**6. Characteristics of ageing**

The elderly are highly heterogeneous group, and individuals become more dissimilar as they age. Individuals over 65 years – with or without chronic diseases – vary widely in their physical, behavioral, and cognitive functions.

The **ageing** – *is an inevitable physiological process, which is the last ontogenetic period of the human life.* People mostly achieve their old age without any enormous problems. They live to their **"successful ageing"**. in quite comfortable physical, psychical and social balance (Duthie et al., 2007; Williams, 2008). The somatic (diseases), psychical (dementia, depression) and social (loneliness) problems begin to appear apparently after 75th year ( more in women) (Barba et al.., 2000)

Pulmonary Embolism in the Elderly – Significance and Particularities 45

in older patients may be the primary or sole manifestation of diseases with classic signs and symptoms in the young (e.g., pneumonia, myocardial infarction, pulmonary embolus, alcoholism or myxedema). These deficits have been named *geriatric syndromes*; they devastate independence without producing obvious or typical indications of disease. Geriatric syndromes may be defined as a set of lost specific functional capacities potentially caused by a multiplicity of pathologies in multiple organ systems. Comprehensive evaluation (Tinetti et al.., 2000) is usually required to identify and treat underlying causes. Although in many instances a geriatric syndrome has several contributing causes,

The most likely explanation for nonspecific presentation is that the additive effects of ageing restrict capacity to maintain homeostasis. Perturbation of homeostasis by disease, trauma, or drug toxicity will be manifested in the most vulnerable organ, or the weakest link, resulting from interactions of biologic ageing and chronic disease. In addition to nonspecific presentation, disease in older patients can present in other atypical ways. Blunting or absence of typical or classic symptoms and signs is well described in many conditions

Health status in ageing is a result of many factors, including the chronic diseases of ageing and many other prevalent conditions that cannot be defined as classic "diseases" because they do not result from a single pathologic cause. Many of the problems affecting aged individuals should be viewed as geriatric syndromes (GS), that are a collection of signs and symptoms with a number of potential causes (Hazzard, 2007). Only nowadays the causes

In spite of indisputable significance of the atypical clinical picture of diseases in the old age, the **crux of geriatric medicine** is involutionarity conditioned *decline of health potential*, *frailty* and *related geriatric syndromes* and *function deficiency* with their multicausal reasons. This status is connected with exhaustion of organ reservoirs – "**homeostenosis"**. Geriatric syndrome is different from the convenient meaning of the word "syndrome" in clinical medicine, where the symptoms are typical for certain disease (Inouye et al.., 2007; Pathy et al., 2006). For the geriatric syndromes numerous and various causes are typical which lead to the occurence of geriatric syndrome at the end. Geriatric syndromology is an essential component of the so-called comprehensive geriatric assessment (CGA) which is extended over the clinical examination in younger non-geriatric population (Gupta, 2008; (Gurcharan

remedying even one or a few may result in major functional improvement.

(Doucet et al.., 1994; Perez-Gusman et al.., 1999; Trivalle et al.., 1996).

& Mulley, 2007; Williams, 2008).

They are characterized by their:

c. Reduced independence

• incontinence,

a. Multicausality b. Chronic course

• **immobility** (pressure sore etc.),

• **iatrogenia** (dangerous polypharmacy).

d. Demanding care and difficult curability

• **anorexia syndrom and malnutrition** 

As further geriatric syndromes are respected (44,49):

• **syndrom of hypomobility, decondition and sarcopenia** 

and effective treatments of these conditions are beginning to be understood.

Geriatric giants (Chase et al.. , 2000; Sherman, 2003;) as geriatric syndromes (GS):

• **instability** (dizziness, posture and gait disorders, falls),

• **intellectual disorders** (delirium, dementia and depression),

*The old age and the disease cannot be considered the same thing* no matter how often it happens in both non-professional and professional community. In most cases the individual in old age is self-sufficient and fit until the last period of his/her life (many times until the last days). The dependence on care of the others comes with the disease, which can be both somatic and psychical. In between 65 and 75 years nearly 85% of people do not suffer from any significant modifying or common life restricting disease. Even in the age above 85 years 40% of the elderly can live self-sufficiently their normal life (Gammack & Morley, 2006).

