The question of enteral or parenteral feeding may arise at a given time if the risk of aspiration and repeated infectious complications becomes major. Percutaneous endoscopic gastrostomy PEG is currently recommended in Charcot disease, as soon as dysphagia is frequent, considering the progressive nature of this disease and the improvement in quality of life provided by PEG. In severe dementia, however, PEG is not recommended. However, each situation requires individual analysis in its context. The symptoms are typical. They depend however on the volume of aspiration, going from classical penetration syndrome, well described by the patient or a witness, associated with attacks of suffocation, cough, dyspnoea, and desaturation, to a rarer and rapidly fatal picture of asphyxia, paradoxically underdiagnosed in acute situations.
Foreign body asphyxia. This is defined as chemical pneumonitis, secondary to the aspiration of regurgitated sterile acid gastric fluid that, at least initially, is not infectious. The occurrence of chemical pneumonitis usually implies the presence of consciousness disorders epilepsy, stroke. Acidity plays a key role. Experimental studies in animals have shown that pH must be below 2. Diagnosis is not a problem when aspiration takes place in the presence of a witness.
Even though these acute symptoms may seem unremarkable, this is the most frequent clinical presentation and the most difficult to understand, firstly because the symptoms of lower respiratory tract infection can be atypical in the elderly, sometimes raising difficult problems with differential diagnoses such as pulmonary embolism. Secondly, because once these differential diagnoses have been ruled out, there is no certainty that the clinical picture can be attributed to a swallowing disorder.
Finally, because once a swallowing disorder has been recognized, it may not be responsible for infections. These are more difficult to understand because clinical signs associating dyspnoea and cough with expectoration can be present in frequent and unremarkable chronic respiratory disorders such as chronic obstructive pulmonary disease and asthma; possible underlying heart failure can add to the confusion. The clinical picture can also be that of recurrent pneumonia, recurrent unexplained fever, non-specific uni- or bilateral radiographic abnormalities, and so on.
Chronic occult aspiration can thus cause specific disorders, quite rarely described but often underestimated considering the context of onset. This disorder is characterized by the presence of foreign particles and bronchiolar inflammatory infiltrates. It occurs in bedridden patients with a history of neurological disorders or dementia presenting swallowing disorders, whether identified or not.
The importance of distinguishing the two entities is theoretically twofold: on the one hand, the prognosis is not the same, it is better in chemical pneumonitis that often regresses with symptomatic treatment; on the other hand, with aspiration of gastric fluid not causing infection, at least initially, there is no need to treat chemical pneumonitis with antibiotics immediately. However, the distinction is not easy to establish because in both cases there are signs suggestive of lower respiratory tract infection. Mylotte et al. This corresponds to what we have called chemical pneumonitis secondary to aspiration of gastric fluid.
In the study by Mylotte et al. Prescriptions were for 5. It recommends that aspiration pneumonia should not be treated with antibiotics if the symptoms have lasted less than 24 hours. Patients whose symptoms exceed 24 hours have a risk of bacterial infection and should be treated. Symptomatic patients without radiographic images do not require antibiotic therapy.
An editorial in The Lancet Infectious Diseases in January stressed the urgency of finding ways to reduce the risk of infection in this age group. Several recent publications argue that we must differentiate community-acquired pneumonias from pneumonias occuring in patients living in institutions or receiving home care.
Concerning aspiration pneumonia, because there are no consensual diagnostic criteria, interpretation of literature data is difficult. Can we prevent aspiration pneumonia in the nursing home? For aspiration pneumonia to develop there must have been aspiration into the larynx and lower respiratory tract of oropharyngeal contents previously colonized by pathogens. Predictors of aspiration pneumonia: how important is dysphagia? Loeb et al. In this study, multivariate analysis revealed that difficulty in swallowing food and medications were the most important risk factors.
Many drugs such as diuretics, antihistamines, anticholinergics, and neuroleptics decrease saliva flow and thus could increase the risk for aspiration pneumonia. Moreover, randomized studies have shown that good quality oral care decreased the number of cases of pneumonia in institutionalized populations. They concluded, however, that there was insufficient proof of effectiveness of the different strategies proposed: patient positioning, dietary changes, oral hygiene, gastrostomy education for caregivers, or drugs. New interventional studies on prevention are required.
However, they consider as special cases institution-acquired pneumonias; we have seen that many of these are probably aspiration pneumonia. Aspiration pneumonia. Despite extensive investigations, a documented bacteriological cause was only found in less than one in two cases in community-acquired pneumonia. This is particularly true in the elderly who are often unable to produce a sputum specimen sufficient for microbiological examination. Clinical studies provide conflicting data on the microbial flora responsible for pneumonia in the elderly.
