PROBLEMS IN DIAGNOSING INFECTIONS IN THE ELDERLY

D.J. Flournoy, PhD, and Marie A. Bernard, MD Oklahoma City, Oklahoma

Elderly individuals often present with altered signs and symptoms to infectious diseases. Altered signs and symptoms may result from underlying illnesses, physiological changes of the elderly, or chemotherapy. Increased awareness of the occurrence of altered signs and symptoms can facilitate determining the medical diagnosis and treatment of the elderly. (J Nati Med Assoc. 1993;85:835-840.)
Key words * elderly * infectious diseases

Infectious diseases and nosocomial infections are very common in the elderly,' causing significant morbidity and mortality. In the United States, the annual incidence of nosocomial infection is approximately 2.1 million in acute care hospitals (with 30% to 40% of patients older than 65 years) and 1.5 million in nursing homes (with greater than 90% of the residents older than 65 years).2 The rate of infection in long-term care facilities is estimated to be about one infection per resident per year.3 In one study, 36.9% of the residents had nosocomial pyogenic infections.4 The following factors are known to predispose elderly people to nosocomial infection: immune system changes, malnutrition, and vitamin deficiencies.5 In addition, elderly people often have underlying medical conditions (eg, diabetes mellitus) that increase their risk to infection6'7 and reduce the efficacy of subsequent treatment.8 The incidence of nosocomial infections in the elderly will most likely increase as the number of elderly requiring long-term care increases. Infectious di$eases that are more devastating to the elderly include: pneumonia, influenza, tuberculosis,
From the Departments of Pathology and Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. Requests for reprints should be addressed to Dr D.J. Flournoy, VAMC (1 13), 921 NE 13th St, Oklahoma City, OK 73104.
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urinary tract infection, gram-negative bacteremia, skin and soft tissue infection, infective endocarditis, intraabdominal sepsis, bacterial meningitis, bacterial arthritis, and herpes zoster infection.9'10 Elderly individuals often respond to the above-mentioned infectious diseases quite differently than younger people. These different responses can delay diagnosis and treatment, thus increasing morbidity and mortality.l Altered signs and symptoms may result from underlying illnesses, physiological changes of the elderly, or chemotherapy. For example, anti-inflammatory and antipyretic drugs can mask the effects of infectious disease. Cytotoxic drugs can cause neutropenia, which then devalues the diagnostic value of the white blood cell count in signaling infection.12 Therefore, altered responses to infectious diseases can delay and make the medical diagnosis difficult. In order to understand the mechanisms of altered responses in the elderly, the effects of aging itself13'14 must be separated from the effects of underlying illnesses.15 Not all elderly individuals are sick; therefore, illness is not an inevitable consequence of aging. It is important for health care providers to recognize predisposing factors16-28 (Table 1) and differences in response to infectious diseases29-48 (Table 2) in order to optimize accurate and timely diagnosis, treatment, and care of the elderly This article will review many of the problems in diagnosing infections in the aged.

IMMUNITY
Clinicians have long noted the increased frequency of negative skin test results or anergy in elderly patients.49'50 However, it is important how cellmediated immunity is measured. When delayed-type hypersensitivity and circulating thymus-derived lymphocyte (T cell) proliferation were compared, both tests correlated well among the delayed-type hypersensitivity reactors but poorly among the nonreactors.51 This implies that there may be age-related immunologic changes in the skin itself that negate the value of skin
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TABLE 1. PREDISPOSING FACTORS TO INFECTION IN THE ELDERLY Expression Factor Urine catheterization Urosepsis,16 UT117 UT117,18 Prostatic hypertrophy Skin infections19,20 Thinning/drying of skin, decreased sebaceous secretions Infection, decreased Ig production8'21'22 Chronic degenerative diseases Infection and poor WBC function,17'21'23 nosocomial infections,5 Diabetes mellitus tuberculosis,22'24 gram-negative pneumonia,22'24 malignant external otitis,18,25 osteomyelitis,18 fungal infection,22'25 UTI,17 necrotizing fascitis,23 influenza,25 nonclostridial gas gangrene,25 extrapulmonary Klebsiella infections,25 Clostridium septicum bacteremia25 Tuberculosis22'24 Previous gastrectomy Tuberculosis22'24 Malignancy Neutropenia12 Cytotoxic chemotherapy Nosocomial infections,5 infections21 Cancer Infections21 Multiple myeloma Infections21 Chronic lymphocytic leukemia Tuberculosis22'24 Abnormal mentation GNR pneumonia26 Coronary artery disease GNR pneumonia26 Cerebrovascular disease Tuberculosis22'24 Atherosclerosis GNR pneumonia,26 nosocomial infections5 Congestive heart failure Pulmonary infection27 Impaired cough mechanism Pulmonary infection27'28 Aspiration GNR pneumonia26 COPD Nosocomial infections5 Emphysema

