Pneumonia in the Elderly

• SAFAA HUSSEIN ALISAFAA HUSSEIN ALI• Associate professor of geriatric Associate professor of geriatric

medicinemedicine• Ain shams universityAin shams university• fersanarabia@gmail.comfersanarabia@gmail.com

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Pneumonia in Old Agein Old Age

• Atypical presentation• Frailty• Risk Factors of Old Age• Age related changes in lungs• Comprehensive geriatric assessment CGA• Prevention• Aspiration pneumonia• Pneumonia in Older Residents of Long-Term Care

Facilities

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History of GeriatricsHistory of Geriatrics• Greek word “geros” mean the old age + Iatric mean

the medical treatment. This is the branch of medicine concerned with the problems of Ageing, including physiological, pathological, and psychological problems.

• Nascher was the first to coin the term Geriatrics. He published a paper in New York medical journal in1909 and a textbook on it in 1914.

• Thus Geriatric came to be recognized as a special branch in first decade of 20th century.

Definition

• The study of physical and psychological changes that occur in old age is called “gerontology”.

• Geriatrics is the branch of general medicine concerned with clinical, preventive, medical and social aspects of illness in the elderly.

• The old age is defined as the age of retirement. In our country it is fixed at 60 years and above.

THE GERIATRIC GIANTS

ConfusionConfusion

FallsFalls

FallsFalls

Geriatric Geriatric GiantsGiants

PressurePressuresoressores

IncontinenceIncontinenceDepressionDepression

VisionVision

HearingHearingImmobilityImmobility

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Overview: Inpatient Setting Important for the Elderly

• Crucial step in the health care continuum – High rates of hospitalization

• Account for 47% of all inpatient days (but represent only 13% of the population)

• Age 85 and over, twice hospitalization risk

– High rates of readmission• 25% of hospital admissions represent readmission of older adults

– Cost—outcomes

Fethke CC, Smith IM, Johnson N. Risk factors affecting readmission to the health care system. Medical Care. 1986;24:429-437Graves EJ, Gillum BS. National Hospital Discharge Survey: annual summary, 1994. Vital Health Stat. 1997;13:12801/05/23

Iatrogenic Problems—a subset of Hazards of Hospitalization

Affects nearly 1 in 3 hospitalized elderly patients

Adverse drug reactions are the most common form

• Other complications of hospitalization:DeconditioningDeliriumFallsNosocomial InfectionPressure ulcersMalnutritionDysphagia→Aspiration PneumoniaPolypharmacy

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Atypical Presentations

• Functional decline, altered mental statuse.g., delirium or falls due to UTI or fecal impaction

• Misleading symptomse.g., pneumonia with normal or low temperature &

normal or low WBC count• Signs of one disease obscured by another e.g., Pneumonia obscured by CHF• Inability to communicatee.g., new pressure ulcer obscured in patient post –

CVA w/ aphasia or with dementia• No presentation symptoms e.g., silent MI , painless acute abdomen01/05/23 8

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Questions raised:

How do you recognize frailty ?How do you define frailty?What is the importance of identifying frailty in

the hospital setting?What do you need to screen in the suspected

frail patient during hospitalization? Can you prevent hospitalization-associated

decline?

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Frailty

“Frailty is a failure to integrate responses in the face of stress. This is why diseases manifest themselves as the “geriatric giants”….functions …such as staying upright, maintaining balance and walking are more likely to fail, resulting in falls, immobility or delirium”

Rockwood Age Ageing 2004i.e. Poor Functional Reserve

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Geriatricians ID frailty featuresAt least 50% of Geriatricians cited each of the following characteristicsassociated w/frailty

– Under nutrition– Functional dependence– Prolonged bedrest– Pressure sores– Generalized weakness– Aged >90– Wt loss– Anorexia– Fear of falling– Dementia– Hip fracture– Delirium– Confusion– Going outdoors infrequently – Polypharmacy Fried LP, Walston J. Principles of Geriatric Medicine & Gerontology 5th ed. 2003:1487-1502.

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What happens to reserves w/aging?

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Frailty Suspected:Why screen?

Impact on Outcomes Prevention

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Comprehensive Geriatric Assessment

Functional AbilityPhysical assessment

Cognitive assessment Psychological assessment

Social/environmental assessment

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The Hospital CGA? –a comprehensive assessment of functional status

● Screen ADLs(Activities of Daily Living) & IADLs(Instrumental Activities of Daily Living).

