Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 574

Bleeding causes or contributes to the death of about 5% of the elderly population. This is primarily due to intracranial and subarachnoid haemorrhage, ruptured aortic aneurysm, gastrointestinal bleeding from peptic ulcers, and gastric or colonic malignancy. Bleeding due to primary disorders of haemostasis in the elderly is relatively rare. Severe congenital bleeding diatheses are usually diagnosed at a young age, with the majority of them now being treatable and carrying a normal life expectancy, while acquired disorders of haemostasis are an uncommon cause of death except as part of the syndrome of multiorgan failure. Most bleeding in the elderly is localized and the result of a specific underlying pathology, frequently malignancy. Bleeding disorders can be classified as being due to abnormalities of platelet number or function, disorders of the coagulation cascade, and disturbances of the vascular endothelium and connective tissues.

Thrombotic disorders are a far more significant cause of morbidity and mortality in the elderly age group. Arterial thrombosis and atheroma cause cardiovascular disease, cerebrovascular disease, and peripheral vascular disease. Likewise, venous thromboembolism is primarily a disease of older age and is now recognized as being due to a combination of both circumstantial and underlying genetic factors. Ageing itself does not result in either any major or significant changes in the range of the common coagulation tests, such as the activated partial thromboplastin time (APTT), prothrombin time (PT), or thrombin time (TT) or in the level of fibrinogen or other specific coagulation factors and inhibitors. However, fibrinogen levels are often high in the elderly as a result of underlying conditions. Likewise, the platelet count does not alter with age. There is, however, convincing evidence from sensitive markers of coagulation activation that background turnover of the proteins increases with age.¹ Although no major changes in haemostasis occur with increasing age, diseases that may result in bleeding problems or thrombosis are more common, and their consequences are more serious in the elderly (Table 24.1).