This assignment will be an analysis on the underlying pathophysiology of Community Acquired Pneumonia (CAP) in older adults (aged 65 or older), and the impact this has on homeostasis.
Psychosocial interventions will be discussed, relating to the risk factor of Smoking, and the role in which the National Health Service (NHS) play in educating, empowering and supporting patients with this addiction and disease.
Pharmacological aspects will also be discussed in relation to pneumonia as a healthcare intervention. The respiratory system will also be looked at, in order to gain an in depth understanding of CAP and homeostasis.
NICE (2014) states that each year between 0.5% and 1% of adults in the United Kingdom (UK) will have CAP. Interventions need to be in place for pneumonia, as 1.4 million die each year as a result (World Health Organization 2015), putting a great strain on healthcare systems around the world (Driver 2012). CAP is defined by Driver (2013) as pneumonia that has not been acquired in a hospital, a long term care facility or from any other recent contact with the health care system.
Pneumonia is simply defined as ‘an acute infection of the alveoli’ (Waugh, 2010). Alveoli are small sacs that make up the lungs, and when a person has pneumonia these are filled with fluid, inflammatory cells and microorganisms. (National Institute of Care Excellence (NICE) 2014). When certain microbes enter the lungs of a susceptible host, they release toxins which cause the inflammation and immune responses to be stimulated. The toxins and immune response then damage the alveoli, causing it to fill with fluid and debris. When this happens, breathing is interfered with (Dickinson and Tortora 2015).
Pneumonia is a serious problem with older adults, as there is a progressive decline in the bodies ability to restore homeostasis with age, making this age group more vulnerable to disease. With ageing, the airways and tissues of the respiratory tract become less elastic and the chest wall becomes more rigid, leading to a decreased lung capacity (Derrickson & Tortora 2015). With increasing age, the cough reflex also becomes impaired, making it difficult to remove foreign bodies and making the person vulnerable to infection (Perry 2013). Due to these factors, vital capacity can be reduced up to 35% by the age of 70, meaning the elderly are much more susceptible to diseases such as pneumonia (Derrickson & Tortora 2015).
In the body, many processes occur to maintain balance, known as equilibrium. The body is constantly monitoring parameters to ensure optimal functioning. If a function falls out of its range, it will not be able to work as efficiently. The act in which the body constantly adjusts and corrects parameters in the body to gain equilibrium is called homeostasis (Henry et al, 2012).
When pneumonia is present, the respiratory system is unable to work as well, meaning the PH of bodily fluids and the level of Carbon Dioxide and Oxygen would not be equal to equilibrium (Dickinson & Tortora 2015). When these physiological variables are not kept within there limits there is a serious risk of health to the individual and can result in mortality (Grant and Waugh 2014).
Control systems maintain homeostasis by detecting and responding to changes in the bodies internal environment. The control system is made up of three parts; a control center which sets limits for the physiological variables, a detector which notices the imbalance and sends an input, and an effector which receives an output after it has been changed by the responding control center. This process is constantly readjusting to maintain equilibrium, and is controlled by a feedback mechanism. To maintain homeostasis in the body there are positive and negative feedback mechanisms, however it is very few variables that require a positive feedback mechanism, and for respiratory homeostasis negative feedback is used. (Grant and Waugh 2014).
DESCRIBE NEGATIVE FEEDBACK
When Pneumonia is present, gas exchange is interfered with due to the infection in the alveoli (Driver 2012), therefore more oxygen needs to be provided to the alveoli for optimal function (Grant and Waugh 2014). Those with pneumonia may present with tachycardia, which is a response from a negative feedback system to maintain homeostasis due to falling oxygen levels and increased carbon dioxide in the body (Dolensek, Runovc and Kordas 2005).
The respiratory system provides oxygen to the body and removes carbon dioxide, as well as helping adjust the PH of body fluids through exhalation of carbon dioxide (Dickinson and Tortora 2015). The exchange of gases between body cells and the environment is called respiration, and to do this the processes of pulmonary ventilation needs to take place.
The process of breathing happens by a combination of body mechanics, accompanied with ventilation (Driver 2012). Breathing can be broken down into two sections, inspiration and expiration. During inspiration, the intercostal muscles and diaphragm must contract simultaneously so that the lungs expand. When this happens, the ventilation in the alveoli drops allowing air to be drawn in (Grant and Waugh 2014).