● Evaluate physical mobility ● Evaluate for sensory impairments—hearing & sight● Screen for dementia● Screen for depression● Screen for environment/social factors

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Activities of Daily Living

BathingDressingTransferenceContinenceToiletingFeeding

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Instrumental Activities of Daily Living

TravelingShoppingPreparing mealsHouseworkTaking medicineManaging moneyUsing the phone

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Gait-timed get up and go

Quantitative evaluation of general functional mobilityTimed command w/rise from chair; walk 10 feet; turn around; walk back and sit in chair.

Wall JC, Bell C, Campbell S, et al J Rehabil Res Dev 200 37(1):109-11301/05/23

Risk factors for Infections in the Risk factors for Infections in the ElderlyElderly

Older, weaker, more at risk

• More comorbidities• Gradual deterioration of immune system with age• May be malnourished, poor accommodation• More likely to harbour resistant organisms as

more likely to have been – Hospitalised– in nursing home– Exposed to multiple antibiotics

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Cellular Immunity in the ElderlyCellular Immunity in the Elderly• Altered T cell phenotype

naïve T cells; memory T cells

Reduced T cell responses response to TCR stimulation T cell proliferation expression of IL2-R IL2 production

Ginaldi et al 1999

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Physiology of the ageing lung

• Limitation of knowledge• Many respiratory studies don’t include the

older patient esp after the age of 80• Is “ageing of the lung” intrinsic or extrinsic?

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Major changes in lung physiology with age or “Intrinsic ageing”

Reduced• Lung elasticity• Respiratory muscle strength• Chest wall compliance• FEV1 (declines before FVC)• Bronchial hyper-responsiveness• Perception of bronchoconstriction• Diffusion capacity• Arterial oxygen pressure and

saturation• Ventilatory response to hypoxia and

(more worryingly) hypercapnia

Increased• Residual volume• Lung compliance• Oxygen uptake on exercise

Unchanged• Total lung capacity• Airways resistance• Pulmonary arterial resistance• Arterial CO2 levels

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The decline

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“Extrinsic lung ageing” – factors identified in age related decline of FEV1

• Tobacco smoking• Occupational exposure• Asthma• Atopy • Obesity• Excessive alcohol consumption• Respiratory infection in early life• Nutritional status at birth• Maternal or passive smoking

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Pulmonary System:Why pneumonia is so common in old age?

Reduced barrier function of Respiratory tracts due to:

• Altered mucous increases bacterial adherence

• Altered respiratory cilia function (slower/less organized)

Leads to; Greater colonization with

Gm neg. bacteria

• Chest wall is less compliant– Dependent on abdominal

breathing for lung expansion

• Lungs are more compliantLeading to: Increase in residual volume Decline FEV1

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FEV-1 Versus Age

100%

50%

% o

f Val

ue a

t 20-

25 y

ears

30 50 70 80

Age in Years

25%

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Why pneumonia is so common in old age?

• Decline in PaO2 PaO2 = 100-(age/3)

• By age 40 yrs, full expansion does not occur supine

• By age 65 yrs, full expansion does not occur sitting

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Effect of Age on p02 Seated and Supine

AGE 20 40 60 80

70

60

80

90

100pO2 Lower Limit of Normal for Age

pO2

mm

Hg

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PREVENTION (6, 7, 8)

Improve host defenses: • Pneumococcal vaccine• Improve cough reflex ( especially during

sleep)-avoid sedatives, hypnotics, narcotics

• Reminders to: deep breath, increase upright activity and incentive respirometers

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PREVENTION- continued (9, 10)

Improve host defenses: • Improve clearance of secretions

-humidify, -reduce drying ( meds: anticholinerigcs)-mucolytics- smoking cessation

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PREVENTION- continued ( 11, 12, 13, 14)

Decrease exposure to bacteria.• Hand washing, contact precautions• Avoidance of antibiotics• Reduce frequency and severity of aspirations

– Control reflux: ( upright after meals)– Avoid NG tubes– Oral hygiene– Screen for and treat dysphagia

(Speech therapy, diet consistency)

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• Definition. Pneumonia is an infection involving the alveoli and bronchioles. It may be caused by bacteria, viruses, or parasites. Clinically pneumonia is characterized by a variety of symptoms and signs.

