Older Adult Patient
by Maggie Galloway
1. Environmental Safety
1.1. Lighting
1.1.1. Fluorescent lights bothersome
1.1.1.1. Causing eye strain and glare
1.1.2. Soft red light in the bedroom at night can improve night vision
1.1.3. Exposure to natural light during normal 24 hour dark-light cycle to maintain body rhythms
1.1.3.1. Influences body temperature, sleep cycles, hormone production
1.2. Temperature
1.2.1. Recommended room temperature should not be lower than 75 degrees
1.2.1.1. If less than 70 degrees, can lead to hypothermia
1.2.2. Temperature greater than 106 degrees can lead to brain damage
1.3. Color
1.3.1. Wall colors like red, yellow, white are stimulating
1.3.1.1. Increases blood pressure, pulse and appetite
1.3.2. Wall colors like blue, brown, earth tones are relaxing
1.3.3. Orange stimulates appetite
1.3.4. Violet decreases appetite
1.3.5. Green is a healing color and allows for a sense of well being
1.3.6. Black and grey are depressing
1.4. Floor coverings
1.4.1. Carpeting can reduce fractures associated with falls
1.4.2. Plush carpeting difficult for wheelchair mobility
1.4.3. Carpeting can be applied to wall surfaces for a noise buffer
1.4.4. Cockroaches, moths, fleas can reside underneath carpet
2. Cardiovascular
2.1. Age Related Changes
2.1.1. Valves are thicker and more rigid
2.1.2. Decreased stroke volume
2.1.3. Less efficient use of O2
2.1.4. Decreased cardiac output
2.1.5. More prominent arteries in head, neck, extremities
2.1.6. Less elasticity of vessels
2.1.7. Aorta becomes dilated and elongated
2.1.8. Increase of blood pressure
2.2. Pathological Changes
2.2.1. Hyperlipidemia
2.2.1.1. Pathophysiology
2.2.1.1.1. In older adults, most likely caused from conditions the adult has
2.2.1.1.2. Elevated total levels of cholesterol
2.2.1.2. Diagnosis
2.2.1.2.1. Obtain full lipid profile
2.2.1.2.2. If secondary causes are ruled out, autosomal dominant trait
2.2.1.3. Treatment
2.2.1.3.1. Dietary changes and exercise
2.2.1.3.2. First drug of choice for elevated LDL is 3-hydroxy-3-methylglutaryl-coenzyme (HMG CoA) reductase inhibitor
2.2.1.3.3. Complementary therapies
2.2.2. Atrial Fibrillation
2.2.2.1. Pathophysiology
2.2.2.1.1. Common in older adults with structural defects and comorbidities
2.2.2.1.2. Degeneration of electrical impulses in the atria
2.2.2.2. Signs and Symptoms
2.2.2.2.1. Palpitations
2.2.2.2.2. Irregular pulse
2.2.2.2.3. SOB
2.2.2.2.4. Chest pain
2.2.2.2.5. Fatigue
2.2.2.2.6. Dizziness
2.2.2.2.7. Delirium
2.2.2.3. Diagnosis
2.2.2.3.1. Physical examination, pt history, ECG, electrophysiology studies, stress tests, echocardiograms
2.2.2.4. Treatment
2.2.2.4.1. Antiarrhythmics, electrical cardioversion are the first things done
2.2.2.4.2. If no response to previous treatments, catheter ablation and maze procedure is done
2.2.2.5. Nurses role
2.2.2.5.1. Educate pt of disease, treatment regimen, activity modifications
2.2.2.5.2. Have pt report symptoms
3. Urinary
3.1. Age Related Changes
3.1.1. Decreased size of renal mass
3.1.2. Decreased tubular function
3.1.3. Decreased bladder capacity
3.1.4. Decrease in amt of nephrons
3.1.5. Weaker bladder muscles
3.1.6. Renal blood flow decreases by 53%
3.1.7. Glomerular filtration rate decreases by 50%
3.2. Pathological Changes
3.2.1. Urinary Incontinence
