If nothing else kills you, pneumonia will.

That is what I have heard.
Okay, the big 3 killers are 1) heart attack 2) cancer and 3) stroke.
Let’s suppose you live a very healthy life, no smoking, proper diet, lots of exercise, safe sex, wear your seat belt, etc. Having done that, you are lucky enough that the big 3 “killers” didn’t get to you.
I have heard if you could avoid all possible disease (and fatal accidents of course), and keep on living into very advanced years, eventually you would succumb to pneumonia. Pneumonia seems to be unavoidable. Why pneumonia? Do the lungs cease proper functioning or does the immune system become so weak that pneumonia eventually sets in? Also, if you could possibly avoid getting pneumonia what would be the cause of death?

Maybe I’m a little thick, but, it seems to me that if you rule out everything else, pneumonia will kill you just by process of elimination. Assuming, of course, that you have to die eventually. It’s like saying that if nothing else kills you, leprosy will.

Lungs eventually wear out. The alveoli break down and the tissue becomes stiff, and they just don’t work well anymore. The rate at which they break down is very individual, and depends on things like heredity, environment, smoking status, other toxic exposures, etc.

But even in the most healthy people with the best genes and the fewest toxic exposures, the lungs will wear out over time. Usually they last long enough for the person to die of other things.

As they deteriorate though, the lungs don’t clear themselves out as well. Fluids build up, lung tissue consolidates, and the respiratory tree can become excellent breeding grounds for infections. If the person is active and strong enough to move around a lot and breath deeply and cough forcefully, then they can still compensate for this tendency. But for a person bedridden by bad hips, or dementia, or stroke, pneumonia becomes even more likely.

Manduck I think that Qadgop the Mercotan has the right idea of what the question is. (Okay, maybe I should heve made the question even more explicit).
So, basically, of all the body’s vital “parts” (heart, lungs, liver, kidneys and so on), it will be the lungs that will be the ones that will succumb to the ravages of time much quicker than the others.
Is that what you mean Qadgop ?

But pneumia is a virus right? That means that you can simply avoid it by never coming into contact with the virus.

Pneumonia is an infection of the lungs. It can be caused by a virus, bacteria, fungus or by inhalation of chemicals. This site has an overview of the disease. There are vaccines for some types of pneumonia, and the elderly and those with chronic illnesses are advised to get them. Children are susceptible to Respiratory Syntactial Virus (RSV), and it is an extremely dangerous disease for very young children and infants.

By and large pneumonia is NOT from a virus. Bacterial pneumonia is often the killer of the elderly and weak.

Most bacterial pneumonias come from your own “bugs”. Usually, your body keeps them in check, but, when your resistance is down (as it is in the elderly), or when you aren’t taking deep breathes or coughing strongly (as happens in the bedridden and elderly), these bacteria take hold, proliferate, and invade.

Let me use this post to add that a MAJOR killer of the elderly and those with Alzheimer’s is so-called aspiration pneumonia. This refers to the inhalation into the lungs of stomach contents and acid. While it is true that one can inhale bacteria this way, it is more likely that the gastric contents so aspirated, including acid, directly damage the lungs. This is a chemical pneumonia. You can also inhale big enough hunks of food, or large enough quantities of fluid (self-produced or from the diet) that fill the lungs or block the air passages. All of these fall under the rubric of aspiration pneumonia and they are all killers of the infirm.

There are four major killers of the elderly:

  1. Heart attack
  2. Cancer
  3. Stroke
  4. Pneumonia and other respiratory diseases

You asked what would happen if you didn’t die of one of the first three causes. Obviously, if we could somehow eliminate the first three, then the fourth one would be the only major killer of elderly people. But the fact is that we’re no closer to eliminating the first three cause of death in elderly people than we are in eliminating the fourth one.

This is what ultimately killed my mother. She was in the late stage of Alzheimer’s and she lost the ability to swallow normally. Instead of swallowing the food, she would accidently inhale it and go into a horrible coughing fit. Usually a nurse had to suction her to get her relief. She died shortly thereafter of pneumonia.

Immobility makes it way easier to get pneumonia. My kid used to get it a lot, and sometimes sitting up would help. That, and banging on his back a bit.

Well, the lungs aren’t that much more vulnerable than other organs. Nor do they necessarily succumb “quicker” than other organs. But when multiple systems start to fail, it’s the lack of oxygen that will cause one to die quickest in most cases.

