Clinical Presentation of CAP and NHAP

Among the most common symptoms of CAP and NHAP, cough (40-81%), sputum (37-66%), chills (8-58%), and pleural pain (9-43%) are reported less frequently in NHAP than in CAP; conversely, elderly patients present more often with altered mental status (delirium) when hospitalized for NHAP (53-77%) than CAP (12-45%) (Janssens et al., 2004). Fever (12-76%) is frequently absent in elderly subjects with pneumonia.

Tachypnea (respiratory rate >20/min) and tachycardia (>100/min) is found in about two-thirds of elderly with pneumonia and may precede other clinical findings by three to four days (Fein et al., 1991). The classical triad of cough, fever, and dyspnea was present in only 56% of 48 elderly veterans admitted for CAP, and 10% of patients had none of these symptoms (Harper et al., 1989). Subtle clinical manifestations of CAP in the very old, such as unexplained falls, incontinence, failure to thrive, or sudden aggravation of a preexisting comorbidity (i.e., diabetes, congestive heart failure, Parkinson's disease) have to be actively sought after.

The regular (monthly) use of pulse oximetry has been suggested as a simple parameter to help detect pneumonia in nursing home patients. In a study of 67 older nursing home patients, an oxygen saturation (SaO2) < 94% had a sensitivity for pneumonia of 80%, a specificity of 91% and a positive predictive value of 95%; a drop in SaO2 of >3% had a sensitivity for pneumonia of 73%, but a specificity and positive predicitive value of 100% (Kaye et al., 2002). Clearly, alternative diagnoses must also be considered in the presence of decreased SaO2, but LRTI is probably the most frequent cause of desaturation in this setting.

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