The annual incidence of pneumonia increases with aging and is higher in institutionalized subjects than in community-dwellers. In noninstitutionalized older subjects, incidence of community-acquired pneumonia (CAP) is estimated at between 25 and 44 per 1000 population— up to four times that of patients less than 65 years of age.
Incidence of nursing-home acquired pneumonia (NHAP) has been reported as high as 137 cases per 1000 population per year (Fein, 1994; Sund-Levander et al., 2003). Mortality rates for older patients in hospital-based studies of CAP (up to 30%) are correlated with comorbidities, nutritional and functional status, and presence of cognitive disorders (delirium) (Kaplan et al., 2002; Janssens et al., 2004; Torres et al., 2004). For NHAP, mortality rates may reach 57%. Hospitalization for community-acquired pneumonia (CAP) per se is associated with a high risk of hospital readmission and a high mortality within the following year (Bohannon et al., 2004).
The diagnosis of pneumonia in this age group is often delayed because of the frequent absence of fever, the paucity or absence of cough, and changes in mental status (delirium), further contributing to the high morbidity and mortality. Cognitive impairment (dementia), present in 20% of subjects aged over 80, is a risk factor for nonspecific presenting symptoms of CAP or NHAP (such as weakness, falls, and delirium), and thus delayed diagnosis and poor prognosis (Johnson et al., 2000; Morrison et al., 2000; Sund-Levander et al., 2003).
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