Women live usually 7 – 8 years longer than men (Tallis & Fillit, 2003). The explanation can be found most likely in gender specific genetic factors and also in biological factors of the environment. The differences in surviving between genders has not changed even in contemporary era, when women smoke more often than ever before and perform originally male professions.

In gerontology we speak sometimes about the so-called **male overmortality**. The consequence of this phenomenon is increasing number of widows as the age increases. This is the base for the typical phenomenon in gerontology – the phenomenon of lonely old women. That fact indirectly increases the consumption of both institutional and noninstitutional care in the health and social sphere.

The beginning of the **social old age** is usually seen in the moment of entitlement to regular retirement or the actual retirement (Blackburn & Dulmus, 2007; Woodford & George, 2007). The classification of the human age in social sphere is as follows: *the first age* (before productive age, childhood and youth, learning, preparation for profession, acquisition of social experience), *the second age* (productive age, adulthood, biological productivity – breeding, economical and social productivity), *the third age* (postproductive, the old age), eventually *the fourth age* (the period of dependance), which does not take place in every person inevitably. The calendar age is uniquely determined but does not reflect the individual differences of the real health status among the human beings.

The determination of the age zones for the old age is conventional and it is a social frame outgoing from the administrative needs of the social state. In the demographic statistics it is usually worked with the border of 60 or 65 years. Nowadays the beginnig of the old age is thought 65 years and the old age itself is considered from 75 years on. From this pattern also the most used division of the old age results:


### **7. Geriatic syndromes and frailty as golden grale of geriatric medicine**

Presentation of illness in older persons less often is a single, specific symptom or sign, which in younger patients, announces the organ with pathology. Older persons often present with nonspecific problems that are in fact functional deficits (Kalvach et al., 2008). Stopping eating and drinking, or the new onset of falls, confusion, lethargy, dizziness, or incontinence

*The old age and the disease cannot be considered the same thing* no matter how often it happens in both non-professional and professional community. In most cases the individual in old age is self-sufficient and fit until the last period of his/her life (many times until the last days). The dependence on care of the others comes with the disease, which can be both somatic and psychical. In between 65 and 75 years nearly 85% of people do not suffer from any significant modifying or common life restricting disease. Even in the age above 85 years 40%

Women live usually 7 – 8 years longer than men (Tallis & Fillit, 2003). The explanation can be found most likely in gender specific genetic factors and also in biological factors of the environment. The differences in surviving between genders has not changed even in contemporary era, when women smoke more often than ever before and perform originally

In gerontology we speak sometimes about the so-called **male overmortality**. The consequence of this phenomenon is increasing number of widows as the age increases. This is the base for the typical phenomenon in gerontology – the phenomenon of lonely old women. That fact indirectly increases the consumption of both institutional and non-

The beginning of the **social old age** is usually seen in the moment of entitlement to regular retirement or the actual retirement (Blackburn & Dulmus, 2007; Woodford & George, 2007). The classification of the human age in social sphere is as follows: *the first age* (before productive age, childhood and youth, learning, preparation for profession, acquisition of social experience), *the second age* (productive age, adulthood, biological productivity – breeding, economical and social productivity), *the third age* (postproductive, the old age), eventually *the fourth age* (the period of dependance), which does not take place in every person inevitably. The calendar age is uniquely determined but does not reflect the

The determination of the age zones for the old age is conventional and it is a social frame outgoing from the administrative needs of the social state. In the demographic statistics it is usually worked with the border of 60 or 65 years. Nowadays the beginnig of the old age is thought 65 years and the old age itself is considered from 75 years on. From this pattern also




Presentation of illness in older persons less often is a single, specific symptom or sign, which in younger patients, announces the organ with pathology. Older persons often present with nonspecific problems that are in fact functional deficits (Kalvach et al., 2008). Stopping eating and drinking, or the new onset of falls, confusion, lethargy, dizziness, or incontinence

