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Age-related differences in management and outcomes in hospitalized healthy and well-functioning bacteremic pneumococcal pneumonia patients: a cohort study
© The Author(s). 2017
Received: 8 December 2016
Accepted: 13 June 2017
Published: 20 June 2017
Limited data are available regarding fit and healthy patients with pneumonia at different ages. We evaluated the association of age with clinical presentation, serotype and outcomes among healthy and well-functioning patients hospitalized for bacteremic pneumococcal community–acquired pneumonia.
We performed a prospective cohort study of consecutive healthy and well-functioning patients hospitalized for this type of pneumonia. Patients were stratified into younger (18 to 64 years) and older (≥65 years) groups.
During the study period, 399 consecutive patients were hospitalized with bacteremic pneumococcal pneumonia. We included 203 (50.8%) patients who were healthy and well-functioning patients, of whom 71 (35%) were classified as older. No differences were found in antibiotic treatment, treatment failure rate, antibiotic resistance, or serotype, except for serotype 7F that was less common in older patients. In the adjusted multivariate analysis, the older patients had higher 30-day mortality (OR 6.83; 95% CI 1.22–38.22; P = 0.028), but were less likely to be admitted to the ICU (OR 0.14; 95% CI 0.05–0.39; P < 0.001) and had shorter hospital stays (OR 0.71; 95% CI 0.54–0.94; P = 0.017).
Healthy and well-functioning older patients have higher mortality than younger patients, but nevertheless, ICU admission was less likely and hospital stays were shorter. These results suggest that the aging process is a determinant of mortality, beyond the functional status of patients with bacteremic pneumococcal pneumonia.
KeywordsBacteremic pneumococcal pneumonia Community-acquired pneumonia Pneumonia in older people
The incidence of pneumonia and associated mortality are higher in older than younger people. Pneumonia is the third most frequent cause of hospitalization in patients aged 65 years or over , streptococcus pneumoniae being the main pathogen isolated. Bacteremic pneumococcal pneumonia constitutes a severe subgroup with its own features.
Many previous studies have found that the mortality risk among older patients with pneumonia depends on the severity of the lung infection, and adequacy of the response to the infection and other host factors including comorbidities and low functional status [2, 3]. Ageing is among the most important known risk factors for most chronic diseases.
Older patients with pneumonia tend to have multiple comorbid chronic conditions leading to loss of functional independence and an inadequate response to the infectious process. The role of age in mortality prediction is controversial due to interactions between age and comorbidities. Further, pneumonia itself can trigger acute mobility impairment and delirium in this population. All of these factors are markers of frailty and increase the likelihood of poor outcomes [4–6]. Frailty refers to an individual’s increased susceptibility towards adverse clinical events, and it is becoming recognized that frailty represents a dynamic geriatric syndrome distinct from, but overlapping with, comorbidities and disability [7–9]. On the other hand, improvements in social and health conditions together with a rise in life expectancy have resulted in an increase in the number of “healthy” and well-functioning older people. There is limited information, however, regarding process of care and outcomes of common medical conditions requiring hospital admission in this subgroup of fit and healthy older patients.
Aging is characterized by progressive tissue degeneration leading to a negative effect on the structure and function of vital organs even in the absence of comorbid illness . For this reason, we hypothesized that the survival of healthy older patients would be poorer than that in younger patients. To test this hypothesis, our aim was to assess the association of age with clinical presentation, serotype, process of care and outcomes among healthy and well-fitted older patients hospitalized for bacteremic pneumococcal community–acquired pneumonia.
Study design and population
This was a prospective observational study of consecutive patients hospitalized for bacteremic pneumococcal pneumonia (positive blood culture taken within 24 h after admission) in two tertiary medical centers. The study was conducted between January 2002 and January 2010. The ethics committees of Cruces and Galdakao Hospitals approved the study.
