**Pulmonary Embolism in the Elderly – Significance and Particularities**

 Pavel Weber, Dana Weberová, Hana Kubešová and Hana Meluzínová *Department of Internal Medecine, Geriatrics and Practical Medicine Masaryk University and University Hospital, Brno Czech Republic* 

#### **1. Introduction**

36 Pulmonary Embolism

Torbicki A, Galie N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ. Right heart thrombi in

Torbicki A, Perrier A, Konstantinides S, et al., Guidelines on the diagnosis and management of pulmonary embolism. European Heart Journal 2008;29:2276-2315. van der Meer RW, Pattynama PM, van Strijen MJ, van den Berg-Huijsmans AA, Hartmann

Vieillard-Baron A, Page B, Augarde R, Prin S, Qanadli S, Beauchet A, Dubourg O, Jardin F.

Wicki J, Perrier A, Perneger TV, et al. Predicting adverse outcome in patients with acute

Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the

pulmonary embolism: a risk score. Thromb Haemost 2000;84:548.

Embolism Registry. J Am Coll Cardiol 2003;41:2245.

Jun;235(3):798-803. Epub 2005 Apr 21.

Med 2001;27:1481–1486.

2002;121:877–905.

pulmonary embolism: results from the International Cooperative Pulmonary

IJ, Putter H, de Roos A, Huisman MV Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3 month follow-up in patients with acute pulmonary embolism. Radiology. 2005

Acute cor pulmonale in massive pulmonary embolism: incidence, echocardiographic pattern, clinical implications and recovery rate. Intensive Care

golden hour of hemodynamically significant pulmonary embolism. Chest

The development of civilization and extreme technical progress leads to increasing hope of longer survival and makes the average life expectancy longer. Both in absolute and relative numbers the amount of the elderly, very old and long-aged people are increasing (Blackburn & Dulmus, 2007; Ratnaike, 2002). This tendency will continue and it will be emphasized by ageing volumes of people born after the World War 2 in the years 2010 -2015 (Kalvach et al., 2004). The basic survey and knowledge of geriatric medicine will be necessary in the future, especially for professionals such as doctors, nurses, psychologists, social workers, physio- and occupational therapists etc.

Knowledge of at least basic extraordinarities and specifics of geriatric medicine will be of huge practical significance, because in the year 2050 there will live 2 billions of people older than 60 years on the Earth. (Moody, 2009). From this fact it is obvious, that there is an objective need to master the basic knowledge of gerontology and geriatry among professionals (including doctors of all medical branches).

In this brief chapter it is not possible to include the whole issue dealing with the medical care of old-aged patients with PE, even if this issue deserves the attention because of its practical meaning and close relationship with other branches (internal medicine, surgery etc.). The emergency situations together with polymorbidity and exhaustion of functional reserves in advanced age (Campbell et al., 2008; Friedman et al., 2008) will be more frequent in all of the organ systems – cardiovascular, respiratory, GI (gastrointestinal) tract, endocrine, immune etc. (Bongard & Sue, 2003; Roberts & Hedges, 2009). We refer to the study of the clinical picture description (incl.therapy) of each of critical states in the old age in appropriate specialized chapters in this monograph and in other gerontologic literature (Hall et al., 2005; Stone & Humphries, 2004).

General knowledge of these aspects can substantially influence an approach of intensivists who face an increasing number of old patients in their practice (Brunner-Ziegler et al., 2008; Pathy et al., 2006). Among the aspects we would like to mention there are: global situation, specific problem of geriatric medicine, pharmacotherapy in the elderly, at last but not least problems of ageing organism as reflected in particularities and pitfalls of medical treatment in multi-morbid old patients.

Ageing and its manifestation as currently understood such as frailty, functional disorders and decreasing mental abilities are not standard symptoms of ageing process but they are

Pulmonary Embolism in the Elderly – Significance and Particularities 39

• Social work creating conditions enabling patients to return to home environment (incl.

Main target of these efforts is improvement in independence and self-sufficiency improvement in older patients (Zavazalova et al., 2007). Geriatric regimen brings benefits especially for patients aged 75+ or even 80+ who are endangered with following risks


Evaluation of the older patient can be time-consuming (Topinkova, 2005), even when it is tailored to the problem. Yet, such initial investment can reduce subsequent morbidity and resource utilization and enhance both patient's and physician's satisfaction. Additionally, the assessment can often be accomplished over several visits. Moreover, much can be gleaned from questionnaires filled out by the patient or caregiver in advance as well as from

Geriatric patients are people of higher age (formally above 65; practically above 75 years), their involutionary and morbid changes (usually multi-morbidity) significantly influenced their functional state, adaptability, ability of regulation, toleration to stress. These patients profit from specific geriatric attitude, they need more complicated coordination of services, often active observation of health and/or functional state, they are in risk of sudden loss of self-sufficiency, danger of delay, adverse effect of remedies is more frequent, institutional care is often needed ( geriatric hospitalism), also they are in danger of frequent professional mistakes for atypical symptoms in comparison to clinical picture, which is for certain disease typical in adult middle age (Friedman et al., 2006; Pathy et al., 2006; Williams, 2008). The following principles of geriatric medicine are helpful to keep in mind while caring for

Comorbidities are common in older people, and the diagnostic "law of parsimony" often does not apply. A disorder in one organ system may lead to symptoms in another, especially the one that is compromised by preexisting disease. Since these organ systems are often the brain, the lower urinary tract, and the cardiovascular or musculoskeletal systems, a limited number of presenting symptoms – i.e., confusion, falling, incontinence, dizziness, and functional decline - predominate irrespectively of the underlying disease. Thus, regardless of the presenting symptoms in older people, the differential diagnosis is often

Many abnormal findings in younger patients are relatively common in older people and may not be responsible for a particular symptom. Such findings may include asymptomatic


home-care)

typical for this age:

observation.

older adults:

similar.




1. Diseases often present atypically.

2. Many disorders are multifactorial in origin.

3. Not all abnormalities require evaluation and treatment.

4. Polypharmacy and adverse drug events are common problems.

their functional reserve (lungs, kidneys etc.)


**3. Geriatric patient – Particularities of health status** 

mostly consequences of simultaneously on-going diseases (Goldmann et al., 2000; Fauci et al., 2008). The target of new **interventional gerontology** is extension of active life period and sustaining functional abilities for maximum time.

Information about function can be used in a number of ways: as baseline information, as a measure of the patient's need for support services or placement, (Tallis & Fillit, 2003) as an indicator of possible caregiver stress, (Asplund et al., 2000) as a potential marker of specific disease activity, to determine the need for therapeutic interventions, and to indicate prognosis.
