KUALA LUMPUR - The elderly are more susceptible to infections than their younger counterparts, says UMMC's Infectious Diseases consultant, Associate Professor Dr Sasheela Ponnampalavanar.
"Unlike younger patients, the clinical manifestation of infections in the elderly is often atypical, subtle and elusive.
"For example, an elderly patient who suffers from urinary tract infection (UTI) may present with confusion and vomiting instead of a burning sensation during urination. A patient with pneumonia could complain of loss of appetite and tiredness instead of a cough. Hence, it is a big challenge for doctors to recognise signs and symptoms of infections in the elderly," says Dr Sasheela, who spoke on Infectious Diseases In The Elderly at the 9th Malaysian National Geriatrics Conference in Kuala Lumpur recently.
"Almost 20 per cent-30 per cent of elderly patients with serious bacterial or viral infections present with a blunted or entirely absent fever response; 20 per cent-45 per cent of them will have a normal rather than a raised white blood cell count, which is the usual laboratory indicator of infection.
"One of the commonest presentations of infection in the elderly is a change in mental function. Therefore, regardless of whether or not fever is present, any change in cognitive function should lead to the consideration that a serious infection may be present. Other non-specific symptoms that an older patient may present with include generalised malaise, falls, anorexia and vomiting," says Dr Sasheela.
According to the Health Ministry, in government hospitals in 2011, the sixth principal cause of hospitalisation and third principal cause of death were infections.
Dr Sasheela advises elderly patients to seek professional advice if they feel unwell instead of medicating themselves with over-the-counter drugs (especially antibiotics) since the infections may not be due to bacteria.
She adds that antibiotics do not treat viral infections and consuming antibiotics unnecessarily could lead to the development and spread of multi-drug resistant organisms.
"With repeatedly use of antibiotics, the bacteria will start building mechanisms in their body to fight these antibiotics. Finally, commonly used antibiotics will become ineffective against certain bacteria. These bacteria are called multi-drug resistant bacteria or 'superbugs'.
"With overuse and misuse of antibiotics, patients will have more multi-drug resistant bacteria in their body rather than the drug-sensitive bacteria. People infected with anti-microbial resistant organisms are more likely to have longer, more expensive hospital stays and may be more likely to die as a result of their infection. The elderly are often infected by multi-drug resistant organisms. Unfortunately, many Malaysians are unaware of the detrimental effects of improper antibiotic use," explains Dr Sasheela.
Risk of mortality
Dr Sasheela shares that common medical concerns afflicting the elderly range from pneumonia to UTI, skin and soft tissue infections (including diabetic foot infections and pressure sores), meningitis, endocarditis (heart valve infection) and appendicitis.
"The risk of mortality in elderly patients due to infections is much higher than in younger patients. The number of deaths among the elderly suffering from pneumonia is three times higher, while mortality rates among elderly patients with UTI are between five and 10 times higher than in younger patients."
She explains that the elderly are more prone to infections due to multiple factors.
"The immune system declines with increasing age and older individuals have more age-related diseases such as diabetes, hypertension and cardiovascular diseases. This increases their risk of infections. Older people also have low or impaired psychological reserves such as decreased cough reflex leading to aspiration pneumonia, impaired blood circulation which compromises wound healing, and bladder changes that predispose a person to urinary tract infections," says Dr Sasheela, adding that the incidence of UTI in the elderly is as high as 50 per cent.
"Their unique living conditions also make the elderly more prone to infections. Frequent hospital admissions, living in a long-term care facility or nursing home are risk factors for acquiring infections, especially with multi-drug resistant bugs. The presence of indwelling urinary catheters, feeding tubes and the like, are a source of infection, too."
Another concern is the rise in HIV infections and sexually transmitted diseases among adults aged 50 and above.
With the availability of very effective HIV treatments, people living with HIV are living longer and healthier lives. The Centres for Disease Control's 2008 HIV Surveillance Report stated that the number of HIV cases in those aged 65 and above in the United States has increased 10-fold in the last decade. With an increase of 2 per cent a year, it is estimated that in 2015, half of the people living with HIV will be over 50 years old.
In Malaysia, between 1986 and 2011, there were 94,841 reported cases of HIV; 4,044 cases were above 50 years. In 2011, there were 3,479 newly diagnosed HIV cases and of this, 9 per cent were above 50.
"The general perception is that the elderly aren't at risk, although many people above 60 are sexually active. It is important to create awareness that HIV is out there among the elderly, too. It is vital to advocate that these diseases can be transmitted at any age if you don't take the right precautions. Those at risk should undergo a thorough medical check-up every six months and seek early treatment," says Dr Sasheela, adding that condom use could help reduce the risk of transmission of diseases such as HIV, syphilis, gonorrhoea and chlamydia.
"The general population should be counselled by healthcare providers and made aware of the risks of HIV and STD, irrespective of age. Early screening, diagnosis and prompt treatment decreases mortality and morbidity associated with these illnesses, besides reducing the risk of transmission."
Infections in the elderly may be reduced or prevented through good nutrition, early medical intervention, proper control of underlying diseases such as diabetes, and good hand hygiene and infection control in hospitals and homes for the elderly.
The elderly should also consider vaccination to reduce the risk of mortality and morbidity. Vaccinations that are recommended for the elderly, according to international guidelines, include those against influenza, pneumonia, chicken pox, shingles, tetanus, diphtheria and pertussis (whooping cough).
In Malaysia, influenza occurs all year round and causes significant morbidity and mortality. The elderly are at increased risk of complications and mortality due to influenza. The vaccine may not prevent mild influenza infection but it has been known to reduce secondary bacterial pneumonia, hospitalisation and deaths by approximately 80 per cent, 30 per cent and 50 per cent respectively, in the elderly.
"Streptococcus pneumoniae is a common cause of bacterial pneumonia in Malaysia. Advanced age predisposes an individual to invasive pneumococcal diseases (IPD) which may affect the brain, joints and blood, resulting in an increase in mortality," says Dr Sasheela.
"Those with underlying co-morbidities such as diabetes, heart disease and chronic lung diseases are at increased risk of IPD. Pneumococcal vaccination prevents invasive pneumococcal diseases."
The health burden of influenza and pneumococcal diseases in Malaysia is being increasingly documented. There is evidence that dual pneumococcal and influenza vaccination reduces strokes, heart attacks, pneumonia and deaths in the elderly.
"Influenza vaccines should be given annually for those over 50 years old, and pneumococcal vaccines should be given once for those over 65 years, especially if they have underlying diseases.
"Unfortunately, the uptake of vaccination among the elderly is not very good in Malaysia. This may be due to lack of awareness, as well as the lack of clear national guidelines on adult vaccination, unlike the ones available for infants and children," Dr Sasheela concludes.