INFECTIOUS DIARRHEA IN THE ELDERLY
Section snippets
EPIDEMIOLOGY
Life expectancy in the United States has risen from an average of 45 years in 1900 to 75 years at present. By the year 2025, 22% of the US population will be older than age 65.5 Gastrointestinal function is altered in many ways with aging,8 and the elderly are at an increased risk for certain illnesses, among which are various diarrheal diseases, including infectious diarrhea.4
Infectious diarrhea is an important cause of morbidity and mortality in the elderly. Although there is extensive
IMMUNOSENESCENCE
The phenomenon of immunosenescence, or an overall decline in immune function as a consequence of advancing age, is supported by many observations. Infection-related mortality increases with age, and the elderly undergo a progressive decline in their ability to react to environmental stresses, such as exposure to new strains of infectious organisms. Several animal and human studies have provided evidence for specific immune system alterations with age that may lead to increased susceptibility to
NONTYPHOIDAL SALMONELLOSIS
Salmonella is one of the most deadly causes of gastroenteritis in the elderly. Several authors reported that Salmonella is the cause of most deaths attributed to outbreaks of infectious intestinal disease in nursing homes.20, 32In a survey of infectious intestinal disease among institutionalized individuals in England and Wales, Salmonella infection accounted for 17% of all identified cases, second in frequency only to small round structured viruses.32 Levine et al20 reported that Salmonella
VIRAL GASTROENTERITIS
The true incidence of viral gastroenteritis among the elderly is not known because routine stool tests do not detect viral pathogens. Rotavirus and Norwalk-like virus are the pathogens most commonly identified as the causative agents in outbreaks of viral gastroenteritis among the elderly. Features of viral gastroenteritis outbreaks among the elderly that are in contrast to bacterial outbreaks include (1) sudden and rapid onset of nausea and vomiting, (2) higher attack rates in general, and (3)
BACTERIAL OVERGROWTH
Although not classically considered to be an infectious cause of diarrhea, bacterial overgrowth is an important consideration when evaluating an elderly patient with diarrhea. In contrast to diarrhea caused by bacterial and viral gastroenteritis, diarrhea caused by bacterial overgrowth usually has a subacute or chronic presentation. The elderly are at increased risk for bacterial overgrowth for many reasons. Hypochlorhydria or achlorhydria is commoner among the elderly because of post-gastric
SUMMARY
Infectious diarrhea is an important disease in the elderly. Some basic principles have been outlined, as follows. In the elderly:
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Infectious diarrhea is an underappreciated health problem.
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There is a higher mortality rate and case-fatality rate compared with younger persons.
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Infectious diarrhea is most often associated with group settings (e.g., nursing homes and skilled nursing facilities) or antibiotic use.
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Infectious diarrhea may be associated with abnormal immune function (i.e.,
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Address reprint requests toPeter Slotwiner-Nie, MD Division of Gastroenterology Department of Medicine Montefiore Medical Center 111 E 210th Street Bronx, NY 10467