**7. Geriatic syndromes and frailty as golden grale of geriatric medicine** 

individual differences of the real health status among the human beings.

of the elderly can live self-sufficiently their normal life (Gammack & Morley, 2006).

male professions.

institutional care in the health and social sphere.

the most used division of the old age results:

rise of dependency.

the free time, activities, self-fulfillment.

changes connected with physiological ageing proceed.

in older patients may be the primary or sole manifestation of diseases with classic signs and symptoms in the young (e.g., pneumonia, myocardial infarction, pulmonary embolus, alcoholism or myxedema). These deficits have been named *geriatric syndromes*; they devastate independence without producing obvious or typical indications of disease. Geriatric syndromes may be defined as a set of lost specific functional capacities potentially caused by a multiplicity of pathologies in multiple organ systems. Comprehensive evaluation (Tinetti et al.., 2000) is usually required to identify and treat underlying causes. Although in many instances a geriatric syndrome has several contributing causes, remedying even one or a few may result in major functional improvement.

The most likely explanation for nonspecific presentation is that the additive effects of ageing restrict capacity to maintain homeostasis. Perturbation of homeostasis by disease, trauma, or drug toxicity will be manifested in the most vulnerable organ, or the weakest link, resulting from interactions of biologic ageing and chronic disease. In addition to nonspecific presentation, disease in older patients can present in other atypical ways. Blunting or absence of typical or classic symptoms and signs is well described in many conditions (Doucet et al.., 1994; Perez-Gusman et al.., 1999; Trivalle et al.., 1996).

Health status in ageing is a result of many factors, including the chronic diseases of ageing and many other prevalent conditions that cannot be defined as classic "diseases" because they do not result from a single pathologic cause. Many of the problems affecting aged individuals should be viewed as geriatric syndromes (GS), that are a collection of signs and symptoms with a number of potential causes (Hazzard, 2007). Only nowadays the causes and effective treatments of these conditions are beginning to be understood.

In spite of indisputable significance of the atypical clinical picture of diseases in the old age, the **crux of geriatric medicine** is involutionarity conditioned *decline of health potential*, *frailty* and *related geriatric syndromes* and *function deficiency* with their multicausal reasons. This status is connected with exhaustion of organ reservoirs – "**homeostenosis"**. Geriatric syndrome is different from the convenient meaning of the word "syndrome" in clinical medicine, where the symptoms are typical for certain disease (Inouye et al.., 2007; Pathy et al., 2006). For the geriatric syndromes numerous and various causes are typical which lead to the occurence of geriatric syndrome at the end. Geriatric syndromology is an essential component of the so-called comprehensive geriatric assessment (CGA) which is extended over the clinical examination in younger non-geriatric population (Gupta, 2008; (Gurcharan & Mulley, 2007; Williams, 2008).

Geriatric giants (Chase et al.. , 2000; Sherman, 2003;) as geriatric syndromes (GS):


They are characterized by their:


Pulmonary Embolism in the Elderly – Significance and Particularities 47

defined as a status of reduced physiological reserves connected with increased inclination towards invalidisation (falls, fractures, daily life restrictions, loss of independence – Leng, 2007; Walston, 2006). Apart from the clinical observations there is elevation of CRP, leukocytes (monocytes), IL-6, IL-1 and TNF. Frailty is not the synonym of multi-morbidity or disability, multi-morbidity can cause this and disability can be the consequence (Fried et al., 2005). **Frailty** *is understood mainly as a risk of sudden deterioration of the status of very risky person. (above 80 years, living alone or with handicapped spouse, with serious somatic or psychical disease).* The outcome for those defined frail seniors is the long term need of help of institutions and community (nursing service). The risks of the development of frailty (Friedman et al., 2006; Szanton et al., 2010) are represented by hypomobility in pre-senium, social isolation,

The concept of frailty is at least coming nearer to the term risky geront, used in the past. The emphasis is put on the retrieval of these people because they can not show their frailty out. Both (the ageing and physical frailty) are conditioned by the decline of proteosynthesis in the muscles, decline of immune function, elevation of the mass of fat in the body and lowering of the amount of body water, lowering of the bone mineral density, loss of the