COMPLETE THIS
The elderly may present signs and symptoms of pneumonia slightly different to any other generation. Due to a weaker cough reflex they may present a relatively mild cough without the presence of sputum (Perry 2013), or no cough at all within an early stage of the disease. As the elderly may be more apparent to chronic illnesses, these might look like they are worsening and the individual might present to be much more lethargic than usual. Other symptoms include loss of appetite, weight loss and a frequent fall which can lead to confusion and disorientation (Driver 2012).
In older Adults, clinical judgment is essential to assess the severity of a disease (British Thoracic Society 2009), however a severity assessment tool can be used in conjunction with this called ‘CRB65’, used when a diagnosis is made in primary care (NICE 2014). The CRB65 works by the individual being scored 1 point per prognostic feature displayed. The features are confusion, a respiratory rate of 30 breaths or more, a blood pressure that is less that 90/60mmHg and aged 65 or over. A score of zero equates to zero is low risk and home based care is recommended, a score of one or two is an intermediate risk and hospital assessment is to be considered, and a score of three of four is high risk which requires urgent hospital admission (NICE 2014).
It is important as a Nurse to be able to identify psychosocial risk factors which could lead to developing disease, in order to promote wellbeing and prevent ill health, making sure peoples physical, social and psychological needs are adhered to (Nursing & Midwifery Council; NMC 2015). 11% of those aged 60 or over are cigarette smokers (Health and Social Care Information Centre 2016), and in the UK is the leading cause of preventable death (Public Health England 2016).
According to the World Health Organization (2017) the chance of quitting cigarette smoking is increased by 84% after being intensively advised by a qualified physician. Kerr at al. (2006) suggests that Health Care Professionals must have an understanding of an individuals smoking related health beliefs, in order to give them person centered care with regards to health advice.
The Compensatory Health Beliefs (CHB) Model is based on the theory of individuals trying to reach a balance in maximizing pleasure and minimizing harm through various cognitive strategies (Rabia, Kanauper and Miquelon 2006). The temptation to indulge in an activity such as smoking, comes from cravings, anticipated pleasure and desire. The resistance to smoking comes from cognitive reasoning, related to the health disadvantages.
Within the CHB model, this thinking process creates a motivational conflict. When the temptations override the reasoning’s, a person has the ability to believe the behavior is no longer harmful, or they are no longer concerned regarding the health effects of the activity (Rabia, Kanauper and Miquelon 2006).
The CHB model also looks at how people define information as a ‘belief’ in order to make their choice to smoke, favour their desires through the activity. Balbach, Smith and Malone (2006) relate this to the older generation, with the argument that although adults make a choice to smoke, the cigarette industry did not make health information as easily accessible when they made that choice, without the knowledge of how powerfully addictive nicotine is.
In 1950, five studies where released linking tobacco smoking to lung cancer, in 1964 this was made more widely available to the public through the endorsement of the government, and in 1966 health warnings where mandatory on cigarette packaging (de Walque, 2010 and Berridge and Loughlin, 2011). For older adults, a lack of education and social encouragement through both social groups and the media, will have been a great influence on their choice to smoke (Waldron, 2008).
When cigarette smoke is breathed in, it passes through unburned tobacco which causes nicotine and over 6000 different components to evaporate. When these components have cooled down, the particles absorb rapidly into the systemic blood (Arnson, Shoenfield and Amital 2010). Some of these components prevent the movement of the cillia, which are hair like structures extended from the surfaces of cells in the respiratory tract, which help keep foreign bodies away from the lungs. Due to this reduced immunity, and the reduced cough reflex in older adults, smokers are more prone to respiratory infections (Dickinson and Tortora 2015).
Microphages are cells which make up the main cell population of the lungs; these have phagocytic properties and have antigen functions, therefore are the first line of defense against pollutants (Arnson, Shoenfield and Amital 2010). Tobacco smoking is known to decrease macrophage activity and impair phagocytosis in the alveoli, which play a huge part in immunity and inflammation response (Grant and Waugh 2014).
The Tobacco Free Initiative (2017) by the World Health Organization is a campaign to reduce the global burden of disease and death caused by tobacco worldwide, by encouraging governments to make effective tobacco control plans and constantly improve these to ensure that are being implemented effectively.
Smoking Cessation is defined as ‘the process of discontinuing tobacco smoking’ (NICE 2013). Stop smoking services have been nationally available since the year 2000, and so far have helped over 1 million people quit the habit (Public Health England 2017). It is estimated that the financial burden to society from treating smoke related illnesses is £13.74 billion per year (NICE 2013), therefore smoking Cessation is something all healthcare professionals should actively promote and educate through their work.
