**10. Multimorbidity in old age and its relations**

Multiple pathology, or concurrence of diseases, is common among older persons. An early Scottish study of community-dwelling persons over age 65 reported 3.5 major problems per person; for those being admitted to hospitals, 6 disorders were documented per patient. Multiple pathology (Crome & Lally, 2011) poses multiple risks to older patients and their physicians. The first hazard is that active medical problems frequently interact to the detriment of the patient -*disease-disease interactions*.

Late detection of treatable problems whose neglecting and interaction have led to functional decline is common in older patients and can be one of the few discouraging features of geriatric care. Preventive dental and medical care could have avoided the sepsis, worsening of diabetes, fall, hip fracture, postoperative heart attack, stroke, and loss of independent living.

The interaction between old age and illness causes specific changes of diseases in senium (Beers et al., 2006; Pathy et al., 2006; Ratnaike, 2002).

Particularities of illness in old age include:


Pulmonary Embolism in the Elderly – Significance and Particularities 51

any practical importance, but can be relevant in the time of bigger stress or in the load. The physiological processes which are decreasing as the age grows are: blood flow through the kidneys, the clearance of the creatinin, the maximum heart rate and pulse volume in stress, glucose tolerance, vital capacity of the lungs, body weight, cell immunity. On the contrary the total lung capacity and the liver function do not change with increasing age, the

Many of mentioned declines, which were thought as natural consequence of the ageing, are significantly influenced by the life style, behaviour, diet and environment in which the senior has been living. The most important physiological change in old age is the predisposition to the higher occurrence of severe diseases. The respiratory functions of a 70 year old healthy man are the 50% of the 30 years old man. The renal function usually goes down in 70 years by 50% and more. This decline in physiological reserve capacity does not influence the everyday life but it can influence the ability to recover from the severe disease

Some of the physiological changes can simulate a disease even if they are just a usual component of the ageing. Diabetes mellitus can appear and disappear in the old age. The ability of the insulin to stimulate the take up of the glucose declines with the age and is usually manifested as postprandial hyperglycaemia with normal fasting level of insulin and glucose. In the stress situations diabetes can be detected in seniors, but it can disappear when the situation gets normal. This loss of the physiological reserves contributes to the

The age conditioned changes, which make the old age people more vulnerable in their everyday life, are usually mild. In the elderly there is an onset of hypo- or hyperthermia easier during the exposition to extreme surrounding influences, because there are a lot of changes in the coordination of the lead of the thermoregulation also in the neurological area. The loss of neurotransmitters in brain stem can cause typical senile walk, as well as it predisposes genetically determined individuals for e.g. to the progress of the Parkinson's disease. Some of the age conditioned changes cause the specific consequences. The menopausis is the physiological process connected with normal ageing but it leads to the symptoms, which predispose the organism to the loss of the bone mass and atherosclerosis. Apart from clinically obvious forms of the diseases in the elderly the sub-clinical form is common as well. Among 6 000 individuals above 65 years which were in the Cardiovascular Health Study (Fried et al., 1991) 31% of them had clinically apparent cardiovascular disease, another 37% had sub-clinical form of the disease which was found by non-invasive

The half of the people above 65 years have two or more diseases and these can mean an added risk of unfavourable consequences like mortality. In some of the seniors the cognitive disturbance can imitate symptoms of a severe disease. The therapy of one disease can act in an undesirable way on the other place – such as e.g. use of aspirin as the prevention of the ictus in the individual with the anamnesis of the gastroduodenal ulcer. The risk leading to disability or dependence on the help is getting higher with the number of co-morbidities. Certain couplets of the diseases can increase the risk of disability synergistically. The arthrosis and the diseases of the heart co-exist in 1/5 of the elderly, even though the risks of progress of disability are 3- or 4-times higher with one of them alone, the risk of both

At the end the severe and common consequence of the chronic disease in old age is physical disability, defined as the presence of difficulties or dependence on the others when

(grave infection, life threatening internal diseases, operations, injuries etc.)

production of the ADH is even growing.

rising prevalence of diabetes with the rising age.

together is 14-times higher (Cassel et al., 1997).

methods.


