Daniel M. Keller, PhD

May 03, 2013

Taipei, Taiwan — The risk of dying of aspiration pneumonia among people with Alzheimer's disease and related dementias (ADRD) is higher for men than women and, in the United States, is higher for younger elderly compared with those 85 years or older, according to a survey of death certificates.

Presenting his analysis here at the Alzheimer's Disease International (ADI) 28th International Conference, Tsung-Hsueh Lu, MD, PhD, from the Department of Public Health at National Cheng Kung University Hospital in Tainan, Taiwan, told delegates that death certificates list a disease or condition directly leading to death and then other antecedent conditions as contributing causes, but often those latter causes are lost in analyses.

For example, a death certificate may list sepsis as the direct cause, but if aspiration pneumonia and Alzheimer's disease are listed as antecedent causes, only sepsis may be considered for purposes of vital statistics. So he and a colleague looked for occurrences of listings of aspiration pneumonia, which can be a preventable cause of premature death, with ADRD.

Between 2002 and 2009, 6% of death certificates in the United States and 3.6% of those in Taiwan that listed ADRD as a cause of death also listed aspiration pneumonia.

Table. Aspiration Pneumonia on Death Certificates Listing ADRD (2002 to 2009)

Endpoint United States (n = 2,002,957) (%) Taiwan (n = 9143) (%)
Total 6.0 3.6
  Men 8.4 4.5
  Women 4.8 2.8
  65 - 74 y 7.5 3.2
  75 - 84 y 6.6 3.7
  ≥85 y 5.5 3.6


Men in the United States were at a 78% greater risk for aspiration pneumonia if they had ADRD than were women (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.776 - 1.80). Similarly, men in Taiwan were 71% more likely than women there to die with aspiration pneumonia with ADRD (OR, 1.71; 95% CI, 1.36 - 2.14).

Compared with people aged 65 to 74 years in the United States, residents with ADRD had a decreasing risk for aspiration pneumonia as they aged (at 75 to 84 years: OR, 0.92 [95% CI, 0.90 - 0.94]; at ≥85 years: OR, 0.84 [95% CI, 0.82 - 0.86]). An interesting finding that Dr. Lu could not explain was that Taiwan residents trended in the direction of a nonsignificant increased risk with age.

In both countries, the proportion of people dying with aspiration pneumonia and ADRD decreased during the study period, from 6.9% in 2002 to 2003 to 5.0% in 2008 to 2009 in the United States (OR, 0.72 [95% CI, 0.70 - 0.73] for later period vs earlier) and (nonsignificantly) from 3.9% to 3.5% in Taiwan for the same periods (OR, 0.86 [95% CI, 0.63 - 1.17]).

Dr. Lu cautioned that aspiration pneumonia may be underreported as a cause of death, so the true figures may be even higher than that found from death certificates. And in the United States, different states may have different systems for determining and reporting the causes of deaths.

Preventing Premature Death

Aspiration of food is a major cause of pneumonia, but the risk can be reduced. "Speech therapists should be consulted to evaluate the swallowing ability in such a patient, training of the swallowing, or preparing of food to prevent this premature death," Dr. Lu advised.

Session moderator David Troxel, MPH, a long-term care consultant and writer in the field of dementia in Sacramento, California, commented to Medscape Medical News that swallowing issues and food aspiration are recognized as big problems among elderly patients with dementia.

"Where I'd say we aren't doing a good job is I think that families don't know to go to a speech pathologist. Doctors may not think about referring to a speech pathologist who can maybe help with that and assess [the patient]," he said. "Certainly in home settings I doubt families know much about how to prepare foods or go to different kinds of puréed foods."

He said he believes families are not getting much support in this area, so problems persist. He suggests that professionals in the elder care field talk to physicians about recognizing problems contributing to aspiration, about referring to speech pathologists, and "to really do more education with the families about different dos and don'ts about food."

Mr. Troxel is a dementia consultant to Atria Senior Living, Home Instead, American Baptist Homes of the West, and Prestige Care, and he previously consulted for Genentech Roche.

Alzheimer's Disease International (ADI) 28th International Conference. Abstract OC024. Presented April 19, 2013.