Treating Infectious Disease in the Older Adult

Sir William Osler referred to pneumonia as “the old man’s friend,” correctly realizing that infection is a common cause of death in old age. Some hundred years later, even in this age of potent antimicrobial agents, Osler’s assessment still holds true. Disease frequently presents in an atypical manner in old age, and often fever in bacterial infections is a late manifestation, following delirium, falls, or “taking to bed.” Delay in treatment may result in poor outcomes but, on the other hand, overtreatment may be likely to harm an older person. One of the most difficult environments in which to accurately diagnose infection is the long-term care (LTC) facility. The residents tend to be more frail and more likely to be cognitively impaired than community-dwelling patients coming to their family doctor’s office; therefore, the utility of the history is much decreased. As well, the vast array of diagnostic tools available in the acute hospital is relatively inaccessible in LTC, and the transfer to acute care from LTC often results in deleterious consequences to the patient.

Our focus in this issue is infectious disease in the older adult, and our CME article addresses a major public health concern: “Long-term Care for Older Adults: Reservoirs of Methicillin-Resistant Staphylococcus Aureus and Vancomyin-Resistant Enterococci” by Drs. D.F. Gilpin, M.M. Tunney, N. Baldwin, and C.M. Hughes. We all know that we should not treat asymptomatic bacteriuria, but most of us are unsure whether our patients are truly asymptomatic or not. The article “Asymptomatic Bacteriuria: To Treat or Not to Treat” by Dr. Dimitri M. Drekonja will address this clinical conundrum. I still remember treating my first case of severe antibiotic-induced colitis as an intern. It was in the wife of my physician-in-chief and occurred two months before clindamycin-associated pseudomembranous colitis was first described in a classic article in the Annals of Internal Medicine. Since then, C. difficile infection has become a major problem in older patients, particularly for those in acute hospital or LTC. This important topic is addressed in the article “Treatment and Prevention of Clostridium difficile Infection in the Long-Term Care Setting” by Dr. Natasha Bagdasarian and Dr. Preeti N. Malani.

Further, we offer our usual collection of important and informative articles on medical care of older people. In geriatric medicine, it has been frequently noted that the risk factors for each of the “geriatric giants” overlap to a great degree. In our Cardiovascular column, our frequent and much valued contributor, Dr. Wilbert S. Aronow, asks the question “Bone Mineral Density: What Is Its Relationship to Heart Disease?” Our Dementia column reviews the difficult area of screening in the article “Screening for Dementia: First Signs and Symptoms Reported by Family Caregivers” by Dr. Mary Corcoran. There is more evidence arriving on a regular basis to show how important our teeth are for both quality of life and for good health, so it is very appropriate that our Biology of Aging column by Dr. Gregory An discusses “Normal Aging of Teeth.” Our Falls and Fitness column, “Psychoactive Medications and Falls” is written by Dr. James Cooper and Dr. Allison Burfield. Our featured geriatrician this month is Dr. Angela Juby, the president of the Canadian Geriatrics Society.

Enjoy this issue,
Barry Goldlist