The proper symptomathology of the basic disease is usually inconspicuous. In the clinical picture manifestation of non-specific and universal symptoms dominates. These are the results of the secondary brain decompensation. Among those the universal *neurologic and psychiatric symptomathology* conditioned on hypo-perfusion (hypoxia) of the brain (TIA, delirium etc.) belong. The senior's brain is usually affected with the degenerative or vascular changes and reacts usually as the first organ.

Among the causes of the morbidity in old age the forward position (Tallis & Fillit, 2003) is being taken by the diseases of the cardiovascular system conditioned with atherosclerosis like CHD (coronary heart disease), MI (myocardial infarction), angina pectoris, stroke, transient ischemic attack, ischemic disease of the lower limbs (atherosclerosis - AS is present in 90% of the people above 75 years.). In old age we find common: the diseases of the locomotive system, sense organs, tumours, accidental injuries, the diseases of the respiratory tract, gastrointestinal tract (biliary problems etc.) and urogenital tract (the prostate in men, gynecological in women). Diabetes, mental and neurological disorders are common (Beckman et al., 2002; Sinclair & Finucane, 2003). Their coincidental and usually independent occurrence is typical for the senior's multi-morbidity. After the age of 60 there is continuous increase mainly of the cardiovascular diseases as CHD, stroke, hypertension (Ferrari, 2003; Oskvig, 1999). Similarly with the age prevalence of diabetes rises (Sinclair & Finucane, 2003).

For the quality of the senior's life crucial matter is not the presence of the disease itself (or more diseases) but the grade of the disability, it means functional disturbance, into which it is proceeding. The full self-sufficiency can be untouched even when there are more diseases present together.

The inclination of the seniors to the diseases is higher (Khaw, 1997) and the balance of the organ homeostasis is very frail (eg. homeostenosis). Similarly it is the case of "primary" mental disorders (dementia, depression, delirium) or in the geriatric social syndromes (neglect sy, elder abuse, geriatric maladaptation sy). The stressor is usually in psychosocial sphere and its clinical manifestation appears most often in cardiovascular area (heart failure, MI, stroke) or in impaired immunity (pneumonia).

As it was mentioned, the diseases and the morbid conditions in old age are marked by many extraordinarities. The diseases in old age have the tendency to cumulate and potentiate each other. In the geriatric medicine multidimensionality is typical. It is needed to comprehend the sick person in old age as the bio-psycho-social unit in more holistic way than in younger age from the viewpoint of etiopatogenesis of the disease and also in the case of everyday clinical practice.

The quoted problems from the somatic, psychic and social areas which are in the mutual interaction are hardly treatable, they are chronic with the progression of the condition and they have relatively unfavourable prognosis. They bring a lot of hardly solvable situations and problems to the ill and the surroundings. By the "old old" people ( ≥ 80 years) the diseases proceed in the way (Crome & Lally, 2011), which differ from the progress of the diseases in middle age and they need the different approach which can improve the health condition or at least maintain the self-sufficiency and they accent the comeback home.

The most of the biological functions achieve the top before the 30th year of the life. Some of them slightly decrease afterwards linearly. For the everyday activity this decrease has not

5. tendency to complications - either of type of "chain reaction" or it is the complication,

6. atypical picture of the diseases – "For the diseases in the old age it is typical that their

The proper symptomathology of the basic disease is usually inconspicuous. In the clinical picture manifestation of non-specific and universal symptoms dominates. These are the results of the secondary brain decompensation. Among those the universal *neurologic and psychiatric symptomathology* conditioned on hypo-perfusion (hypoxia) of the brain (TIA, delirium etc.) belong. The senior's brain is usually affected with the degenerative or vascular

