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Demography of aging and the epidemiology of gastrointestinal disorders in the elderly
Best Practice & Research Clinical Gastroenterology 23 (2009) 793–804
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Best Practice & Research Clinical Gastroenterology
1
Demography of aging and the epidemiology of gastrointestinal disorders in the elderly Michael J. Goldacre, MA, MSc, BM, BCh, FFPHM, FRCP, Professor of Public Health * Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
Keywords: aging demography epidemiology gastrointestinal digestive cancer
Population aging is a global phenomenon. It is estimated that there were 600 million people in the world aged 60 and over in 2000 and that there will be 1.2 billion by 2025. People aged 65 and over comprise 16% of the population of Europe. About half of the world’s elderly population live in the developing world. Many of the gastrointestinal disorders seen in specialist practise show age-specific incidence and prevalence rates that increase substantially with increasing age. In this review, hospitalization rates for gastroenterological disorders in England are presented by age to demonstrate gradients with age. Some of the disorders, such as colorectal cancer, appendicitis, diverticular disease and inflammatory bowel disease, became common in developed countries in association with economic development and changes in lifestyle. As the developing world becomes more urbanised and westernised, disorders that are now rare in the developing world will probably become much more common. Ó 2009 Published by Elsevier Ltd.
In this paper, I outline some of the major characteristics of the demography of the elderly, consider the gastrointestinal disorders that commonly afflict the elderly, and summarise some of the main epidemiological characteristics of these disorders. Demography: the global phenomenon of aging populations The fact that the world’s population is growing fast, and that the elderly population is expanding substantially, is well recognised but the extent of growth is phenomenal. The world population has
* Tel.: þ44 1865 289377; fax: þ44 1865 289379. E-mail address: [email protected] 1521-6918/$ – see front matter Ó 2009 Published by Elsevier Ltd. doi:10.1016/j.bpg.2009.10.008
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been estimated as 2.5 billion people in 1950 and 6.7 billion in 2007 [1]. The elderly population has expanded considerably both in sheer size and as a percentage of total population. The World Health Organisation (WHO) estimates that, globally, there were 600 million people aged 60 years and over in 2000, that there will be 1.2 billion by 2025, and two billion by 2050 [2]. The factors that drive population growth and aging are different in different parts of the world. However, in general, growth reflects, in part, increases in numbers of births 60 and more years ago; increased survival through the hazardous years of infancy and early childhood; and, in most countries, continuing improvements in life expectancy thereafter at every age through life up to and including old age [3,4]. People aged 60 years and over in 2010 are the survivors of the cohorts born in the population of 2.5 billion people in 1950 and earlier; people aged 60 years and over in 2067 will be the survivors of the cohorts born in the population of 6.7 billion people in 2007 and earlier. It is estimated that people aged 65 years and over currently comprise 7.4% of the world population, 3.4% of the population of the continent of Africa, 5.6% of south east Asia, 12.6% of northern America, 13.1% of Australasia and 16.1% of Europe [5]. Projections of future population size and age structure are inherently uncertain but in the UK, for example, it is projected that the percentage of the population aged 65 and over will rise from 16% in 2006 to 22% by 2031. In many parts of the developed world, the sharpest rises in the elderly have been in the very elderly. In the UK, the population aged 80 and over rose from 2.8% of the total population in 1981 to 4.5% by 2006. Expressed as percentages, the aging of the population is seen as particularly striking in the developed world at present. However, the median age of the population is rising in almost every country whether in the developed or developing world. Expressed as numbers, the huge rise in the elderly population is a global phenomenon. The WHO estimates that there are about 492 million people aged 65 and over globally, 117 million in Europe, 43 million in northern America, and 258 million in the much bigger total population of Asia [5]. Today, about two-thirds of all older people in the world are living in the developing world; by 2025, it will be 75% [2]. Life expectancy Figures for life expectancy from birth for selected countries are shown in Table 1, obtained from the WHO Demographic Yearbook [6]. The figures show that babies born now in the developed world can be expected to live, on average, to ages in the mid to late 70s for males and to the late 70s to mid 80s for females. Life expectancy calculations from birth do, of course, include loss of life in infancy, childhood and young adult life; and actuarial calculations can be made from any age. In the UK, for example, current life expectancy for people who reach the age of 65 is now, on