Polmonite: quale percorso diagnostico terapeutico

La polmonite nell’anziano: effetti sulla
disabilità e sulla cognitività
Piera Ranieri
Dirigente Medico U.O. Medicina
Responsabile Ambulatorio di Fisiopatologia Respiratoria
Istituto Clinico S’Anna, Brescia
Gruppo di Ricerca Geriatrica, Brescia
CURB-65 (Confusion, BUN, FR, BP-65y)
Confusione
Azotemia
Freq. respiratoria
Pressione arteriosa
Età
(demenza o delirium)
(>45 mg/dl)
(> 30/min)
(PAS<90 o PAD<60mmHg)
(65+)
score
1
1
1
1
1
Totale
_____
Gruppo
Mortalità
Gruppo 1
Gruppo 2
Gruppo 3
bassa (1,5%):
intermedia (9,2%):
alta (22,0%):
Score
Trattamento
0-1
2
3+
Domiciliare
Hosp (LOS breve)
Hosp (se 4-5: ICU)
Indice di severità di polmonite- PSI
Caratteristiche dei pazienti
anziani ospedalizzati
per polmonite
(Rozzini et al. 2003)
Characteristics, in H and 3-mos mortality rate of 356 Elderly Pts
Hospitalized for Pneumonia
CAP
(N=235)
M+SD / N(%)
HCAP
(N=76)
M+SD / N(%)
P*
HAP
(N=45)
M+SD /N (%)
P†,
P‡
Age (years)
Gender (males)
CPR (mg/dl)
Serum Albumin (g/dl)
COPD
Heart failure (NYHA III-IV)
Renal Failure
Stroke
Cancer
Delirium
Dementia
Charlson Index
Drugs (n)
Disabled (2 wks before adm)
APACHE II-APS
CURB-65 (Class 3)
Length of stay (days)
81.6+8.2
115 (48.9)
9.4+10.4
3.4+0.6
117 (49.8)
82 (34.9)
56 (24.0)
30 (12.8)
27 (11.5)
46 (19.6)
85 (38.6)
2.9+1.9
6.5+3.2
42 (17.9)
7.3.9+6.2
118 (50.2)
6.7+3.4
81.2+8.9
35 (46.1)
10.3+10.2
3.1+0.6
38 (50.0)
35 (46.1)
26 (35.6)
15 (19.7)
12 (15.8)
17 (22.4)
37 (51.4)
3.2+1.8
7.1+3.5
25 (32.9)
9.8+6.9
42 (55.3)
6.5+3.8
0.785
0.380
0.506
0.009
0.540
0.055
0.038
0.097
0.217
0.353
0.039
0.191
0.244
0.006
0.003
0.263
0.811
78.7+8.5
20 (44.4)
11.7+10.1
2.9+0.6
26 (57.8)
15 (33.3)
12 (27.9)
11 (24.4)
8 (17.8)
18 (40.0)
24 (58.5)
4.1+2.9
8.0+3.6
15 (33.3)
10.9+5.9
28 (62.2)
8.2+5.3
0.033
0.349
0.181
0.000
0.206
0.493
0.356
0.041
0.179
0.004
0.014
0.000
0.009
0.019
0.003
0.094
0.013
0.118
0.507
0.478
0.101
0.261
0.118
0.259
0.349
0.482
0.032
0.100
0.040
0.205
0.557
0.874
0.289
0.050
In hospital mortality
Total 3 months mortality
23 (9.8)
65 (27.7)
14 (18.4)
29 (38.2)
0.038
0.011
10 (22.2)
20 (44.4)
0.022 0.389
0.021 0.312
(unpublished data)
Polmonite e stato funzionale
Rozzini et al. Chest 2011
La dipendenza funzionale
premorbosa come indicatore di una
condizione “stabile” di fragilità
Rozzini, et al. JAGS, 2007
La perdita funzionale come
esito di polmonite
Hospital diagnoses, Medicare charges, and nursing home admissions in
the year when older persons become severely disabled
L. Ferrucci, J. M. Guralnik, M. Pahor, M. C. Corti and R. J. Havlik
OBJECTIVE: To characterize hospital diagnoses, procedures and charges, and
nursing home admissions in the year when older persons become severely disabled,
comparing those in whom severe disability develops rapidly with those in whom
disability develops gradually.
MAIN OUTCOME MEASURES: Characteristics associated with development of severe
disability after the fourth annual follow-up, in which the disability is classified as
catastrophic disability if the individual did not report any ADL disability in the 2
interviews prior to severe disability onset or as progressive disability if the individual
had previous disability in 1 or 2 ADLs.
RESULTS: In the year during which severe disability developed, hospitalizations
were documented for 72.1% of those developing catastrophic disability and for 48.6%
of those developing progressive disability. The 6 most frequent principal discharge
diagnoses included stroke, hip fracture, congestive heart failure, and pneumonia in
both severe disability subsets. These diagnoses occurred in 49% of those with
catastrophic disability and 25% of those with progressive disability.