Among the causes of the morbidity in old age the forward position (Tallis & Fillit, 2003) is being taken by the diseases of the cardiovascular system conditioned with atherosclerosis like CHD (coronary heart disease), MI (myocardial infarction), angina pectoris, stroke, transient ischemic attack, ischemic disease of the lower limbs (atherosclerosis - AS is present in 90% of the people above 75 years.). In old age we find common: the diseases of the locomotive system, sense organs, tumours, accidental injuries, the diseases of the respiratory tract, gastrointestinal tract (biliary problems etc.) and urogenital tract (the prostate in men, gynecological in women). Diabetes, mental and neurological disorders are common (Beckman et al., 2002; Sinclair & Finucane, 2003). Their coincidental and usually independent occurrence is typical for the senior's multi-morbidity. After the age of 60 there is continuous increase mainly of the cardiovascular diseases as CHD, stroke, hypertension (Ferrari, 2003; Oskvig, 1999). Similarly

For the quality of the senior's life crucial matter is not the presence of the disease itself (or more diseases) but the grade of the disability, it means functional disturbance, into which it is proceeding. The full self-sufficiency can be untouched even when there are more diseases

The inclination of the seniors to the diseases is higher (Khaw, 1997) and the balance of the organ homeostasis is very frail (eg. homeostenosis). Similarly it is the case of "primary" mental disorders (dementia, depression, delirium) or in the geriatric social syndromes (neglect sy, elder abuse, geriatric maladaptation sy). The stressor is usually in psychosocial sphere and its clinical manifestation appears most often in cardiovascular area (heart failure,

As it was mentioned, the diseases and the morbid conditions in old age are marked by many extraordinarities. The diseases in old age have the tendency to cumulate and potentiate each other. In the geriatric medicine multidimensionality is typical. It is needed to comprehend the sick person in old age as the bio-psycho-social unit in more holistic way than in younger age from the viewpoint of etiopatogenesis of the disease and also in the case of everyday

The quoted problems from the somatic, psychic and social areas which are in the mutual interaction are hardly treatable, they are chronic with the progression of the condition and they have relatively unfavourable prognosis. They bring a lot of hardly solvable situations and problems to the ill and the surroundings. By the "old old" people ( ≥ 80 years) the diseases proceed in the way (Crome & Lally, 2011), which differ from the progress of the diseases in middle age and they need the different approach which can improve the health condition or at least maintain the self-sufficiency and they accent the comeback home. The most of the biological functions achieve the top before the 30th year of the life. Some of them slightly decrease afterwards linearly. For the everyday activity this decrease has not

which does not have the direct relation ("crowd-out effect")

with the age prevalence of diabetes rises (Sinclair & Finucane, 2003).

MI, stroke) or in impaired immunity (pneumonia).

running is atypical"

present together.

clinical practice.

changes and reacts usually as the first organ.

any practical importance, but can be relevant in the time of bigger stress or in the load. The physiological processes which are decreasing as the age grows are: blood flow through the kidneys, the clearance of the creatinin, the maximum heart rate and pulse volume in stress, glucose tolerance, vital capacity of the lungs, body weight, cell immunity. On the contrary the total lung capacity and the liver function do not change with increasing age, the production of the ADH is even growing.

Many of mentioned declines, which were thought as natural consequence of the ageing, are significantly influenced by the life style, behaviour, diet and environment in which the senior has been living. The most important physiological change in old age is the predisposition to the higher occurrence of severe diseases. The respiratory functions of a 70 year old healthy man are the 50% of the 30 years old man. The renal function usually goes down in 70 years by 50% and more. This decline in physiological reserve capacity does not influence the everyday life but it can influence the ability to recover from the severe disease (grave infection, life threatening internal diseases, operations, injuries etc.)

