Risk Factors for Aspiration Pneumonia in Frail Older People: A Systematic Literature Review

doi:10.1016/j.jamda.2010.12.099

Journal of the American Medical Directors Association

Volume 12, Issue 5, June 2011, Pages 344-354

https://doi.org/10.1016/j.jamda.2010.12.099 Get rights and content

Objective

To systematically review the risks for aspiration pneumonia in frail older people and the contribution of bad oral health among the risk factors.

Design

Systematic literature review.

Setting

PubMed (Medline), Web of Science, Cochrane Library, EMBASE, and CINAHL were searched for eligible studies, published in English in the period January 2000 to April 2009.

Participants

Frail older people.

Measurements

Only publications with regard to hospitalized, institutionalized, or frail home-dwelling people of 60 years and older were eligible. Two authors independently assessed the publications for their methodological quality. Unadjusted and adjusted odds ratios and their corresponding 95% confidence intervals for respective risk factors related to aspiration pneumonia were extracted. The results were evaluated according to the levels of evidence of the Oxford Centre for Evidence-based Medicine.

Results

A total of 21 publications fulfilled the quality criteria. Evidence level 2a (systematic review with homogeneity of cohort studies) was found for a positive relationship between aspiration pneumonia and age, male gender, lung diseases, dysphagia, and diabetes mellitus; 2b (individual cohort study) for severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, and bad oral health; 3a (systematic review with homogeneity of case-control studies) for malnutrition; 3b (individual case-control study) for Parkinson’s disease and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health among the risk factors seems limited.

Conclusion

Thirteen significant risk factors were identified: age, male gender, lung diseases, dysphagia, diabetes mellitus, severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, bad oral health, malnutrition, Parkinson’s disease, and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health seems limited.

Section snippets

Data Sources and Search Strategy

A comprehensive literature search was carried out. The electronic retrieval systems and databases searched for relevant articles were PubMed (Medline), Web of Science, Cochrane Library, EMBASE, and CINAHL. The keywords (Medical Subject Headings in Medline) used were “aspiration pneumonia” or “pneumonia,” “frail elderly” or “aged,” “nursing homes” or “long-term care” or “geriatric nursing,” “risk factors,” “periodontal disease” and “oral health,” isolated or in different combinations using

Results

The keyword search identified 1802 potentially relevant publications: 613 from PubMed (Medline), 185 from Web of Science, 35 from Cochrane Library, 922 from EMBASE, and 47 from CINAHL. Duplicates were excluded. Screening of titles and abstracts revealed that 35 publications were relevant for further review and these publications were read in full text and assessed for their methodological quality. Fourteen publications were excluded after methodological quality assessment (Table 3).6, 10, 11, 12

Discussion

A limitation of this study is the inconsistency of definitions used for the various risk factors. Dysphagia, for example, is defined as aspiration, absence of reflex cough after swallow, Logemann-aspiration, swallowing difficulty, and swallowing disorder. The dysphagia-related factors “mechanically altered diet,” “suctioning use,” and “feeding tube,” although related to dysphagia, were not included because too much heterogeneity would have hindered an appropriate comparison of results. A second

Conclusion

Thirteen significant risk factors of aspiration pneumonia in frail older people could be identified. The results showed evidence level 2a (systematic review with homogeneity of cohort studies) for a positive relationship between aspiration pneumonia and the risk factors of age, male gender, lung diseases, dysphagia, and diabetes mellitus. For the risk factors severe dementia, ACE DD genotype and bad oral health evidence level 2b (individual cohort study) was found. The results showed evidence

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Cited by (199)