CONCLUSIONS: In the year when they become severely disabled, a large proportion
of older persons are hospitalized for a small group of diseases. Hospital-based
interventions aimed at reducing the severity and functional consequences of these
diseases could have a large impact on reduction of severe disability.
JAMA 1997;277:728–734.
La perdita funzionale come
ulteriore “marker” di vulnerabilità
Rozzini, et al. JAGS, 2005
Functional status does not
predict mortality in older
adults admitted with
infection, but change in
functional status does.
When an acute disease
such as infection produces
a functional impairment,
this condition becomes an
index of outcome and
sholud be detected to
predict poor clinical course
Rozzini and Trabucchi JAGS, 2012
JAGS, 2008
Ranieri et al. JAGS 2008
Decadimento cognitivo come
fattore di rischio di polmonite
Characteristics and 3-months mortality rate of 3300 in patients
affected by Low Respiratory Tract Infections (LRI) and dementia.
Age (years)
Gender (males)(%)*
MMSE score
GDS score
Barthel Index (15 days bef)
Barthel Index (on adm)
IADL (functions lost)
Diseases (n)
Charlson Index
Drugs (n)
APACHE II score
APACHE II-APS subscore
Serum Albumin (g/dl)
Hemoglobin (g/dl)
Serum Cholesterol (mg/dl)
CPR (mg/dl)
Creatinine (mg/dl)
Length of stay (days)
3 mos mortality (%)*
Total
(N=3300)
NoLRI-NoD
(N=2566)
YLRI-NoD
(N=265)
NoLRI-YD
(N=345)
YLRI-YD
(N=124)
M+SD (%)
M+SD (%)
M+SD (%)
M+SD (%)
M+SD (%)
79.2+8.0
(38.3)
21.8+8.5
4.6+3.5
78.7+27.9
60.1+38.1
3.3+2.9
5.1+2.0
5.3+1.8
5.7+2.9
10.6+5.9
4.4+5.2
3.7+0.7
12.5+2.3
187.3+53.3
4.4+7.4
1.1+0.7
6.5+3.7
78.4+7.7
(24.5)
24.9+4.4
4.6+3.5
86.5+19.8
71.8+32.2
2.6+2.6
5.1+1.9
5.0+1.7
5.4+2.6
9.1+4.9
3.1+3.9
3.8+0.6
12.6+2.3
192.2+51.9
2.9+5.7
1.1+0.6
6.5+3.6
80.0+8.2
(24.5)
23.4+4.9
4.2+3.1
76.2+26.6
48.6+37.1
3.4+2.9
5.3+2.0
5.5+1.9
6.2+3.3
13.7+4.9
6.1+5.1
3.4+0.6
12.2+2.2
162.8+49.6
9.1+10.4
1.3+0.8
7.8+4.1
83.2+7.7
(24.5)
4.5+4.7
--45.7+34.5
22.0+29.2
6.3+2.4
5.2+2.2
5.8+2.1
5.8+3.1
13.0+6.8
6.5+6.4
3.3+0.7
12.0+2.5
175.4+53.5
7.3+9.6
1.2+1.0
5.8+4.0
83.4+8.4
(19.3)
3.7+4.4
--30.2+28.7
5.5+14.2
7.0+1.6
5.4+2.3
6.5+2.2
6.9+3.0
18.3+6.6
10.9+6.9
3.1+0.6
11.9+2.5
160.9+52.5
11.1+9.1
1.4+1.1
5.4+3.9
0.001
0.001
0.001
0.155
0.001
0.001
0.001
0.142
0.001
0.194
0.001
0.001
0.001
0.000
0.001
0.001
0.000
0.001
(13.9)
(9.0)
(14.7)
(35.4)
(54.0)
0.001
p
JAMDA, 2008
n=2566
n=265
n=345
n=124
JAMDA, 2008
Delirium e polmonite
Rozzini et al.2011
Rozzini et al. Chest 2011
Disabilità cognitiva pre-morbosa
Disabilità funzionale pre-morbosa
Delirium
POLMONITE IN OSPEDALE
Delirium
Ulteriore peggioramento della
disabilità funzionale
Ulteriore peggioramento delle
prestazioni cognitive
PROGNOSI NEGATIVA a breve e lungo termine
Hospitalized CAP are associated with many deaths outside the time frame normally
considered in this otherwise acute disease. They may support the hypothesis that
pneumonia is an epiphenomenon of a preexisting condition, i.e. of reduced vitality (as
indicated by higher prevalence of disability two weeks before admission); on the
contrary we assist to the possibility of an independent pathological event induced by
pneumonia itself. In the first case it would be rather difficult to reduce mortality hazard
in old patients after pneumonia due to the frailty of the subjects, while in the second
case interventions became object of specific studies.
Ours data indicate that clinicians must take in consideration the poor outcomes of old
pneumonia patients predisposing the most appropriate care. On the same time we are
well aware that the available instruments to reduce mortality are very poor and that
studies should be urgently performed to give a more precise direction to our therapeutic
efforts. Improved understanding of the poor long-term prognosis associated with CAP is
needed to modify the dismal outcome of this common disease in elderly patients.
Rozzini & Trabucchi (2011)
Vi ringrazio per l’attenzione