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• Cough (which may be productive of purulent, mucopurulent, or “rust-colored” sputum), fever, chills, and pleuritic chest pain are among its manifestations. Extrapulmonary symptoms such as nausea, vomiting, or diarrhea may occur. There is a spectrum of physical findings, the most common of which is crackles or rales in the lungs. Other findings in the lungs may include dullness to percussion, increased tactile and vocal fremitus, bronchial breathing, and a pleural friction rub.

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• It is important to remember that pneumonia in the elderly may present with few respiratory symptoms and signs and instead may be manifest as delirium, worsening of chronic confusion, and falls. Delirium or acute confusion was found in 45 [44.5%] of 101 elderly patients with pneumonia compared with 29 (28.7%) of 101 age- and sex-matched control subjects. Falls are usually an indication that the person is ill.

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Problems…..• Pneumonia is a common and often serious

illness. It is the sixth leading cause of death • About 600,000 persons with pneumonia are

hospitalized each year, and there are 64 million days of restricted activity due to this illness

• The caregiver burden associated with pneumonia has not been measured, although we know that longterm caregiving is associated with an increased mortality rate among the caregivers

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• The mortality rate among persons providing long-term care and experiencing strain has been reported to be 63% higher than among noncaregiving control subjects.

• Recovery is prolonged in the elderly, especially the frail elderly who may require up to several months to return to their baseline state of mobility. Indeed, hospitalization, with its enforced immobility, often hastens functional decline in the elderly; 25%–60% of older patients experience a loss of independent physical function while being treated in the hospital

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• Older patients with pneumonia complain of fewer symptoms than do younger patients with pneumonia; patients aged 45–64, 65–74, and >75 years had 1.4, 2.9, and 3.3 fewer symptoms than patients aged 18–44

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Respiratory infections

• Incidence of community acquired pneumonia(CAP) substantially higher in older people, especially men

• 60% of over 70’s hospitalised with CAP will die • Age is a prognostic factor in severity of CAP

(CURB 65)• Most common pathogen is still streptococcus

pneumoniae

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Case HistoryCase History

• 67 yr old woman• PC: cough, left sided chest pain, rigors x

24h• HPC: productive cough most mornings,

but increasingly purulent recently• PMHx: MI 2 yrs ago, smoked 40/day until

then

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On Examination:On Examination:

• T: 40oC• Pulse: 130/min, BP: 145/90• Tachypnoea• PMHx: MI 2 yrs ago

smoked 40/day until then• Resp exam suggestive of consolidation

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TestsTests

• FBC, WCC• Sputum for

microscopy and culture

• Blood culture• CXR• ABG

• WCC – 22, 90% neutrophils• Sputum – pus cells, gram

positive diplococci

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CXRCXR GramGram

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Sputum resultSputum resultSputum – pus cells, gram positive

diplococci…What does this tell us?

More than you think – • No epithelial cells - suggests this is a

good specimen from lower RT so should provide a good result on culture

• Gram positive diplococci likely to be?

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Sputum Gram Stain Sputum Gram Stain

• No longer done routinely• Not sensitive or specific enough• Not recommended in IDSA CAP guidelines

• Guidelines now recommend another test instead...

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Urinary Antigen TestingUrinary Antigen Testing

• All severe pneumonias should have urine test for – Legionella Urinary Antigen– Pneumococcal Urinary Antigen

• Should also think of CXR, pulse oximetry, ABG,

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TreatmentTreatmentPneumococcus

BenzylPen unless allergic or live in area of resistance (Irish rate of resistance-?)

When cause unknown, use augmentin or cefotaxime to cover Haemophilus

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later…later…IV BenPenTransferred to ICU for ventilation because of

hypoxiaBCs – positive for S pneumoniae x2WCC – 35CXR – shows increasing consolidation and

pleural effusion24 hrs later – Cardiac arrest – RIPNext day S pneumoniae sensitivity available: R- PenicillinS – Erythromycin, Ceftriaxone

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RTI in ElderlyRTI in Elderly

• Strep. Pneumoniae

• Influenza Virus

• Recurrence of TB

• Normal causes of RTI

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PneumococcusPneumococcus• Common cause of community acquired pneumonia• Risk increased by smoking• Often occurs as secondary pneumonia after influenza

infection• More common during winter months• Can also cause ENT, bacteremia and CNS infections• Latest EARSS Resistance Rates for Ireland:

– Pen Non Susceptible 16.2%– Erythromycin Resistant 14.1%– Ceftriaxone/Cefotaxime Resistance Rare

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Pneumonia SymptomsPneumonia Symptoms

