (1 mg/kg IV q8h), both for
46 weeks Can use streptomycin (7.5 mg/kg q12h) in lieu of gentamicin
if there is not high-level resistance to streptomycin
Ampicillin (2 g IV q4h) plus gentamicind (1 mg/kg IV q8h), both for 46
weeks
Vancomycinc (15 mg/kg IV q12h) plus gentamicind (1mg/kg IV q8h), both
for 46 weeks
Staphylococci
Methicillin-susceptible,
Nafcillin or oxacillin (2 g IV q4h for 46 weeks) plus (optional)
gentamicind (1 mg/kg IM or IV q8h for 35 days)
Staphylococci
Methicillin-resistant, infecting prosthetic valves
Vancomycin (15 mg/kg IV q12h for 68 weeks) plus
gentamicin (1 mg/kg IM or IV q8h for 2 weeks) plus
HIV IN
ELDERLY
INTRODUCTION
AIDS is increasing in elderly population:
1. the success of combination antiretroviral therapy added to life
expectancy of the patients.
2. the risk of new HIV infections is also likely to increase:
1. the use of sildenafil to effectively treat erectile dysfunction and
enhance sexual performance may increase risky sexual behavior.
2. Additionally, postmenopausal women may be less likely to request
that condoms be used as they face no risk of pregnancy.
3. Finally, age-associated declines in immunity may place older
individuals at higher risk of transmission with each exposure
CLINICAL PRESENTATION
Like in younger patients, acute infection
may be completely asymptomatic or
present as a flu-like syndrome.
older who are chronically infected with
HIV and in care, the most common selfreported symptoms are fatigue, peripheral
neuropathy, problems sleeping, myalgias
or arthralgias.
Physical exam
Skin: Kaposis sarcoma, psoriasis, seborrheic dermatitis and varicella
zoster scars
Oral pharynx: Periodontal disease, thrush, Kaposis sarcoma
Optic fundi: HIV cotton wool spots, CMV retinitis
Lymphatic: Lymphadenopathy, splenomegaly
Genital and rectal exam: Herpes simplex (HSV) ulcers or scars,
fissures, fistulas, condyloma accuminatum, condyloma latum
Neurologic exam:
neuropathy
Altered
mini-mental
status,
distal
sensory
Neurologic syndromes
Acute aseptic meningitis
Fungal meningitis
Unexplained dementia
Skin findings
Oral findings
Thrush
Hairy leukoplakia
Aggressive periodontitis
Severe recurrent aphthous ulceration
Kaposis sarcoma
Pneumonias
Hepatitis
Hepatitis B
Hepatitis C
Herpes simplex
Gonorrhea
Chlamydia
Human papilloma virus
Genital warts
Syphillis
Hematologic findings
Thrombocytopenia
Neutropenia
Anemia
Lymphopenia (absolute count <1000 roughly
corresponds with CD4 <200)
DIAGNOSIS
Antibody tests are the standard tests for detecting HIV infection in most
patients. These tests are highly sensitive but can miss HIV infection in
some circumstances, such as when the infection is caused by HIV-2, a
virus common in West Africa, or when the test is performed early in HIV
infection before antibody has had a chance to develop.
Confirmation:
INITIATION OF THERAPY
Untreated asymptomatic adults should be examined every 6 months,
and the CD4 count and HIV viral load should be performed and
evaluated every 3 months.
Guidelines have been established as to when ARV treatment should be initiated
based on the CD4 count. In general, ARV treatment should be recommended to
anyone with an AIDS-defining illness, HIV-associated nephropathy, or a CD4 count
<200cells/mm3 regardless of viral load level
HIV TREATMENT
a combination regimen, usually including a minimum of 3 different
ARV agents, preferably from at least two different classes.
Nucleoside reverse transcriptase inhibitors (NRTIs)
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