Aging Clinical and Experimental Research (2021) 33:1091–1100

https://doi.org/10.1007/s40520-019-01437-7

REVIEW ARTICLE

Pneumonia prevention in the elderly patients: the other sides

Najla Chebib1 · Clémence Cuvelier2 · Astrid Malézieux‑Picard2 · Thibault Parent2 · Xavier Roux2,3 · Thomas Fassier2,4 ·
Frauke Müller1 · Virginie Prendki2,4,5

Received: 18 May 2019 / Accepted: 3 December 2019 / Published online: 31 December 2019
© Springer Nature Switzerland AG 2019, corrected publication 2020

Abstract
Pneumonia is one of the leading causes of morbidity and mortality from infection in elderly patients. The increased frequency
of pneumonia among elderly subjects can be explained by the physiological changes linked to the progressive aging of the
respiratory tree and the diminished immunological response. A spiral of event leads to frailty, infection and possible death;
preventing pneumonia consists of controlling the risk factors. Dysphagia, which is associated with malnutrition and dehy-
dration, is recognized as one of the major pathophysiological mechanism leading to pneumonia and its screening is crucial
for the pneumonia risk assessment. The impairment in the oropharyngeal reflexes results in stagnation of foreign material
in the lateral cavities of the pharynx which may then get aspirated repeatedly in the lungs and cause pneumonia. Pneumonia
prevention starts with lifestyle modifications such as alcohol and tobacco cessation. A careful review of the risk–benefit of
the prescribed medication is critical and adaptation may be required in elders with multiple morbidities. Respiratory physi-
otherapy and mobilization improve the functional status and hence may help reduce the risk of pneumonia. Maintaining
teeth and masticatory efficiency is important if malnutrition and its consequences are to be avoided. Daily oral hygiene and
regular professional removal of oral biofilm can prevent the onset of periodontitis and can avoid an oral environment favor-
ing the colonization of respiratory pathogens than can then be aspirated into the lungs.

Keywords Pneumonia · Prevention · Aged over 80 · Oral hygiene · Nutrition · Dysphagia

Introduction and 69 years and increases to 22/1000 persons between the

ages of 85 and 89 years [2]. Clinical pneumonia resulted in
Pneumonia is one of the leading causes of morbidity and 6.8 million hospitalizations worldwide and about in 1.1 mil-
mortality from infection in elderly patients [1]. The inci- lion in-hospital deaths occurred among them in 2015. The
dence of community-acquired pneumonia (CAP) is approxi- hospital admission rate was increased with age and higher
mately 3 episodes/1000 persons in those aged between 65 in men [3].
The diagnosis of pneumonia is based on respiratory clini-
* Virginie Prendki cal symptoms such as cough, dyspnea and fever and the pres-
[email protected] ence of a new infiltrate on the chest X-ray. In the elderly,
the diagnosis is more complex due to age-related atypical
1
Division of Gerodontology and Removable Prosthodontics, symptoms, like for example, lowering of the temperature
University Clinics of Dental Medicine, University
of Geneva, Geneva, Switzerland threshold. Patients often present to the emergency for falls
2
or with a simultaneous decompensation of comorbidities [4,
Division of Internal Medicine of the Aged, Department
of Internal Medicine, Rehabilitation and Geriatrics, Geneva
5]. A good-quality chest X-ray is often difficult to perform
University Hospitals, University of Geneva, Geneva, and to interpret in ≥ 65 years old, and the low-dose computed
Switzerland tomography proved to be a more adequate tool for diagnos-
3
Department of Anesthesiology, Pharmacology and Intensive ing pneumonia in the elderly population [6].
Care, Geneva University Hospitals, Geneva, Switzerland Prognosis largely depends on comorbidities such as
4
Faculty of Medicine, University of Geneva, Geneva, chronic heart failure, chronic respiratory diseases, neuro-
Switzerland logical diseases, level of dependence, nutritional and cog-
5
Hôpital des Trois-Chêne, Chemin du Pont‑Bochet 3, nitive status of the patient [7, 8]. Functional status is an
1226 Thônex‑Genève, Switzerland

