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

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 older adults:


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 similar.

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

Pulmonary Embolism in the Elderly – Significance and Particularities 41

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. Falls, which occur in one third of older adults, result in injuries, fractures, and high risk for disability and mortality. Severe cognitive impairment and urinary incontinence have a substantial adverse impact on an elderly person, as does sensory isolation resultnig from hearing and visual impairment; all

Older patients differ from young or middle-aged adults with the same disease in many ways, one of which is the frequent occurrence of comorbidities and of subclinical disease. A second way in which older adults differ from younger adults is the greater likelihood that their diseases present with nonspecific symptoms and signs. As a result, the diagnostic evaluation of geriatric patients must consider a wider spectrum of diseases than generally

Ageing and advanced age is a terminal phase of ontogenetic development of every individual (Beers et al., 2006; Pathy et al., 2006). **Specific degenerative morphological** and **functional changes** occur in individual organs at all levels from the cells to whole organism (Heltweg, 2006). Important role in aging is **apoptosis.** In the cell, which may compromise the body (eg, activated leukocyt, as malignant cells), respectively a correction would be

Despite the biologic controversy, from a physiologic standpoint human ageing is characterized by progressive constriction of the homeostatic reserve of every organ system. This decline, often referred to as *homeostenosis*, is obvious by the third decade and is gradual and progressive, although the rate and extent of decline vary. The decline of each organ system appears to occur independently of changes in other organ systems and is influenced

Even beyond age 85, only 30% of people are impaired in any activity required for daily living and only 20% reside in a nursing home. Yet, as individuals age they are more likely to suffer from disease, disability, and the side effects of drugs, all of which, when combined with the decrease in physiologic reserve, make the older person more vulnerable to

This happens in different periods of times and in different speed. It affects any living substance from the moment of it's birth (conception). The life expectancy of an individual in nature is species specific and has important inter-individual variability. Ageing speed of an individual is genetically coded – it is presumed that this type of genetics is a multi-factorial one (Masoro & Austad, 2006). Maximum potential life expectancy of a human being attainable under ideal circumstances could be 110 - 120 y. The influence of genetic factor on the life expectancy is considered about 35 per cent. The resting 65 per cent represent an

by diet, environment, and personal habits as well as by genetic factors.

environmental, pathologic, and pharmacologic challenges.

influence of a life style and external environment. Common and **typical features of ageing** in general:

alone (Leng et al.., 2007; Yaffe et al.., 2007).

of these conditions are frequent with aging.

would be considered in middle-aged adults.

difficult to run programmed cell death.

**4. Biology of ageing** 

of patients contains those with higher risk of falls, dementia syndrome, with very bad mobility, labile somatic disease (i.e. frail cardiac with repeated cardiac failure or electric instability), also with complicated orientation (visual disturbance and hearing loss), people in social distress and very old above 85 years old, especially when they live

bacteriuria, premature ventricular contractions, and slowed reaction time. In addition, many older patients with multiple comorbidities may have laboratory abnormalities that, while pathologic, may not be clinically important. A complete workup for a mild anemia of chronic disease in a person with multiple other issues might be burdensome to the patient with little chance of impacting quality of life or longevity.

Ageing is associated with a decline in expectation of healthiness. Those over age 65 generally give more positive evaluations of their healthiness in the face of increasing burden of disease and disability (Kriegsman et al.., 1996; Tinetti et al., 2000). The older the person is, the more likely they are to report very good health status (Gross et al.., 1996). However, overestimating healthiness (also called normalization) often results in explaining away symptoms or problems as caused by minor illnesses or even by external events. In either case, late recognition and delayed intervention are the usual outcome. Previous neglecting of symptoms by health care professionals is also likely to teach older patients that frailty and loss of independence are normal and to be expected with ageing; again, late detection and intervention are likely, resulting in high cost and discouraging outcomes. Perhaps these attitudes explain the finding of greater pessimism in older persons compared with those middle-aged, even when health status was factored in. *Underreporting of symptoms* is a common theme in discussions of illness behavior of older persons.

The problems identified were common and usually treatable diseases; congestive heart failure, correctable hearing and vision deficits, tuberculosis, incontinence, anemia, bronchitis, claudication, cancers, malnutrition, diabetes, immobility, oral disease preventing eating, dementia, and depression were frequent. Considerable underreporting was also seen among people with chronic diseases. More than a half of chronically ill individuals, who were surveyed in one study, failed to report at least one disease. Older people tend to report inaccurately cardiac disease, arthritis, and stroke (Kriegsman et al.., 1996).

The riskiness of underreporting of symptoms by older patients is obvious; late identification of disease (inclusive of PE) leads to late initiation of treatment, usually after substantial morbidity associated with advanced pathology has already occurred and caused major functional losses. Rehabilitation to independence from these losses is difficult; permanent dependence in spite of "successful" treatment may occur.

Majority of all biological functions culminates before the age of 30 y. Some of them gradually continuously decrease afterwards (Masoro & Austad, 2006). This decay is practically of no significance in terms of current everyday activity but it can matter under stress or extended load (Humes, 2000; Hunter et al., 2002).

Seniors as such represent very heterogenous group and from the point of wiev of fitness, risk and need of help (or specific service) they can be divided to the 3 basic areas with different focus of health attention:


of patients contains those with higher risk of falls, dementia syndrome, with very bad mobility, labile somatic disease (i.e. frail cardiac with repeated cardiac failure or electric instability), also with complicated orientation (visual disturbance and hearing loss), people in social distress and very old above 85 years old, especially when they live alone (Leng et al.., 2007; Yaffe et al.., 2007).

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. Falls, which occur in one third of older adults, result in injuries, fractures, and high risk for disability and mortality. Severe cognitive impairment and urinary incontinence have a substantial adverse impact on an elderly person, as does sensory isolation resultnig from hearing and visual impairment; all of these conditions are frequent with aging.

Older patients differ from young or middle-aged adults with the same disease in many ways, one of which is the frequent occurrence of comorbidities and of subclinical disease.

A second way in which older adults differ from younger adults is the greater likelihood that their diseases present with nonspecific symptoms and signs. As a result, the diagnostic evaluation of geriatric patients must consider a wider spectrum of diseases than generally would be considered in middle-aged adults.
