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The Older Patient

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The Older Patient
By A. G. Moore 5/10/2013


Risk Assessment Chart
World Health Organization
Wikimedia Commons, Public Domain

W
hen diagnosing and treating an illness, doctors first consider the most probable scenarios. If, for example, someone shows up with a malar rash, rosacea rather than lupus is suspected–because rosacea is a far more common condition. The doctor’s assessment is influenced by what he knows about the patient’s ethnicity, lifestyle–and other factors. So, it’s important for doctors to understand how diseases tend to manifest in different groups. Which leads me to the subject of today’s blog: research in recent years has shown that lupus in the elderly is more common than once thought, and the elderly seem to suffer higher rates of mortality from the disease.

This is big news. When I was first diagnosed with lupus, I was told I was likely to have a mild course of the disease because I was older. While in some respects this is true–lupus tends to occur less acutely in the older patient–in another respect this is not true. The older, much older, patient is more likely to die from the disease. Longer life spans, for lupus patients in particular, have given doctors the opportunity to discover the enhanced risk to the elderly.

The incidence of autoimmunity increases with age. This is because the immune system is compromised–grows less vigorous–as we grow older. One part of the body in which this is dramatically evident is the thymus gland, which plays a significant role in the immune response. The older we get the smaller the thymus gland becomes. As the thymus gland shrinks, there are disruptions in B and T lymphocytes, two significant actors in the development of autoimmune disease–especially in the development of lupus.

Differential diagnosis–deciding whether we have one disease or another–becomes more challenging the older we get because we are likely to have co-morbidities (other diseases). It is often difficult to sort the symptoms of one co-existing illness from another. An additional concern doctors have in treating the elderly is medication burden. Drug interactions are more likely because of the several medications the elderly are usually prescribed. Aging kidneys and other organs also may not work well, and thus medication may not clear efficiently from the body. Slow or inefficient drug clearance increases the risk of adverse side effects. 

There are many differences, besides rates of mortality, between the way the young and the elderly experience lupus. To start with, the term “elderly” has to be defined. Some researchers set the cut off at age fifty; others set the threshold at 65. Whatever the cutoff, certain facts are emerging. Specific differences in the way lupus affects the elderly (as opposed to a younger patient) include:

  • acute onset is more likely in a younger than an older patient
  • diagnosis may take longer in an older patient because symptoms may be less obvious and occur over the span of months, or years
  • the percentage of males who have lupus seems to increase as the population ages
  • the same relative increase is observed in Caucasians who have lupus
  • malar rash seems to be less common in the elderly
  • lupus is more likely to overlap with Sjogren’s in the elderly
  • certain auto-antibodies indicating involvement of the central nervous system are more commonly found in the elderly, though seizure does not appear to occur in the elderly with the same frequency that it does in younger patients

As the greater risk of mortality from lupus in the elderly becomes evident, doctors adjust their appraisal of this disease in their older patients. The message, for both care providers and consumers, is that lupus is always a formidable enemy. The dangers of this disease should never be underestimated.

(Please note a contradictory study from Israel which holds the more traditional view that lupus is the elderly runs a milder course than it does for younger patients)

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