Some of the physiological changes can simulate a disease even if they are just a usual component of the ageing. Diabetes mellitus can appear and disappear in the old age. The ability of the insulin to stimulate the take up of the glucose declines with the age and is usually manifested as postprandial hyperglycaemia with normal fasting level of insulin and glucose. In the stress situations diabetes can be detected in seniors, but it can disappear when the situation gets normal. This loss of the physiological reserves contributes to the rising prevalence of diabetes with the rising age.

The age conditioned changes, which make the old age people more vulnerable in their everyday life, are usually mild. In the elderly there is an onset of hypo- or hyperthermia easier during the exposition to extreme surrounding influences, because there are a lot of changes in the coordination of the lead of the thermoregulation also in the neurological area. The loss of neurotransmitters in brain stem can cause typical senile walk, as well as it predisposes genetically determined individuals for e.g. to the progress of the Parkinson's disease. Some of the age conditioned changes cause the specific consequences. The menopausis is the physiological process connected with normal ageing but it leads to the symptoms, which predispose the organism to the loss of the bone mass and atherosclerosis.

Apart from clinically obvious forms of the diseases in the elderly the sub-clinical form is common as well. Among 6 000 individuals above 65 years which were in the Cardiovascular Health Study (Fried et al., 1991) 31% of them had clinically apparent cardiovascular disease, another 37% had sub-clinical form of the disease which was found by non-invasive methods.

The half of the people above 65 years have two or more diseases and these can mean an added risk of unfavourable consequences like mortality. In some of the seniors the cognitive disturbance can imitate symptoms of a severe disease. The therapy of one disease can act in an undesirable way on the other place – such as e.g. use of aspirin as the prevention of the ictus in the individual with the anamnesis of the gastroduodenal ulcer. The risk leading to disability or dependence on the help is getting higher with the number of co-morbidities. Certain couplets of the diseases can increase the risk of disability synergistically. The arthrosis and the diseases of the heart co-exist in 1/5 of the elderly, even though the risks of progress of disability are 3- or 4-times higher with one of them alone, the risk of both together is 14-times higher (Cassel et al., 1997).

At the end the severe and common consequence of the chronic disease in old age is physical disability, defined as the presence of difficulties or dependence on the others when

Pulmonary Embolism in the Elderly – Significance and Particularities 53

enlarge, and it may eventually fail to perform. A large PE can cause heart or lung failure. This seems to be especially important in advanced age where CHD (heart failure too) has growing tendency. Fortunatelly chances of surviving a PE increase when a physician can

The acquired and genetic factors contribute to the likelihood of VTE. The acquired predispositions include generally long-haul air travel, obesity (Barba et al., 2008), cigarette smoking, oral contraceptives, pregnancy, postmenopausal hormone replacement (LaCroix et al., 2011; Sare, 2008), surgery (Einstein et al., 2008; Secin et al., 2008), trauma, and medical conditions such as antiphospholipid antibody syndrome, cancer, systemic arterial hypertension, and chronic obstructive pulmonary disease. Some patients with predisposing

PE and DVT are common problems in the elderly (Kniffin et al., 1994). They both increase with age, but the effects of race and sex are small. Current treatment patterns appear to be effective in preventing both PE after DVT and recurrence of PE. They both are associated with substantial 1-year mortality, suggesting the need to understand the role of associated conditions as well as the indications for prophylaxis and the methods of treatment. Gangireddy (Gangireddy et al., 2007) describes preoperative risk factors associated with symptomatic VTE older age, male gender, corticosteroid usage, COPD, recent weight loss, disseminated cancer, low albumin, and low haematocrit but not DM. Patients with a low probability of PE have a good prognosis in comparison to those having risk factors (Bertoletti et al., 2011). In isolation, they have limited diagnostic value and none can be used

