Prevalence of Helicobacter Pylori infection in elderly patients and in institutionalized old people: correlation with nutritional status

Prevalence of Helicobacter Pylori infection in elderly patients and in institutionalized old people: correlation with nutritional status

M.C. Neri

Introduction

Helicobacter pylori is a Gram-negative, spiral-shaped bacterium with a strong affinity for gastric-type epithelium [1]. Since its identification and isolation by Marshall and Warren in 1983 [2], various epidemiological studies have demonstrated that this organism plays an aetiological role in the development of type B active chronic gastritis [3] and is likely to be involved in the pathogenesis and recurrence of peptic ulcer [4-6]. Moreover, H. pylori is associated with duodenal ulcer in 70-100% of cases [7, 8] and with gastric ulcer in 5090% [9, 10]. It is still not well established that H. pylori infection is related to non-ulcer dyspepsia [11, 12] and gastric neoplasia, in particular adenocarcinoma and lymphoma of the `mucosa associated lymphoid tissue’ (MALT lymphoma) [13-16].

H. pylori infection is distributed worldwide, but its prevalence changes considerably with age, ranging from less than 20% in adults aged under 20 years to more than 60% in the population aged over 60 in developed countries [17-20]. Subjects aged over 90 are reported to have a lower prevalence, probably owing to severe gastritis [21], but scanty information is available for this age group [22]. Earlier and more frequent H. pylori infection at younger ages is found in populations with low socio-economic status and poor hygiene [23-28]. This type of distribution of the infection and the recent report that H. pylori is found in the stool of infected subjects [29, 30] and in dental plaque [31, 32] suggest that person-to-person transmission between household or family contacts may occur [33-35].

The scanty information about a possible higher prevalence of H. pylori infection in custodial institutions (such as institutes for mental diseases or orphanages) and crowded communities [36-38] confirms that the organism spreads among subjects by the orofaecal route or from mouth to mouth via dental plaque [39, 40].

This study investigated the prevalence of H. pylori infection, detected serologically, in elderly subjects in short- or long-term care in geriatric rehabilitation institute in Milan.

Patients and Methods

From May to June 1994 we enrolled 96 patients (48 women, 48 men; mean age: 79.8 years, SD 9.4, range 60-100) in a geriatric institute in Milan, Northern Italy. Forty-eight of them (24 women and 24 men; mean age 79.6 years, SD 8.9, range 61-100) were admitted consecutively to a geriatric ward for rehabilitation after femoral or hip fractures, stroke, polyarthrosis, or senile Parkinson-like disease, and were studied at admission to the ward. They were age- and sexmatched with 48 subjects institutionalized for more than 1 year (24 women and 24 men, mean age: 79.9 years, SD 10 range 60-100). Patients with cancer or terminal status were excluded.

Hygiene and living conditions conformed to the European Union uniform requirements for this kind of institutionalization and were checked periodically.

At admission the patients or their relatives were asked about current use of drugs such as antibiotics, [H.sub.2]-antagonists and omeprazole, and alcohol and/or smoking habits. Self-sufficiency was assessed on the activities of daily living (ADL) scale [41] and cognitive function by the Short Portable Mental Status Questionnaire (SPMSQ) [42]. Anthropometric measurements included body mass index (BMI), triceps skin-fold thickness (TSF), and arm muscle area (AMA) [43]. BMI is derived from the subject’s height (cm) and weight (kg) (kg/[m.sup.2]) and reflects general nutritional status. TSF is an indicator of fat reserves, and AMA [(mid-arm circumference TSF x 0.314)2/ 4 x 0.314] estimates skeletal protein status.

Specific serum antibodies to H. pylori (IgG) were detected by ELISA (fluorescent enzymatic immunoassay, Helori-Test IgG, Europharma R, cut-off < 30%, OD at 405 nm 0.809).

Blood samples were taken for iron (colorimetric method), transferrin (immunonephelometric method), total proteins and albumin (colorimetric method), prealbumin (nephelometric method), haemoglobin, glucose and BUN measurements. For statistical analysis of data, Student’s t test for unpaired data, simple regression analysis and [X.sup.2] test were used as appropriate.

The study was approved by the local ethics committee and informed consent was obtained from patients or their relatives before entry to the study.

