Penuaan (aging) dikaitkan dengan sejumlah besar perubahan fungsi imunitas tubuh, Kemampuan imunitas kelompok lanjut usia menurun sesuai penambahanusia termasuk kecepatan respons imun melawan infeksi penyakit. Hal itu berarti bahwa kelompok lansia beresiko tinggi terserang penyakit seperti infeksi, kanker, jantung koroner, kelainan autoimmun atau penyakit kronik lainnya. penyakit ini Orang-orang tua yang umumnya menderita kekurangan gizi makro dan mikro akan memiliki respons sistem dan fungsi imun yang rendah. Oleh karena itu, kasus malnutrisi pada lansia seharusnya memiliki perhatian khusus secara dini, termasuk pemberian vaksinasiuntuk pencegahan penyakit. Penyakit infeksi yang dialami oleh lansia dapat dicegah atau diturunkan melalui upayaupayaperbaikan gizi karena sistem imun akan meningkat. Jika fungsi imun lansia dapat ditingkatkan, maka kualitashidup individu meningkat dan biaya pelayanan kesehatan dapat ditekan.

Sistem imunitas tubuh memiliki fungsi yaitu membantuperbaikan DNA manusia; mencegah infeksi yangdisebabkan oleh jamur, bakteri, virus, dan organismelain; serta menghasilkan antibodi (sejenis protein yangdisebut imunoglobulin) untuk memerangi seranganbakteri dan virus ke dalam tubuh. Tugas sistemimun adalah mencari dan merusak invader (penyerbu)yang membahayakan tubuh manusia.Fungsi sistem imunitas tubuh (immunocompetence)menurun sesuai umur. Kemampuan imunitas tubuhmelawan infeksi menurun termasuk kecepatan responsimun dengan peningkatan usia. Hal ini bukan berartimanusia lebih sering terserang penyakit, tetapi saatmenginjak usia tua maka resiko kesakitan meningkatseperti penyakit infeksi, kanker, kelainan autoimun,atau penyakit kronik. Hal ini disebabkan olehperjalanan alamiah penyakit yang berkembang secaralambat dan gejala-gejalanya tidak terlihat sampaibeberapa tahun kemudian. Di samping itu, produksiimunoglobulin yang dihasilkan oleh tubuh orang tuajuga berkurang jumlahnya sehingga vaksinasi yangdiberikan pada kelompok lansia kurang efektifmelawan penyakit. Masalah lain yang muncul adalahtubuh orang tua kehilangan kemampuan untukmembedakan benda asing yang masuk ke dalam tubuhatau memang benda itu bagian dari dalam tubuhnyasendiri.Salah satu perubahan besar yang terjadi seiringpertambahan usia adalah proses thymic involution 3.Thymus yang terletak di atas jantung di belakang tulangdada adalah organ tempat sel T menjadi matang. Sel Tsangat penting sebagai limfosit untuk membunuhbakteri dan membantu tipe sel lain dalam sistem imun.Seiring perjalanan usia, maka banyak sel T ataulimfosit T kehilangan fungsi dan kemampuannyamelawan penyakit. Volume jaringan timus kurang dari5% daripada saat lahir. Saat itu tubuh mengandungjumlah sel T yang lebih rendah dibandingkansebelumnya (saat usia muda), dan juga tubuh kurangmampu mengontrol penyakit dibandingkan denganmasa-masa sebelumnya. Salah satu komponen utama sistem kekebalan tubuhadalah sel T, suatu bentuk sel darah putih (limfosit)yang berfungsi mencari jenis penyakit pathogen lalumerusaknya. Limfosit dihasilkan oleh kelenjar limfeyang penting bagi tubuh untuk menghasilkan antibodimelawan infeksi. Secara umum, limfosit tidak berubahbanyak pada usia tua, tetapi konfigurasi limfosit danreaksinya melawan infeksi berkurang. Manusia