average, 17.2 further years of life for men and 19.9 for women [7]. Implications of an aging population are manifold. The dependency ratio – the ratio of the number of people who do not work to those who do – increases. Typically, women outlive men in almost all societies and by very old age the female:male ratio is close to 2:1 [2]. Needs for social support and medical care increase with advancing age. Some of the implications for professionals concerned with the prevention, treatment and care for gastrointestinal disorders in the elderly are as follows. The larger number of elderly will, of course, substantially increase the need for services for, and expertise in the care of, gastrointestinal disorders in the elderly. The total burden of disease will increase for those disorders that are strongly related to increasingly old age – such as gastric, colorectal and pancreatic cancer. Elderly patients with gastrointestinal disorders will also tend to have the complication of higher levels of other clinical co-morbidity. Higher levels of dependency with advancing old age, and increasing numbers of elderly lone women, will create challenges for after-care in patients who are treated successfully for acute and acute-on-chronic illnesses. Urbanisation Another worldwide demographic phenomenon deserves brief mention for its likely future impact: urbanisation. There have been major population shifts in recent decades from rural to urban areas. Throughout human history, the majority of people have lived in rural settings. It is estimated that by 2008, for the first time in history, the majority of humankind were urban dwellers [8]. Urbanisation, and the
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Table 1 Life expectancy for males and females in selected countries. Country
Males
Females
United Statesa Canadab Mexico Egyptc Indiad Hong Kongd Singapore Japan England Finland Franced Germany Greecea Israel Italya Netherlands Norway Portugal Spainb Russia Sweden Switzerland Australia New Zealand
74.9 77.8 72.6 67.9 62.6 79.4 78.1 79.2 77.2 75.8 77.2 76.9 77.0 78.8 78.1 78.0 78.2 75.2 77.0 61.4 78.9 79.2 79.0 78.0
79.9 82.6 77.4 72.3 64.2 85.5 82.9 86.0 81.5 82.9 84.2 82.3 82.0 82.5 83.7 82.3 82.7 81.6 83.5 73.9 83.0 84.1 83.7 82.2
Life expectancy data for 2007 except where otherwise indicated as a2005, b2004, c2003, d2006.
adoption of western lifestyles, are likely to bring behavioural and environmental changes on an unprecedented scale. Some of the chronic gastrointestinal disorders that are now common in westernised countries became common in association with urbanisation, economic growth, and lifestyle changes. These disorders remain uncommon in low income countries with traditional rural ways of life. Time will tell whether these chronic gastrointestinal diseases that are familiar in western countries, but rare in rural populations in low income countries, will become more common in these newly urbanised populations. Age and cohort effects As indicated above, chronological age is a function of calendar time and birth cohort: people aged, for example, 80 in the year 2010 are also people who were born in 1930. Some of their characteristics in 2010 will be attributable to age and aging; others may be a function of having been born in 1930, having been a child in the 1930s, a teenager in the 1940s, a young adult in the 1950s, and so on. As an example, the age-specific prevalence of Helicobacter pylori infection is higher in older than in younger people in Europe and North America. The risk of H. pylori infection is associated with socio-economic deprivation in childhood, and it is relatively high in unsanitary or overcrowded living conditions. The current age-related prevalence of infection is, at least in part, a cohort effect: successive birth cohorts have had a successively lower risk of chronic childhood infection with H. pylori [9]. There is also evidence of a birth cohort effect in the rise and fall of peptic ulcer disease during the course of the 20th century – an effect whereby individuals born at certain times were exposed to causative factors that preceding and succeeding cohorts did not experience on such a scale [10–13]. Some measures of population ‘burden’ of gastrointestinal disease Some of the standard sources of routinely collected information about disease occurrence include national and regional collections of mortality statistics; hospital admission statistics; cancer registration statistics; in some countries, data from general practices that choose to collect and share anonymised data about patients’ contacts with primary care services; and population prevalence
