Geriatric MedicineTier 1Disease (DEADMAN)

Respiratory conditions - pneumonia or aspiration pneumonia

Description

Community-acquired pneumonia (CAP) and aspiration pneumonia - major cause of morbidity/mortality in older adults
Aspiration pneumonitis (chemical injury) vs aspiration pneumonia (infective) - distinct but overlapping entities

Leading infectious cause of death in >65s
Aspiration risk rises steeply with dysphagia prevalence (stroke, dementia, Parkinson's)
Often under-recognised - silent aspiration common in dementia/stroke

CAP organisms

Strep pneumoniae most common; atypicals (Mycoplasma, Legionella) less common in frail elderly than younger
Influenza/viral pneumonia, secondary bacterial

Aspiration

Impaired swallow (stroke, dementia, Parkinson's, sedation) + impaired cough reflex + reduced immune clearance
Polymicrobial - oral anaerobes, gram-negatives, less classically "typical" organisms
Silent aspiration common - no witnessed choking episode

Atypical presentation dominant - confusion, falls, anorexia, functional decline rather than fever/cough
- Fever may be absent - blunted febrile response in elderly
CXR - consolidation; aspiration classically right lower lobe (more vertical bronchus) or dependent segments
CURB-65 - underestimates severity in frail elderly (confusion/urea/age already elevated at baseline) - use with clinical judgement, not in isolation
Swallow assessment (SLP) after acute event to guide ongoing risk and diet texture
Blood cultures, sputum if productive, urinary antigens (pneumococcal/Legionella) per severity

Antibiotics

CAP - per local antibiotic guideline/severity (amoxicillin +/- doxycycline mild; broader cover incl. atypicals if more severe)
Aspiration pneumonia - cover as per CAP; routine anaerobic cover not required in most current guidance unless periodontal disease/lung abscess/empyema suspected
De-escalate per culture results, review need for ongoing IV vs oral

Aspiration risk reduction

SLP swallow assessment -> texture-modified diet/thickened fluids only if clearly beneficial - very restrictive diets reduce quality of life and oral intake without always reducing aspiration pneumonia risk - individualise, discuss with patient/family
Oral hygiene - reduces oropharyngeal bacterial load, meaningfully reduces aspiration pneumonia incidence
Upright positioning during/after meals, small volumes, supervised feeding
Review sedating medications

Goals of care

Recurrent aspiration pneumonia in advanced dementia - discuss ceiling of care, comfort-focused approach; PEG feeding does not reduce aspiration pneumonia risk or improve survival in advanced dementia
Vaccination - influenza, pneumococcal

High mortality in frail elderly (~10-20%+ inpatient for severe CAP; higher for aspiration in advanced frailty)
Recurrent aspiration pneumonia often marks advanced/terminal trajectory in dementia
Each episode -> stepwise functional decline

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