Abbreviations: UTI=urinary tract infection, WBC=white blood count, COPD=chronic obstructive pulmonary disease, and GNR = gram-negative rod.

testing as a means of determining the integrity of cell-mediated immunity. In addition, not all T cells are affected equally by aging.52

FEVER
Fever responses in the elderly may be absent, blunted, or unusually prolonged.4 Some elderly patients fail to show a fever despite having serious infections like bacteremia,30'31 pneumonia,32 infective endocarditis,34 and tuberculosis.36 There are several explanations for altered fever responses in the elderly. It has been demonstrated experimentally that older animals are less sensitive to endogenous pyrogen53 and tumor necrosis factor alpha54 than are young animals. Aged persons often have a decreased capacity to thermoregulate, based on reduced effectiveness of the key physiological systems.55 Since humans rely on food to maintain a narrow body temperature, malnutrition (often seen in the elderly) can decrease the ability of older subjects to maintain their temperature. Elderly individuals have lower basal metabolic rates, impaired ability to maintain body temperature during winter, and poor peripheral blood flow responses to cooling and warming when compared with younger individuals. Older subjects
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display a greater degree of dehydration and less thirst during heat exposure. A decrease in vasodilation and in the capacity to sweat makes the elderly more susceptible to the effects of a warm environment.55 In some cases, fever may be present but not recognized. Some elderly nursing home patients have a low (<98.6' F) baseline temperature, therefore, their peak temperature during infection is often <1010 F and not considered to represent a fever response. An increase in temperature of 2.40 F from a baseline temperature should be considered a fever response.56

TUBERCULOSIS
Tuberculosis has been recognized as a common disease of elderly individuals for many years.57 When comparing elderly men to younger men with tuberculosis, elderly men had more underlying conditions (atherosclerosis, previous gastrectomy, malignancy) fewer classical symptoms and signs (fever, weight loss, night sweats, sputum production, hemoptysis), more abnormal mentation and mortality.24 Increased liver enzymes, hypoalbuminemia, hyponatremia, and hypocalemia were more common in elderly patients with tuberculosis than in younger patients.58
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TABLE 2. ATYPICAL SIGNS/SYMPTOMS OF INFECTION THAT MAKE DIAGNOSIS DIFFICULT Infection Atypical Response No fever29 Serious infection Bacteremia No fever30.31 No fever,2 unrevealing auscultation, no cough, no sputum production33 Pneumonia No fever,34 prolonged pyrexia, FU035 Infective endocarditis Tuberculosis No fever,24,36-38 prolonged pyrexia, FUO,35 no weight loss,24 no night sweats,2438 no sputum production,24 no hemoptysis,2438 unrevealing auscultation,3 acid-fast smear results negative,33 anergy to tuberculin,27,39 atypical radiographic manifestations,27'37,40 no cough38 Influenza No fever41 No fever, chills, or joint symptoms42'43 Infective arthritis Bacteriuria No dysuria, frequency, hesitancy, incontinence, urgency, suprapubic or flank pain or fever44-48 No stiff neck, headache, chills, fever, tachycardia, confusion, seizures, or Meningitis

Abdominal abscess

coma33 Prolonged pyrexia, FU035

Abbreviations: FUO =fever of undetermined origin.