memiliki jumlah T sel yang banyak dalam tubuhnya,namun seiring peningkatan usia maka jumlahnya akanberkurang yang ditunjukkan dengan rentannya tubuhterhadap serangan penyakit.Kelompok lansia kurang mampu menghasilkan limfosituntuk sistem imun. Sel perlawanan infeksi yangdihasilkan kurang cepat bereaksi dan kurang efektifdaripada sel yang ditemukan pada kelompok dewasamuda. Ketika antibodi dihasilkan, durasi responskelompok lansia lebih singkat dan lebih sedikit selyang dihasilkan. Sistem imun kelompok dewasa mudatermasuk limfosit dan sel lain bereaksi lebih kuat dancepat terhadap infeksi daripada kelompok dewasa tua.Hilangnya efektivitas sistem imun pada orang tua biasanya disebabkan olehperubahan kompartemen sel T yang terjadi sebagaihasil involusi timus untuk menghasilkan interleukin 10(IL-10). Pada orang tua, perasaan depresi dan marah dapatmelemahkan sistem imun. Mereka rentan terhadapstress dan depresi. Stress menyebabkan perubahanperubahanfisiologis tubuh yang melemahkan sistemimun, dan akhirnya mempengaruhi kesehatan sehinggamudah terserang penyakit, serta timbulnya kelainansistem imun dengan munculnya psoriasis dan eczema.Saat terjadi stress, maka hormon glukokortikoid dankortisol memicu reaksi anti-inflammatory dalam sistemimun.

Peneliti telah mempelajari hubungan antara marah,perasaan depressi, Gangguan tidur pada orang tua dapat melemahkansistem imun karena darah mengandung penurunanNKC (Natural Killer Sel). NKC adalah bagian darisistem imun tubuh, jika kadarnya menurun dapatmelemahkan imunitas sehingga rentan terhadappenyakit. Studi yang dilakukan di Pittsburgh tahun1998 menunjukkan pentingnya tidur bagi orang tuauntuk memelihara kesehatan tubuh 7.

It is important to remember that pneumonia in the elderlymay present with few respiratory symptoms and signs (datagiven below) and instead may be manifest as delirium, wors-ening of chronic confusion, and falls. Delirium or acute confusionwas found in 45 [44.5%] of 101 elderly patients withpneumonia studied by Riqueleme et al. [6], compared with 29(28.7%) of 101 age- and sex-matched control subjects. Falls areusually an indication that the person is ill. Among the healthyelderly, rough or slippery ground accounted for 54% of falls,but in the sick elderly this factor accounted for only 14% offalls [7]. Dizziness, syncope, cardiac and neurological disease,poor health status, and functional disability are more likely toaccount for falls among the sick elderly [7]

s

Pneumonia in the elderly is a common and serious problem with a clinical presentationthat can differ from that in younger patients. Older patients with pneumonia complain ofsignificantly fewer symptoms than do younger patients, and delirium commonly occurs. Indeed,delirium may be the only manifestation of pneumonia in this group of patients. Alcoholism,asthma, immunosuppression, and age 170 years are risk factors for communityacquired

pneumonia in the elderly. Among nursing home residents, the following are riskfactors for pneumonia: advanced age, male sex, difficulty in swallowing, inability to take oralmedications, profound disability, bedridden state, and urinary incontinence. Streptococcuspneumoniae is the most common cause of pneumonia among the elderly. Aspiration pneumoniais underdiagnosed in this group of patients, and tuberculosis always should be considered.In this population an etiologic diagnosis is rarely available when antimicrobial therapy mustbe instituted. Use of the guidelines for treatment of pneumonia issued by the InfectiousDiseases Society of America, with modification for treatment in the nursing home setting, isrecommended.

