• palliative care
• geriatric medicine
• pneumonia
• Osler

The use of the term ‘old man’s friend’ when referring to pneumonia is attributed to William Osler, who in the first edition of his book The Principles and Practice of Medicine (1892)1 wrote,

In children and in healthy adults the outlook is good. In the debilitated, in drunkards and in the aged the chances are against recovery. So fatal is it in the latter class [i.e. the elderly] that it has been termed the natural end of the old man.1

This was later rephrased in the ninth edition, after Osler himself died from pneumonia in 1919 at the age of 70 years, as ‘… one may say that to die of pneumonia is almost the natural end of old people’.2 Fortunately, a lot changed for the better in the century that followed, but pneumonia is still an important cause of mortality.

Respiratory infections are by far one of the main diagnoses in the internment of the internal medicine being universally recognised as an important cause of mortality and morbidity, especially in elderly patients.

During the period of my internship in the service of the Intern Medicine (January 1, 2017 to June 30, 2018), 206 patients were cared for by the team, of which I was part. 99 of those patients had the main diagnosis of the lower respiratory tract infection (pneumonia or tracheobronchitis).

By examining this group of patients more carefully, we observed the average age was 83.8 years, the average period of internment by these pathologies was 21.8 days and that 25% of them showed dementia as a secondary diagnosis. A significant percentage were institutionalised (34%), and 30.2% of the patients who were discharged with respiratory infection diagnosis died in the following 6 months.

These numbers show the great fragility of our patients and the relevance of the discussion of the use of antibiotics on patients with advanced dementia. Not being in direct comparison with the described results, since not all patients had advanced dementia, some studies show that 50% of the patients with severe dementia and diagnosed with pneumonia die within the next 6 months.3 4 According to the CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-life) study, patients with advanced dementia and pneumonia who were treated with antibiotics lived on average 273 days longer but were associated with a higher level of discomfort (low scores on the scale Symptom Management at the End-of-Life in Dementia).5 The mortality rate was similar regardless of the route of administration of the antibiotic (oral, intramuscular, or intravenous). We also know the isolated use of antibiotics to palliate the symptoms is not superior to optimal medical therapy.4

With this data, one cannot plead ‘always’ or ’never’ regarding the use of antibiotics for patients with advanced dementia. It will always be necessary to weigh the benefits and harms, to consider the recurrent nature of infections and the irreversibility of the predisposing factors, and the absence of significant improvements to the patient’s comfort.