The main etiological and patogenetic mechanisms (Leng et al., 2007; Walston et al., 2006) of

• loosing of spontaneous action – nutrition, hydration, movement, behavioral and social • dysfunction of autonomic nervous system ( falls, sarcopenia, decubital ulcer and healing – with the consequence like loosing the weight, incontinence, delirium,

• apathy – as the consequence of lack of the dopamine in CNS ( depression, dementia)

• menopausis and andropausis as the consequence of hormone deficiency with the development of the syndrome ADAM and PADAM, somatopausis as the result of lack

• functionally important consequences of chronic diseases which limit in an activity (hemiparesis, severe diabetic neuropathy, respiratory or heart insufficiency, hard

Polypharmacy is a common problem in the elderly. Particularly in those who have multiple comorbidities. Their therapy should be guided by the estimated life expectancy and

depression, bad subjective feeling of the own health etc.

• anorexia with loosing of the weight and malnutrition

• depression, anxious status, organic psychosyndrome

whole body mass and strength.

• fall of efficiency of lower hints

• the inflammation or hypercoagulation

disturbance in thermoregulation etc.)

• hypomobility with the sedentary lifestyle

anemia of chronic diseases) • adverse effects of the medicaments

**8. Polypharmacy in the elderly** 

• development of cognitive deficiency

the syndrome of frailty are:

• oxidative stress • insulin resistence

• sarcopenia

of IGF-1 • chronical pain

• chronic stress


The above mentioned geriatric syndromes not always threaten patient's life but they essentially influence quality of their following life (Fauci et al., 2008; Salvedt et al.., 2002). Patients become fully dependent on other people´s assistance (family, friends, neighbours, community services). Not exceptionally they must be admitted to an institutional care (hospitals, nursing homes etc.) because of domestic care system failure or necessity to manage an acute phase of a disease. The expression of the concept of geriatric syndromes in the last decades is a very fundamental step forward in geriatric medicine. The marked part of multi-morbid disabled handicapped seniors can be better understood and earlier and effectively solved (Williams, 2008). GS are more complicated problem with inner connections very often. Their proper identification is made possible by:


The involutionary loss of muscle tissue in the old age is called **sarcopenia** and it is characterized by reduction of muscle tissue, reduction of the force, tenacity, plasticity and speed of contraction (Roubenoff & Hughes, 2000a). The probable cause of sarcopenia in senium (Roubenoff, 2000b) is apart from somatopausis (lowered level of anabolic IGF-1, growth hormone and testosterone) also influence of oxidatory stress and free radicals produced by muscle mitochondrias (Masoro & Austad, 2006). The metabolic result of sarcopenia in the old age is also impaired glucose tolerance and higher risk of diabetes of 2nd type (Fauci et al., 2008; Sinclair & Finucane, 2001).

The meaningful concept which is tightly connected with ageing is **frailty** (Friedman et al., 2008; Rockwood & Hubbard, 2004; Woodhouse & O'Mahony, 1997). This belongs to key characteristics of geriatric patients, the next milestone and the keystone of geriatric medicine. Frailty is a biologic syndrome (Crome & Lally, 2011) of decreased reserves in multiple systems that results from dysregulation that can occur with ageing and is initiated by physiological changes of ageing, disease, and/or lack of activity or inadequate nutritional intake.

It is rather more multidimensional concept than just the expression of a degree of dependence in the everyday life activities. Frailty is basically connected with the grow of fatal somatic ailments and lowering of functional reserve of the old person, which is wasting away excessively without any fundamental cause disease (Juraskova et al., 2010). **Frailty** can be defined as a status of reduced physiological reserves connected with increased inclination towards invalidisation (falls, fractures, daily life restrictions, loss of independence – Leng, 2007; Walston, 2006). Apart from the clinical observations there is elevation of CRP, leukocytes (monocytes), IL-6, IL-1 and TNF. Frailty is not the synonym of multi-morbidity or disability, multi-morbidity can cause this and disability can be the consequence (Fried et al., 2005).

