CLINICAL INVESTIGATIONS Outcome Predictors of Pneumonia in Elderly Patients: Importance of Functional Assessment Olga H. Torres, MD, à Jose Mun ˜ oz, MD, w Domingo Ruiz, MD, à Josep Ris, MD, z Ignasi Gich, MD, § Eva Coma, MD, w Merce ` Gurguı´, MD, PhD, z and Guillermo Va ´zquez, MD, PhD w (Editorial comments by Dr. Kevin P. High on pp 1768–1770) OBJECTIVES: To evaluate the outcome of elderly patients with community-acquired pneumonia (CAP) seen at an acute-care hospital, analyzing the importance of CAP se- verity, functional status, comorbidity, and frailty. DESIGN: Prospective observational study. SETTING: Emergency department and geriatric medical day hospital of a university teaching hospital. PARTICIPANTS: Ninety-nine patients aged 65 and older seen for CAP over a 6-month recruitment period. MEASUREMENTS: Clinical data were used to calculate Pneumonia Severity Index (PSI), Barthel Index (BI), Charl- son Comorbidity Index, and Hospital Admission Risk Pro- file (HARP). Patients were then assessed 15 days later to determine functional decline and 30 days and 18 months later for mortality and readmission. Multiple logistic re- gression was used to analyze outcomes. RESULTS: Functional decline was observed in 23% of the 93 survivors. Within the 30-day period, case-fatality rate was 6% and readmission rate 11%; 18-month rates were 24% and 59%, respectively. Higher BI was a protective factor for 30-day and 18-month mortality (odds ratio (OR) 5 0.96, 95% confidence interval (CI) 5 0.94–0.98 and OR 5 0.97, 95% CI 5 0.95–0.99, respectively; Po.01), and PSI was the only predictor for functional de- cline (OR 5 1.03, 95% CI 5 1.01–1.05; P 5.01). Indices did not predict readmission. Analyses were repeated for the 74 inpatients and indicated similar results except for 18- month mortality, which HARP predicted (OR 5 1.73; 95% CI 51.16–2.57; Po.01). CONCLUSION: Functional status was an independent predictor for short- and long-term mortality in hospitalized patients whereas CAP severity predicted functional decline. Severity indices for CAP should possibly thus be adjusted in the elderly population, taking functional status assessment into account. J Am Geriatr Soc 52:1603–1609, 2004. Key words: community-acquired pneumonia; elderly; outcome; functional status; prospective C ommunity-acquired pneumonia (CAP) is an acute dis- ease that causes high mortality in the elderly; in-hos- pital mortality as high as 10% is reported in patients aged 65 and older admitted to the hospital with CAP, and many more die within a month of discharge. 1 Approximately 12% of survivors require placement in a long-term care facility or rehabilitation center, 2 and when long-term effects of CAP in elderly patients have been investigated, there is a high risk of subsequent mortality for several years. 3 Addi- tionally, pneumonia is among the six-most-frequent dis- charge diagnoses in patients with severe disability developed in the previous year. 4 Although short-term func- tional decline has not been well studied in CAP, it has been well documented in nursing-home residents. 5,6 Predicting the outcome in elderly patients diagnosed with CAP is important in clinical practice when making decisions such as hospital admission or the need for inten- sive care measures, but in the elderly population, scoring systems such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score (SAPS) appear to predict higher mortality than the rates that are actually observed. 7 The scoring system de- veloped and validated by the Pneumonia Patient Outcome Research Team (PORT), the Pneumonia Severity Index (PSI), 8 has proven to be a good prognostic score for CAP in adults. Nevertheless, it does not provide an assessment of the patient’s functional status, so vital in the elderly pop- ulation in reference to outcome in terms of survival and disability. 9–12 Previous studies have shown that dependence in daily living is an important mortality predictor for nurs- ing home–acquired pneumonia, 13–16 but to the authors’ Address correspondence to Olga Torres, MD, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Avgda. Sant Antoni M Claret, 167, 08025 Barcelona, Spain. E-mail: otorres@hsp.santpau.es From the à Department of Internal Medicine, Division of Geriatrics, w Division of General Internal Medicine and Emergencies, z Division of Infectious Diseases, and § Department of Statistics and Epidemiology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain. JAGS 52:1603–1609, 2004 r 2004 by the American Geriatrics Society 0002-8614/04/$15.00