Background: Pneumonia (PNA) is the fourth most common diagnosis for hospital admissions in the United States. Although the Infectious Diseases Society of America (IDSA) defines PNA as requiring specific clinical features (cough, fever, sputum production and pleuritic chest pain) along with radiographic imaging confirmation, older adults can present with non-specific symptoms. Furthermore, in a landmark publication of community acquired PNA in the elderly, the combination of cough, fever and dyspnea was only present in 31% of patients. The purpose of this study was to explore the clinical presentation of PNA in hospitalized older adults to determine whether the presence of specific symptoms is associated with increased in-hospital mortality.
Methods: Data were collected at two large tertiary medical centers of patients ≥65 years, admitted to a medicine service who had a chest x-ray (CXR) and a CT chest within 48 hours of admission, as well as a documented discharge diagnosis of PNA. Vital signs and presenting complaints were manually extracted from the ED, as well as the initial history and physical examination documents. CXR results were taken from the radiographic impression. We defined specific symptoms of PNA as fever, cough, chest pain, shortness of breath and other respiratory complaints. Chi-square was performed on categorical variables and t-test for continuous variables.
Results: Of the 433 patients, average age was 81, 54% were male, and 63% were white. With regard to the four specific symptoms of PNA studied, 13% had none, 30% had one, 36% had two, 19% had three and 2% had four. The word “pneumonia” was not mentioned on 43% of the CXR reports.Vital signs (median) were: systolic BP 127 (range: 70-233); diastolic BP 68 (range: 35-165); pulse 87 (range: 39-150); respiratory rate 19 (range: 12-55); temperature 98.5 (range: 95-105); oxygen saturation 97 (range: 70-100). Median white blood cell (WBC) count was 11.2 (range: 0.1-136).
When comparing in-hospital mortality (11%) vs discharged alive, there was no significant association with presenting symptoms but there was an association with ICU LOS (1 days vs 0 days respectively, p<.001), systolic blood pressure (BP) (111 vs 129, p=.01), pulse (94 vs 87, p=.01), and WBC count (12.5 vs 11.0, p=.02).
Conclusions: Older adults admitted with PNA do not consistently present with specific symptoms, abnormal vital signs, and a positive CXR. Further research is needed to determine more reliable criteria for the diagnosis of PNA in older adults.