Stages of pneumonia in older adults
Stages Of Pneumonia In The Elderly: Guidance For Carers
Pneumonia can be a serious, life-threatening condition in older people, so it is important to understand its severity, how each stage might play out for older people, and how caregivers can help them to recover from pneumonia. Here, we are looking more closely at how pneumonia manifests differently in older people, the 4 progressive stages, the critical differences in how this presents in older people, how home care can provide support for each stage, and when hospitalisation may be necessary.
At Home Instead, our aim is to help people age positively and in place by bringing expert care to their home. For over 20 years, we have been providing the highest standard of care, and creating industry-leading training programmes for our Care Professionals that are accredited by nursing and medical professionals. Today, we are the world’s largest global domiciliary care network, supporting over 100,000 older adults with personalised, tailored care at home. So whatever questions you have about pneumonia in older adults, we can help.
What are the critical differences in pneumonia in older adults vs younger age groups?
Pneumonia is an infection that causes inflammation in one or both lungs. This can either present as specific symptoms, or there may be no symptoms at all, known as ‘atypical pneumonia’. Pneumonia is an infection that causes inflammation in one or both lungs. According to the NHS, it is most commonly caused by a bacterial or viral infection, but it can also result from a fungal infection or from aspiration — when food, drink or saliva is accidentally breathed into the lungs rather than swallowed. Aspiration pneumonia is particularly relevant for older adults, who may have a weaker swallow reflex or neurological conditions that affect swallowing. Fungal pneumonia is rare in healthy people in the UK but is more likely in those with a weakened immune system.
- A weakened immune system
- Existing infections or illnesses
- A history of smoking
- Existing chronic health conditions such as chronic obstructive pulmonary disease (COPD), asthma, diabetes or heart, liver or kidney disease – if you live with any of these conditions, you should see a doctor straight away if you develop pneumonia
- Neurological conditions – These often mean there is a higher risk of inhaling foods or liquids which can cause pneumonia
- A weaker cough reflex – This means they are unable to clear infections from the lungs as easily, which is demonstrated in a 2020 study on stroke patients that found respiratory infections in 80% of patients with no cough, 50% of patients with a weak cough, and only 26.3% of patients with a normal cough
The symptoms of pneumonia tend to present differently in older people, and may include:
- Confusion or a change in mental state (usually the case in those aged 65+)
- A lower than normal body temperature, which differs from the typical fever experienced in younger age groups (although fever can still occur in older people)
- Lack of appetite
- Urinary incontinence
- Shortness of breath and/or rapid breathing
- A rapid heart rate
- Loss of blood pressure and circulation problems
- Diarrhoea
Each year, between 0.5% and 1% of adults in the UK develop pneumonia, and studies suggest if left untreated this could result in death in 30% of cases. Pneumonia in those aged 65 or older is known to be associated with increased risk of hospitalisation and death compared to other age groups, as symptoms can be hard to detect and can get worse very quickly. For this reason, it is extremely important for older adults and their caregivers to know the early signs of pneumonia and take action in the earliest stages.
Without complications, and with early medical intervention, older adults can recover from pneumonia, and can sometimes do so in their own home. Depending on the progression of their symptoms and any underlying health conditions they have, hospitalisation may be advised, particularly if they are over the age of 65.
The 4 progressive stages of pneumonia
There are usually 4 stages of pneumonia, and while this is never an exact blueprint for every case, it helps to know the symptoms to expect from each stage and the signs caregivers should watch out for.
Stage 1: Congestion
The first stage of pneumonia takes place in the first 24 hours or thereabouts, as initial symptoms of pneumonia can develop over 24 to 48 hours in some cases. It is called “congestion” as it causes congestion in the lungs, and symptoms may include (but are not limited to):
- A wet cough that may bring up yellow or green mucus/phlegm
- Chest pain
- Slight fever
- Some difficulty breathing
- Fatigue
- Body aches
- Loss of appetite
Keep in mind that in the first stage of pneumonia in older adults, typical symptoms like a cough or fever may not present in the same way. Instead, they may experience a low temperature, feelings of weakness, and confusion.