The great majority of all persons having tuberculin reactions show no evidence of clinical tuberculosis. As many as 25% of persons who are clinically ill with tuberculosis may show no reactions to 5 units of tuberculin. Some persons, especially the elderly, may show no reaction when tested with tuberculin the first time, yet show a significant reaction if tested a second time (1 week later) or even a third time with the same dose.59 Continued boosting of the tuberculin reaction occurs in a substantial number of persons who receive a third sequential test. Marked increases in the size of reactions caused by boosting may explain high apparent conversion rates found in facilities where the third test is delayed for one year.60 This is called "booster" or recall phenomenon. There is an increased incidence of anergy to purified protein derivative (PPD) in elderly. A decrease in tuberculous skin sensitivity is known to occur in patients over 50 and is most notable in patients over 70. The incidence of negative skin tests due to anergy is 10% to 30% in elderly persons with tuberculosis. Therefore, the usefulness of a negative PPD skin test is somewhat limited in the elderly.27

PNEUMONIA
Pneumonia is the leading cause of death from infectious disease in persons over the age of 65 years."I Of all causes of death, pneumonia and influenza rank fifth in persons 65 years of age and over.61 It is difficult to diagnose pneumonia in the elderly because the usual symptoms often are missing. The interested reader may wish to read several excellent reviews discussing altered immune status62 and atypical manifestations,63 including a classic text by William Osler.64 Indeed,
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many unusual manifestations of pneumonia were recognized 100 years ago. In community-acquired bacteremic pneumococcal pneumonia, older patients tended to report rigors and pleuritic chest pain less frequently than did the younger patients.33 Cough and sputum production often are not possible when the patient is obtundent. The size of infiltrates on radiograph is not consistent with the condition, or the radiograph is distorted by complicating conditions such as congestive heart failure. Signs of consolidation, fever and pleuritic chest pain are often absent or mild, and auscultatory findings are often unrevealing.65 Accurate sputum cultures usually cannot be obtained from long-term care facility residents, many of whom suffer from dementia or dehydration and are unable to cooperate with proper specimen collection.65 Some elderly patients with pneumonia may present with unexplained sepsis, shock, or respiratory failure without a clue that the precipitating factor was pneumonia.27 Also, patients with bacteremic gramnegative pneumonia can have a 77.8% mortality rate.63 Pneumonia symptoms are especially subtle in patients with organic brain disease, and there are major limitations to the physical examination of these uncommunicative patients.66

BACTERIURIA
Urinary tract infection (UTI) is very common in the elderly and presents a series of problems for the clinician. Urinary tract infection occurs with equal frequency in elderly men and women. The increased incidence of UTI in men is due to prostatic disease, and in women to inefficient micturition, previous genitouri837

DIAGNOSING INFECTIONS IN THE ELDERLY

nary instrumentation, or underlying disease such as diabetes mellitus.17 Asymptomatic bacteriuria in the elderly is common, causes little or no other morbidity, and may or may not be associated with increased mortality. Asymptomatic bacteriuria was noted in 15% of 521 predominantly geriatric male patients.48 In the absence of obstructive uropathy, antimicrobial therapy of UTI should be instituted only when the patient is symptomatic or at risk of developing more significant complications because significant morbidity could result from treatment of benign disease.46'47'67 Until highly effective, safe, low-cost therapies are found and the benefits for morbidity and mortality are shown to outweigh the risks and costs, asymptomatic bacteriuria in the elderly should not be treated.45'47 Elderly individuals with asymptomatic bacteriuria had significantly higher IgG and IgA levels for prolonged periods than age-matched controls.68 This may explain why some individuals are asymptomatic.

more chronic debilitating diseases or is on immunosuppressive therapy.42'43 In a series of 21 elderly individuals with meningitis, Massanari found that unusual central nervous system and multiple pathogens were common.73 Meningitis in elderly patients may lack the classical symptoms of stiff neck and back, headache, chills and fever, tachycardia, confusion, seizures, and coma.33 Non-central nervous system infections may mimic central nervous system infections.74 In the geriatric population, influenza has been described as a disease of low morbidity and high mortality. The disease frequently is inapparent, modified, or atypical in the elderly and often is recognized only after bacterial complications have supervened.4'

SUMMARY
Infections in the elderly may be difficult to diagnose due to physiological changes of aging, underlying disease, or accompanying chemotherapy, which cause alterations in symptomatology (eg, fever, sputum production, auscultation, radiographic) and immunity. It is important that future studies attempt to separate and study the mechanisms of these alterations, distinguishing those that occur from aging from those of underlying diseases.
Acknowledgments The authors thank Dorothy C. Belknap (College of Nursing) and Doug Voth (College of Medicine) of the University of Oklahoma Health Sciences Center for editorial assistance.

