Introduction

Geriatric Essentials

• The immune response to active immunization tends to decrease with aging.
• Many elderly people are not given indicated vaccines (eg, influenza, pneumococcal, diphtheria and tetanus).

By the time most people reach old age, they have been immunized or exposed to many disorders. Nonetheless, they still need immunizations (see Table 132-1). Certain immunizations are indicated only for elderly people; others are not recommended for all elderly people but are available and appropriate in specific cases.

Many elderly people do not receive indicated vaccines, adversely affecting individual and public health. When deciding whether an immunization is appropriate for an elderly person, clinicians should weigh the risks and benefits.

Several vaccines may be given together without loss of efficacy. For example, influenza and pneumococcal vaccines may be given together at separate sites.

Vaccination recommendations by the Advisory Committee on Immunization Practices are available from the Centers for Disease Control and Prevention.

Active immunization: This type of immunization is used to stimulate the patient's immune system. Vaccines or toxoids are used; the amount of protection conferred depends on the recipient's immunologic response.

Immunologic response decreases in most elderly people; whether the cause is aging per se or an underlying disorder is unclear. For example, elderly nursing home residents produce much lower levels of antibody in response to influenza or pneumococcal vaccine than do younger people. In most elderly people, response is sufficient to confer protection; however, elderly people need to be revaccinated with some vaccines or toxoids (eg, tetanus and diphtheria toxoid booster injections every 10 yr) because of waning response.

Passive immunization: This type of immunization is used when exposure to a disorder has recently occurred or is anticipated or when active immunization may not confer adequate protection. People are given immune globulins, which are usually derived from humans but sometimes from animals, or hyperimmune globulins, which are derived from donor pools preselected for a high level of antibody against a specific disorder (eg, hepatitis B, herpes zoster, rabies, tetanus).

Adverse effects: Adverse effects appear to be similar in elderly and younger people. The most common type is a hypersensitivity reaction, which occurs because vaccines and toxoids contain specific immunogenic substances. This reaction is a particular concern with immune globulins of equine origin (eg, botulism antitoxin, several antivenins); a skin prick test should be done first to determine whether a person is allergic or hypersensitive to the specific vaccine. Hypersensitivity to a substance used in culture media is possible but uncommon. In general, known hypersensitivity to a vaccine component is a contraindication to using the vaccine.

Some vaccines (eg, pneumococcal vaccine) produce more local inflammation when they are given before immunity has waned, but such a reaction is rarely sufficient reason to withhold the vaccine if a clinician lacks information about prior immunization.

Clinicians should discuss risks of vaccination with patients. In the US, selected events that occur after routine vaccination should be reported to the manufacturer and to the Centers for Disease Control and Prevention's Vaccine Adverse Event Reporting System (VAERS). Forms and instructions can be obtained by calling 800-822-7967 (Health and Human Services) or at the VAERS web site.

Contraindications: In general, live attenuated viral or bacterial vaccines should not be given to immunocompromised patients because these vaccines may induce infections. These vaccines should also not be given to patients who have received immune or hyperimmune globulins (or probably blood or plasma) within the preceding 3 mo; these products may interfere with development of subclinical infection, which is the desired response to the vaccine. All vaccinations should be delayed in patients with a temperature > 39° C until the temperature subsides and in patients with a fluctuating neurologic disorder (eg, Guillain-Barré syndrome) until the disorder has been stable for >= 1 yr.

This topic was last updated February 2006.