3.2.1.1. Pathophysiology
3.2.1.1.1. Failure of storage function of the lower urinary tract
3.2.1.2. Types
3.2.1.2.1. Stress Incontinence
3.2.1.2.2. Urgency Incontinence
3.2.1.2.3. Overflow Incontinence
3.2.1.2.4. Neurogenic (reflex) Incontinence
3.2.1.2.5. Functional Incontinence
3.2.1.2.6. Mixed Incontinence
3.2.1.3. Treatment
3.2.1.3.1. Kegel exercises
3.2.1.3.2. Catheterization
3.2.2. Urinary tract infection
3.2.2.1. Pathophysiology
3.2.2.1.1. Inflammation of renal tract due to bacteria
3.2.2.2. Symptoms
3.2.2.2.1. Early indicators
3.2.2.2.2. Older adults can develop delirium and incontinence
3.2.2.2.3. Retention and hematuria can occur
3.2.2.3. Treatment
3.2.2.3.1. Antibiotics to control infection
4. Respiratory
4.1. Age Related Changes
4.1.1. Decreased ciliary action
4.1.2. Forced expiratory volume reduced
4.1.3. Loss of elasticity
4.1.4. increased rigidity
4.1.5. PO2 reduced by 15%
4.1.6. Blunting of cough and laryngeal reflexes
4.1.7. Alveoli fewer in number and larger in size
4.1.8. Thoracic muscles more rigid
4.1.9. Reduced basilar inflation
4.1.10. Increase in residual capacity by about 50% by age 90
4.2. Pathological Changes
4.2.1. Pneumonia
4.2.1.1. Pathophysiology
4.2.1.1.1. Infection of the lungs caused by bacteria, virus, or fungi
4.2.1.1.2. Alveoli become inflammed and fill with pus and/or fluid
4.2.1.2. Signs & Symptoms
4.2.1.2.1. Pleuratic pain
4.2.1.2.2. Minimal or no fever
4.2.1.2.3. Cough, fatigue, rapid respirations
4.2.1.2.4. Confusion, restlessness, behavioral changes
4.2.1.3. Treatment
4.2.1.3.1. Mobility
4.2.1.3.2. Pneumococcal vaccine
4.2.2. Lung cancer
4.2.2.1. Pathophysiology
4.2.2.1.1. Genetic factors
4.2.2.1.2. Exposure to environmental pollutants and carcinogens
4.2.2.2. At Risk
4.2.2.2.1. Cigarette smoker or exposure to cigarettes
4.2.2.2.2. Abestos
4.2.2.2.3. Coal and radon gas
4.2.2.2.4. Air pollutants
4.2.2.2.5. Highest African American males, white American Indian/Alaska native, Asian/Pacific Islander, Hispanic Men
4.2.2.3. Signs & Symptoms
4.2.2.3.1. Dyspneac
4.2.2.3.2. Cough
4.2.2.3.3. Chest pain
4.2.2.3.4. Fatigue
4.2.2.3.5. Anorexia
4.2.2.3.6. Wheezing
4.2.2.3.7. Recurrent upper respiratory tract infections
4.2.2.4. Treatment
4.2.2.4.1. Diagnosis
4.2.2.4.2. Surgery
4.2.2.4.3. Chemotherapy
4.2.2.4.4. Radiotherapy
4.2.3. Influenza
4.2.3.1. Pathophysiology
4.2.3.1.1. Virus enters the respiratory tract
4.2.3.2. Signs & Symptoms
4.2.3.2.1. Fever (not as high compared to young adults)
4.2.3.2.2. Myalgia
4.2.3.2.3. Sore throat
4.2.3.2.4. Nonproductive cough
4.2.3.3. Treatment
4.2.3.3.1. Influenza vaccine annually
5. Neurological
5.1. Age Related Changes
5.1.1. Decreased conduction velocity
5.1.2. Slower response and reaction time
5.1.3. Decreased brain weight
5.1.4. Reduced blood flow to brain
5.1.5. Changes in sleep pattern
5.2. Pathological Changes
5.2.1. Dementia
5.2.1.1. Pathophysiology
5.2.1.1.1. Damage to brain tissue due to degenerative tissue, circulatory problems, lack of oxygen, infection, trauma, hydrocephalus, tumor, alcoholism
5.2.1.2. Onset
5.2.1.2.1. Slow takes months to years before symptoms are evident
5.2.1.3. Behavior
5.2.1.3.1. Inappropriate
5.2.1.3.2. May be unsteady on feet
5.2.1.3.3. Have difficulty with coordinated movements
5.2.1.4. Recovery