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1092 Aging Clinical and Experimental Research (2021) 33:1091–1100

independent predictor for short- and long-term mortality occurs in case of host immunodeficiency, the presence of
in patients hospitalized for CAP and is associated with a viral pathogens, or a significant bacterial inoculum which
risk of recurrent pneumonia in the elderly [9]. Comorbidi- favors the development of pneumonia. Different mechanisms
ties increase the risk of CAP by two-to-fourfold. The more were proposed to how pathogens reach the lower respiratory
frequent ones are: cardiovascular and chronic respiratory tract. The inhalation of pathogens can give access to the
diseases, cerebrovascular and neurodegenerative diseases lower respiratory tract, another major route is the aspira-
such as dementia and Parkinson’s disease, chronic renal or tion of secretions from the oropharynx either directly or by
liver disease and immunosuppression [10]. A summary of reflux from the stomach [15]. A contiguous extension of a
the effect of morbidities on the risk of CAP is presented in colonization/infection and the haematogenous carriage can
Table 1. also lead to pneumonia [16]. Pneumonia is often classified in
Mortality varies between 5 and 15% in hospitalized relation to where it was acquired: community-acquired pneu-
patients to 30–50% in intensive care unit patients. In addi- monia (CAP), nursing home-acquired pneumonia (NHAP),
tion, mortality is increased not only during the first months, hospital-acquired pneumonia (HAP) or ventilator-associated
but also in the years following pneumonia, partly related to pneumonia (VAP) have been described. HAP is defined as
an increase in cardiovascular events [11]. pneumonia which manifests 48 h or more after admission to
Given the high incidence of mortality, pneumonia preven- hospital, and VAP generally occurs more than 48–72 h after
tion is particularly relevant in elderly patients. Vaccination endotracheal intubation. Healthcare-acquired pneumonia
is the most effective and known preventive measure and will (HCAP) occurs in patients with frequent contact with the
be treated in another article of this issue. The objectives of health system, numerous antibiotic intake and/or a functional
this review are to summarize relevant information regarding state of frailty [17, 18].
the particularities of pneumonia in the elderly and its predis- Pneumonia is also classified by its physio-pathological
posing factors, and to provide an overview of the preventive mechanism (i.e., aspiration pneumonia) or, if identified, by
measures other than vaccination for the elderly population. the etiological pathogen [15]. Jain et al. showed that the
presence of influenza and S. pneumoniae was five times
higher in pneumonia patients older than 65 years when
Pneumonia: etiology and pathophysiology compared to younger ones, and rhinovirus presence was ten
times higher [12]. Obtaining high-quality samples is difficult
Pneumonia is an inflammatory condition of the lung affect- with older patients and only 6% could provide high-quality
ing primarily the alveoli. It is most commonly caused by sputum [13]. Comprehensive molecular testing performed in
bacteria, but the implication of viruses is now recognized nasopharyngeal and oropharyngeal swabs is poorly predic-
[12]. The etiological agent is rarely identified, especially tive of the presence of pneumonia and proved less sensitive
in elders [13]. In healthy individuals, bacterial density in than routine microbiological methods for old patients in a
the lower airways is defined by a constant exchange from cohort of 199 with a mean age of 83 years [19]. In a review
the upper respiratory tract and oral microbiota by micro- of 33 studies published between January 2005 and July 2012
aspiration, and retrograde clearance by respiratory epi- and focusing on the etiology and treatment of CAP among
thelium cilia and cough [14]. An imbalance to this system adults in Europe, Torres et al. concluded that Streptococ-
cus pneumoniae, Haemophilus influenzae and respiratory
viruses were the most frequently observed pathogens, and
Table 1  Chronic diseases and their effect on pneumonia onset that Mycoplasma pneumoniae was less frequently found
(according to Torres et al. 2013) among patients ≥ 65 years old [20]. General hygiene meas-
Morbidities Risk of CAP ures as contact and droplet precaution and use of masks
are necessary tools to tackle global respiratory infections,
Chronic cardiovascular disease 3 × the risk among which viral infections [21].
Chronic respiratory disease 2 to 4 × the risk
Neurological disease (cerebrovascular disease or 2 × the risk
stroke, and neurodegenerative disease)
Dysphagia and malnutrition
Chronic renal disease 2 × the risk
Chronic liver disease 2 × the risk
The high frequency of pneumonia among elderly subjects
Diabetes mellitus Moderate risk
can be explained by the physiological changes linked to the
Cancer Moderate risk
progressive decline of the respiratory tree. The mucocili-
Immunosuppression: asplenia, HIV 2 × the risk
ary clearance and the coughing reflexes are reduced leading
Rheumatoid arthritis Moderate risk
to a poor airway clearance. Furthermore, the mobility of
Previous pneumonia Moderate risk
the oropharynx is often impaired resulting in swallowing