Definition. It is important to remember that pneumonia in the elderlymay present with few respiratory symptoms and signs (datagiven below) and instead may be manifest as delirium, worsening of chronic confusion, and falls. Delirium or acute confusionwas found in 45 [44.5%] of 101 elderly patients withpneumonia studied by Riqueleme et al. [6], compared with 29(28.7%) of 101 age- and sex-matched control subjects. Falls areusually an indication that the person is ill. Among the healthyelderly, rough or slippery ground accounted for 54% of falls,but in the sick elderly this factor accounted for only 14% offalls [7]. Dizziness, syncope, cardiac and neurological disease,poor health status, and functional disability are more likely toaccount for falls among the sick elderly

definisi

pneumonia pada orang tua memililiki beberapa gejala klinis yang berbeda dibandingkan pada usia muda

berikut ini beberapa gejala pneuomina dan persenrtasi kasusnya by Riqueleme et al

delirium 44,5% daro 101 responden

pneumonia pada usia lanjut biasanya 20 % dari mereka tidak disertai dengan batuk yang produktif dan perasaan dingin. Hal ini sesuai dengan gejala klinis pasien dimana batuk pasien tidak produktif. Pada pemeriksaan fisik tanda klasik seperti perkusi yang redup, suara napas bronchial, ronki basah tidak selalu dijumpai. Frekuensi pernapasan 24 kali per menit cukup bermakna pada penderita pneumonia usia lanjut. Pneumonia usia lanjut dapat bersama sama syok septik yang memberi gejala letargi, anoreksi, dan perubahan mental. Pada sebagian besar penderita didapatkan leukosit yang normal atau sedikit meninggi, kadang-kadang didapatkan leukositosis. Dapat terjadi peningkatan ureum, kreatinin dan glukosa, terdapat juga hiponatremi atau hipernatremi, hipofosfatemi; dapat terjadi hipoksemi yang disebabkan infeksi akut dan dapat disertai payah jantung, PPOK atau keduanya. Pada pneumonia usia lanjut diagnosis radiologik ditegakkan bila didapatkan gambaran infiltrat baru. Tetapi kadang-kadang sulit menilai gambaran radiologik terutama jika didapatkan keadaan dehidrasi. Sering kali infiltrat belum terlihat pada 24-48 jam setelah perawatan . Gambaran radiologi kadang-kadang masih tampak normal pada pneumonia dini, pneumonia oleh bakteri gram negatif dan tuberkulosis endobronkial. Pada pneumonia usia anjut sering didapatkan penyakit penyerta seperti PPOK, gagal jantung dan sindrom gawat napas pada dewasa; pada keadaan ini gambaran radiologi sangat sukar dinilai.

Namun, pada lansia, tidak jarang gejala tersebut tidak muncul sama sekali, dan penderita hanya merasa lemas dan cepat letih. Hilangnya berbagai gejala tersebut, tak lain karena daya tahan dan kemampuan melawan serangan kuman pada lansia sudah jauh menurun dibandingkan dengan orang dewasa yang lebih muda. Respons perlawanan tubuh terhadap serangan kuman, yaitu misalnya demam dan batuk sudah tidak berjalan secara optimal. Selain itu, lemahnya daya tahan tubuh juga menyebabkan kuman penyebab peradangan bisa bermacam-macam.

Dalam perburukan penyakitnya, penderita lanjut usia juga berbeda dengan kelompok usia lain. Perburukan penyakit dapat terjadi begitu cepat. Berbagai gangguan metabolisme dan keseimbangan Elektrolit mudah sekali terjadi. Gangguan pasokan udara juga terjadi secara cepat sehingga pasien mengalami kekurangan oksigen dan kegagalan bernapas. Selain karena daya tahan sudah menurun ini, ternyata hal ini biasanya diperparah penyakit lain yang juga menjadi �langganan� para lanjut usia, seperti misalnya penyakit jantung dan penyakit paru-paru kronik lainnya.

Physical examination of the chest reveals adventitious soundsover the area of pneumonia. Loud, tubular breath soundssuggest copious secretions in the large bronchi, and are notdiagnostic of pneumonia per se, but may accompany pneumonia.Dullness at the bases may be reflective of carcinoma, CHF,pleural effusion due to carcinoma or an intra-abdominal process,or a bacterial pneumonia. Bilateral pleural effusions arerarely, if ever, due to an infectious etiology. Bilateral pleuraleffusions should suggest CHF as the most likely diagnosticpossibility. Legionnaires’ disease may also present with a unilateralpleural effusion. Among the bacterial pneumonias, mostfrequently H. influenzae presents with a mild to moderatepleural effusion. Pneumococcal pneumonia and klebsiellapneumonia more often present with empyema rather thanpleural effusion, but the clinical presentation, in terms ofauscultation of the chest, would be the same. Dullness mayalso be reflective of consolidation over the involved lobe of the_ 2001 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 7, 581–588