Is polypharmacy a risk factor for aspiration pneumonia in older adults? A case-control study
2024, Archives of Gerontology and Geriatrics
The incidence of aspiration pneumonia and the number of medicines prescribed increase with older age. Many medicines pose a risk for aspiration pneumonia, especially those that decrease swallowing function. Older adults with polypharmacy often receive a combination of these medicines. This study aimed to clarify whether polypharmacy is a risk factor for aspiration pneumonia.
Older adults aged ≥ 65 years receiving oral medicines were included in this case-control study. Patients hospitalized for pneumonia served as the case group, and other age-matched hospitalized patients served as the control group. Patient data were collected retrospectively, and logistic regression analysis was performed using items that showed significant differences in the univariate analysis as explanatory variables.
Logistic regression analysis revealed that the number of medicines was not a risk factor for aspiration pneumonia; however, it was associated with the Functional Oral Intake Scale score, male sex, body mass index, and number of comorbidities.
Although polypharmacy is often defined only by the number of medicines, it is not a risk factor for aspiration pneumonia. A detailed comparison of prescription medicines between the pneumonia and non-pneumonia groups is necessary.
Identifying patients at increased risk of non-ventilator-associated pneumonia on admission to hospital: a pragmatic prognostic screening tool to trigger preventative action
2023, Journal of Hospital Infection
Non-ventilator healthcare-associated pneumonia (NV-HAP) is an important healthcare-associated infection. This study tested the feasibility of using routine admission data to identify those patients at high risk of NV-HAP who could benefit from targeted, preventive interventions.
Patients aged ≥64 years who developed NV-HAP five days or more after admission to elderly-care wards, were identified by retrospective case note review together with matched controls. Data on potential predictors of NV-HAP were captured from admission records. Multi-variate analysis was used to build a prognostic screening tool (PRHAPs); acceptability and feasibility of the tool was evaluated.
A total of 382 cases/381 control patients were included in the analysis. Ten predictors were included in the final model; nine increased the risk of NV-HAP (OR between 1.68 and 2.42) and one (independent mobility) was protective (OR 0.48; 95% CI 0.30–0.75). The model correctly predicted 68% of the patients with and without NV-HAP; sensitivity 77%; specificity 61%. The PRHAPs tool risk score was 60% or more if two predictors were present and over 70% if three were present. An expert consensus group supported incorporating the PRHAPs tool into electronic logic systems as an efficient mechanism to identify patients at risk of NV-HAP and target preventative strategies.
This prognostic screening (PRHAPs) tool, applied to data routinely collected when a patient is admitted to hospital, could enable staff to identify patients at greatest risk of NV-HAP, target scarce resources in implementing a prevention care bundle, and reduce the use of antimicrobial agents.
Construction and evaluation of a nomogram prediction model for aspiration pneumonia in patients with acute ischemic stroke
2023, Heliyon
Aspiration Pneumonia (AP) is a leading cause of death in patients with Acute Ischemic Stroke (AIS). Early detection, diagnosis and effective prevention measures are crucial for improving patient prognosis. However, there is a lack of research predicting AP occurrence after AIS. This study aimed to identify risk factors and develop a nomogram model to determine the probability of developing AP after AIS.
A total of 3258 AIS patients admitted to Jinshan Hospital of Fudan University between January 1, 2016, and August 20, 2022, were included. Among them, 307 patients were diagnosed with AP (AP group), while 2951 patients formed the control group (NAP group). Univariate and multivariate logistic regression analyses were conducted to identify relevant risk factors for AP after AIS. These factors were used to establish a scoring system and develop a nomogram model using R software.
Univariate analysis revealed 20 factors significantly associated (P < 0.05) with the development of AP after AIS. These factors underwent multivariate logistic regression analysis, which identified age (elderly), National Institute of Health Stroke Scale (NIHSS) score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, elevated Fasting Blood Glucose (FBG), elevated C-Reactive Protein (CRP), elevated Neutrophil percentage (NEUT%), and decreased prealbumin as independent risk factors. A nomogram model incorporating these 11 risk factors was constructed, with a C-index of 0.872 (95 % CI: 0.845–0.899), indicating high accuracy. Calibration and clinical decision analyses demonstrated the model's reliability and clinical value.
A nomogram model incorporating age, NIHSS score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, FBG, CRP, NEUT%, and prealbumin effectively predicts AP risk in AIS patients. This model provides guidance for early intervention strategies, enabling the identification of high-risk individuals for timely preventive measures.
Pneumonia Risk Increased by Dementia-Related Daily Living Difficulties: Poor Oral Hygiene and Dysphagia as Contributing Factors
2023, American Journal of Geriatric Psychiatry
Although pneumonia is the leading cause of death among patients with dementia, the specific underlying causes remain unclear. In particular, the potential connection between pneumonia risk and dementia-related daily living difficulties, such as oral hygiene practice and mobility impairment, and the use of physical restraint as a management practice, has not been extensively studied.
In our retrospective study, we included 454 admissions corresponding to 336 individual patients with dementia who were admitted to a neuropsychiatric unit due to behavioral and psychological symptoms. The admissions were divided into two groups: those who developed pneumonia while hospitalized (n=62) and those who did not (n=392). We investigated differences between the two groups in terms of dementia etiology, dementia severity, physical conditions, medical complications, medication, dementia-related difficulties in daily living, and physical restraint. To control potential confounding variables, we used mixed effects logistic regression analysis to identify risk factors for pneumonia in this cohort.
Our study found that the development of pneumonia in patients with dementia was associated with poor oral hygiene, dysphagia, and loss of consciousness. Physical restraint and mobility impairment showed a weaker, nonsignificant association with the development of pneumonia.
Our findings suggest that pneumonia in this population may be caused by two primary factors: increased pathogenic microorganisms in the oral cavity due to poor hygiene, and an inability to clear aspirated contents due to dysphagia and loss of consciousness. Further investigation is needed to clarify the relationship between physical restraint, mobility impairment, and pneumonia in this population.
Long-Term Survival After Aspiration Pneumonia in Older Inpatients: A Comparative Study
2023, Journal of the American Medical Directors Association
Aspiration pneumonia (AsP), a leading cause of death in older people, remains poorly studied. We aimed to evaluate short- and long-term prognosis after AsP in older inpatients.
Retrospective cohort study.
All consecutive patients aged ≥75 years hospitalized in a 62-bed acute geriatric unit during a 1-year period.
We compared clinical characteristics and overall 2-year survival between patients with a main diagnosis of AsP, patients with other types of acute pneumonia (non-AsP), and patients hospitalized for another cause.
Among the 1774 patients hospitalized over 1 year (median age: 87 years, 41% female), 125 (7%) had a primary diagnosis of acute pneumonia, of whom 39 (31%) had AsP and 86 (69%) non-AsP. Patients with AsP were more frequently male, lived more frequently in a nursing home, and had a more frequent history of stroke or neurocognitive disorders. Mortality rates were much higher after AsP, reaching 31% at 30 days (vs 15% after Non-AsP and 11% in the rest of the cohort, P < .001), and 69% 2 years after admission (vs 56% and 49%, P < .001). After adjustment for confounders, AsP was significantly associated with mortality but non-AsP was not [adjusted hazard ratio (95% CI): 3.09 (1.72-5.57) at 30 days and 1.67 (1.13-2.45) at 2 years for AsP; 1.36 (0.77-2.39) and 1.14 (0.85-1.52) for non-AsP]. However, among patients who survived at 30 days, mortality did not significantly differ between the 3 groups (P = .1).
In an unselected cohort of patients hospitalized in an acute geriatric unit, a third of AsP patients died within the first month after admission. However, among those surviving at 30 days, long-term mortality did not significantly differ from the rest of the cohort. These findings underline the importance of optimizing the early management of AsP.
Health Care-Associated Infections in Older Adults: Epidemiology and Prevention
2023, Infectious Disease Clinics of North America