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problems. The immunosenescence involves alterations to cluster-randomized trial showed the absence of benefit of
the innate and adaptive immune systems favoring infections antibiotic prophylaxis in patients with dysphagia after stoke
after broncho-aspirations [22, 23]. Oropharyngeal dysphagia and hospitalized in stroke units [36].
(OD) is recognized as one of the major pathophysiological
mechanisms leading to aspiration pneumonia in the elders
[15, 24]. Swallowing disorders or dysphagia affects 30–40%
of the population over 65 years with a prevalence of 75% Lifestyle‑related risk factors
in stroke patients, 82% in patients with neurodegenerative
disease such as Parkinson’s disease or 84% with dementia Along with the aging of the global population, the number
[25]. Dysphagia is also prevalent in 30% of independently of smokers aged 65 years or more is increasing worldwide.
living older adults and is independently associated with mal- A recent study in Europe estimated their prevalence to be
nutrition in population of elders with a mean age 82 years 11.5% as of 2010 [37]. Their mortality is doubled when
[26]. Malnutrition (evaluated by mini nutritional assess- compared to non-smokers [38]. Smokers, former smokers
ment, body mass index (BMI) and serum albumin levels) and passive smokers have an increased risk of CAP [10, 39].
is also highly prevalent and strongly associated with OD in Former and current smokers have an increased mortality due
older patients hospitalized for an acute disease [27]. Neuro- to infectious diseases in general, and current heavy smoking
logical diseases, incompetent lip closure, tongue protrusion (> 20 cigarettes/days) is a strong risk factor for pneumonia
and poor buccinators muscle strength induce poor masti- (HR = 3.30) [40]. Current smoking increases the 30-day
catory ability, frequently associated with a decreased BMI mortality in pneumococcal CAP versus non-smokers and
and serum albumin concentrations [28]. The preparation of ex-smokers [41]. Tobacco smoking plays an indirect role
a food bolus can be impaired following the loss of teeth, by causing chronic obstructive pulmonary disease (COPD),
which increases the risk of macro-aspiration into the airways which is also recognized as a CAP risk factor [42]. Smok-
[29]. The loss of masticatory efficiency changes food selec- ing cessation decreases the risk of CAP when compared to
tion towards decreased consumption of vegetables, fruits, current smokers, but the time free from tobacco required
proteins, minerals and vitamins [30]. This poor nutritional to achieve a decreased CAP risk is long (> 10 year) [43].
intake worsens the decrease of lean muscular mass that Moreover, the risk is only decreased if the former smoker
occurs naturally with age and aggravates sarcopenia [31]. does not present with COPD [44]. For old passive smok-
Moreover, dysphagia patients are often dehydrated because ers, the risk of CAP is also increased when compared to
of a reduced sensation of thirst, or the fear of aspiration non-exposed persons (OR 1.59) when exposed to smoke for
during drinking, potentially leading to oral dryness. Oral extended periods [39]. Smoking cessation can increase life
dryness favors oropharyngeal bacterial colonization [25]. expectancy, with those quitting at younger age benefiting the
The impaired swallowing efficacy often causes the stagna- most. Quitting at age 65 years increases the life expectancy
tion of foreign material in the lateral cavities of the pharynx 1.4–2 years for men and 2.7–3.7 years for women [45, 46].
which may then get aspirated in the lungs when patients are Another risk factor for CAP relates to alcohol consump-
placed in supine position [25]. Aspiration is often clinically tion, which is one of the leading causes of mortality world-
silent because of impaired cough reflexes [32]. Having a wide [47]. Excessive alcohol ingestion is commonly linked
low BMI is a predictor for a poor outcome for pneumonia in with liver disease, but it is also an independent risk factor for
elder patients hospitalized or in intensive care [8]. For the CAP [10, 48, 49]. Drinkers have an 83% increase in the risk
very old patients aged over 85 years who are hospitalized for of CAP when compared to non-drinkers. The effect is dose
CAP, nutritional parameters at admission such as serum pro- dependent and consuming 10–20 g of alcohol per day was
tein and albumin are associated with a decreased likelihood linked to an 8% increase of acquiring CAP [50]. The severity
of death [7]. Malnutrition is independently associated with of CAP and the frequency of pneumococcal pneumonia are
30-day mortality in HAP in nursing home residents [33]. higher in drinkers than in the general population [51]. For
A seated position with the head-up by approximately 30°, older drinkers, the CAP can result in a severe sepsis [52].
during the day and at night, may reduce gastroesophageal They tend to spend more time in the hospital for pneumonia
regurgitation-associated aspiration [34]. Percutaneous endo- and have a higher risk of in-hospital mortality when com-
scopic gastrostomy which is often performed in case of bron- pared to non-drinkers [53]. Moreover, certain pneumococcal
choaspiration did not decrease its incidence when compared serotypes (serotypes 4, 11A, and 19F) were more frequently
to patients fed with a nasogastric tube [35]. associated with invasive pneumococcal pneumonia in alco-
In acute stroke patient who are particularly at risk of hol abusers [48]. Alcohol intake disturbs the local lung
pneumonia because of swallowing disorders and an altered immunological defenses by altering the mucociliary clear-
mental status, antibiotic prophylaxis is sometimes pre- ance and by diminishing neutrophil chemotaxis and alveolar
scribed for pneumonia prevention. Nevertheless, a recent macrophage functions. With chronic alcohol consumption,