• Fever (less common in those >75)• Cough with coloured sputum• Pleuritic chest pain, dyspnea• Altered mental function, particularly in the

elderly• Increased or decreased WBC

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Strep pneumoniaeStrep pneumoniae

• RTI: Amoxicillin/Clarithromycin if sensitive • If infection severe or previous antibiotic

exposure, use IV Ceftriaxone or Cefotaxime• Augmentin has no added benefit because

resistance is not due to B-lactamase production but do to different Pen binding proteins

• In countries where Ceftriaxone resistance occurs in significant numbers use IV Ceftriaxone and IV Vancomycin empirically

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Pneumococcal PneumoniaPneumococcal Pneumonia• Elderly patients often have fewer or less

severe symptoms than younger patients

• Many community-acquired pneumonias are perfectly treatable as outpatients by oral antibiotics

• >90 polysaccharide capsular types

• HPSC Guidelines:

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Pneumococcal VaccinesPneumococcal Vaccines2 types of pneumococcal vaccine:

1. Polysaccharide Pneumococcal Vaccine (PPV23)– incorporates 23 of the most common capsular types which together

account for up to 90% of serious pneumococcal infections– Only suitable for use in those ≥ 2 years of age

2. A conjugate 7 valent vaccine (PCV7) containing polysaccharide antigens from the 7 most common serotypes conjugated to a protein (CRM 197) has enhanced immunogenicity compared with the polysaccharide vaccine. – immunogenic even in infancy– active against approximately 70% of isolates causing invasive

disease, and against a significant number of penicillin-resistant strains.

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HPSC Groups Requiring VaccinationHPSC Groups Requiring VaccinationAt risk categories:• Asplenia or reduced splenic dysfunction (e.g. splenectomy, sickle cell

disease and coeliac syndrome)• Chronic renal disease or nephrotic syndrome• Chronic heart, lung, or liver disease, including cirrhosis• Diabetes mellitus• Complement deficiency (particularly early component deficiencies C1, C2,

C3, C4)• Immunosuppressive conditions (e.g. HIV, leukaemia, lymphoma,

Hodgkin’s disease) and those receiving immunosuppressive therapies• CSF leaks either congenital or complicating skull fracture or neurosurgery• Intracranial shunt• Candidate for, or recipient of, a cochlear implant• Children under 5 years of age with a history of invasive pneumococcal

disease, irrespective of vaccine history.

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Adults >65Adults >65

• All should be offered single dose of Pneumococcal Polysaccharide Vaccine (PPV23)

• Adults 65 years or older should receive a second dose of PPV23 if they received vaccine more than 5 years before and were less than 65 years of age at the time of the first dose.

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CURB-65 ScoreCURB-65 Score• Confusion – new onset• Urea - >7 mmol/l• Respiratory rate >30 breaths/minute• Blood Pressure <90/60• Age>65

Score: 0-1 – Treat as outpatient2 – consider admission or follow closely as outpatient> 3 requires hospitalization, mortality >17%

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InfluenzaInfluenza

• H1N1 flu pandemic declared over by WHO• now seen as part of seasonal flu• Current seasonal flu vaccine includes a H1N1

strain• Primary Influenza A infection can present

abruptly as rapidly progressive diffuse pneumonia with pulmonary haemorrhage

• More severe in elderly, may develop meningoencephalitis or encephalitis

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InfluenzaInfluenza• Treatment: Neuraminidase inhibitors such as oseltamivir

(PO) and Zanamivir (IV) given early in severe or at risk cases

• Often followed by secondary bacterial pneumonia e.g. S pneumoniae, S aureus

• Vaccine less effective in elderly

• Adults over 50 should have annual vaccination

• Those in nursing homes and other long stay facilities should also have annual vaccination

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Another CaseAnother Case

• 82 year old woman with 2 months of cough, fatigue, night sweats

• Poor response to Coamoxiclav, tetracycline

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TB TB

• Common in the 1950s

• Many people who were exposed/treated as children then are now presenting with TB now as their immune system wanes with age

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Varicella Zoster VirusVaricella Zoster Virus• Cause of Chicken Pox and later Shingles

• Extremely infectious

• Can be severe and even fatal in immunocompromised

• Shingles not uncommon in elderly hospital patients, can leave severe pain of post-herpetic neuralgia

• Pose an infection control risk to immunocompromised, and non immune staff especially to non immune pregnant staff

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Not routinely recommended in ElderlyNot routinely recommended in Elderly