BACTEREMIA
Elderly patients with septic shock may present with confusion rather than fever or hypotension.29 In one study of 25 elderly patients experiencing afebrile bacteremia, 32% failed to demonstrate leukocytosis,30 however, 84% exhibited a "left shift" as defined by an excessive number of neutrophilic bands. Bacteremia is difficult to diagnose and is associated with a higher mortality than noted in younger patients.69 The elderly may fail to show a fever despite having bacteremia30'31 or infective endocarditis.34

MISCELLANEOUS INFECTIONS
As in other infections in the elderly, gastrointestinal infections may not present with the usual signs of fever and abdominal pain. Leukocytosis may be absent or mild, and confusion and hypotension may be the only symptoms of gastrointestinal infection.70 Clinical manifestations of intraperitoneal infection may be atypical, with an insidious onset. Signs of peritoneal irritation may be absent in an abdomen distended with ascites.71 In a series of 600 cases (all ages, both sexes) of acute generalized or localized peritonitis over a 3-year period, the following signs were absent or minimal in patients over 65 with appendicitis: nausea and vomiting, pain, abdominal tenderness, temperature, and elevated leukocyte count.72 This absence of symptoms occurs because patients often are taking anti-inflammatory or antimalignancy medication. Fever, chills, or joint symptoms of septic arthritis may be minimal, especially if the patient has one or
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Literature Cited 1. Smith PW. Nursing home-acquired infections. What to do about control and treatment. Postgrad Med. 1987;81 :55-66. 2. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidemiol. 1 985;1 21:159-167. 3. Garibaldi RA, Brodine S, Matsumiya S. Infections among patients in nursing homes: policies, prevalence, problems. N Engl J Med. 1981;305:731-735. 4. Chan KM. Infection in the elderly. Annals of the Academy of Medicine. 1990;1 9:364-369. 5. Stolley JM, Buckwalter KC. latrogenesis in the elderly. Nosocomial infections. Journal of Gerontological Nursing. 1991;17:30-34. 6. Yoshikawa TT. Geriatric infectious diseases: an emerging problem. J Am Geriatr Soc. 1983;31:34-39. 7. Singer C, Kaplan MH, Armstrong D. Bacteremia and fungemia complicating neoplastic disease-a study of 364 cases. Am J Med. 1977;62:731-742. 8. Moellering RC. Factors influencing the clinical use of antimicrobial agents in elderly patients. Geriatrics. 1978;33:8391.

