Coeliac disease in the elderly

A recent review paper looked at the epidemiology, clinical presentations, complications, diagnosis and management of coeliac disease in the elderly.

Prevalence

Coeliac disease is a common disorder not only in the young but also in the elderly. Recent reports show an increased rate of diagnosis of coeliac disease in adults.

Symptoms

Symptoms of coeliac disease vary from person to person and can range from mild to severe. Gut symptoms are less prominent in elderly people with coeliac disease compared to younger people. Older people with gut symptoms may present with milder symptoms such as abdominal bloating, flatulence and abdominal discomfort, making diagnosis more difficult.

Signs of nutrient deficiencies may be the first and often the only symptom in the elderly. Anaemia is present in 60 to 80% of elderly people with coeliac disease. Elderly people may also present with deficiencies in calcium and vitamin D and some may have developed low bone density.

Coeliac disease can also present through associated disorders and complications.

Dermatitis herpetiformis is recognised as a skin manifestation of coeliac disease. The average age of presentation is in the 40’s, with most people affected between 20 and 70 years old.

Coeliac disease is an autoimmune condition and can occur alongside other autoimmune conditions including, Type 1 diabetes, autoimmune thyroid disease and autoimmune liver disease. Type 1 diabetes is more common in children with coeliac disease than adults, although it can occur at any age. Autoimmune thyroid disorders seen in coeliac disease are more common in older people.

Diagnosis

Diagnosis of coeliac disease in older people can be difficult due to the subtle clinical symptoms, lack of awareness of coeliac disease in older people, and consideration of more threatening conditions such as malignancy. Awareness of coeliac disease in older people is important to prevent long delays in diagnosis.

Coeliac disease is diagnosed by screening with a blood test for tissue transglutaminase (TTGTissue Transglutaminase - an antibody that is measured in the blood as part of the diagnosis process for coeliac disease. Depending on the laboratory performing the test, one or more antibodies may be measured (see Endomysial antibody)) antibody and confirmed by endoscopy with a small bowel biopsy. Healing of the intestine may be slower in older people diagnosed with coeliac disease. Close follow up is important to ensure symptoms improve.

Complications

Undiagnosed coeliac disease can result in low bone density and increased risk of bone fractures in older people.

Refractory coeliac disease

Refractory coeliac disease (RCD) is a term used to describe coeliac disease that is not responding to a strict gluten-free diet. Other conditions and gluten in the diet should be ruled out before a diagnosis of RCD is made. RCD can occur in about 5% of people with coeliac disease and is most common in older people.

Malignancy

The risk of small bowel cancer, non-Hodgkins and Hodgkin’s lymphoma is increased in undiagnosed coeliac disease. The incidence of lymphoma is greater in older people and occurs more commonly in patients diagnosed with coeliac disease between 50 and 80 years of age. A gluten-free diet has been shown to have a protective effect on the risk of malignancy in people with coeliac disease.

Management

Coeliac disease is managed by a strict gluten-free diet. Data suggests that compliance to the diet among older people is high. However, older people may find the diet difficult as a life time of dietary habits may be hard to change.

There may also be difficulties due to the cost of gluten-free foods on a more limited budget and accessing gluten-free foods if mobility is limited. Older people in assisted living accommodation may find it difficult accessing suitable foods on a gluten-free diet. Limited vision can make it difficult to check ingredient lists to find suitable products.

Advice should be tailored to the individual and information should be provided to family members and/or relevant staff at assisted living accommodation where appropriate.

Support

A multidisciplinary approach in the management of coeliac disease can help in following the diet and treating associated conditions where additional considerations are necessary. Investigations for anaemia, calcium and vitamin D deficiency, osteoporosis, thyroid and liver disease should be carried out at follow up appointments.

Rashtak S, Murray JA (2009) Celiac disease in the elderly. Gastroenterology Clinical North American. 38, 433-446