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surveys. Each source has its strengths and weaknesses. Important international collections of pooled national and sub-national data notably include cancer incidence data, compiled and disseminated for many years, as Cancer Incidence in Five Continents, by the International Agency for Research on Cancer (IARC) [14]; mortality data published by the WHO [15]; and data on the ‘burden’ of disease, also published by the WHO, measured by Disability-Adjusted Life-Years (DALYs) [16]. DALYs are time-based measures that combine years of life lost due to premature mortality and years of ‘quality of life’ lost as a result of years of life spent in states of less than full health. In DALY calculations for a specific disease, the component of ‘years of life lost’ is calculated as the difference between age at death from the disease and achievable longevity. Typically, Japanese life expectancy statistics are used as the standard for measuring premature death, as, among the world’s large countries, the Japanese have the longest life expectancy. The disability component is based on calculations of years of life spent disabled by the disease. The years of life lost and the years spent disabled by the disease, taken together, give a measure that combines the population ‘burden’ of mortality and morbidity. DALYs are typically calculated on an all-ages basis but, as with the life expectancy figures described above, could in principle be calculated as from any age. If calculated from the age of (say) 60, they can provide estimates of the burden of gastroenterological diseases in the elderly that combines mortality and morbidity. The WHO has published DALY data for all ages, and for people aged 60 and over, for selected disorders including some gastroenterological disorders, for a wide range of countries [16]. Presentation of age- and sex-specific hospitalization rates and basic epidemiology In the sections that follow, I show disease rates measured as hospital admission rates, which include both overnight stays and admissions for ambulatory day case care, in England by age group. These are the only measures of rates of morbidity that are routinely available for the elderly for all diseases for the country as a whole. The use of one main source of data also means that disease rates and age gradients between different diseases can easily be compared. The rates provide a profile of gastrointestinal disease as seen in specialist gastroenterological practice. The data are shown, below, in five-year age groups from 55 years of age, to show how rates in people aged 65 and over compare with those in the preceding two younger quinquennia. They are shown separately for males and females to compare the sexes. The measures given are average annual admission rates for people admitted for each disease in each age group and sex, expressed per 100,000 people in the general English population in the same age group and of the same sex (i.e. they are age-specific and sex-specific rates). The diagnoses are those given on the hospital record as the principal diagnostic reason for the hospital stay as recorded at the time of the patient’s discharge. The hospital data are linked – that is, successive admissions for the same person are brought together – so that anyone admitted more than once for the same disease in the year is counted once only. Some of the international comparisons, below, are made using all-ages rates. This is because, generally, rates confined to the elderly are not routinely available for such international comparisons. For most diseases described, there is a substantial increase in rates with increasing age and, in practice, the all-ages rates will generally be dominated numerically by international differences in disease incidence and prevalence of the disease in the elderly. The following sections cover the basic descriptive epidemiology of common gastroenterological diseases with comments on known aetiological risk factors. It is noteworthy that, where aetiological risk factors have been established, they are generally not strong: they account for only a small fraction of disease risk. Nonetheless, many common and important gastrointestinal diseases show substantial international geographical variation; and some have shown striking trends over time. This means that there must be important behavioural and environmental factors that influence the aetiology of gastrointestinal diseases that are yet to be identified. Interested readers may also wish to consult the epidemiological sections of other publications [13,17–20]. Gastrointestinal malignancies Most gastrointestinal malignancies show a steep gradient of increasing frequency with increasing age. The hospital admission rates show approximately a doubling of rates between ages 60–64 and
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Table 2 Gastrointestinal malignancies: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
C15
Malignant neoplasm of oesophagus Malignant neoplasm of stomach Malignant neoplasm of small intestine Malignant neoplasm of colon Malignant neoplasm of rectosigmoid junction Malignant neoplasm of rectum Malignant neoplasm of liver and intrahepatic bile ducts Malignant neoplasm of gallbladder Malignant neoplasm of pancreas
M F M F M F M F M F M F M F
47.5 13.8 28.6 10.4 3.3 2.6 63.6 50.5 15.4 9.0 51.5 25.2 10.8 5.1
68.2 22.9 52.7 18.4 4.7 3.3 112.2 79.1 26.1 14.3 81.9 36.5 15.6 7.9
91.9 33.1 85.0 28.8 6.1 4.1 173.1 119.5 37.5 19.9 116.7 51.1 22.9 11.5
120.3 49.6 121.9 44.7 6.9 5.3 244.8 158.5 48.0 22.4 141.9 66.7 28.7 14.7
150.6 66.2 153.6 59.7 8.3 6.3 303.4 197.0 50.9 27.1 166.1 78.2 38.6 17.4
161.6 80.1 178.1 76.6 9.8 6.5 327.6 221.1 48.7 23.5 172.0 87.6 37.1 23.6
162.7 91.5 200.9 89.2 9.2 5.5 323.4 219.7 42.4 22.7 171.1 92.2 38.6 21.7
M F M F
0.8 1.8 21.0 15.1
1.1 2.6 33.0 25.1
2.0 3.7 46.5 35.3
2.6 4.5 59.9 47.6
3.7 4.7 74.1 59.8
3.5 5.1 85.4 71.1
4.6 5.5 92.2 80.4
C16 C17 C18 C19 C20 C22
C23 C25 a
International Classification of Diseases, tenth Revision.