Pneumonia is, as a practical matter, going to continue to be a major cause of mortality in the elderly (which may not be a bad thing; even in the past 50 years, pneumonia was called, in medical circles “the old man’s friend” because it often resulted in a relatively peaceful passing, while asleep.)

However, given the control and amangement of infectious diseases is one of the great sucesses of medicine (‘new’ diseases, like AIDS, notwithstanding), I think it’s probable that we will be able to substantially reduce the incidence of pneumonia long before we achieve the same level of control over the cellular and molecular processes responsible for cancer. (We could take a big bite out of pneumonia today, if it were possible to provide prompt universal health care to those who are unwilling/unable to seek it until their condition becomes too serious for them to go to the hospital or recover on their own)

Even without avoidable environmental exposures or genetic predisposition, cancer (etc) arises randomly, and increases with age as the general physiology degrades, and the ability to tolerate treatments decreases. When I was in medical school, we said “If you didn’t die of cancer, you’d die of cancer,” not pneumonia.

Of course, Qadgop is also correct. As a practical matter, tissues (interrrelated cells and structure that must function together) will alwaystend to gradually fail, and the loss of organ function will increase susceptibility to incidental causes like pneumonia. Some cancers are arguably incidental to systemic degradation, too.

To some degree, the “cause of death” is a matter of definition (chosen to suit our social and scientific needs. Pneumonia patients often actually die of organ failure or metabolic disruptions caused by dehydration, biochemical stress reactions, etc., rather than the infection itself. We find it more useful to consider pneumonia the cause of death, not dehydration, which we might use in other cases.

BTW: most community acquired pneumonia is viral – or at least starts that way.

The viral infection makes the lungs more susceptible to an added infection by a bacterial agent. Mycoplasma pneumonia, a bacterial infection, is the pneumonia most commonly seen in clinics for healthy older children and young adults (say 5-35); pneumoccocal (Strep. pneumoniae) and Hemophilus are “classic” bacterial pneumonias that are more common in older patients, but often these bacterial infections are secondary to an initial viral infection. They have simply progressed by the time we see them (as pneumonias).

Other factors increase elder mortality from pneumonia. In addition to chronic, degenerative, or other diseases that increase with age (organ degradation, high blood sugar, immunocompromise, etc.) nursing homes or hospitals offer more chances for bacterial strains to spread through a susceptible community.

BTW - does any MPH, statistician, etc. here happen to know the current stats on “listed cause of death”? As late as the 1980s, ‘meaningless’ terms like “cardiopulmonary arrest” (“loss of heartbeat and respiration” - more a definition of death than a cause) were said to outrank all specific causes as the “primary cause” listed on death certificates. Statistical studies often had to refer to the “secondary to” or “other relevant conditions” entries to piece together a fair picture - but obviously this decreased the accuracy of the studies. Is this still the huge problem as it used to be? I’m just curious, because it used to be a major peeve of mine. I can only assume that professors/attendings at other schools didn’t consider them as meaningless as mine did.

From a strictly pragmatic standpoint, many elderly people who decide they’re “ready to die” may stop taking their medications. Also, the next of kin of elderly patients with Alzheimer’s, end-stage cancer, permanent effects of a stroke, congestive heart failure, etc., may opt out of “aggressive” treatment and choose “palliative” treatment instead. The end result of all this is to let what might be a relatively mild inflammation of the lungs continue unchecked until it eventually becomes pneumonia and overwhelms the already weakened patient.

IIRC there was a study which showed that feeding by PEG tube (a tube under the skin that goes straight into the stomach) did not significantly reduce the incidence of aspiration pneumonia in elderly people with advanced dementia.

Personally, I am in absolutely no doubt that in the event of deciding whether or not one of my close relatives should be fed by PEG due to advanced dementia I would decline the PEG. I would also decline aggressive (pain relief and anything to make them more comfortable not included) treatment for pneumonia for them. No treatment is going to bring the person I knew back, and prolonging their life because modern medicine allows us to seems a little cruel and pointless to me.

Admittedly my experiences have skewed my point of view. I was present when an elderly lady who had Alzheimer’s passed away peacefully from pneumonia. I’ve also seen distressed and confused demented people after they’ve pulled out their PEG tubes, or in restraints so that IV anti-biotics could be administered.

I disagree.

From the New England Journal of Medicine 1995; 333:1618-24.

The full text of the relevant article may be available here.