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oxidative stress pathways interfere with the normal immune drugs as thiazolinediones, which have immunomodulatory
reaction, thus impairing pathogen clearance [54]. and glucocorticoid-like properties [67]. Nevertheless, the
Environmental exposures are less-noticed risk factors for evidence is conflicting and large epidemiological studies are
pneumonia but they are known to be involved in the patho- needed to confirm the association of antidiabetic drugs with
genesis of lung diseases. Even in older adults, the long-term the incidence of pneumonia [68–70].
exposure to nitrogen dioxide and fine particulate matter were On the other side, some medications were reported to
associated with hospitalization for pneumonia [55]. have a protective effect on the occurrence of pneumonia.
A meta-analysis supported the hypothesis that statins may
reduce the risk of pneumonia but the quality of the currently
Medication available scientific evidence is unfortunately very low [71].
There is conflicting information on the protective effect
Elderly patients have often several comorbidities requiring of angiotensin II receptor blockers (ARB), and angiotensin-
multiple drug prescription. Immunosuppressive therapy and converting enzyme inhibitors (ACE) on the incidence of
oral steroids have been reported to be risk factors for pneu- pneumonia. ARB and ACE were shown to decrease the risk
monia of which clinicians need to be aware when prescribing of pneumonia in old hypertensive patients with Parkinson’s
these drugs [56]. disease and in post-stroke patients with aspiration pneu-
The risk of pneumonia with gastric-acid-suppressive monia [72, 73].The possible explanation for the action of
drugs (proton-pump inhibitors (PPI) and Histamine 2 recep- statins, ARB and ACE would be a modulatory effect in the
tor antagonists) has also been reported in many studies as the inflammatory state by altering the production of proinflam-
acid suppression promotes an increase of gastric coloniza- matory cytokines, improving endothelial and mitochondrial
tion by pathogens and consequently an alteration of the gut dysfunction and to decreasing the reactive oxidative species
microbiome [57]. The risk seems to be even higher when the [74]. Another mechanism of ACE would be an increase of
treatment has been only recently prescribed [58]. substance P levels in the airways and plasma, improving
Inhaled corticosteroids (ICS) and antipsychotics (Aps) swallowing function and cough reflexes [75].
may increase also the risk of pneumonia and negatively Amantadine was found to have a beneficial effect on
impact on its clinical outcome [59, 60]. ICS, recommended the risk of pneumonia in patients with a history of stroke,
to prevent and treat COPD, lower the pulmonary host the dopamine supplementation improved the swallowing
defense, hence reducing extracellular release of nitric oxide reflexes thus reducing by 20% the pneumonia risk [76].
by alveolar macrophages and decreasing cytokine produc- More evidence from well-designed trials is needed to
tion [61]. Concerning the use of Aps, a systematic review assess the link between therapeutic drugs and the risk of
suggested an increase in the risk for CAP [62], being highest pneumonia, but at any rate, clinicians need to be particularly
during the early phase of treatment and being dose depend- cautious when treating elders with multiple morbidity who
ent [63]. The extrapyramidal adverse effect could explain the take already multiple prescribed medications. The adequate
increased risk for aspiration pneumonia. The anticholinergic policy for elders is to minimize prescriptions and potentially
side effects of Aps induce dryness of the mouth hence poor stop inappropriate ones [77].
bolus preparation and transport. The sedative and anticho-
linergic side effects of Aps decrease the peristalsis result-
ing in an increased risk of aspirations [63]. The current use Physiotherapy
(< 90 days) of benzodiazepine receptor agonists is associ-
ated with hospitalization for pneumonia occurrence and is Physiotherapy is not commonly suggested as prevention of
dose dependent, the risk of hospitalization from benzodi- pneumonia [78], although poor functional status is consid-
azepine hypnotic agents was higher than non-hypnotic and ered a risk factor for recurrent CAP [9]. The loss of muscle
anxiolytic agents. Midazolam was found to increase almost mass is an independent predictive factor of 3-month mortal-
five times the risk of hospitalization for pneumonia. Short- ity in patients hospitalized for aspiration pneumonia [79]. In
and intermediate-acting benzodiazepine receptor agonists functionally unimpaired older adults, the development of a
increased the risk more than long-acting agents. [64]. The mobility limitation increases the risk of developing pneu-
risk of pneumonia was also increased with non-hypnotic monia [80]. Hence, two physiotherapeutic novel approaches
benzodiazepine in older adults [65]. The muscarinics-1 and could modify the pneumonia risk. The first concerns respira-
histaminergic-1 effects cause esophageal dilation and hypo- tory physiotherapy, which consists in guiding the patient into
motility in addition to sedation thus explaining the increased performing deep breathing exercises, coordinated breathing.
risk for pneumonia infection [66]. The assisted cough helps the patient clear the secretions.
The susceptibility to pneumonia is increased among It was shown that non-invasive ventilation and continuous
patients with diabetes and could be associated to antidiabetic positive airway pressure used prior to abdominal high-risk