Necropsy studies in the United Kingdom (Alikhan et al., 2004) and Sweden (Hansson et al., 1997; Nordstrom et al., 1998) continued to show a high incidence of PE, which was considered the main cause of death in about 10% of necropsies. Since the inpatient mortality in general hospitals is about 10%, it is estimated that about 1% of patients admitted to hospital die from PE. However, for every patient who dies of PE in a surgical ward, three die in nonsurgical wards. This is not only a common problem but a serious one: the inhospital mortality of elderly patients over the age of 65 with documented pulmonary embolism was 21% in the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED, 1990) Study, and the 1-year mortality was 39% (Stein, 2008).Recent data suggest

The clinical non-recognition of venous thrombembolism prior to fatal PE implies that its detection and treatment cannot have a major impact on its mortality; hence, identificaton and primary prophylaxis of hospitalized in-patients (medical and surgical) at high absolute

The high occurrence of PE (particularly its silent form) has crucial importance in the elderly mortality. Our recommendations would like to emphasize the need of no underestimation of this fact and to carry out preventive measures in all age groups (including "oldest old"

Immobilization in medical ward is due to illness (e.g. infection, malignancy, heart failure, myocardial infarction and stroke). The cumulative risk of DVT and PE increases with the duration of immobility, suggesting a role for venous stasis in the inactive leg in the

Prophylaxis against PE is of paramount importance because venous thromboembolism is difficult to detect and poses an excessive medical and economic burden (Kakkar et al., 2010).

genetic factors will never develop clinical evidence of clotting (Reynolds et al., 2009).

to rule in or rule out PE without further testing (West et al., 2007).

these numbers may be even higher (Heit et al., 1998).

risk of DVT is required for its prevention.

and frail persons.

pathogenesis of DVT.

diagnose and treat the patient quickly.

doing common everyday activities, from the basic self-service ( the toilet and washing up) to the tasks needed for leading the independent life ( shopping, preparing food, paying the bills etc.).

On the onset and the progress of the critical conditions in old age following factors can significantly participate: the poor mobility, loneliness, bad eating habits, insufficient hydration, mental deterioration, disturbance of the sight and hearing. The mentioned ill individuals have, as it is with multi-morbidity in old age common, an atypical picture, or they can be without symptoms or the problems are seemingly moved to the other organ area. The important role is played also often by rich pharmacotherapy in old age, which can itself cause different organ symptoms (also by the mutual interactions).

The management of the critical ill persons in old age will demand very active approach from the all clinical doctors (not only intensivists) and sometimes also usage of more invasive procedures in the diagnostics and therapy of PE, which can act unfavourably in some of the cases and sometimes also iatrogenically.

#### **11. Pulmonary embolism in the elderly – General view of a geriatritian**

The entities of deep venous thrombosis (DVT) and pulmonary embolism (PE) present a continuum of venous thromboembolic disease (VTE), which is of crucial importance for elderly patients, and offer constant diagnostic and therapeutic challenges to physicians caring for patients of any age. For multiple reasons, the incidence of both DVT and PE increase with age (Hansson et al., 1997). First, there is often a decrease in the leg muscle mass, setting the stage for stasis. There are increased thrombotic tendencies in the elderly (Price et al., 1997), beginning around the age of 60, which may involve up to 20% of those over age 85; these include impaired vascular wall fibrinolysis and hypercoagulable states.

The diagnosis of venous thrombembolism (VTE) in the elderly is difficult, although the presentation is usually quite similar to that seen in younger patient groups (Matějovská-Kubešová et al., 2009). The most common presenting symptom of PE is some complaint of chest discomfort or pain, seen in approximately 35% of patients in most series, usually without hemoptysis. Dyspnea and tachypnea occur frequently. Although circulatory collapse occurs in a relatively small proportion of the elderly, these latter patients are much more likely to have sustained massive pulmonary emboli and often have evidence of neurologic deficits and findings of pulmonary hypertension. Although virtually all younger patients present with one of these syndromes, about 10% of the elderly do not, and in the setting of respiratory distress this minority may show only confusion or atypical new radiographic findings. The major diagnostic strategy (Wells, 1998) required is one of constant suspicion and concern and a consideration that, in any older hospitalized patient who is "failing to thrive," to ask whether this could be due to pulmonary embolism, because both the symptoms and standard laboratory findings are nonspecific and the diagnosis is too often made postmortem. The classic triad of hemoptysis, pleuritic chest pain, and clinically apparent thrombophlebitis is infrequently seen, in less than 10% of elderly patients with VTE.