View all citing articles on Scopus

: Authors report no conflict of interest.

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ReviewRisk Factors for Aspiration Pneumonia in Frail Older People: A Systematic Literature Review

Objective

Design

Setting

Participants

Measurements

Results

Conclusion

Section snippets

Data Sources and Search Strategy

Results

Discussion

Conclusion

Am J Emerg Med

Arch Gerontol Geriatr

Arch Gerontol Geriatr

Am J Med

Am J Hypertens

J Clin Epidemiol

Am J Infect Control

Chest

Infectious complications of dental and periodontal diseases in the elderly population

Clin Infect Dis

Oral biofilms, periodontitis, and pulmonary infections

Oral Dis

Role of oral bacteria in respiratory infection

J Periodontol

Differences in the features of aspiration pneumonia according to site of acquisition: Community or continuing care facility

J Am Geriatr Soc

Aspiration pneumonia: Dental and oral risk factors in an older veteran population

J Am Geriatr Soc

Pneumonia in the elderly

Curr Opin Pulm Med

Impact of oral diseases on systemic health in the elderly: Diabetes mellitus and aspiration pneumonia

J Public Health Dent

Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia, 1991–1998

Am J Public Health

Bronchopneumonia and oral health in hospitalized older patients. A pilot study

Gerodontology

Nosocomial pneumonia after acute stroke: Implications for neurological intensive care medicine

Stroke

Risk factors for nursing home–acquired pneumonia

Clin Infect Dis

Acute stroke predisposes to oral gram-negative bacilli: A cause of aspiration pneumonia?

Gerontology

Does the presence of esophagitis prior to PEG placement increase the risk for aspiration pneumonia?

Dig Dis Sci

Modification of the risk of mortality from pneumonia with oral hygiene care

J Am Geriatr Soc

Oral symptoms predict mortality: A prospective study in Japan

J Dent Res

Association of dry tongue to pyrexia in long-term hospitalized patients

Gerontology

Community-acquired legionella pneumonia in elderly patients: Characteristics and outcome

J Am Geriatr Soc

Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: A case-control study

Am J Phys Med Rehabil

Review
Risk Factors for Aspiration Pneumonia in Frail Older People: A Systematic Literature Review