70–74 years (Table 2). Most show striking variation between countries. International comparative data, published in considerable detail, can be found at the IARC website [14]. Cancer of the oesophagus In most populations, male rates are considerably higher than those in females and there is a strong gradient of increased incidence with increasing age. For example, hospitalization rates increased from 68 per 100,000 population in men aged 60–64 to 162 in men aged 80–84 (Table 2). In women the corresponding rates were 23 and 80. Oesophageal cancer is characterized by substantial geographical variation in rates throughout the world. Age-standardised cancer registration rates for oesophageal cancer in men are four per 100,000 population in Los Angeles, five in New Delhi, nine in Hong Kong and Shanghai, and 20 in the Jiashan province of China [14]. European rates range from two per 100,000 in parts of Italy, three in Finland Norway and Sweden, seven in the Netherlands and eight in London [14]. In some European countries, there is substantial regional variation: in France, rates are six per 100,000 in Herault and 15 in Calvados [14]. In Singapore rates are much higher in ethnic Chinese than in its Indian population. Rates in migrants from high incidence areas to low incidence areas tend, with time, to diminish. For example, residents of Los Angeles with Chinese ancestry have rates that are similar to those of whites in Los Angeles [14]. These changes in risk indicate the importance of modifiable environmental and behavioural risk factors in the aetiology of oesophageal cancer. Risk factors include smoking, high alcohol consumption, and, in all probability, a synergistic effect of the two such that people who both smoke and have high intakes of alcohol are at particularly high risk. It is also likely that there are associations with particular components of diet and food preparation – and perhaps also with carcinogenic food-related toxins or substances chewed for recreational purposes in populations in China and the Caspian with particularly high rates – but these are not yet well defined. Cancer of the stomach Stomach cancer, too, is strongly age-related and much more common in men than women in most populations. Hospitalization rates in England increased from 53 per 100,000 population in men aged
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60–64 to 178 in men aged 80–84 (Table 2). In women the corresponding rates were 18 and 77. Stomach cancer shows substantial variation in incidence between populations. Age-standardised cancer registration rates for men per 100,000 are three in New Delhi, seven in California and in Sweden, ten in London, 11 in Holland, 15 in Hong Kong, and 34 in Shanghai [14]. Its incidence is particularly high in Japan: the rate in men per 100,000 population in Osaka is 51, compared with seven in the white population of Los Angeles and 17 in the Japanese population resident in Los Angeles [14]. The tendency of rates in high-risk populations to move, following migration, towards the rates in the host population indicates the importance of environmental and behavioural factors in the aetiology of stomach cancer. The high levels of risk decline with increasing duration of residence. At least in western populations, stomach cancer incidence tends to show a strong relationship with socio-economic circumstances: it is more common in poor than affluent people. One of the most striking features of the epidemiology of stomach cancer has been its decline over time. Albeit at different rates in different places, it has declined over time in many populations. The decline has been found in all age groups. It is associated with the decline in infection with H. pylori. High levels of salt consumption have been implicated in the aetiology of stomach cancer. Improvements in food preservation methods, including refrigeration, and the decreased use of salting, pickling and smoking food may have contributed to the decline. The increased availability and affordability of fresh fruit and vegetables, perhaps particularly in childhood and young adult life, may also have contributed. Colorectal cancer Cancers of the colon and rectum show a steep gradient of increasing incidence with increasing age. Male rates are higher than those in females, but the male excess is not quite as great as that for cancers of the oesophagus and stomach. Hospitalization rates for colon cancer increased from 112 per 100,000 population in men aged 60–64 to 328 in men aged 80–84 (Table 2). In women the corresponding rates were 79 and 221. Hospitalization rates for rectal cancer increased from 82 per 100,000 population in men aged 60–64 to 172 in men aged 80–84. In women the corresponding rates were 37 and 88. International comparisons of rates show substantial variation, but, contrasting to some extent with oesophageal and stomach cancer, there is a more clearly delineated profile of high rates in the developed world countries and low rates in the developing world. Age-standardised registration rates for colorectal cancer in men per 100,000 population are five in New Delhi, seven in Pakistan and in Uganda, 35 in California, 43 in Canada, 47 in New South Wales in Australia, 30 in Grenada in Spain, 42 in Milan, 32 in London, 40 in the Netherlands and 30 in Sweden [14]. Dietary factors are probably the major cause of colorectal cancers. Colorectal cancers are associated with high consumption of meat, and of animal or saturated fat more generally, with low levels of dietary fibre intake, and low consumption of fruit and vegetables. Risks of colorectal cancer are increased in people with adenomatous polyps of the colon and rectum, and in people with inflammatory bowel disease. Cancer of gallbladder and pancreas Cancer of the gallbladder is rare (Table 2). Like gallstone disease, and unlike other gastrointestinal cancers, it is more common in women than men. Cancer of the pancreas is reasonably common in elderly people. Its incidence is higher in men than in women but the sex difference is not as striking as that for several other gastrointestinal cancers. Hospitalization rates increased from 33 per 100,000 population in men aged 60–64 to 85 in men aged 80–84 (Table 2). In women the corresponding rates were 25 and 71. Smoking is the main known risk factor for pancreatic cancer but the attributable risk is far lower than that for smoking and lung cancer. Its incidence in the developed world has been fairly stable over time. It seems to exhibit much less geographical variation than oesophageal, stomach and colorectal cancer. For example, age-standardised cancer registration rates in males are reported as two in New Delhi, six in Holland, seven in Canada, California, London and Australia, eight in Shanghai and in Denmark, and nine in Osaka and in Milan and Finland.
