ABSTRACT
Cancer and infection make up the leading causes of death among persons aged 65 and older. Serious infectious complications are the dose-limiting factor for the treatment of the aged cancer patient. Strategies to improve tolerance of intensive therapy are being explored, especially with the use of cytokines and prophylactic antimicrobials. However, delay in diagnosis of infectious complications because of atypical clinical manifestations in the aged is a serious concern. Decremental biologic changes with age, often accelerated by coexisting diseases, can influence the physiologic response to an acute illness and thus alter the clinical manifestations of a geriatric patient with a given disorder.1 Some elderly patients may exhibit minimal or no focal signs pointing to a specifically involved organ system as in acute appendicitis or cholecystitis.1 The high prevalence of multiple chronic and debilitating diseases may further complicate the therapy of infections in the elderly cancer patient. Peak temperatures, maximum white blood cell counts, and intensities of many clinical symptoms and signs are less marked in the elderly.2 The blunting of the febrile response in the elderly was cited by Hippocrates in his Aphorisms.1 The febrile response may be blunted or even absent in a small but significant number of older patients with common infections such as pneumonia.1 Afebrile bacteremia complicating pneumonia, urinary tract infections, and cellulitis occurs predominantly in aged patients.3 In one study, 90% of afebrile patients with culture-proven bacteremia were elderly.3 In addition, medications frequently taken by older patients, such as antipyretics and corticosteroids, may diminish the febrile response.1 Frequently, the elderly may have a low basal temperature. An oral temperature greater than 99°F (37.2°C) should be regarded as elevated represent a significant increase if a low basal temperature in patients older than 65.4 A temperature of 100°F may was present.1 Ninety-five percent of elderly patients who have infection will show some febrile response.5 Elderly patients with fever are more likely to have serious bacterial infections, in contrast to younger patients, in whom fever usually signifies viral or benign bacterial infections.1 Occult bacterial infection should be suspected in the elderly patient with the new onset of fever, and is a frequent cause of fever of unknown origin (FUO) in this population.2 Unlike FUO in the young, a cause for prolonged fever in older patients could be determined in most cases.1 In one series, 36% of cases were treatable infections, 26% connective tissue diseases, and 24% neoplasia (lymphoma and carcinoma).2,5 Lymphoma is the most common neoplasm, most cases being intraabdominal.5