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Resistance to AntibioticsResistance to AntibioticsNo antibiotic – no selection for resistant organisms

sensitive resistant

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Resistance to AntibioticsResistance to Antibioticsantibiotic – selects for resistant organisms

sensitive resistant

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The Problem:Stroke Complications • Pneumonia occurs in 6.7-22% of hospitalized patients with

stroke • Three fold increase in 30 day mortality with pneumonia• Many pneumonia cases preventable with stroke protocols in

place:– Swallow screening– Swallow evaluation– Diet modifications (Katzan, Dawson, Thomas, Votruba and Cebul, 2007)

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Pneumonia and oropharyngeal dysphagia

Pneumonia thought to occur most often as result of oropharyngeal dysphagia with secondary aspiration

• 42-76% patients with acute stroke develop dsyphagia

• Half will experience aspiration• Although not all develop pneumonia

• (Katzan, Cebul, Husak, Dawson, Baker, 2003)

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Risk of pneumonia in the stroke population demographics:• Older patients• Men• More likely admitted from a nursing

home or via the emergency room• More co-morbid illnesses• Physiologic abnormalities• More severe neurologic impairments

at admission(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)

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Ramifications of Pneumonia in Stroke

• Higher 30 day mortality rates• Longer lengths of stay• Discharged alive were more likely to require

extended care• More likely to be readmitted to hospital within

30 days (Katzan,Dawson,Thomas, Votruba and Cebul, 2007)

(Rosenvinge and Starke, 2005)

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Strategies to prevent pneumonia after stroke• Focus: to identify at –risk patients• Swallow screening• Modify oral intake• Obtain swallow therapy to improve swallow safety

and dsyphagia(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)

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The Joint Commission (JC) Performance Measure for Dysphagia in Acute Stroke

• “A swallow screen for dysphagia should be performed on all ischemic and hemorrhagic stroke patients before being given food, fluids or medications by mouth.”www.jointcommision.org

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JC’s rationale for Dysphagia Screening

• 27-50% of stroke patients develop dysphagia• 43-54% of stroke patients with dysphagia will experience

aspiration• Of those patients, 37% will develop pneumonia• If not part of a dysphagia diagnosis and treatment program,

3.8% with pneumonia will die• Other adverse effects include malnutrition and increased

length of hospital stay www.jointcommision.org

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Swallow Screen Project Description

Purpose:

• Increase Dysphagia Screening Rates in Stroke Patients

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Stroke Core Measures

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Current SituationJoint Commission Core Measure # 7 Swallow screen prior to any oral medication, fluids or food

• Rate was 54% at the 2005 certification date

• Rate has increased to 76% (4th quarter 2006)

• Rate increased to 83% (Jan-Mar 2007)

• Rate increased to 88% (April-June 2007)

• Rate increased to 94% (July-Sept 2007)

• Rate 91% (Oct-Dec 2007)

• 2007 yearly average = 89%01/05/23 79

ResultsDysphagia ScreeningDysphagia Screening rate has increased from 54% 3rate has increased from 54% 3rdrd quarter 2005 to 91% in 4quarter 2005 to 91% in 4thth quarter 2007 (average in 2007- quarter 2007 (average in 2007- 89%).89%).

Dysphagia ScreeningDysphagia Screening rate has increased from 56% to 91% rate has increased from 56% to 91% following Physician Champion and Stroke Educator following Physician Champion and Stroke Educator turnover (an issue 2turnover (an issue 2ndnd & 3 & 3rdrd quarters, 2006) quarters, 2006)

Aspiration rate was 3.3% in 2006 with increased Aspiration rate was 3.3% in 2006 with increased compliance aspiration pneumonia rates have decreased to compliance aspiration pneumonia rates have decreased to 2.5 in 20072.5 in 2007

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Standardization

• Hiring Stroke Program Manager• Staff Education in ETC (Emergency department, Neuro

unit and ICU• Implemented Pyxis prompt and documentation tools• Sharing Swallow screening goals with ETC, Neuro and

ICU Units as well as their respective Collaborative Practice Councils, the Professional Practice Council, the Organizational Performance Improvement Committee, Interdisciplinary Team and Stroke Team Members

• Revised Stroke Physician Orders, Benchmarking Guidelines, Patient Education Tools, and Instructions for Care at Home.