The healthy and well-functioning patients´ state condition was assessed using the Clinical Frailty Scale (CFS) . This tool provides a quick and easy estimation based on clinical judgment and quantifies frailty on a scale ranging from 1 (very fit) to 9 (terminally ill). Each patient was assigned a score on the CFS by two seniors researchers using data extracted from Cruces/Galdakao prospective pneumonia registry. For the purpose of the study, we only included patients who were considered independent in activities of daily living and had no medical comorbidities (categories 1, “very fit”, and 2, “well”, of the CFS). These patients were stratified into two groups according to their age: 1) younger adults (18–64 years); and 2) older adults (≥ 65 years).
Since 2000, there has been an ongoing prospective and standardized registry of all patients hospitalized for pneumonia in our two hospitals. This registry includes multiple variables characterizing patients and their pneumonia. For eligible patients, we assessed data on socio-demographic characteristics (including ability to carry out basic activities of daily living, self-care activities and regular physical activity), medical comorbidities, influenza and pneumococcal vaccination status, vital signs, results of routine laboratory tests, including the pneumococcal urinary antigen test, and radiological findings on admission. Patients were empirically treated in accordance with the National Guidelines of the Spanish Society of Pulmonology [SEPAR]  at the discretion of the attending doctor. The severity of patients’ clinical condition was assessed on admission using the CURB-65 score . All survivors were followed up to 30 days after discharge or until complete radiological resolution.
Two consecutive blood cultures were taken for all patients within 24 h after hospital admission. Tests were conducted to assess the susceptibility of Streptococcus pneumoniae to the following antibiotics: penicillin, ceftriaxone, erythromycin and levofloxacin. Pneumococcal serotypes were assessed and grouped according to the associated risk of mortality into the following categories: 1) high risk, serotypes 3, 6A, 6B, 9 N, 19F, 19A, and 23F; 2) intermediate risk, serotypes 9 V, 12F, 14, and 22F; and 3) low risk, serotypes 1, 7F, 8, 4 and 5 .
To assess the treatment, the following variables were studied: 1) appropriateness of the empirical antibiotic used (according to the recommendations of the Spanish Society of Pulmonology [SEPAR]) ; 2) and 3) whether antibiotic treatments were started within 4 or 8 h after arrival at the emergency department, respectively; and 4) the class of antibiotics administered.
Clinical in-hospital course and outcome measures included: 1) admission to the intensive care unit (ICU); 2) use of invasive mechanical ventilation; 3) septic shock; 4) in-hospital, early (≤ 48 h)  and 30-day mortality; 5) treatment failure; 6) length of hospital stay; and 7) 30-day readmission.
Pneumonia was defined as the presence of new pulmonary infiltrate on the chest X-ray together with signs and symptoms suggestive of lower respiratory tract infection. Septic shock was defined as a systolic blood pressure of less than 90 mmHg and a need for vasopressor drugs for at least 4 h, after fluid therapy . Treatment was considered to have failed when patients’ clinical condition worsened during their hospital stay with: hemodynamic instability; appearance or worsening of respiratory failure; a need for mechanical ventilation; progression of the pneumonia, as indicated by radiological findings or the appearance of a new focus of infection; or persistence or reappearance of fever, if a change of treatment was required . The diagnosis of altered mental status was based on observation that the patient’s mental state was not normal and that this was a new phenomenon. Comorbidities including the follow conditions: chronic respiratory disease, diabetes mellitus, chronic cardiovascular disease, neurologic disease, liver disease and chronic renal disease.
Descriptive analysis was undertaken, using frequencies and percentages, means and standard deviations (SDs) or medians and interquartile ranges (IQRs). Patient characteristics were compared between the groups (younger vs older patients), as were variables related to treatment, serotypes, in-hospital course and outcomes. Comparisons were performed with chi-square or Fisher’s exact tests for qualitative variables, and with t tests or non-parametric Wilcoxon tests for quantitative variables.