At this stage, the small air sacs in the lungs (called alveoli) and nearby blood vessels are becoming inflamed and the lungs are beginning to become congested with fluid, making breathing harder. If pneumonia is detected at this stage and treated straight away, complications are unlikely, and an older person can make a full recovery. Pneumonia does tend to cause complications in older people, so it is always best to seek medical advice through the person’s GP, NHS 111 or, in severe cases, A&E or by calling 999.
If no complications are present at this stage, caregivers should aim to increase their fluids, monitor their temperature, and seek a prompt appointment with their GP so they can begin treatments such as antibiotics if they think this is best.
Stage 2: Red Hepatization
The second stage of pneumonia takes place usually around days 2 and 3, which is when symptoms tend to worsen. This is because red blood cells rush to the lungs to fight off infection, and reduced oxygen levels can cause the lungs to become drier. This may cause patients to cough up mucus that is more rusty or reddish in colour, and chest pain and fever may also continue in the red hepatization stage. It is best to monitor an older person’s oxygen levels to ensure they do not drop to a dangerous level, which would be 92% oFr less.
In this stage, the lungs may become firmer and are said to take on the consistency of the liver as the capillaries fill with blood. If complications of pneumonia occur, these usually happen in this second stage, and could include sepsis in extreme cases.
It is important to recognise the symptoms of sepsis in an older person, such as confusion, slurred speech, discoloured skin, a rash, and/or difficulty breathing. If these occur, take action as soon as possible, as this can be life-threatening. You can learn more in our guide to sepsis symptoms in the elderly.
Pneumonia can also be life-threatening for older adults with heart failure or chronic lung problems, so seek medical help straight away if this is the case for your loved one.
Stage 3: Grey Hepatization
Between days 4 and 6 is when the third stage of pneumonia occurs. In this stage, the red blood cells start to break up, and the lungs become more greyish in colour, hence its name “grey hepatization”. The lungs also continue to become drier with a liver-like consistency.
Symptoms in this stage may mimic the second stage, but could also include coughing up blood, severe coughing fits, or more laboured breathing that might require oxygen therapy or ventilation.
Some people experience complications during this stage rather than in the first stage, and these could include:
- The formation of a lung abscess that could lead to bleeding in the lungs
- Coughing up a foul-smelling sputum
- Weight loss
- Chest pain
At this stage, medical intervention is crucial if this has not yet been sought. If your loved one is turning pale, blue or has blotchy skin, feels suddenly confused, or is struggling to breathe, call 999 or take them to A&E without delay.
Stage 4: Resolution
If no complications have occurred and pneumonia has progressed in a typical fashion, the final stage usually occurs between weeks 1 and 2, but symptoms can last longer than this in some cases. In the “resolution” stage, the airways may start to heal and symptoms will lessen. Signs that pneumonia is improving include:
- Reduced phlegm production
- Reduced coughing and shortness of breath
- No more fever
- Less fatigue and more energy
- No or lessened chest pain
- Improved blood oxygen levels
- Reduced signs of infection, such as headaches
While recovering, it is important to remember fatigue and a mild cough may persist for several weeks after the infection has cleared. The best thing to do during this stage is to drink plenty of fluids and eat a nutritious diet to boost your immune system. Seek an urgent GP appointment or call NHS 111 if you have had a cough for 3 weeks or more, as they may be able to help you clear the infection.
The total length of time pneumonia lasts will depend on its severity, and the age of the patient. In some cases, the recovery timeline may look like:
- 1 week – No more fever
- 4 weeks – Reduced chest pain and mucus
- 6 weeks – Reduced cough and easier breathing
- 3 months – Most symptoms gone, with potential lingering fatigue
- 6 months – Most people back to normal
How can caregivers effectively manage each stage of pneumonia?
