Recurrent Hospitalisation with Pneumonia is Associated with Higher 1-year Mortality in Frail Older People

Background: Previous studies persistently showed that functional dependence was associated with higher long-term (≥1 year) mortality of older patients hospitalised with community-acquired pneumonia (CAP). The importance of other factors was, however, not well reported.

Aim: This study aimed to investigate the relative contributions of comorbidity, nutritional status and frailty to 1-year mortality.

Methods: We prospectively recruited older patients, aged ≥65 years, hospitalised with CAP from October 2009 to September 2010 at the Prince of Wales Hospital, Hong Kong. Demographics, Charlson's Comorbidity Index, mid-arm circumference (MAC) and Clinical Frailty Scale (CFS) were recorded as baseline characteristics. The severity of pneumonia was evaluated by the CURB score (confusion, blood urea nitrogen, respiratory rate and low blood pressure). The surviving patients were followed for 1 year since discharge to monitor readmission for CAP and all-cause mortality. We entered the following variables into the multivariate Cox regression model to identify independent predictors of 1-year all-cause mortality: age, sex, residential status, MAC, Charlson's Comorbidity Index, CFS and readmission for CAP.

Results: The final cohort consisted of 428 patients who were discharged from hospital. Within 1 year after hospital discharge, all-cause mortality and readmission for CAP were 22.4% and 32.0% respectively. Independent predictors of 1-year mortality were male sex (hazard ratio (HR) = 1.57, 95% confidence interval (CI) = 1.02-2.48), severe under-nutrition (MAC ≤21 cm) (HR = 3.75, 95% CI = 1.66-8.46), frailty (CFS ≥5) (HR = 2.36, 95% CI = 1.29-4.27) and readmission for CAP (HR = 4.50, 95% CI = 2.82-7.17).

Conclusions: Recurrent pneumonia may be a terminal life event of frail older people so that advance care planning should be considered in those with recurrent admission for pneumonia.