Cunha Pneumonia in the elderly 583lung. Consolidative pneumonias may occur with any of thepathogens and are not specific for any particular etiologic agent[1,2,8,12,19,27–29].The physical findings associated with influenza are minimal.Because influenza is an interstitial process, the auscultation ofthe chest is silent in primary influenza pneumonia. If rales areheard, especially if they are localised to one segment or lobe in apatient with viral pneumonia, then there is a superimposedbacterial pneumonia also present. In mycoplasma pneumonia,there is a discrepancy between the clinical findings, e.g. auscultatoryfindings, and the appearance on chest X-ray, whichmay be a clue to the diagnosis. C. pneumoniae pneumonia has nopathognomonic findings on physical examination, and resemblesmycoplasma pneumonia closely in clinical presentation,except for the added presence of laryngitis. Laryngitis may becaused by one of many respiratory viruses, but these viruses donot usually cause viral pneumonia in elderly adults. The associationof pneumonia and laryngitis should suggest C. pneumoniae

pneumonia until proven otherwise, since hoarseness is afeature with C. pneumoniae pneumonia but not M. pneumoniaepneumonia [1–4].

Epidemiologi

For centuries, pneumonia has often been the terminal infectiousdisease event in the elderly. Elderly patients are more predisposedto pneumonia because of their impaired gag reflex,decreased mucociliary function, waning immunity, impairedfebrile response, and various degrees of cardiopulmonary dysfunction.Central nervous system disorders and/or an impairedgag reflex predispose elderly patients to aspiration pneumonia.The distribution and extent of aspirated oropharyngeal contentsdetermine the radiologic appearance, clinical presentation andseverity of the pneumonia in elderly patients. Elderly patientsoften have some degree of cardiopulmonary disease that has,through one or more events during their lifetime, decreasedtheir heart and lung function. Fever resulting from pneumoniamay further burden an already compromised myocardium,resulting in congestive heart failure (CHF) and/or myocardialinfarction. Not uncommonly, patients presenting with CHFhave pneumonia-induced fever as the proximate cause of theircardiac decompensation. Patients with long smoking historiesmay have bronchogenic carcinoma, which may predispose topneumonia, depending upon extent and location. Postobstructivepneumonias due to bronchogenic carcinomas aremost common in the elderly. Patients with chronic bronchitisresulting from a lifetime of heavy smoking are also predisposedto pneumonia. Depending upon severity, chronic bronchiticshave degrees of lung damage which may be further exacerbatedby superimposed pneumonia. Such patients often have littlenormal lung reserve, and the added insult of bacterialpneumonia often presents as a severe pneumonia because ofpre-existing anatomic and functional decreases in pulmonaryfunction.The elderly also have many underlying systemic disordersthat may predispose to impaired splenic function. Humoralimmunity dependent upon intact B-lymphocyte function maybe decreased in the elderly. Older individuals may have a varietyof systemic disorders that impair splenic function with resultantloss of antibody production. Impaired B-lymphocyte functionpredisposes to infection with encapsulated pathogens that arecommon causes of bacterial pneumonia, i.e. Streptococcus pneumoniaeand Haemophilus influenzae. Infiltrative disorders of the