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elective surgeries reduce the risk of post-operative pulmo- cascade, various signaling molecules are implicated, i.e.
nary complication such as pneumonia and atelectasis [81]. cytokines, the cytokines secreted into mucosal saliva may
Preoperative inspiratory muscle training in adults under- promote adhesion and colonization by respiratory pathogens
going cardiac and major abdominal surgery decreases the such as Pseudomonas aeruginosa and enteric bacilli [97].
post-operative pulmonary complications and reduces the Ortega et al. showed that oral colonization by respiratory
length of hospital stay [82–84]. A pulmonary rehabilitation pathogens was more common in frail patients with oral dys-
program initiated on the day following surgery showed a phagia (with or without pneumonia) than in healthy subjects
reduction in the incidence of pneumonia in elderly patients without dysphagia (93% vs. 67%) [98]. Hence, the oral bio-
treated for hip fracture [85]. Moreover, early rehabilitation film constitutes a likely reservoir for pulmonary pathogens
reduced the 30-day in-hospital mortality in geriatric patients [99–103]. It has also been suggested that an imbalanced
with aspiration pneumonia [86]. oropharyngeal microbiota reduces colonization resistance
The second approach is the mobilization physiotherapy; allowing pathogens to spread [104]. Elderly pneumonia
it targets mobility rather than chest function; it is well docu- patients presented a higher proportion of some Streptococcus
mented in post-operative care. The mobilization protocols species and Rothia, whereas Gemellales, Prevotella, Veil-
are not structured and standardized and their effectiveness lonella dispar, Parascardovia and Leptotrichia had lower
is still questionable, but mobilization reduces nevertheless relative abundance compared to non-pneumonia controls.
the risk of complications associated with bed rest [87]. In An age-related decrease in anaerobic colonization (Prevo-
a post-operative context, early mobilization and respiratory tella, Veillonella, Leptotrichia) increased the susceptibility
physiotherapy are associated with a decrease in pneumonia to pneumonia. Bacterial diversity (expressed as Shannon
incidence and respiratory complications [88]. diversity index) and bacterial load of oropharyngeal micro-
Among medical patients, early mobilization reduced the biota were increased in elderly pneumonia patients in com-
incidence of HAP with a hazard ratio of 0.39, it also reduced parison to elderly without pneumonia [104].
the length of stay in hospital [89]. Including an inpatient These cytokines produced at high levels in gingival fluid
exercise-based rehabilitation program improves the func- and serum are in contact with respiratory epithelial cells via
tional status of the patient as well as quality of life but may the hematogenous route. This inflammatory event can lead to
not have a direct impact on pulmonary function or the length epithelial and endothelial injury that increases susceptibil-
of hospitalization [90]. ity to infections; they were shown to result in a shift from
a diverse microbiota in the lungs to a dominance by single
species such as Streptococcus pneumonia and Pseudomonas
Oral health aeruginosa [105].
A systematic review conducted in 2008 analyzed the
A natural dentition can be a major advantage in term of link between oral hygiene and the risk of pneumonia and
retaining the masticatory capabilities and chewing muscle concluded that one in ten deaths could be avoided in elders
bulk. Nevertheless, keeping one’s natural teeth can become living in institutions through adequate and regular den-
more challenging when physical limitations occur, as poor tal hygiene [106]. However, according to the authors, the
oral hygiene fosters the accumulation of dental plaque, a mechanical cleaning of the teeth should be done by dental
bacterial biofilm adhering to the teeth [91]. Patients having professionals, such as hygienists or dentists, because the risk
more than ten natural teeth and periodontal pocket depths of pneumonia was unchanged when hygiene was provided
of more than 4 mm presented an increased mortality due by the nursing or auxiliary staff [107].
to pneumonia than those with periodontal pockets smaller Tongue coating is also associated with a higher bacte-
than 4 mm [92, 93]. The quantity of periodontal bacteria ria count in the saliva and the development of aspiration
in 85-year-old persons increases with the number of teeth pneumonia [108]. Furthermore, patients wearing removable
[94]. Broncho-alveolar lavage samples from patients admit- dentures at night were more likely to develop pneumonia
ted to the hospital with clinical symptoms of pneumonia than those removing it before bedtime [109]. The dentists’
have confirmed the involvement of oral microorganism current recommendation is to remove dentures at night to
[95]. Anaerobic germs (Veillonella sp. and Porphyromonas prevent oral candidiasis promoting bacterial superinfection
gingivalis) implicated in periodontal disease were found in and to keep them dry or in a disinfectant bath [110–112].
dentate patients as well as a high concentration of Staphylo- Chlorhexidine mouthwashes significantly reduce bacterial
coccus aureus in patients wearing prosthetic appliances [95]. colonization in elders [113]. However, chlorhexidine is an
Periodontal disease leads to an increase in the mass and adjuvant and cannot replace mechanical cleaning or brush-
the diversity of the microbiota causing the destruction of the ing because its chemical efficacy against bacterial biofilm is
tissues surrounding the teeth [96]. It prompts a true immune limited. Thus, concentrations of 0.12–0.2% can be used, an
response of the host with triggering of the inflammatory initial debridement of dental plaque is still necessary [114].