The part about being bedridden can get younger people as well. I spent a couple of weeks flat on my back in the hospital after leg surgery at age 28, and I could literally feel the gunk pooling in my lungs. (I’m guessing the narcotic painkillers, which depress respiration, and the fact that I generally have somewhat crummy and asthmatic lungs didn’t help, either.) After a few days they gave me a little gadget for breathing exercises (it involved keeping a plastic ball aloft by blowing into a tube), which was surprisingly difficult to use because of how weak I was at the time. I could really feel the gunk rattling around when I tried to control my breathing.

So I didn’t end up with pneumonia per se, but given that I’ve had mild cases a couple of times previously without any other complicating factors involved, I can see how it could happen pretty easily, if the hospital staff weren’t careful. And I’m certainly less ancient than the people under discussion here, and much healthier overall.

In the spirit of academic discussion, I did not say (or mean to say) that “viral pneumonia” was the commonest form, I said that most pneumonias start as viral infections. However, I see that my words may have been ambiguous. I thank you for drawing my attention to this, so that I may clarify.

I believe my exact words were: BTW: most community acquired pneumonia is viral – or at least starts that way. The viral infection makes the lungs more susceptible to an added infection by a bacterial agent. I then proceeded to say that Mycoplasma spp., Strep. pneumoniae, H. influenza -all bacteria- were the commonest pneumonia agents in various populations. I also meant to include a sentence or two on Staph. aureus and gram-negatives like Klebsiella pneumoniae and Pseudomonas aeruginosa -again, all bacteria- which are major causes of hospital-acquired pneumonia.

The common bacterial pneumonias are infrequently contagious, but viral repiratory infections, like colds and flu are extremely contagious. These viral infections do not usually proceed to pneumonia themselves, but make their victims more susceptible to bacterial infections that do. These later infectious agents are the ones that would be detected by a study like the one you cite.

I had meant to resolve a contention, earlier in the thread, over the viral or bacterial origin of most pneumonia (i.e. in one sense, both are correct), and add some remarks about relative contagiousness, since most pneumonia is treated at home, and many SDMB’ers will find themselves in the same household with a pneumonia victim. Alas those remarks fell by the wayside of the narrative thread. I had hoped to make the point that the initial illness might be separate from the pneumonia, since I didn’t feel that would be obvious to laymen: “Just because you caught Grandpa’s cold (which became pneumonia) doesn’t mean you’re at significantly greater risk of getting pneumonia than you would be with any other cold.”

I actually recall that specific review because I was active in MMS at the time, and was scheduled for a pulmonary rotation in January, 1996. I happened to discuss the review with some members of the NEJM Editorial Board, including the then-Editor in Chief Jerry Kassirer, at a meeting of an unrelated committee. As the review itself notes, it only addressed hospitalized cases vs. the incidence seen in outpatient clinics or private practice. I had had fairly little experience with the general community, and only knew what I’d read or been told in the hospital, so my question sparked some jovial debate over the ranking of various agents in the community (You know how senior attendings can be. The wizened heads finally came to a truce with “Well, maybe in your population…”)

As noted in the article, determinations of the responsible pathogen were made by methods that explicitly attempted to avoid concomitant or pre-existing URIs (including viral URI); etc. That is, of course, precisely what you’d want if presumptively treating a hospitalized pneumonia of unknown agent, so it’s not at all a criticism of the study. Etiology or prior history wasn’t addressed at all, and the study’s conclusion (supporting the pneumonia vaccine for at-risk groups) stands whether the initial infection was bacterial or not.

I mention these points only because the linked article is only available to NEJM subscribers, which our other readers may not be. I, personally, don’t have any problem with the findings of that study. It may or may not reflect the incidence of pneumonia in the general, but despite its brief broad title, the paper itself doesn’t claim to represent community acquired pneumonia in the community. I certainly agree, based on similar papers, that I would treat presumptively with antibiotics, not antivirals.

I think the Merck Manual’s section on pneumonia especially the section on community acquired pneumonia is a detailed, but readable, overview of the disease for interested lay readers.

To sum up: yes, most pneumonias are probably bacterial by the time they become pneumonias. This is certainly true of the subset that lands in the hospital. I simply meant to note that they often begin as viral infections, because I felt it was interesting. I’m sorry if I gave any other impression.

So, is that why elderly people in hospital often die of pneumonia? Even people who seem to get better from their original disease. Is it a hospital disease? Would you be better of at home?

You are always better off at home…

(take it from someone who has colonized lungs.)

Everyone should get the pneumococcol vacine for pneumonia prevention. After 65 years of age, you should get it again. It is basically a once in a lifetime shot, but always get it again after 65 to be sure. It is an effective remedy that fights bacterial pneumonia.