5.2.1.4.1. Progression can be slowed but cannot be reversed
5.2.1.4.2. Continues to worsen
5.2.2. Delirium
5.2.2.1. Pathophysiology
5.2.2.1.1. Disruption in brain function d/t medication side effect, circulatory disturbance, dehydration, low of high BP, low or high thyroid activity, low or high blood glucose, surgery, stress
5.2.2.2. Symptoms
5.2.2.2.1. Altered attention span
5.2.2.2.2. Worsened memory
5.2.2.2.3. Poor judgement
5.2.2.2.4. Altered LOC
5.2.2.2.5. Hyper vigilance
5.2.2.2.6. Mild drowsiness
5.2.2.2.7. Semicomatose status
5.2.2.3. Onset
5.2.2.3.1. Rapid
5.2.2.3.2. Change is noted within days
5.2.2.4. Mental status
5.2.2.4.1. Short term memory impaired
5.2.2.4.2. Disoriented and confused
5.2.2.4.3. Incoherent speech
5.2.2.4.4. Hallucinations
5.2.2.4.5. Exaggeration of personality features
5.2.2.5. Behavior
5.2.2.5.1. Hyperactive
5.2.2.5.2. Less active than normal
5.2.2.6. Recovery
5.2.2.6.1. Can be reversed and normal mental status can return if cause is treated promptly
6. GI
6.1. Age Related Changes
6.1.1. Decreased taste sensation
6.1.2. Esophagus more dilated
6.1.3. Reduced saliva
6.1.4. Smaller liver
6.1.5. Reduced intestinal blood flow
6.1.6. Slower peristalsis
6.1.7. Fewer cells on absorbing surface of intestines
6.1.8. Atrophy of gastric mucosa
6.1.9. Decreased esophageal motility
6.1.10. Decreased stomach motility
6.1.11. Decreased hunger contractions
6.1.12. Decreased emptying time
6.1.13. Less production of HCl acid, pepsin, lipase, pancreatic enzymes
6.2. Pathological Changes
6.2.1. Dysphagia
6.2.1.1. Pathophysiology
6.2.1.1.1. Lesions on upper digestive tract
6.2.1.1.2. Obstruction of upper digestive tract
6.2.1.1.3. Alterations in the nervous or muscular control of swallowing
6.2.1.2. Assessment
6.2.1.2.1. When did the problem begin?
6.2.1.2.2. Any other symptoms?
6.2.1.2.3. Do certain foods trigger the symptoms? Solids or liquids?
6.2.1.2.4. Does it occur with every meal?
6.2.1.2.5. Observe intake of food
6.2.1.2.6. Refer to speech language pathologist
6.2.1.2.7. Monitor I&O’s and weight
6.2.1.3. Treatment
6.2.1.3.1. Goal: adequate nutritional status and prevent aspiration
6.2.1.3.2. Soft diet
6.2.1.3.3. Thickening of liquids
6.2.1.3.4. Eat sitting in an upright position
6.2.2. Hiatal Hernia
6.2.2.1. Pathophysiology
6.2.2.1.1. Displacement of the gastroesophageal junction
6.2.2.1.2. More common in older women
6.2.2.1.3. Low fiber diet can contribute to this condition
6.2.2.2. Types
6.2.2.2.1. Sliding (axial)
6.2.2.2.2. Rolling (paraesophageal)
6.2.2.3. Symptoms
6.2.2.3.1. Heartburn
6.2.2.3.2. Dysphagia
6.2.2.3.3. Belching
6.2.2.3.4. Vomiting
6.2.2.3.5. Regurgitation
6.2.2.4. Diagnosis
6.2.2.4.1. Barium swallow
6.2.2.4.2. Esophagoscopy
6.2.2.5. Treatment
6.2.2.5.1. Weight loss if pt is obese
6.2.2.5.2. Bland diet
6.2.2.5.3. Milk and antacids for symptomatic relief
6.2.2.5.4. Multiple small meals a dayd
6.2.2.5.5. Do not eat before bed
6.2.2.5.6. H2 blockers (ranitidine, cimetidine, or nizatidine)
6.2.2.5.7. proton pump inhibitors (lansoprazole or omeprazole)
6.2.3. Diverticulitis
6.2.3.1. Pathophysiology
6.2.3.1.1. Multiple pouches of intestinal mucosa in the weakened muscular wall of the large bowel
6.2.3.2. Symptoms
6.2.3.2.1. Slight bleeding
6.2.3.2.2. Changes in bowel habits