However, in the majority of studies a higher incidence of Gram-negative enterobacteria and S.
Respiratory tract virus infections in the elderly with pneumonia | BMC Geriatrics | Full Text
Nevertheless, in community-acquired pneumonia in the elderly, pneumococci remain the agents the most commonly involved. In fact, it is impossible to describe the microbiology of respiratory infections in patients with swallowing disorders because no studies to date have focused on this specific issue.
The origin of the pathogens responsible for aspiration pneumonia is the oropharynx. Furthermore, in edentulous patients, anaerobic flora would be reduced. Studies are definitely required to better understand the microbiology of aspiration pneumonia in general, and particularly pneumonia in institutionalized elderly patients.
Taking a sample for bacteriology, possibly endoscopic, is justified in this case, to enable direct examination and guide the decision, and mainly to readjust the prescription after 48—72 hours of initial probabilistic treatment. The decision to take a sample depends on the treatment plan and obviously other more practical factors: facilities for performing the examination, and ethical issues.
Concerning the prescription, the oral route is possible from the outset in non-severe forms. Parenteral treatments are more aggressive and have a higher risk of side effects. The switch to oral treatment must be as rapid as possible.
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These authors acknowledge, however, that this attitude is not respected by many practitioners, especially if there are co-morbidities, a precarious state that corresponds well to elderly patients. Antibiotic therapy can certainly be prescribed when the acid barrier of the stomach is not functional e.
The antibiotics the most often prescribed are: AAC, injectable third generation cephalosporins, and antipneumococcal fluoroquinolones APFQ. The risk of Pseudomonas or MRSA infection theoretically exists and depends on many factors prior antibiotic treatment, state of dependence, life in an institution with nosocomial type flora. This risk is taken into account on a case-by-case basis. The persistence or the appearance of signs of pulmonary infection is an indication for antibiotic therapy similar to that for aspiration pneumonia. Emergency endoscopic aspiration is required.
For secondary ventilatory disorders, the indication for antibiotic therapy depends on the time to diagnosis and the possibilities of reventilation after endoscopy. Anaerobic bacteria should systematically be taken into account when deciding on treatment prolonged anaerobiosis distal to the obstruction. The authors declare that they have no conflicts of interest concerning this article. Key points. Andujar, S. Lanone, P. Brochard, J.
Fiche revue Archives Sommaire. Boniface, M. Article gratuit! Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly. Baconnier c , D.
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Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Previous: Diagnosing Heel Pain in Adults. Jul 15, Issue. Geriatric Failure to Thrive. Abstract Initial Evaluation Treatment References. B 18 — 20 High-intensity resistance exercise training counteracts muscle weakness and physical frailty in very elderly people. A 25 The goal of dietary supplements is to provide adequate energy and protein intake, so almost anything the patient eats is suitable.
TABLE 2 Common Medical Conditions Associated with Failure to Thrive in Elderly Patients Medical condition Cause of failure to thrive Cancer Metastases, malnutrition, cancer cachexia Chronic lung disease Respiratory failure Chronic renal insufficiency Renal failure Chronic steroid use Steroid myopathy, diabetes, osteoporosis, vison loss Cirrhosis, history of hepatitis Hepatic failure Depression, other psychiatric disorders Major depression, psychosis, poor functional status, cognitive loss Diabetes Malabsorption, poor glucose homeostasis, end-organ damage Hip or other large-bone fracture Functional impairment Inflammatory bowel disease Malabsorption, malnutrition Myocardial infarction, congestive heart failure Cardiac failure Previous gastrointestinal surgery Malabsorption, malnutrition Recurrent urinary infections or pneumonia Chronic infection, functional impairment Rheumatologic disease e.
Failure to Trive in Elderly Patients Figure 2 Algorithm for the diagnosis and management of elderly patients with failure to thrive. Read the full article. Over the years Geriatrics and gerontology have developed a language shared by most clinicians and researchers who unequivocally defines the health conditions of aging people: one could speak of "geriatric canon", i.
The aim of this paper is to describe and report the most important terms of the geriatric canon, in a simplified way, in order to establish a more precise use of geriatric terminology that can be easily utilized by the cardiologists, or other specialists who takes care of elderly patients, without depriving them of their clinical significance, and becoming heritage of ordinary medical language. Register Login. Article Sidebar. Published: Apr 5,