Univariate logistic regression models were used to compare in-hospital course and clinical outcomes between the groups. Then, multivariate logistic regression models were built adjusting for CURB score (as a continuous variable), variables with p < 0.05 and other variables considered clinically relevant in the univariate analysis as potential independent variables. The results are reported as odds ratios (ORs) and 95% confidence intervals (CIs), considering the younger patients (age < 65 years) as the reference group. For comparing length of stay, a general linear model was used, and due to their skewed distribution, these data were log-transformed. Hence, the results are given as the exponential of the estimated beta parameter, indicating how many times longer the mean stay of older patients was than that of younger patients.
A P value <0.05 was considered statistically significant. All the statistical analysis was performed using the SAS software for Windows version 9.2 (SAS Institute, Cary, NC).
During the study period, a total of 4978 consecutive patients diagnosed with pneumonia were hospitalized in our two hospitals, including 399 with bacteremic pneumococcal pneumonia. Of these, 203 (50.8%) were healthy and well-functioning, 132 patients being <65 years and 71 being 65 years old or older.
Demographic and clinical characteristics at admission
Age < 65 years
(N = 132)
Age ≥ 65 years
(N = 71)
Age (years), mean (SD)
Current tobacco use
Heavy drinker (> 80 mg alcohol/day)
Clinical characteristics at admission
Body temperature (°C), mean (SD)
Respiratory rate, mean (SD)
Heart rate, mean (SD)
Altered mental status
Systolic blood pressure < 90 mmHg
Laboratory and radiological findings
BUN >30 mg/dL
PaO2 < 60 mmHg
CRP (mg/dL), mean (SD)
Urinary antigen positive
Indicators for healthy and well-functioning hospitalized patients with pneumococcal pneumonia
Process of care
Age < 65 years
(N = 132)
Age ≥ 65 years
(N = 71)
Prior antibiotic treatment
Antibiotic within 4 h
Antibiotic within 8 h
Length of antimicrobial treatment, days, mean (SD)
Combination therapy including a macrolide
Serotype distribution by age group
Age < 65 years
(N = 132)
Age ≥ 65 years
(N = 71)
High risk (3 + 6A+ 6B + 9 N + 19F + 19A + 23F)
Intermediate risk (9 V + 12F + 14 + 22F)
Low risk (1 + 7F + 8 + 4 + 5)
In- hospital and 30-day outcomes by age group
Age < 65 years
(N = 132)
Age ≥ 65 years
(N = 71)
Odds ratio (95% CI)
Intensive care unit
Invasive mechanical ventilation
Length of hospital stay, daysb
The results of this study show that the mortality of healthy older people hospitalized for bacteremic pneumococcal pneumonia is higher than that of younger adult patients (<65 years old) with the same characteristics, independent of the serotype, severity and the type of care provided. Despite their good baseline health and functional status, ICU admission rates are lower in patients ≥65 years old. The interest of our study lies in the type of population studied. To our knowledge, this is the first study specifically focused on the subgroup of healthy and well-functioning young and older adults with bacteremic pneumococcal pneumonia.
In developed countries, the prognosis of pneumonia in older people has changed in the last decade, mainly due to improvements in healthcare and social conditions. As a consequence, it has recently been proposed that diagnostic and therapeutic decisions should be based more on the patients’ degree of frailty than their age [18, 19]. This concept may be a better reflection of biological than chronological age. Nevertheless, frail is not synonym for having comorbidities or functional limitations; rather it is recognized as a distinct clinical syndrome characterized by a decrease in physiological reserve and resistance to stressful situations, making individuals more vulnerable to health problems . There is no consensus, however, as to how frailty should be assessed. There are many definitions, the majority of which are based on complex scales and which have not gained acceptance among practicing clinicians . The CSHA Clinical Frailty Scale is a simple and reproducible tool that provides a realistic and simple way to assess the reality of these patients in different medical conditions [21, 22].
The prevalence rates of chronic disease and functional impairment in adults increase proportionally with age . Nonetheless, the contribution of underlying diseases to outcomes in patients with pneumonia remains somewhat controversial [24–26]. Further, a recent study has shown that serotype rather than the presence of comorbidities is the most important risk factor for the development of respiratory failure in patients with pneumococcal pneumonia . Conversely, evidence on the role of functional status seems to be one of the most consistent predictors of poor clinical outcomes [28, 29].