Half of the people, who have PE, have no symptoms. With increasing age the amount of people with silent PE is growing. This is, after myocard infarction and cerebrovascular events, the third most frequent cardiovascular cause of the death. Simultaneously it is one of the least often correctly diagnosed cardiovascular diseases.

That is a medical emergency because a large embolism, or sometimes many repeated smaller ones, can be fatal in a short time. When the heart is continually overworked, it may

doing common everyday activities, from the basic self-service ( the toilet and washing up) to the tasks needed for leading the independent life ( shopping, preparing food, paying

On the onset and the progress of the critical conditions in old age following factors can significantly participate: the poor mobility, loneliness, bad eating habits, insufficient hydration, mental deterioration, disturbance of the sight and hearing. The mentioned ill individuals have, as it is with multi-morbidity in old age common, an atypical picture, or they can be without symptoms or the problems are seemingly moved to the other organ area. The important role is played also often by rich pharmacotherapy in old age, which can

The management of the critical ill persons in old age will demand very active approach from the all clinical doctors (not only intensivists) and sometimes also usage of more invasive procedures in the diagnostics and therapy of PE, which can act unfavourably in some of the

The entities of deep venous thrombosis (DVT) and pulmonary embolism (PE) present a continuum of venous thromboembolic disease (VTE), which is of crucial importance for elderly patients, and offer constant diagnostic and therapeutic challenges to physicians caring for patients of any age. For multiple reasons, the incidence of both DVT and PE increase with age (Hansson et al., 1997). First, there is often a decrease in the leg muscle mass, setting the stage for stasis. There are increased thrombotic tendencies in the elderly (Price et al., 1997), beginning around the age of 60, which may involve up to 20% of those over age 85; these include impaired vascular wall fibrinolysis and hypercoagulable states. The diagnosis of venous thrombembolism (VTE) in the elderly is difficult, although the presentation is usually quite similar to that seen in younger patient groups (Matějovská-Kubešová et al., 2009). The most common presenting symptom of PE is some complaint of chest discomfort or pain, seen in approximately 35% of patients in most series, usually without hemoptysis. Dyspnea and tachypnea occur frequently. Although circulatory collapse occurs in a relatively small proportion of the elderly, these latter patients are much more likely to have sustained massive pulmonary emboli and often have evidence of neurologic deficits and findings of pulmonary hypertension. Although virtually all younger patients present with one of these syndromes, about 10% of the elderly do not, and in the setting of respiratory distress this minority may show only confusion or atypical new radiographic findings. The major diagnostic strategy (Wells, 1998) required is one of constant suspicion and concern and a consideration that, in any older hospitalized patient who is "failing to thrive," to ask whether this could be due to pulmonary embolism, because both the symptoms and standard laboratory findings are nonspecific and the diagnosis is too often made postmortem. The classic triad of hemoptysis, pleuritic chest pain, and clinically apparent thrombophlebitis is

Half of the people, who have PE, have no symptoms. With increasing age the amount of people with silent PE is growing. This is, after myocard infarction and cerebrovascular events, the third most frequent cardiovascular cause of the death. Simultaneously it is one of

That is a medical emergency because a large embolism, or sometimes many repeated smaller ones, can be fatal in a short time. When the heart is continually overworked, it may

**11. Pulmonary embolism in the elderly – General view of a geriatritian** 

itself cause different organ symptoms (also by the mutual interactions).

infrequently seen, in less than 10% of elderly patients with VTE.

the least often correctly diagnosed cardiovascular diseases.

cases and sometimes also iatrogenically.

the bills etc.).

enlarge, and it may eventually fail to perform. A large PE can cause heart or lung failure. This seems to be especially important in advanced age where CHD (heart failure too) has growing tendency. Fortunatelly chances of surviving a PE increase when a physician can diagnose and treat the patient quickly.

