How it shows itself
Cough and fever may be absent. In older people the commonly recognised signs of serious infection are often missing, and delirium and falls are more likely 28. A resident with a chest infection may first appear more confused, more breathless, more tired or less interested in food.
Observations that help the treating clinician include breathing rate, oxygen saturation, pulse, blood pressure, temperature and level of alertness, set against the resident’s usual readings.
Aspiration and mouth care
Aspiration means food, drink, saliva or stomach contents going into the airway. Pneumonia in nursing home residents is associated with poor oral hygiene and may be caused by breathing in bacteria from the mouth and throat 22.
A speech pathologist can assess swallowing and advise on positioning and on food and drink textures. Near the end of life, decisions about eating and drinking are different, and the related pages below cover them.
Treatment and prevention: the evidence
Graded on randomised evidence in nursing homes.
A structured treatment pathway in the nursing home
Promising, not yet provenHospital admissions roughly halved, with no difference in deaths, in one Canadian trial.
The evidence
In a cluster randomised trial in 22 Ontario nursing homes (680 residents with lower respiratory infection), a pathway of oral antibiotics, portable chest X-ray, oxygen saturation monitoring, rehydration and close monitoring by a research nurse reduced hospital admissions from 22% to 10%. Deaths (8% against 9%), quality of life and function did not differ significantly, and costs were lower 21.
In practice
The trial ran from 2001 to 2005 and used a dedicated research nurse to monitor residents 21.
Professional oral care
Uncertain / conflictingEffect on pneumonia unclear; possibly fewer deaths from pneumonia.
The evidence
A 2022 Cochrane review of six trials (6,244 participants, all at high risk of bias) found insufficient evidence of a difference in pneumonia compared with usual oral care. Low-certainty evidence from two trials suggested fewer pneumonia deaths at 24 months (risk ratio 0.43), with no clear difference in deaths from any cause 22.
In practice
No trial compared oral care with no oral care 22.
Treating in the facility or in hospital
Whether to treat in the facility depends on what the resident wants, how unwell they are, and whether the facility can provide fluids, oxygen and monitoring through the night. The Canadian trial shows what was possible with dedicated monitoring; it does not show that every facility can do the same 21.
Related pages on this site
- Eating and drinking at the end of life Palliative care section: eating, drinking and swallowing near the end of life.
- Advanced dementia and end-of-life care Dementia care section: recurrent chest infection and antibiotics in advanced dementia.
- Hospital transfer at the end of life Palliative care section: weighing hospital transfer for residents near the end of life.
Sources cited on this page
- 2 Australian Commission on Safety and Quality in Health Care. Sepsis Clinical Care Standard. Sydney: ACSQHC; June 2022. (Primary settings are ambulance services, hospitals and urgent care centres; also listed as relevant to aged care homes and general practice.) View source
- 8 High KP, Bradley SF, Gravenstein S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc. 2009;57:375–94. (US guideline; checked at abstract level.) View source
- 21 Loeb M, Carusone SC, Goeree R, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA. 2006;295:2503–10. (Cluster randomised; 680 residents in 22 nursing homes in Hamilton, Ontario.) View source
- 22 Cao Y, Liu C, Lin J, et al. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev. 2022;11:CD012416. (Six randomised trials, 6,244 participants, all at high risk of bias.) View source
See every source cited across the deteriorating resident section →
Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at November 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment, and it does not set escalation rules for any facility. Antibiotic choices and doses follow current prescribing guidelines and local advice. Evidence, Australian regulatory requirements and local services change — always confirm current advice with the treating GP and the facility’s own procedures.
This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.