Review
Ageing and infection

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Summary

Average life expectancy throughout developed countries has rapidly increased during the latter half of the 20th century and geriatric infectious diseases have become an increasingly important issue. Infections in the elderly are not only more frequent and more severe, but they also have distinct features with respect to clinical presentation, laboratory results, microbial epidemiology, treatment, and infection control. Reasons for increased susceptibility include epidemiological elements, immunosenescence, and malnutrition, as well as a large number of age-associated physiological and anatomical alterations. Moreover, ageing may be the cause of infection but infection can also be the cause of ageing. Mechanisms may include enhanced inflammation, pathogen-dependent tissue destruction, or accelerated cellular ageing through increased turnover. In most instances, treatment of infection leads to a satisfactory outcome in the elderly. However, in palliative care situations and in patients with terminal dementia, the decision whether or not to treat an infectious disease is becoming a difficult ethical issue.

Section snippets

Prevalence of infections in the elderly

Certain infections are more prevalent in the elderly than in younger adults. This increased prevalence ranges from three-fold for community-acquired pneumonia to 20-fold for urinary-tract infection.5, 6, 7, 8, 9, 10, 11 The most commonly encountered infections are due to pyogenic bacteria, in particular urinary-tract infection, pneumonia, diverticulitis, endocarditis, bacteraemia, and skin and soft tissue infection (especially diabetic foot infection).1 The frequency of nosocomial bacterial

Infection as a cause of ageing

Ageing is not only a major risk factor for infection, but infection may also contribute to the ageing process. We suggest three possible models to explain this hypothesis. First, in the simplest model, direct tissue destruction by a pathogen may participate in the ageing process. Second, there is possibly a trade-off between the capacity of our host defence system to kill microorganisms and the damage it causes to surrounding host tissue.102 Thus, the beneficial effects of inflammation devoted

Atherosclerosis

Atherosclerosis is a universal form of vascular ageing seen in both human beings and animals.103 However, while every individual will eventually develop atherosclerosis, the severity of the disease and the age of onset of clinical symptoms varies tremendously. Thus there are modifying factors, which might be genetic—eg, apoE4104—or biochemical—eg, LDL cholesterol.105 Recent progress in the understanding of atherosclerosis has clearly shown that it is an inflammatory disease: macrophages in the

Ethical aspects

Is pneumonia the old man's friend, as Sir William Osler suggested in 1899 in his third edition of the Principles and practice of medicine?4 In other words, is the treatment of infectious diseases in the geriatric setting an unnecessary prolongation of suffering? This question leads to the essence of palliative care and is therefore closely associated with, although not specific to, geriatrics. Indeed, a large part of our population over 75 years, does not suffer from a terminal disease and does

Conclusions

Infections may participate in ageing throughout life and certainly participate towards the end of life. Infectious disease specialists will be increasingly confronted in the next few decades with the problems and issues of a fast-growing elderly population. The specialty is broad and there is an urgent need to undertake research to elucidate the subtle mechanisms that lead to the increased susceptibility of infection. Clinical research is also needed in diagnostic procedures, treatments,

Search strategy and selection criteria

Data for this review were identified by a Medline search of articles published in English or French since 1981 in the field of geriatric and infectious diseases. Inclusion in the reference list depended on relevant original approaches for each major section of the review, particularities of infection in the elderly, mechanisms of susceptibility to infection, infection as cause of ageing, and ethical aspects. The two main search terms used were “elderly population” and “infection"; a subset of

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