The acquired and genetic factors contribute to the likelihood of VTE. The acquired predispositions include generally long-haul air travel, obesity (Barba et al., 2008), cigarette smoking, oral contraceptives, pregnancy, postmenopausal hormone replacement (LaCroix et al., 2011; Sare, 2008), surgery (Einstein et al., 2008; Secin et al., 2008), trauma, and medical conditions such as antiphospholipid antibody syndrome, cancer, systemic arterial hypertension, and chronic obstructive pulmonary disease. Some patients with predisposing genetic factors will never develop clinical evidence of clotting (Reynolds et al., 2009).

PE and DVT are common problems in the elderly (Kniffin et al., 1994). They both increase with age, but the effects of race and sex are small. Current treatment patterns appear to be effective in preventing both PE after DVT and recurrence of PE. They both are associated with substantial 1-year mortality, suggesting the need to understand the role of associated conditions as well as the indications for prophylaxis and the methods of treatment. Gangireddy (Gangireddy et al., 2007) describes preoperative risk factors associated with symptomatic VTE older age, male gender, corticosteroid usage, COPD, recent weight loss, disseminated cancer, low albumin, and low haematocrit but not DM. Patients with a low probability of PE have a good prognosis in comparison to those having risk factors (Bertoletti et al., 2011). In isolation, they have limited diagnostic value and none can be used to rule in or rule out PE without further testing (West et al., 2007).

Necropsy studies in the United Kingdom (Alikhan et al., 2004) and Sweden (Hansson et al., 1997; Nordstrom et al., 1998) continued to show a high incidence of PE, which was considered the main cause of death in about 10% of necropsies. Since the inpatient mortality in general hospitals is about 10%, it is estimated that about 1% of patients admitted to hospital die from PE. However, for every patient who dies of PE in a surgical ward, three die in nonsurgical wards. This is not only a common problem but a serious one: the inhospital mortality of elderly patients over the age of 65 with documented pulmonary embolism was 21% in the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED, 1990) Study, and the 1-year mortality was 39% (Stein, 2008).Recent data suggest these numbers may be even higher (Heit et al., 1998).

The clinical non-recognition of venous thrombembolism prior to fatal PE implies that its detection and treatment cannot have a major impact on its mortality; hence, identificaton and primary prophylaxis of hospitalized in-patients (medical and surgical) at high absolute risk of DVT is required for its prevention.

The high occurrence of PE (particularly its silent form) has crucial importance in the elderly mortality. Our recommendations would like to emphasize the need of no underestimation of this fact and to carry out preventive measures in all age groups (including "oldest old" and frail persons.

Immobilization in medical ward is due to illness (e.g. infection, malignancy, heart failure, myocardial infarction and stroke). The cumulative risk of DVT and PE increases with the duration of immobility, suggesting a role for venous stasis in the inactive leg in the pathogenesis of DVT.

Prophylaxis against PE is of paramount importance because venous thromboembolism is difficult to detect and poses an excessive medical and economic burden (Kakkar et al., 2010).