Several studies have investigated the association between frailty and outcomes in hospital and after discharge but none of them to our knowledge have been designed to compare healthy and well-functioning patients stratified by age [21, 30, 31]. Although there are no specific studies on this population, it is generally assumed that there are no significant differences between the management of older and younger patients with the same characteristics . In this study, however, we found that older patients have higher 30-day mortality. Other authors have reported a poorer prognosis for pneumonia in elderly patients without comorbidities but none of these studies have been adjusted for severity [32, 33].
The reason for this poorer outcome is not clear. Despite the fact that we have previously reported that mortality in elderly patients with bacteremic pneumococcal pneumonia is associated with age and the severity of the infectious condition itself, the role of age as a prognostic factor is controversial [34, 35]. From a theoretical point of view, a healthy non-frail patient might represent a good model for studying the effect of ageing itself on the management and prognosis of multiple diseases. In our study, given the lack of significant differences in the class of antibiotics provided and virulence of the serotype involved, age seems likely to be relevant to prognosis. In fact, a causative role of immunosenescence in the outcome of older patients seems highly plausible . Aging is associated with changes in immune response impairment of alveolar macrophage function and increases in cellular apoptosis during sepsis, leading to a greater severity of infection . Nevertheless, other authors have reported that age itself did not have any impact on mortality in patients with one or no comorbid conditions, except for those aged 80 years and older . In our study, we cannot exclude in a subgroup of patients a pre-frail stage revealing a vulnerable state of relatively low physiological reserve to respond adequately to any acute clinical deterioration. Such a state may identify a subset of patients who are at high risk of progressing to frailty or reverse to non-frail under external stressors .
On the other hand, it is recognized that age itself is an important limiting factor for ICU admission, independent of baseline status and severity of illness [39–42]. However, to our knowledge no previous studies have focused on older patients who were fit and “healthy”. Given the progressive aging of the population, we should consider changing ICU admission criteria to take into account biological age, more than chronological age.
Our study has some limitations: 1) We have not used any functional assessment scale, and hence, we cannot completely rule out a certain degree of functional limitation in some patients. The effect of any misclassification in this study would be limited, because according to some authors self-reported measures of mobility limitation are well correlated with other objective scales [43, 44]. 2) Due to the characteristics of our registry, we may not have adequately identified the subgroup of “vulnerable” patients (CFS = 3, 4), namely, those who are not dependent but do have some limitations and complain of being “slowed up” or tired [11, 30]. Although such patients should not be considered frail, we cannot rule out a pre-frail state having contributed to the poor outcome in some patients. Further, we have not assessed the role of concomitant medications that could have influenced the outcome of these patients . 3) There was a low rate of inpatient death, and this is reflected in wide CIs. This is attributable to the type of population eligible for this study and the marked reduction in mortality among pneumonia patients in recent years. 4) The observational study design could have introduced bias. In particular, decisions on the process of care were left to the discretion of the managing physicians. The effect of this potential source of heterogeneity may be limited by the high degree of reliability and prospective collection of data, together with the adjustment for potential confounding variables. Given this and to avoid possible age bias, the multivariate logistic regression models adjusted for CURB score (excluding age). In our opinion, this design represents a realistic approach to investigate the real-world care of patients with pneumonia. Despite these limitations, we believe that this study has produced important findings that should be considered in the management of older patients.
In this study, we have described the observation that bacteremic pneumococcal pneumonia in healthy and well-functioning older patients behaves as a clinical entity distinct from that in younger patients, and notably, outcomes are poorer in the older age group. These differences in survival do not seem to be explained by process of care or serotype. Future multicentre studies are required to confirm these results. In the meantime, we suggest that biological age should be more routinely assessed to guide clinical decision making in older patients in general and, in particular, to help clinicians identify older patients with pneumonia who might benefit from ICU admission.
Not applicable for that section.