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1096 Aging Clinical and Experimental Research (2021) 33:1091–1100

Table 2  Overview of pneumonia preventive measures (adapted from Prina et al. 2015)
Risk factor Recommendation

Patient status
Old age Vaccination against H. influenza and S. pneumonia
Swallowing disorder Thicken liquids, small bolus, adjust head position
Hyposalivation Chewing of gum, oral moisturizers
Malnutrition Food supplements, adjustment of diet, assuring chewing efficiency
Physical frailty Physiotherapy
CPAP prior to surgery and preoperative training
Environment
Environmental exposure Limit exposure to nitrogen dioxide and fine particulate matter
Living in a nursing home or frequently exposed to Favor home care when possible
healthcare environment
Habits
Smoking Smoking cessation
Alcohol Adjust alcohol consumption
Medications
Immunosuppressive drugs and oral steroids Monitor carefully when used and adjust if possible
PPI and H2 receptor antagonists Monitor carefully when used and adjust if possible
Inhaled corticosteroids Monitor carefully when used and adjust if possible
Antipsychotics Monitor salivary flow and in case of hyposalivation treat xerostomia
Benzodiazepine Check level of sedation and adjust where necessary
Statin Prescribe when indicated, as it may reduce the risk of pneumonia
ACE inhibitors and ARB’s Prescribe when indicated, as it may reduce the risk of pneumonia in Parkinson patients
Amantadine Prescribe when indicated, as it may reduce the risk of pneumonia in stroke patients
Oral health
Oral hypofunction Regular dental check-up visits and treatment where indicated
Poor oral hygiene Daily oral hygiene in addition to regular oral hygiene provided by dental hygienist
Poor tongue hygiene Use of tongue scrapping
Dental prosthesis Assure denture hygiene and remove denture during sleep