6.2.3.2.3. Overeating, straining during a bowel movement, alcohol, irritating foods may contribute
6.2.3.2.4. Abrupt onset of pain in LLQ
6.2.3.2.5. n/v
6.2.3.2.6. Blood or mucus in stool
6.2.3.2.7. Low grade fever
6.2.3.3. Treatment
6.2.3.3.1. Reducing infection, provide nutrition, relieve discomfort, promote rest
6.2.3.3.2. IV therapy
6.2.3.3.3. Acute attack; consume low residue diet
6.2.3.3.4. Surgery may be performed
7. Integumentary
7.1. Age Related Changes
7.1.1. Thicker hair in ears and nose
7.1.2. Darkening and wrinkling of skin around orbits
7.1.3. Growth of facial hair in women
7.1.4. Ectropion of eyelids
7.2. Pathological Changes
7.2.1. Skin cancer
7.2.1.1. Pathophysiology
7.2.1.2. Types
7.2.1.2.1. Basal cell carcinoma
7.2.1.2.2. Squamous cell carcinoma
7.2.1.2.3. Melanoma
7.2.2. Pressure Injury
7.2.2.1. Pathophysiology
7.2.2.1.1. Tissue anoxia and ischemia from pressure can result in necrosis, sloughing, and ulceration of the tissue
7.2.2.2. Stages
7.2.2.2.1. Stage 1
7.2.2.2.2. Stage 2
7.2.2.2.3. Stage 3
7.2.2.2.4. Stage 4
7.2.2.2.5. Unstageable
7.2.2.3. Nursing interventions
7.2.2.3.1. Encourage activity
7.2.2.3.2. Turn pt
7.2.2.3.3. Avoid shearing forces by not elevating the HOB greater than 30 degrees
7.2.2.3.4. Use pillows, flotation devices, alternating pressure mattresses, or water beds
7.2.2.3.5. Keep sheets wrinkle free
7.2.2.3.6. High protein, vitamin rich diet
7.2.2.3.7. Good skin care
8. Reproductive
8.1. Male
8.1.1. Pathological Changes
8.1.1.1. Erectile Dysfunction
8.1.1.1.1. Pathophysiology
8.1.1.1.2. Causes
8.1.1.1.3. Treatment
8.1.1.2. BPH
8.1.1.2.1. Pathophysiology
8.1.1.2.2. Symptoms
8.1.1.2.3. Treatment
8.1.2. Age Related Changes
8.1.2.1. Prostate enlarges
8.1.2.2. Venous and arterial sclerosis of penis
8.1.2.3. Reduction in sperm count
8.1.2.4. Fluid-retaining capacity of seminal vesicles reduces
8.2. Female
8.2.1. Age Related Changes
8.2.1.1. Fallopian tubes atrophy and shorten
8.2.1.2. Ovaries become thicker and smaller
8.2.1.3. Cervix becomes smaller
8.2.1.4. Drier, less elastic vaginal canal
8.2.1.5. Flattening of the labia
8.2.1.6. Endocervical epithelium atrophies
8.2.1.7. Uterus becomes smaller in size
8.2.1.8. Endometrium atrophies
8.2.1.9. More alkaline vaginal environment
8.2.1.10. Loss of vulvar subcutaneous fat and hair
8.2.2. Pathological Changes
8.2.2.1. Perineal Herniation
8.2.2.1.1. Pathophysiology
8.2.2.1.2. Types
8.2.2.1.3. Symptoms
8.2.2.1.4. Treatment
8.2.2.2. Cervical Cancer
8.2.2.2.1. Pathophysiology
8.2.2.2.2. Symptoms
8.2.2.2.3. Treatment
8.2.2.2.4. Most prevalent among Hispanic women, then black women, white Native American/Alaskan Native, Asian Pacific women
9. Musculoskeletal
9.1. Age Related Changes
9.1.1. Shortening vertebrae
9.1.2. High decreases by approx 2 inches
9.1.3. Bones are more brittle
9.1.4. Slight knee flexion
9.1.5. Decrease in bone mass and bone material
9.1.6. Slight kyphosis
9.1.7. Slight hip flexion
9.1.8. Slight wrist flexion
9.1.9. Impaired flexion and extension movements
9.2. Pathological Changes
9.2.1. Osteoporosis
9.2.1.1. Pathophysiology
9.2.1.1.1. Metabolic disease of the bone
9.2.1.1.2. Demineralization of the bone
9.2.1.1.3. Decrease in mass and density of the bones
9.2.1.2. Symptoms
9.2.1.2.1. Inactivity or immobility
9.2.1.2.2. Diseases