Dr. Restrepo’s time is partially supported by Award Number K23HL096054 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Heart, Lung, and Blood Institute, the National Institutes of Health, or the Department of Veterans Affairs.
The sponsors had no role in this study.
Availability of data and materials
Data supporting findings in the study can be requested from corresponding author.
LAR, PPE, AB, AC, MR and RZ conceived and designed the study. LAR, PPE, AG, CJ, AA and RZ enrolled patients and collected and compiled data. AB performed the statistical analysis. LAR, PPE, AG, AB, CJ, AA, AC, MR and RZ analyzed and interpreted the data. LAR, PPE, AB, AC, MR and RZ wrote the manuscript, which was critically reviewed and revised by AG, CJ, AA, AC and MR. All authors have read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Not applicable for that section.
Ethics approval and consent to participate
The protocol for the study has been approved by Hospital Universitario Cruces and Hospital Galdakao-Usansolo Ethics Committee. As the study used data that was collected as part of routine medical care, the ethics committee determined that individual consent was not required.
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- May DS, Kelly JJ, Mendlein JM, Garbe PL. Surveillance of major causes of hospitalization among the elderly, 1988. MMWR CDC Surveill Summ. 1991;40(1):7–21.PubMedGoogle Scholar
- Simonetti AF, Viasus D, García-Vidal C, Carratalá J. Management of community-acquired pneumonia in older adults. Ther Adv Infect Dis. 2014;2(1):3–16.View ArticlePubMedPubMed CentralGoogle Scholar
- Naito T, Suda T, Yasuda K, Yamada T, Todate A, Tsuchiya T, et al. A validation a potential modification of the pneumonia severity index in elderly patients with community-acquired pneumonia. J Am Geriatr Soc. 2006;54:1212–9.View ArticlePubMedGoogle Scholar
- Janssens JP, Krause KH. Pneumonia in the very old. Lancet Infect Dis. 2004:112–24.Google Scholar
- Bellelli G, Guerini F, cerri AP, Trabucchi M. A sudden decline in mobility status as an early sign of acute infection in elderly patients: evidence from three case reports. Aging Clin Exp Res 2012; 24: 281–284.Google Scholar
- Khokhar SR, Stern Y, Bell K, Anderson K, Noe E, Mayeux R, et al. Persistent mobility deficit in the absence of deficits in activities of daily living: a risk factor for mortality. J Am Geriatr Soc. 2001;49:1593–43.View ArticleGoogle Scholar
- Fried L, Tangen C, Walston J, Newman AB, Hirsch C, Gottdener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:146–56.View ArticleGoogle Scholar
- Dent E, Chapman I, Howell S, Piantadosi C, Visvanathan R. Frailty and functional decline indices predict poor outcomes in hospitalized older people. Age Ageing. 2014;43:477–84.View ArticlePubMedGoogle Scholar
- Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state in a dynamic process. Gerontology. 2009;55:539–49.View ArticlePubMedGoogle Scholar
- Dillin A, Gottschling DE, Nystrom T. The good and the bad of being connected: the integrons of aging. Curr Opin Cell Biol. 2014;26:107–12.View ArticlePubMedGoogle Scholar
- Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. Can Med Assoc J. 2005;173:489–95.View ArticleGoogle Scholar
- Menéndez R, Torres A, Aspa J, Capelastegui A, Prat C, Rodríguez-Castro F. Community-acquired pneumonia. New guidelines of the Spanish Society of Chest Diseases and Thoracic Surgery (SEPAR). Arch Bronconeumol. 2010;46:543–58.View ArticlePubMedGoogle Scholar
- Lim WS, Van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58:377–82.View ArticlePubMedPubMed CentralGoogle Scholar