The chance of being diagnosed with CAP can triple or quadruple when age is over 65 years, and one of the best ways to prevent this, is to stop smoking. Evidence shows that after 5 years of being smoke free, the risk of being diagnosed with CAP reduces by 50% (Almirall, Blanquer and Bello 2014).
One intervention provided through the NHS is the supported use of pharmacotherapy. This is the use of medicine chosen by the smoker and commissioned through GP prescriptions, which can easily be started from one appointment with a smoking cessation practitioner, continued with a follow up appointment (NICE 2013).
Varenicline is one of the prescribed recommended medicines for smoking cessation, which is known to be the most effective stop smoking medication (Mospan 2016 and NHS 2016). To receive Varenicline, smokers must set an exact stop date prior to starting their treatment (NICE 2013). This is due to the way the medication is given; Varenicline is an oral drug given at an initial dose of 500mcg once daily for three days, followed by the same dose twice daily for four days and then if this is tolerated up to 1mg twice daily for a maximum of 11 weeks. The treatment is recommended to start 1-2 weeks before the start date (BNF 2017).
Another pharmacotherapy treatment the NHS offers is Burpropion hydrochloride. This is very similar to Varenicline in its guidelines but they cannot be used in conjunction with one another. The dose is initially given at 150mg daily and after 6 days is given twice daily. Again it is recommended to start 1-2 weeks before the stop date, but should be discontinued after 7 weeks if smoking cessation is not achieved (BNF 2017).
Both medications alleviate the symptoms of withdrawal and craving by binding to the neuronal nicotinic acetylcholine receptor (NICE 2013).
DISCUSS BOTH MEDICATIONS
DISCUSS TALK THERAPY
Health Practitioners usually treat patients with CAP with antibiotics at home, following antibiotic guidance from Public Health England (2017) relating to the CRB65 score. Although guidance is provided with the best available evidence, it is important for health professionals to make a holistic, professional judgment and where possible involve the patient in the management and treatment of their illness (Public Health England 2017).
Guidelines from Public Health England (2017) state that antibiotics should only be given to a patient when there is no other alternative treatment that is likely to have a clear clinical benefit. This is due to the global threat of antimicrobial resistance (Frieri, Kumar and Boutin 2017), defined by the World Health Organization (2016) as the change of microorganisms when exposed to antimicrobial drugs, developing resistance. This then results in medicines such as antibiotics becoming ineffective, threatening the ability to treat common infectious diseases resulting in a spread of illness and consequently death.
If a patient is diagnosed with CAP with a CRB65 score of 0, Amoxicillin is recommended orally at 500mg three times daily for five days with a review at 3 days. If there is no improvement in the patient condition this can be continued for 7-10 days (Public Health England 2017).
Amoxicillin is a type of penicillin which fight illness by being bactericidal. This means the drug kills the bacteria by interfering with bacterial cell wall synthesis. Penicillin medication have quick acting effect diffusing well into the bodies fluids and tissues, and are excreted through the kidneys into urine. Due to this, if severe renal impairment is present a lower dose may need to be given due to difficulties in excreting the drug (NICE 2017).
Penicillin has generic side effects such as diarrhea, fever, joint pains and anaphylaxis and angioedema, however the specific ones listed for Amoxicillin include nausea, vomiting and a rash (BNF 2017).
As older adults are at a much higher risk of gaining community acquired pneumonia, it is recommended that adults age 65 and over are offered the pneumococcal vaccine per government policy issued by Public Health England (2017). Pneumococcal disease is a term used to define illness and disease caused by a common bacterium ‘Streptococcus Pneumoniae’ (Public Health England, 2017). Steptococcus Pneumoniae is the most common type of bacterial pneumonia, easily transmitted to a susceptible host via airborne droplets especially in older adults with a lower immune system (Driver, 2012).
The vaccine is administered in one single dose in the upper arm for those in the at risk age group of over 65 years (NICE, 2017). The World Health Organization (2012) states that the vaccine should be used along side other pneumonia control measures such as appropriate diagnosis and case management and the reduction of risk factors such as smoking. Although there is significant evidence that the vaccination reduces invasive pneumococcal diseases in older adults, there is still evidence lacking establishing prevention of Community acquired Pneumonia in those 65 and older (Esposito and Principi, 2015). Furthermore, it is important for health promotion that these are offered to the high risks group routinely and are easily accessible (Campus-Outcalt, 2014). As previously discussed, antimicrobial resistance is an on going problem for health care systems world wide, therefore vaccines play an important role in confronting this problem. By using vaccines as a preventative for disease, the need for antibiotics will be reduce, slowing down the ability for microorganisms to resist antimicrobials (Lipsitch and Siber, 2016).