9.2.1.2.3. Reduction in anabolic sex hormones
9.2.1.2.4. Diet
9.2.1.2.5. Drugs
9.2.1.3. Treatment
9.2.1.3.1. Calcium or vitamin D supplements
9.2.1.3.2. Selective estrogen receptor modulators (SERMs)
9.2.1.3.3. Hormone therapy
9.2.1.3.4. Biphosphonates
9.2.1.3.5. Diet rich in protein and calcium
9.2.1.3.6. Braces can be used to prevent spasms
9.2.1.3.7. Avoid heavy lifting, jumping, or other activities that can result in fracture
9.2.2. Gout
9.2.2.1. Pathophysiology
9.2.2.1.1. Metabolic disorder excess uric acid accumulates in blood
9.2.2.2. Symptoms
9.2.2.2.1. Severe pain
9.2.2.2.2. Tenderness of joint
9.2.2.2.3. Warmth, redness, swelling of tissue surrounding joint
9.2.2.3. Treatment
9.2.2.3.1. Aimed to reduce sodium urate through a low-purine diet
9.2.2.3.2. Alcohol and drugs should be avoided
9.2.2.3.3. Colchicine or phenylbutazone manage acute attacks
9.2.2.3.4. Long term management
9.2.2.4. Nurses role
9.2.2.4.1. Monitor pain
9.2.2.4.2. Encourage good fluid intake to prevent formation of renal stones
10. Sensory
10.1. Safety
10.1.1. Reduced peripheral vision
10.1.1.1. Approach individuals from the back or side
10.1.2. Altered depth perception
10.1.2.1. Reduce the ability to detect changes in levels
10.1.2.1.1. Alleviated by good lighting, no clutter on staircase, use contrasting colors on stairs
10.1.3. Hearing deficits
10.1.3.1. Hearing impaired individuals should live near people with adequate hearing
10.1.3.1.1. Can be alerted about fire alarms or other warnings
10.1.3.2. Trained dogs for people with hearing deficits
10.2. Age Related Changes
10.2.1. Sight
10.2.1.1. More opaque lens
10.2.1.2. Decreased pupil size
10.2.1.3. More spherical cornea
10.2.2. Smell
10.2.2.1. Impaired ability to identify and discriminate among odors
10.2.3. Taste
10.2.3.1. High prevalence of taste impairment
10.2.4. Touch
10.2.4.1. Reduction in tactile sensation
10.2.5. Hearing
10.2.5.1. Atrophy of hair cells of organ of Corti
10.2.5.2. Tympanic membrane sclerosis and atrophy
10.2.5.3. Increased cerumen and concentration of keratin
10.3. Pathological Changes
10.3.1. Cataracts
10.3.1.1. Pathophysiology
10.3.1.1.1. Clouding of the lens or its capsule that causes the lens to lose its transparency
10.3.1.2. Symptoms
10.3.1.2.1. No discomfort or pain
10.3.1.2.2. Vision distorted
10.3.1.2.3. Night vision decreased
10.3.1.2.4. Nuclear sclerosis develops
10.3.1.3. Treatment
10.3.1.3.1. Only cure - surgical removal of lens
10.3.1.3.2. Only affects one eye
11. Endocrine
11.1. Age Related Changes
11.1.1. Decrease thyroid gland activity
11.1.1.1. Lower basal metabolic rate
11.1.1.2. Reduced radioactive iodine uptake
11.1.1.3. Less thyrotropin secretion and release
11.1.2. ACTH secretion decreases
11.1.2.1. Secretory activity of adrenal gland also decreases
11.1.3. Pituitary gland decreases in volume by 20%
11.1.4. Decrease TSH, follicle-stimulating hormone, LH, luteotropic hormone
11.1.5. Delay and insufficient release of beta cells by pancreas
11.1.6. Ability to metabolize glucose reduced
11.1.6.1. Higher concentrations of glucose and more prolonged hyperglycemia levels
11.2. Pathological Changes
11.2.1. Hypothyroidism
11.2.1.1. Pathophysiology
11.2.1.1.1. Decreased levels of thyroxine (T4) and triiodothyronine (T3) that are produced by the thyroid gland