spleen, conditions that anatomically impinge on splenic bloodsupply and systemic conditions associated with impaired splenicfunction, e.g. cirrhosis and inflammatory bowel disease, aloneor in combination, may result in an age-dependent decrease inprotective antibody function. Bacteria are the commonestcauses of pneumonia in older individuals. The organismsaffecting the elderly are the same as in young adults, but witha different age-related distribution. Streptococcus pneumoniae isstill the most important pathogen in younger as well as olderadults. However, H. influenzae is relatively more common inelderly patients than in non-elderly adults. Moraxella catarrhalis isof particular importance as a cause of community-acquiredpneumonia (CAP) in patients with chronic bronchitis. Atypicalpathogens in the elderly are the same as in younger adults butwith a different age-dependent distribution. For example,Mycoplasma occurs in the elderly but is more common in youngadults. Conversely, legionnaires’ disease is more common inelderly adults than in younger adults. Chlamydia pneumoniaeoccurs in all age groups and in the nursing home setting, butprobably is most common in young adults. Rickettsial andparasitic pneumonias are relatively rare in immunocompetentelderly individuals. The most important viral cause of pneumoniain the elderly is influenza, which appears in the wintermonths and occurs in outbreaks, either in the community or inchronic-care facilities or hospitals [1–4].Pneumonias of the elderly may be classified according to howthe infection is acquired, i.e. hematogenously or by primaryinhalation. Aspiration is a variant of pneumonia acquired viainhalation. Urinary tract infections are not uncommon inelderly men and may result in urosepsis with secondary hematogenousspread to the lungs, resulting in pneumonia. Alternatively,pneumonia may be classified according to the patient’slocation when the pneumonia was acquired. Pneumoniasacquired from the community are termed community-acquiredpneumonia, those that are acquired in chronic care facilities ornursing homes are termed nursing home-acquired pneumonia(NHAP), and those that are contracted in the hospital are calledhospital-acquired pneumonia (HP). HP is synonymous withnosocomial pneumonia (NP), a term which is sometimes usedinterchangeably with ventilator-associated pneumonia. Clearly,ventilator-associated pneumonia differs fromNP or HP becausethe patient is intubated and on a respirator, but is otherwiseequivalent. Pneumonias may also be classified on the basis of thecausative organism. Since organisms pathophysiologicallyexpress themselves in a stereotypical fashion, an etiologicclassification of pneumonia correlates best with the patient’s

signs and symptoms. Pneumococcal pneumonia, whether communityacquired or nursing home acquired, presents in exactlythe same fashion regardless of location, since clinical manifestationsare determined by the microbe and not the location wherethe patient’s pneumonia was acquired. Similarly, pneumococcalpneumonia may manifest itself early during hospitalisation(_hospital day 5), but does not occur later in the hospitalcourse, i.e. after a week of hospitalisation. So-called NP due toStreptococcus pneumoniae presenting soon after hospitalisation, infact, represents CAP that has become manifest in the first fewdays after admission to the hospital. Streptococcus pneumoniaepneumonia in this setting presents in precisely the same manneras hospital-acquired pneumococcal pneumonia, since it is thesame clinical entity. Similarly, legionnaires’ disease, whetherpresenting as CAP, as NHAP, or in the nosocomial setting, isaccompanied by signs and symptoms referable to Legionella’scharacteristic pattern of extrapulmonary organ involvement[B.a Chunca

Pneumonia is a common and often seriousillness. It is the sixth leading cause of death in the United States.About 600,000 persons with pneumonia are hospitalized eachyear, and there are 64 million days of restricted activity due tothis illness [8, 9]. The caregiver burden associated with pneumoniahas not been measured, although we know that longtermcaregiving is associated with an increased mortality rateamong the caregivers [10]. The mortality rate among personsproviding long-term care and experiencing strain has been reportedto be 63% higher than among noncaregiving controlsubjects(pn 1].

Pneumonia sering menjadi momok pada usia lanjut, hal ini dikarenakan gangguan reflex muntah, penuruna fungis mucus silaris, imunitas yang menurun, gangguan respon demam, gangguan cardiopulmonary. Gangguan system saraf pusat dan refleks muntah pada usia lanjut sering menimbulkan pneumonia aspirasi.

Usia lanjut juga seirng mengalami gangguan sistemik, gangguan hormonal, dimana terjadi penurunan fungsi limfosit b akinat penuaan.

Pneumonia penyebab utama kematian keenam di amerika seikat, dan lebih dari 600 ribu orang dirawat Karena penyakit ini. (PN1)

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