Results

The overall prevalence of H. pylori infection was 70.8%, the prevalence in hospitalized patients being 72.9% and in institutionalized patients 68.7% (Table I). H. pylori antibodies were found in 79.2% of the men (mean age 74 years, range 60-90) and 62.5% of the women (mean age 84 years, range 70-100) (Table I).

Table I. Prevalence of Helicobacter pylori infection by sex and

hospitalized or institutionalized status

H. pylori %

No. + –

Men 48 79.2 20.8

Women 48 62.5 37.5

Hospitalized 48 72.9 27.1

Institutionalized 48 68.7 31.3

All cases 96 70.8 29.2

Various explanations exist for the falling prevalence of H. pylori infection in the population over 90; the lower tendency to socialize of old people, owing to physical and psychosocial factors, with a reduced spread of infection; the progressive atrophy in the aged stomach, produces an unfavourable environment for H. pylori overgrowth; and the insufficient immunological response to an infective agent and/or the loss of immunocompetence of very old people. Finally many people over 90 are edentulous, and the absence of dental plaque could explain the reduced spread of the infection [52].

In our study the prevalence of H. pylori infection was higher in men than in women, in line with another Italian study in which younger people were recruited [53]. The difference observed by us could be due to the fact that the men were usually more prone to socialize than the women. Moreover, the latter were older and showed higher levels of physical disability, as their lower ADL score demonstrated.

We did not observe any relation between prevalence of H. pylori infection and type of care. This could be due to the hygienic conditions which were comparable in the institutionalized patients and the others who had all been in hospital for less than 1 month. The absence of any relation between the prevalence of H. pylori infection and the length of institutionalization suggests that the standards of living of the institutionalized population were no different from those of the population still living at home. This observation does not support the notion of crowded communities as a major source of infection in older people, as reported in other studies in which, however, younger people were considered [36-38].

According to the literature H. pylori infection is not related to personal habits, such as smoking or alcohol intake, or administration of drugs, such as NSAIDs, or active treatments for dyspeptic symptoms. These symptoms are also probably underestimated because elderly people frequently underrate gastrointestinal symptoms, and cognitive impairment often makes it difficult to collect a medical history [54-56].

In our series, no correlations were found between H. pylori infection and nutritional indices, in particular, there was no relation between anti-H. pylori IgG titre and BMI, in contrast with a recent study showing such a correlation in younger subjects [56]. Possibly, BMI reflects social class-related aspects of current living conditions more accurately in younger than older subjects. Alternatively, BMI in elderly people may be more influenced by random variations, which would tend to reduce the magnitude of an effect [56]. It is commonly believed that institutionalization leads to malnutrition. However, patients arriving in our rehabilitation ward usually come from an acute-care hospital after short medical treatments and are often already weak, in poor health, and nutritionally depleted. Moreover, it has recently been underlined that institutionalization does not necessarily lead to malnutrition [57].

In conclusion, the prevalence of H. pylori infection in the elderly patients referred to our geriatric institute in Milan is similar to that reported in other older populations. The observed prevalence does not support the notion that crowded communities favour this infection. The oldest subjects are apparently more protected against the infection. Morbidity and mortality in old patients with H. pylori infection and peptic ulcer disease is aggravated by the tendency of elderly people to declare few symptoms, and peptic disease in this population is frequently revealed only when major complications such as bleeding or perforation develop, due in most cases to the uncontrolled use of NSAIDs [55, 58]. These observations suggest that doctors should use more precautions in treating H. pylori-positive elderly patients, especially if NSAIDs are to be given. Moreover, eradication of H. pylori in old patients not only represents an important goal in the treatment of peptic disease, but it may also prevent transmission to younger family members or co-residents in geriatric institutions.

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Authors’ addresses M. C. Neri, L. Lai, P. Bonetti, M. Monti, P. De Luca, E. Cunietti IV Reparto, Istituto Geriatrico `Pio Albergo Trivulzio, via Trivulzio, 15, 20146 Milano, Italy

A. R. Baldassarri, M. Quatrini Cattedra di Gastroenterologia, IRCCS, Ospedale Maggiore, Milano, Italy

Received 23 May 1995

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