Pulmonary Embolism in the Elderly – Significance and Particularities 55

venous valves lead to deep vein thrombosis, which damages the valves, deep vein

Deep vein thrombosis occurs in 20 to 25% of patients > 40 after routine surgery and in

DVT usually occurs in the leg, regardless of the cause. The hallmark symptom is rapid onset of unilateral leg swelling with dependent edema – in advanced age predominantly asymptomatic. Generally, patients first note swelling when they awaken. In ambulatory patients, swelling is maximal at the ankle and lower leg, usually developing over 1 or 2

Calf vein thrombosis may produce no symptoms or mild tenderness and mild edema. Calf vein thrombosis without swelling is common only among sedentary or bedridden patients. Complications of DVT include venous thromboembolism, particularly pulmonary embolism

Risk factors (eg, dehydration, estrogen use (LaCrox et al., 2011; Sare et al., 2008), heart failure, hip fracture, hypercoagulable states, immobilization or decreased physical activity, malignancy, obesity (Barba et al., 2008), polycythemia, thrombocytosis, trauma, venous

**Orthopedic procedures:** DVT is common among the elderly because they commonly undergo high-risk orthopedic procedures, particularly semi-elective or urgent procedures (eg, after a traumatic fracture). If the procedure involves the extremities, the value of lowdose heparin is limited; full-dose heparin or warfarin is effective, but each has a significant

After elective total hip replacement, the incidence of proximal deep vein thrombosis (without prophylaxis after surgery) approaches 25%, and the incidence of fatal pulmonary embolism is 3 to 4%. Prophylaxis reduces the occurrence of venous thromboembolism by 30

Low-dose heparin or low-molecular-weight heparin reduces the occurrence of deep vein

The objective is to prevent pulmonary embolism and chronic venous insufficiency. Patients > 70 (especially women) receiving warfarin therapy are at high risk of hemorrhage. Since many elderly persons with arthritic or neurologic disorders fall frequently, warfarin is

Since the symptoms and signs are nonspecific, pulmonary embolism may be overdiagnosed or underdiagnosed, especially in the elderly. Patients with cardiac and respiratory disorders

The first step in making the diagnosis is a careful physical examination to evaluate alternative diagnoses, for example, congestive heart failure, coronary artery disease,

almost 50% after hip surgery when no prophylaxis is given.

(which can lead to death within 30 minutes of onset).

damage) should be sought unless the cause is clear.

often contraindicated in patients > 80 and frail patients > 70.

thrombosis tends to recur.

**12.1.2 Symptoms and signs** 

days.

**12.1.3 Diagnosis** 

**12.1.4 Prophylaxis** 

risk of bleeding.

**12.1.5 Treatment** 

thrombosis by at least 50%.

**12.2 Pulmonary embolism** 

are especially at risk of misdiagnosis.

to 50%.

Mechanical and pharmacologic measures often succeed in preventing this complication. Patients who have undergone total hip replacement, total knee replacement, or cancer surgery will benefit from extended pharmacologic prophylaxis for a total of 4 to 6 weeks, especially with LMWH or UFH about 2 in 3 cases (Bottaro et al., 2008; Reynolds et al., 2009).

Thromboembolic complications are prevalent in the perioperative period. It has been estimated that between 20% and 30% of patients undergoing general surgery develop deep venous thrombosis, and the incidence is as high as 40% in hip and knee surgery, gynecological cancer operations, open prostatectomies, and major neurosurgical procedures. Although fatal pulmonary embolism occurs in 1% to 5% of all surgical patients, it accounts for a larger proportion of operative deaths in middle-aged and older individuals. Because venous thrombosis and pulmonary emboli can be difficult to diagnose and treat, considerable effort has been focused on prophylaxis.

Patients at high risk can receive a combination of mechanical and pharmacologic modalities. Graduated compression stockings and pneumatic compression devices may complement mini-dose unfractionated heparin (5000 units subcutaneously twice or preferably three times daily), low-molecular-weight heparin, a pentasaccharide or warfarin administration.

Overall the literature suggests that any association of age with risk of bleeding on heparin or warfarin is weak, and contrasts with the strong, consistent finding of an exponential increase in thrombembolic risk with age (Kanaan et al., 2007; Kakkar et al., 2010). However, geriatritians should consider several practical considerations when prescribing oral anticoagulants to the elderly (Beers et al., 2006; Cassel et al., 2003).