- Weinberger DM, Harboe ZB, Sanders EA, Ndiritu M, Klügman KP, Ruckinger S, et al. Association of serotype with risk of death from pneumococcal pneumonia is a stable serotype-associated property: a meta-analysis. Clin Infect Dis. 2010;51:692–9.View ArticlePubMedPubMed CentralGoogle Scholar
- García-Vidal C, Fernández-Sabe N, Carratalá J, Díaz V, Verdaguer R, Dorca J, et al. Early mortality in patients with community-acquired pneumonia: causes and risk factors. Eur Respir J. 2008;32:733–9.View ArticlePubMedGoogle Scholar
- Levy MM, Fink M, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ATS/SIS international sepsis definitions conference. Crit Care Med. 2003;31:1250–6.View ArticlePubMedGoogle Scholar
- Menéndez R, Torres A, Zalacain R, Aspa J, Martín Villasclaras JJ, et al. Neumofail group. Risk factors of treatment failure in community-acquired pneumonia: implications for disease outcome. Thorax. 2004;59:960–5.View ArticlePubMedPubMed CentralGoogle Scholar
- González del Castillo J, Martín-Sánchez FJ, Linares P, Menéndez R, Mujal A, Navas E, et al. Consensus guidelines for the management of community acquired pneumonia in the elderly patient. Rev Esp Geriatr Gerontol. 2014;49(6):279–91.View ArticlePubMedGoogle Scholar
- Faverio P, Aliberti S, Bellelli G, Suigo G, Lonni S, Pesci A, et al. The management of community-acquired pneumonia in the elderly. Eur J Intern Med. 2014;25:312–9.View ArticlePubMedGoogle Scholar
- Bouillon K, Kivimaki M, Hamer M, et al. Measures of frailty in population-based studies: an overview. BMC Geriatr. 2013;13:64.View ArticlePubMedPubMed CentralGoogle Scholar
- Murali-Krihnan R, Iqbal J, Rowe R, Hatem E, Parviz Y, Richardson J, et al. Impact of frailt on outcomes after percutaneous coronary inervention: a prospective cohort study. Open Heart. 2015;2:e000294.View ArticleGoogle Scholar
- Bagshaw SM, Stelfox HT, McDermid MD, Rolfson DB, Tsuyuki RT, Baig N, et al. Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study. CMAJ. 2014;186:E95–102.View ArticlePubMedPubMed CentralGoogle Scholar
- Clegg A, Young J, Iliffe S. Frailty in elderly people. Lancet. 2013;381:752–62.View ArticlePubMedGoogle Scholar
- Cillóniz C, Polverino E, Ewing S, Aliberti S, Gabarras A, Menéndez R, et al. Impact of age and comorbidity on cause and outcome in community -acquired pneumonia. Chest. 2014;144:999–1007.View ArticleGoogle Scholar
- Ma HM, Tang WH, Woo J. Predictors of in-hospital mortality of older patients admitted for community-acquired pneumonia. Age Ageing. 2011;40:736–41.View ArticlePubMedGoogle Scholar
- Conte H, Chen Y, Mehal W. A prognostic rule for elderly patients admitted with community-acquired pneumonia. Am J Med. 1999;106:20–8.View ArticlePubMedGoogle Scholar
- Burgos J, Lujan M, Larrosa MN, Fontanals D, Bermudo G, Planes AM, et al. Risk factors for respiratory failure in pneumococcal pneumonia: the importance of pneumococcal serotypes. Eur Respir J. 2014;43:545–53.View ArticlePubMedGoogle Scholar
- Torres OH, Muñoz JM, Ruiz D, Ris J, Gch I, Coma E, et al. Outcome predictors of pneumonia in elderly patients: importance of functional assessment. J Am Geriatr Soc. 2004;52:1603–9.View ArticlePubMedGoogle Scholar
- Greysen SR, Stjacic I, Auerbach A, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175:559–65.View ArticlePubMedPubMed CentralGoogle Scholar
- Kahlon S, Pederson J, Majumdar S, Belga S, Lau D, Fradette M, et al. Association between frailty and 30-day outcomes after discharge from hospital. CMAJ. 2015;187(11):799–804.View ArticlePubMedPubMed CentralGoogle Scholar