**Frailty** *is understood mainly as a risk of sudden deterioration of the status of very risky person. (above 80 years, living alone or with handicapped spouse, with serious somatic or psychical disease).* The outcome for those defined frail seniors is the long term need of help of institutions and community (nursing service). The risks of the development of frailty (Friedman et al., 2006; Szanton et al., 2010) are represented by hypomobility in pre-senium, social isolation, depression, bad subjective feeling of the own health etc.

The concept of frailty is at least coming nearer to the term risky geront, used in the past. The emphasis is put on the retrieval of these people because they can not show their frailty out. Both (the ageing and physical frailty) are conditioned by the decline of proteosynthesis in the muscles, decline of immune function, elevation of the mass of fat in the body and lowering of the amount of body water, lowering of the bone mineral density, loss of the whole body mass and strength.

The main etiological and patogenetic mechanisms (Leng et al., 2007; Walston et al., 2006) of the syndrome of frailty are:


46 Pulmonary Embolism

The above mentioned geriatric syndromes not always threaten patient's life but they essentially influence quality of their following life (Fauci et al., 2008; Salvedt et al.., 2002). Patients become fully dependent on other people´s assistance (family, friends, neighbours, community services). Not exceptionally they must be admitted to an institutional care (hospitals, nursing homes etc.) because of domestic care system failure or necessity to manage an acute phase of a disease. The expression of the concept of geriatric syndromes in the last decades is a very fundamental step forward in geriatric medicine. The marked part of multi-morbid disabled handicapped seniors can be better understood and earlier and effectively solved (Williams, 2008). GS are more complicated problem with inner

• **syndrom of dual combined sensoric deficiency (visual and hearing)** 

• **syndrom of terminal geriatric deterioration - FTT** ("failure to thrive")

connections very often. Their proper identification is made possible by:

• attempting to influence the disinterest and weariness by interesting daily activity • using all of the occupational utilities, which can minimise the dependence ( walker, rods, crutches, wheelchairs and other – glasses, magnifying glass, hearing aids

• adjustment of the living ( lightning, grab handles on toilet and corridors, the correct

The involutionary loss of muscle tissue in the old age is called **sarcopenia** and it is characterized by reduction of muscle tissue, reduction of the force, tenacity, plasticity and speed of contraction (Roubenoff & Hughes, 2000a). The probable cause of sarcopenia in senium (Roubenoff, 2000b) is apart from somatopausis (lowered level of anabolic IGF-1, growth hormone and testosterone) also influence of oxidatory stress and free radicals produced by muscle mitochondrias (Masoro & Austad, 2006). The metabolic result of sarcopenia in the old age is also impaired glucose tolerance and higher risk of diabetes of 2nd

The meaningful concept which is tightly connected with ageing is **frailty** (Friedman et al., 2008; Rockwood & Hubbard, 2004; Woodhouse & O'Mahony, 1997). This belongs to key characteristics of geriatric patients, the next milestone and the keystone of geriatric medicine. Frailty is a biologic syndrome (Crome & Lally, 2011) of decreased reserves in multiple systems that results from dysregulation that can occur with ageing and is initiated by physiological

It is rather more multidimensional concept than just the expression of a degree of dependence in the everyday life activities. Frailty is basically connected with the grow of fatal somatic ailments and lowering of functional reserve of the old person, which is wasting away excessively without any fundamental cause disease (Juraskova et al., 2010). **Frailty** can be

changes of ageing, disease, and/or lack of activity or inadequate nutritional intake.

• optimal coordination of community and institutional services • influence on anorexia by adjustment of nutrition ( proteins 1.3g/kg) • psychotherapeutical support with elimination of the depression • lasting physiotherapy ( everyday walking at least for 30minutes)

• **syndrom of thermoregulatory disturbance** 

• **syndrom of geriatric maladaptation** 

• screeenig tests and observation

• recondition programs

hight of the bed and furniture)

type (Fauci et al., 2008; Sinclair & Finucane, 2001).

• optimalisation of geriatric hospital regime

• **syndrom of elder abuse, neglect and self-neglect sy** 

• **syndrom of dehydration with subsequent manifestation of acute renal failure** 