CPAP continuous positive airway pressure, PPI proton-pump inhibitors, H2 histamine 2 receptor antagonist, ACE inhibitors angiotensin-convert-
ing enzyme inhibitors, ARB angiotensin II receptor blockers

A recent systematic review evaluated the effect of oral onset of pneumonia. Dysphagia is a major risk factor for
care measures for residents in nursing homes and long-term pneumonia, its screening and management is also impor-
facilities. The analysis was unable to confirm that profes- tant to prevent malnutrition, dehydration and xerostomia.
sional oral care resulted in a lower incidence of NHAP or Controlling lifestyle related risk factors such as smok-
reduced the risk of pneumonia associated mortality. The ing, and alcohol consumption could decrease the risk of
authors concluded that professional oral care or oral care pneumonia, even in elderly patients. A careful review of
measures may reduce mortality due to pneumonia but the the prescribed medications and a close monitoring of side
level of evidence is still insufficient [115]. effects can also reduce the risk of pneumonia. Maintain-
An overview of suggested preventive measures than can ing teeth and thus chewing muscle mass can improve oral
be undertaken to control the risk factors for pneumonia in function, nutritional and functional status. Simple every-
the elderly is presented in Table 2. day practices such as oral biofilm removal or removing the
denture before bedtime are easy to implement and efficient
measures to reduce the risk of pneumonia.
Conclusion
Acknowledgements The contribution of the ESCMID Study Group
for Infections in the Elderly (ESGIE; http://www.escmi​d.org/esgie​) to
While the vaccine remains the best known and best stud- this study is also acknowledged.
ied pneumonia prevention strategy, it is important to rec-
ognize the modifiable risk factors that are related to the

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Funding VP received grants from the Geneva University Hospitals review. Thorax 68:1057–1065. https:​ //doi.org/10.1136/thorax​ jnl-
(HUG) (Research & Development Grant, Medical Directorate, HUG 2013-20428​2
and Research Fund of the Department of Internal Medicine of the Uni- 11. Corrales-Medina VF, Alvarez KN, Weissfeld LA et al (2015)
versity Hospital and the Faculty of Medicine of Geneva) and the Ligue Association between hospitalization for pneumonia and subse-
Pulmonaire Genevoise, a non-profit association involved in the care of quent risk of cardiovascular disease. JAMA 313:264–274. https​
patients with respiratory diseases. ://doi.org/10.1001/jama.2014.18229​
12. Jain S, Self WH, Wunderink RG et al (2015) Community-
acquired pneumonia requiring hospitalization among US
Compliance with ethical standards adults. N Engl J Med 373:415–427. https​://doi.org/10.1056/
nejmo​a1500​245
Conflict of interest The authors declare no conflict of interest. The 13. Musher DM, Abers MS, Bartlett JG (2017) Evolving under-
funders had no role in the design of the study, in the collection, analy- standing of the causes of pneumonia in adults, with spe-
ses, or interpretation of data, in the writing of the manuscript, or in the cial attention to the role of pneumococcus. Clin Infect Dis
decision to publish the results. 65:1736–1744. https​://doi.org/10.1093/cid/cix54​9
14. Dickson RP, Erb-Downward JR, Huffnagle GB (2014) Towards
Ethical approval This article does not contain any studies with human an ecology of the lung: new conceptual models of pulmonary
participants or animals performed by any of the authors. microbiology and pneumonia pathogenesis. Lancet Respir Med
2:238–246. https​://doi.org/10.1016/s2213​-2600(14)70028​-1
Informed consent No informed consent was needed for this article. 15. Mandell LA, Niederman MS (2019) Aspiration pneumonia.
N Engl J Med 380:651–663. https​://doi.org/10.1056/NEJMr​
a1714​562
16. Pirracchio R, Mateo J, Raskine L et al (2009) Can bacterio-
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