9. Berk SL, Smith JK. Infectious diseases in the elderly. Med Clin North Am. 1983;67:273-293.
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10. Yoshikawa TT. Important infections in elderly persons. West J Med. 1981;135:441-445. 11. Smith IM. Infections in the elderly. Hosp Pract (Off Ed). 1982; 1 7:69-85. 12. Galask RP, Larsen B. Identifying and treating genital tract infections in postmenopausal women. Geriatrics. 1981 ;36:69-79. 13. Gupta KL. Normal aging vs disease in the elderly. Hosp Pract (Off Ed). 1986;21:34-39. 14. Young CH. The chemistry of aging. Laboratory Management. 1988;26:16-23. 15. King DW, Pushparaj N, O'Toole K. Morbidity and mortality in the aged. Hosp Pract (Off Ed). 1982;17:97-109. 16. Gleckman R, Blagg N, Hibert D, et al. Catheter-related urosepsis in the elderly: a prospective study of communityderived infections. JAm Geriatr Soc. 1982;30:255-257. 17. Yoshikawa TT, Guze LB. UTI: special problems in the elderly. Geriatrics. 1982;37:109-118. 18. Edwards JE, Jr, Tillman DB, Miller ME, Pitchon HE. Infection and diabetes mellitus. West J Med. 1979;130:515521. 19. Rosen T, Rudolph AH. Identifying and treating bacterial and fungal infections of the skin. Geriatrics. 1978;33:71-81. 20. Shelley WB, Shelley ED. The ten major problems of aging skin. Geriatrics. 1982;37:107-1 13. 21. Polly SM, Sanders WE, Jr. Surgical infections in the elderly: prevention, diagnosis, and treatment. Geriatrics. 1 977;32:88-97. 22. Smith IM. Common infections in the elderly diabetic. Geriatrics. 1980;35:55-58. 23. Sen P, Louria DB. Infectious complications in the elderly diabetic patient. Geriatrics. 1983;38:63-71. 24. Alvarez S, Shell C, Berk SL. Pulmonary tuberculosis in elderly men. Am J Med. 1987;82:602-606. 25. Schoenbaum SC. How to minimize infectious complications of diabetes. Geriatrics. 1979;34:51-58. 26. Cunha BA, Gingrich D, Rosenbaum GS. Pneumonia syndromes: a clinical approach in the elderly. Geriatrics. 1 990;45:49-55. 27. Block E. Pitfalls in diagnosing and managing pulmonary diseases. Geriatrics. 1979;34:70-80. 28. Feinberg MJ, Knebl J, Tully J, Segal L. Aspiration and the elderly. Dysphagia. 1990;5:61-71. 29. Norman DC, Grahn D, Yoshikawa TT. Fever and aging. J Am Geriatr Soc. 1985;33:859-863. 30. Gleckman R, Hibert D. Afebrile bacteremia: a phenomenon in geriatric patients. JAMA. 1982;248:1478-1481. 31. Finklestein MS, Petkun WM, Freedman ML, Antopol SC. Pneumococcal bacteremia in adults. Age-dependent differences in presentation and in out-come. J Am Geriatr Soc. 1983;31 :19-27. 32. Marrie TJ, Haldane EV, Faulkner RS, Durant H, Kwan C. Community-acquired pneumonia requiring hospitalization. Is it different in the elderly? J Am Geriatr Soc. 1985;33:671-680. 33. Deal WB. Unusual manifestations of infectious diseases in the aging. Geriatrics. 1979;34:77-84. 34. Terpenning MS, Buggy BP, Kauffman CA. Infective endocarditis: clinical features in young and elderly patients. Am J Med. 1987;83:626-634. 35. Esposito AL, Gleckman RA. Fever of unknown origin in the elderly. J Am Geriatr Soc. 1978;26:498-505.
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36. Alvarez S, Shell C, Berk SL. Pulmonary tuberculosis in elderly men. Am J Med. 1987;82:602-606. 37. Iseman MD. Tuberculosis in the elderly: treating the 'white plague.' Geriatrics. 1980;35:90-107. 38. Rudd A. Tuberculosis in a geriatric unit. J Am Geriatr Soc. 1985;33:566-569. 39. Bobrowitz I. Active tuberculosis undiagnosed until autopsy. Am J Med. 1982;72:650-658. 40. Nagami PH, Yoshikawa TT. Tuberculosis in the geriatric patient. JAm Geriatr Soc. 1983;31:356-363. 41. Eickhoff TC. The significance of influenza in geriatric practice. Gerontologist. 1961;1:78-84. 42. Argen RJ, Wilson JR, Wood P. Suppurative arthritis. Arch Intem Med. 1966;1 17:661-666. 43. Newman JH. Review of septic arthritis throughout the antibiotic era. Ann Rheum Dis. 1976;35:198-205. 44. Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986;81 :979-982. 45. Abrutyn E, Boscia JA, Kaye D. The treatment of asymptomatic bacteriuria in the elderly. J Am Geriatr Soc. 1 988;36:473-475. 46. Kaye D. Urinary tract infections in the elderly. Bull NY Acad Med. 1980;56:209-220. 47. Mayer TR. UTI in the elderly: how to select treatment. Geriatrics. 1980;35:67-77. 48. Wolfson SA, Kalmanson GM, Rubini ME, Guze LB. Epidemiology of bacteriuria in a predominantly geriatric male population. Am J Med Sci. 1965;250:168-173. 49. Felser JM, Raff MJ. Infectious diseases and aging: immunologic perspectives. J Am Geriatr Soc. 1983;31 :802-807. 50. Schneider EL. Infectious diseases in the elderly. Ann Intem Med. 1983;98:395-400. 51. Castle SC, Norman DC, Perls TT, Chang MP, Yoshikawa TT, Makinodan T. Analysis of cutaneous delayedtype hypersensitivity reaction and T cell proliferative response in elderly nursing home patients: an approach to identifying immunodeficient patients. Gerontology. 1990;36:217-229. 52. Terpenning MS, Bradley SF. Why aging leads to increased susceptibility to infection. Geriatrics. 1991;46:77-80. 53. Lipton JB, Ticknor CB. Influence of sex and age on febrile responses to peripheral and central administration of pyrogens in the rabbit. J Physiol (Lond). 1979;295:263-272. 54. Miller D, Yoshikawa T, Castle SC, Norman D. Effect of age on fever response to recombinant tumor necrosis factor alpha in a murine model. J Gerontol. 1991;46:176-179. 55. Wongsurawat N, Davis BB, Morley JE. Thermoregulatory failure in the elderly. St. Louis University Geriatric Grand Rounds. J Am Geriatr Soc. 1990;38:899-906. 56. Castle SC, Norman DC, Yeh M, Miller D, Yoshikawa TT. Fever response in elderly nursing home residents: are the older truly colder? J Am Geriatr Soc. 1991;39:853-857. 57. Bloch RG. Tuberculosis, a disease of old age. Arch Intem Med. 1958;1 01:1 057-1064. 58. Morris CDW, Bird AR, Nell H. Hematological and biochemical changes in severe pulmonary tuberculosis. 0 J Med. 1989;73:1 151-1159. 59. Stead WW, T To. The significance of the tuberculin skin test in elderly patients. Ann Intern Med. 1987;1 07:837-842. 60. Gordin FM, Perez-Stable EJ, Flaherty D, et al. Evaluation of a third sequential tuberculin skin test in a chronic care
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population. Am Rev Respir Dis. 1 988;1 37:153-157. 61. Rosenberg HM, Chevarley F, Powell-Griner E, Kochanek K, Feinleib M. Causes of death among the elderly: information from the death certificate. Vital Health Stat 5. Washington, DC: US Government Printing Office; 1991. US Dept of Health and Human Services. 62. Simons RJ, Reynolds HY. Altered immune status in the elderly. Semin Respir Infect. 1990;5:251-259. 63. Fein AM, Feinsilver SH, Niederman MS. Atypical manifestations of pneumonia in the elderly. Clin Chest Med.