11.2.1.2. Symptoms
11.2.1.2.1. Fatigue, weakness, lethargy
11.2.1.2.2. Depression
11.2.1.2.3. Anorexia
11.2.1.2.4. Weight gain and puffy face
11.2.1.2.5. Impaired hearing
11.2.1.2.6. Periorbital or peripheral edema
11.2.1.2.7. Constipation
11.2.1.2.8. Cold intolerance
11.2.1.2.9. Myalgia, parenthesia, ataxia
11.2.1.2.10. Dry skin, coarse harir
11.2.1.3. Treatment
11.2.1.3.1. Replacement of thyroid hormone using synthetic T4
11.2.1.4. Nursing interventions
11.2.1.4.1. Help pt with management of other symptoms
11.2.1.4.2. Help pt understand that they will need thyroid replacement therapy for the rest of their life
11.2.2. Hyperthyroidism
11.2.2.1. Pathophysiology
11.2.2.1.1. Thyroid gland excretes excess amounts of thyroid hormones
11.2.2.2. Symptoms
11.2.2.2.1. Diaphoresis
11.2.2.2.2. Tachycardia
11.2.2.2.3. Palpitations
11.2.2.2.4. HTN
11.2.2.2.5. Tremor
11.2.2.2.6. Diarrhea
11.2.2.2.7. Stare
11.2.2.2.8. Lid lag
11.2.2.2.9. Insomnia
11.2.2.2.10. Nervousness
11.2.2.2.11. Confusion
11.2.2.2.12. Heat intolerance
11.2.2.2.13. Increased hunger
11.2.2.2.14. Proximal muscle weakness
11.2.2.2.15. Hyperreflexia
11.2.2.3. Treatment
11.2.2.3.1. Graves’ disease
11.2.2.3.2. Goiter
11.2.3. Diabetes Mellitus
11.2.3.1. Pathophysiology
11.2.3.1.1. Glucose intolerance
11.2.3.1.2. Increased amount of fat tissue in older adults who are obese and inactive
11.2.3.2. Diagnosis
11.2.3.2.1. Fasting blood sugar every 3 years if over 45 years of age
11.2.3.2.2. Glucose tolerance test
11.2.3.2.3. Diagnosis is established if one of these exist
11.2.3.2.4. Results are confirmed by repeat testing on another day
11.2.3.3. Patient education
11.2.3.3.1. Barriers
11.2.3.3.2. Provide reassurance, support, and information to reduce barriers
11.2.3.4. Drug Therapy
11.2.3.4.1. Metformin
11.2.3.4.2. Sulfonylurea
11.2.3.4.3. Acarbose
11.2.3.5. Patient self care and monitoring
11.2.3.5.1. Observe patients ability to handle a syringe and a vial of insulin
11.2.3.5.2. Observe the patient performing the finger-prick technique
11.2.3.5.3. Monitor triglycerides due to the development of metabolic syndrome
11.2.3.6. Exercise and nutrition
11.2.3.6.1. Regular exercise is very important!
11.2.3.6.2. Maintain consistent daily food intake
11.2.3.6.3. Nutritional supplements can reduce the complications
11.2.3.7. Symptoms of hypoglycemia in the older adult
11.2.3.7.1. Confusion
11.2.3.7.2. Abnormal behavior
11.2.3.7.3. Altered sleep patterns
11.2.3.7.4. Nocturnal headache
11.2.3.7.5. Slurred speech
12. Immune System
12.1. Age Related Changes
12.1.1. Immunosenescence
12.1.1.1. Increase in the amount of infections
12.1.1.2. Decline in T cell activity
12.1.1.2.1. More immature T cells
12.1.1.3. Decline in cell mediated immunity
12.1.1.4. T lymphocytes are not able to proliferate as well in response to mitogens
12.1.1.5. IgM lower
12.1.1.6. IgA and IgG higher
12.1.1.7. Responses to certain vaccines are less effective
12.1.1.7.1. Influenza
12.1.1.7.2. Parainfluenza
12.1.1.7.3. Pneumococcal
12.1.1.7.4. Tetanus
12.1.1.8. Decline in inflammatory responses
12.1.1.9. Inflammation presents atypically in older adults
12.1.1.9.1. Low grade fever
12.1.1.9.2. Minimal pain
12.1.1.10. Increase in proinflammatory cytokines
12.1.1.10.1. Associated with atherosclerosis, diabetes, osteoporosis