- Dai YT, Chang-Wu SC, Weng R. Unplanned hospital readmission and its predictors in patients with chronic conditions. J Formos Med Assoc. 2002;101:779–85.PubMedGoogle Scholar
- Klapdor B, Ewing S, Platz M, Rohde G, Schütte H, Schaberg T, et al. For the CAPNETZ study group community-acquired pneumonia in younger patients is an entity on its own. Eur Respir J. 2012;39:1156–61.View ArticlePubMedGoogle Scholar
- Naucler P, Darenberg J, Morfeldt E, Ortqvist A, Normak BH. Contribution of host, bacterial factors and antibiotic treatment to mortality in adult patients with bacteraemic pneumococcal pneumonia. Thorax. 2013;68:571–9.View ArticlePubMedGoogle Scholar
- Ruiz LA, Zalacain R, Capelastegui A, Bilbao A, Gómez A, Uranga A, et al. Bacteremic pneumococcal pneumonia in elderly and very elderly patients. Host- and pathogen-related factors, process of care and outcome. J Gerontol A Biol Sci Med Sci. 2014;69:1018–24.View ArticlePubMedGoogle Scholar
- Sligi WI, Majumdar SR. How important is age in defining the prognosis of patients with community-acquired pneumonia? Curr Opinion Infect Dis. 2011;24:142–7.View ArticleGoogle Scholar
- MacNee W, Rabinovich RA, Choudhury G. Ageing and the border between health and disease. Eur Respir J. 2014;44:1332–52.View ArticlePubMedGoogle Scholar
- De Gaudio AR, Rinaldi S, Chelazzi C, Borracci T. Pathophysiology of sepsis in the elderly: clinical impact and therapeutic considerations. Curr Drug Targets. 2009;10:60–70.View ArticlePubMedGoogle Scholar
- Turnbull A, Lau B, Ruhl A, Mendez-Tellez P, Schanholtz CB, Needham DM. Age and decisions to limit life support for patients with acute lung injury: a prospective cohort study. Crit Care. 2014;18:R107.View ArticlePubMedPubMed CentralGoogle Scholar
- Luna C, Palma I, Niederman MS, Membrani E, Giovani V, Wiemken TL, et al. The impact of age and comorbidities on the mortality of patients of different age groups admitted with community-acquired pneumonia. Ann Am Thoracic Soc. 2016;13(9):1519–26.View ArticleGoogle Scholar
- Boumendil A, Angus D, Guitonneau AL, Menn AM, Ginsburg C, Takun K, et al., on behalf of the ICE-CUB study group. Variability of intensive care admission decisions for the very elderly. PLoS One. 2012;7:e34387.View ArticlePubMedPubMed CentralGoogle Scholar
- Docherty AB, Anderson NH, Walsh TS, Lone NI. Equity of access to critical care among elderly patients in Scotland: a national cohort study. Crit Care Med. 2016;44:3–13.View ArticlePubMedGoogle Scholar
- Stelfox HT, Bagshaw SM, Song G. A retrospective cohort study of age-based differences in the care of hospitalized patients with sudden clinical deterioration. J Crit Care. 2015:1025–31.Google Scholar
- Bean JF, Olveczky DD, Kiely DK, LaRose SI, Jette AM. Performance-based versus patient reported physical function. What are the underlying predictors? Phys Ther. 2011;91:1804–11.View ArticlePubMedPubMed CentralGoogle Scholar
- Jauthani-Mehta M, De Rekeneire N, Allore H, Chen S, O’Leary JR, Bauer DC, et al. Modifiable risk factors for pneumonia requiring hospitalization of community-dwelling older adults: the health, aging, and body composition study. J Am Geriatric Soc. 2013;61:1111–8.View ArticleGoogle Scholar
- Mortensen EM, Nakashima B, Cornell J, Copeland LA, Pugh MJ, Anzueto A, et al. Population –based study of statins, angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors on pneumonia-related outcomes. Clin Infect Dis. 2012;55(11):1466–73.View ArticlePubMedPubMed CentralGoogle Scholar