1991;12:319-336.
64. Osler W. The Principles and Practices of Medicine. New York, NY: Appleton and Co; 1892. 65. Marrie TJ, Durant H, Kwan C. Nursing home-acquired pneumonia-a case-control study. J Am Geriatr Soc. 1 986;34:697-702. 66. Heckerling PS. The need for chest roentgenograms in adults with acute respiratory illness. Arch Intern Med. 1986;146:1321-1 324.

67. Boscia JA, Abrutyn E, Kaye D. Asymptomatic bacteriuria in elderly patients: treat or do not treat? Ann Intern Med. 1987; 106:764-766. 68. Nicolle LE, Brunka J. Urinary IgG and IgA antibodies in elderly individuals with bacteriuria. Gerontology. 1990;36:345355. 69. Terpenning MS, Buggy BP, Kauffman CA. Infective endocarditis: clinical features in young and elderly patients. Am J Med. 1987;83:626-634. 70. Maasdam CF, Anuras S. Are you overlooking GI infections in your elderly patients? Geriatrics. 1981;36:127-134. 71. Levison ME. DDx for abdominal infections: heading off peritoneal emergencies. Geriatrics. 1982;37:69-79. 72. Chaitin H, Wienick L. Peritonitis in geriatric patients. J Am Geriatr Soc. 1970;1 8:834-837. 73. Massanari RM. Purulent meningitis in the elderly: when to suspect an unusual pathogen. Geriatrics. 1977;32:55-59. 74. Roeltgen DR Infections and the nervous system in the elderly. Geriatrics. 1983;38:105-116.

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