Infection Control in Older Adults

Original Editor - Tolulope Adeniji

Top Contributors - Tolulope Adeniji and Kim Jackson  

Introduction

Infectious diseases were the leading cause of death in older adults until the 20th century and this is because symptoms such as leukocytosis and fever are generally absent[1]. Pneumonia, flu and other infectious diseases (including COVID-19) have resulted in high mortality rates among older adults. Certain bacterial infections are also becoming resistant to antibiotic agents that were previously effective, leading to multi-drug resistant bacteria.[1] There are also challenges with specific vaccines or anti-viral therapy for some infectious conditions, including the class of coronaviruses that include SARS, MERS, and COVID-19.  Active infection is a challenge not only for older adults with infectious diseases, but also for health care providers[2]. It is therefore essential for clinicians, such as physiotherapists who manage older adults in different settings, to identify challenges in the control of infection in older adults and measures to stop the spread of infection.

Infection Control Challenges in Older Adults

This section will focus on issues related to infection control in older adults, taking into account physiological changes and health care settings.

Physiological Changes

Immunosenescence describes an age-related poor immune function that predisposes older adults to infectious diseases[3]. This was attributed to a functional decline in the innate and adaptive immune system due to ageing. One physiological change in innate immunity due to ageing is the upregulation of a number of pro-inflammatory cytokines, such as IL-6, C-reactive protein, and others[3]. Such a chronic pro-inflammatory state can lead to anorexia, nutritional impairment, muscle weakness, and weight loss, all of which can contribute to infections in older adults[4]. In addition to ageing immunosensitivity, many organs in the body undergo physiological changes that can predispose older adults to infection. Thus, any of the above symptoms may necessitate the need to suspect infection in older adults.

Health Care Settings

Due to the unique needs of older adults, there are a variety of settings in which they may reside or seek care. Among common places of residence are family homes, senior apartments, older adult day care centers, long-term care facilities, acute care, rehabilitation centers and home care. Some of these selected settings will therefore be discussed with respect to infection control and challenges in older adults.

Acute Care Centers

Older adults often reside in acute care centers due to the presence of comorbidities. Infection control challenges at this center include poor assessment of the infection status of older adults by physician prior to transfer to acute centers and poor record of comorbidity and drug resistance pathogens. Another challenge is the atypical clinical findings of infection among this population. For instance, an older adult with pneumonia may be more likely to present with confusion and functional deterioration than shortness of breath or new cough, and that may result in delayed diagnosis, resulting in inappropriate intervention and ultimately a delay in effective interventions[5].

Nursing Homes

Residents of nursing homes are susceptible to infectious diseases due to the following factors: host factors, structural concerns and process factors[5][6]. Host factors that make older adults susceptible to infectious diseases include immunosensecence, multi-morbid conditions, impaired mental status, and incontinence. Also, some older adults may serve as hosts for antimicrobial-resistant pathogens. Structural control is the ability of the facility to have sufficient resources to manage the infection in the nursing home. This involves preparing and implementing programs to monitor infections at nursing homes. Process factors include a nursing home's ability to deliver effective health care delivery services. It includes having highly-educated personnel with knowledge of controlling infections among older adults. Process factors also include good diagnostic tools and effective infection monitors. In the case of affected older adults, unavailability of this equipment or problems in any of the above factors may result in delayed intervention or mismanagement of infection.

Home Healthcare and Rehabilitation Services

Home health services are becoming increasingly utilized for older adults, as they require a longer period of medical attention in the home setting. Atypical clinical presentation that may mask the presence of infection in this population present challenges to controlling infection in older adults. This may further delay intervention in the affected individual as is deemed necessary. In rehabilitation services, older adults receiving treatment for hydrotherapy and functional rehabilitation should be considered for proper screening of infections because they may be asymptomatic[5].


Recommendations

Control of infections in older adults is particularly challenging for clinicians and healthcare systems. Clinicians need to consider the multi-modal aspects of infection risk factors in older adults when conducting general assessments in order to prevent and reduce the spread of infection. Also, during this pandemic of COVID-19, older people need to be familiar with the prevention of infection in order to prevent the contraction and spread of covid-19 (see video below)

References

  1. 1.0 1.1 Mouton CP, Bazaldua OV, Pierce B, Espino DV. Common infections in older adults. American family physician. 2001 Jan 15;63(2):257.
  2. El Chakhtoura NG, Bonomo RA, Jump RL. Influence of aging and environment on presentation of infection in older adults. Infectious Disease Clinics. 2017 Dec 1;31(4):593-608.
  3. 3.0 3.1 Goronzy JJ, Weyand CM. Understanding immunosenescence to improve responses to vaccines. Nature immunology. 2013 May;14(5):428.
  4. Franceschi C, Campisi J. Chronic inflammation (inflammaging) and its potential contribution to age-associated diseases. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences. 2014 Jun 1;69(Suppl_1):S4-9.
  5. 5.0 5.1 5.2 Mody L. Infection control issues in older adults. Clinics in geriatric medicine. 2007 Aug 1;23(3):499-514.
  6. High KP, Juthani-Mehta M, Quagliarello VJ. Infectious diseases in the nursing home setting: challenges and opportunities for clinical investigation. Clinical infectious diseases. 2010 Oct 15;51(8):931-6.