• Hospitalist Stroke Champion assignment

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Future Plans• Strive for 100% Dysphagia Screening rate

• Build Dysphagia Screen monitoring report into computerized medical record

• Continue to monitor pneumonia rates, especially aspiration

• Share Stroke Results with Internal MVH Team Members and Success Strategies with Other Hospitals

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Questions and Comments

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Treatment by ClassTreatment by Class• Penicillins

• Cephalosporins

• Penicillins +B-lactamase inhibitor

• Quinolones

• Aminoglycosides

• Carbapenems

Useless

Useless

Unreliable

If sensitive

If sensitive

Most reliable...for now

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CarbapenemsCarbapenems• E.g. Meropenem, 1E.g. Meropenem, 1stst line choice for line choice for

treatment of serious ESBL infectionstreatment of serious ESBL infections

• stability to all the currently recognised, stability to all the currently recognised, frequently occurring ESBLsfrequently occurring ESBLs

• extensive clinical experienceextensive clinical experience

• Ertapenem also useful for UTIs, home IV tx Ertapenem also useful for UTIs, home IV tx (once daily)(once daily)

• Excess carbapenem use will result in Excess carbapenem use will result in resistanceresistance

Paterson DL and Bonomo RA. Clin Microbiol Rev 2005; 18 (4): 657-686

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A glimpse of the future...

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Vancomycin and Gentamicin DosingVancomycin and Gentamicin Dosing• Vancomycin and Gentamicin are nephrotoxic and

ototoxic• Important not to overdose in this age group• Elderly often have some degree of renal impairment• Assess renal function by urea and creatinine levels• If normal, treat normally but watch levels after 24 h

of treatment • If levels high will have to reduce dose

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Frailty suspected…What about prevention of hazards of hospitalization?

Prevention Delirium—Inouye model—orientation & cognitive exercises, early mobilization,

prevent dehydration, hearing aides/glasses Deconditioning—out of bed, PT/OT Falls—bed alarms, pads Pressure ulcers—nutrition, frequent repositioning, special mattresses Adverse drug reactions—med review for best drug choices Comprehensive discharge planning—recognize need @ admission w/ social work

involvement

Models of improved care for frail elders: HELP (Hospital Elder Life Program), GEM (GeriatricEvaluation and Management) unit, ACE ( Acute Care ofthe Elderly)unit models

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Functional decline occurs in the hospital

Functional limitations increase with age.Functional decline occurs in approx. 34-50% hospitalized older pts.

Higher mortality—twice the risk Higher rates of institutionalizationProlonged hospital stay

Interventions can decrease functional decline (Hospital Elder Life Program).

Functional status determines D/C plan.01/05/23

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Hospital Elder Life Program:A program of prevention

Yale hospital system, ≥ age 70, admitted to acute care hospitalScreened for cognitive impairment, sleep

deprivation, immobility, dehydration, vision or hearing impairment

Targeted interventionsOutcomes

Decrease in delirium rate in intervention groupDecrease in functional decline (14%vs. 33%)Decrease in cognitive decline (8%vs. 26%)

Inouye S, et al JAGS 2000; 48:1697-1706Inouye SK, et al. NEJM. 1999;340:669-676

Inouye SK , et al. Ann Intern Med. 1993;119:474-48101/05/23

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Targeted Interventions

Orientation/Activities

CognitiveImpairment Sleep Deprivation

Non-drug; sleep enhancement

Immobility

EarlyMobilization

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Targeted Interventions

Visual Aids, Devices

Visual Impairment Hearing Impairment

Hearing devices,Remove earwax

Dehydration

Early recognition& po repletion

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Prevention Protocols

Inouye SK, et al. NEJM. 1999;340:669-676 SEE CHALK 01/05/23

References • Katzen, I. L. , Dawson, N.V., Thomas, M.E., C. L., Votruba,

M.E., and Cebul, R. D. The cost of pneumonia after acute stroke. Neurology 2007;68;1938-1943

• Martino PhD, Rosemary, Foley, BSc, Norine, et. al., “Dysphagia After Stroke.” Stroke. 2005; 36;2756-2763. pg. 275

• Rosenvinge, Sally K and Starke, Ian D. Improving care for patients with dysphagia

• www.jointcommision.org

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Aspiration Pneumonia (17, 18, 19, 20)

• Aspiration of bacterial of oropharyngeal or gastric secretions

• Common in elderly population, especially with altered mental status & dysphagia

• Risk factor in both community and nosocomial acquired pneumonia

• Caused by mixed anaerobic flora and viridans streptococci in community-acquired

• Gram-negatives more important in nosocomial aspiration penumonia

• Dependant portions of the lung: superior segment and RLL most common site

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