If pneumonia is severe, the patient may be sent for an X-ray of their chest or have blood taken to determine the extent of the infection, and treatments for pneumonia may include:
- Taking antibiotics to assist in recovery and get rid of the infection
- Taking additional fluids (drinking plenty at home, or you may be given these intravenously in hospital)
- Oxygen therapy if breathing is difficult
For older adults, having a caregiver present or at least providing visiting care during a bout of pneumonia is crucial to their health and recovery. They can do this by:
- Monitoring for complications such as a low breathing rate or sudden confusion
- Encouraging rest and minimal contact with others to limit the spread of infection
- Changing their position to dislodge phlegm and make coughing easier
- Providing help around the home when they are unable to continue basic tasks
- Encouraging them to give up smoking
- Providing mobility assistance as they regain their strength after illness
- Maintaining good hygiene through regular personal care practices
- Maintaining a healthy, balanced diet to improve immune function
- Helping them adhere to treatment plans through medication management and more
Caregivers can also help older adults reduce their chance of contracting pneumonia in the first place, or of contracting it again while their immune system is weak, by helping them arrange to get the pneumococcal vaccine (recommended for adults ages 65 years and older) to avoid the infection, and other vaccines such as the flu vaccine, covid-19 vaccine and RSV vaccine which could help them to avoid other illnesses that lower their immune system.
When is hospitalisation necessary?
Pneumonia can be a very serious issue for an older person, particularly those over the age of 65, so it is vital to know when it’s time to stop caring for an older loved one at home, and transfer them to a hospital setting for medical care.
Hospitalisation may be necessary when their symptoms become severe, or if any of the aforementioned complications arise, such as:
- Severe chest pain
- A rapid heart rate
- A dangerously high fever (depending on their normal temperature, this could be between 38°C and 41°C)
- Severe breathing difficulties
- Extreme weight loss
- Coughing up blood or a foul-smelling sputum
- A dangerously low oxygen level of 92% or less
- Symptoms of sepsis, including confusion, slurred speech, discoloured skin, a rash, and/or difficulty breathing
- A suspected lung abscess
Hospital care may also be needed if the person has an existing condition such as a heart issue, chronic obstructive pulmonary disease (COPD), or asthma, and hospital admission is usually recommended for older adults over the age of 65.
Mortality risk assessments (also known as a CURB-65 score) are often used in clinical settings to determine a person’s risk of dying from pneumonia based on their age, symptoms and blood pressure. This can help when it comes to decision‑making processes about how to treat the infection, whether the person can receive treatment and care at home or if they should be in hospital, and which tests and antibiotics are likely to be best for each scenario.
Using the CURB-65 assessment can help to promote better treatment outcomes, and the score is calculated using the following point-based criteria, with one point for each feature:
- Age 65 years or more.
- Confusion – The person will be given a mental test, and if they score 8 or less, this could count as confusion. They may also get a point in this category if they experience new disorientation.
- Raised blood urea nitrogen (a blood test that measures the amount of urea nitrogen in your blood) – This must be over 7 mmol/litre.
- Raised respiratory rate – This must be 30 breaths per minute or more.
- Low blood pressure – This must be a rate of diastolic 60 mmHg or less, or systolic 90 mmHg or less. You can learn more about this in our article: Understanding An Elderly Blood Pressure Chart
0 or 1 point means they have a low risk of death (less than 3% mortality risk), 2 points means they have an intermediate risk of death (3‑15% mortality risk), and 3-5 points means they are at a high risk of death (over 15% mortality risk).
Caregivers can help older adults prepare for discharge from hospital after pneumonia by ensuring they are coming home to a safe, warm and comfortable home environment. They can also get advice from the person’s GP and hospital discharge team about any necessary equipment they may need to support their recovery, such as mobility aids or oxygen.
Hospital staff will usually go over the person’s discharge plan with the patient and their caregivers, so pay attention to which medications are needed, any necessary follow-up appointments, and how to spot signs of a relapse. Ultimately, the goal is to support the person’s rest, hydration, movement, and to help them to eat a nutritious diet to bolster their immune system for recovery.
Care providers like Home Instead can help families to effectively manage the ongoing care associated with pneumonia recovery in older adults, by providing both visiting care and live-in care options that are flexible as your loved one’s needs change over time. We can also provide respite care when families need to take a break from caregiving duties for any reason, such as due to carer’s burnout.
Our experienced, supportive Care Professionals can provide the help needed to manage the symptoms at all stages of pneumonia within an older person’s own home, where they feel safe and at ease. For the support you need, reach out to your local Home Instead office to discuss your options.
We’re an award-winning home care provider and part of a worldwide organisation devoted to providing the highest-quality relationship-led care for older people in their own homes. Arranging care for yourself or your loved one shouldn’t be stressful, so whatever questions you would like answered, feel free to reach out to the Home Instead team to discuss your needs.