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Table 3 Non-malignant diseases of the upper and lower gastrointestinal tract: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
K20
Oesophagitis
K21
Gastro-oesophageal reflux disease
K25
Gastric ulcer
K26
Duodenal ulcer
K27 K28
Peptic ulcer, site unspecified Gastrojejunal ulcer
K29
Gastritis and duodenitis
K30
Dyspepsia
K35
Acute appendicitis
K36
Other appendicitis
K37
Unspecified appendicitis
K50
Crohn’s disease
K51
Ulcerative colitis
K55
K58
Vascular disorders of intestine Diverticular disease of intestine Irritable bowel syndrome
K65
Peritonitis
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
105.7 88.5 192.2 197.4 50.6 45.7 51.6 24.4 3.2 2.3 0.6 0.3 223.6 242.1 94.2 144.2 30.8 29.7 0.7 0.8 3.2 3.0 19.6 25.9 60.7 45.2 6.5 7.0 118.0 151.8 8.4 22.8 9.5 6.9
129.4 109.6 216.6 231.8 72.7 62.2 66.9 33.0 4.4 2.9 1.0 0.5 297.4 301.5 110.6 160.8 26.8 25.0 0.4 0.7 2.5 2.3 18.9 24.9 61.2 45.3 10.6 11.1 172.8 234.7 7.4 19.4 12.4 9.8
139.5 115.9 226.2 229.8 94.6 81.3 85.8 42.1 5.2 3.5 1.1 0.6 343.3 325.9 119.9 150.6 24.8 21.5 0.4 0.7 2.0 2.2 17.3 22.9 64.1 45.8 16.3 18.1 245.4 333.8 6.1 14.6 17.2 14.2
141.7 120.8 214.1 211.6 115.5 101.9 111.9 55.7 7.0 4.7 1.6 0.8 361.3 347.1 107.6 132.2 22.0 18.7 0.4 0.6 1.9 1.8 16.7 23.1 65.1 46.3 26.0 26.1 325.2 431.0 5.0 12.5 25.3 20.9
145.9 121.9 205.9 195.0 147.1 128.6 140.3 75.9 9.5 6.9 1.7 1.1 389.0 346.8 103.7 107.9 18.2 16.3 0.4 0.3 1.7 1.4 15.7 20.4 55.7 42.5 37.2 41.4 402.1 504.5 4.7 9.7 35.1 33.4
139.7 115.3 189.8 168.7 162.5 144.3 172.5 99.4 11.6 9.4 2.3 1.3 380.8 326.5 83.6 79.1 17.2 14.0 0.4 0.3 1.7 1.3 14.4 17.7 42.2 33.9 50.3 55.3 432.2 527.9 3.8 7.5 48.3 53.8
136.3 97.2 167.9 124.1 177.0 149.6 219.7 129.6 19.9 15.1 2.7 1.1 337.4 256.3 60.5 42.9 13.4 10.0 0.3 0.2 2.2 1.2 10.4 10.7 29.6 22.1 70.7 77.0 417.0 466.7 3.4 5.7 71.2 87.2
K57
a
International Classification of Diseases, tenth Revision.
Non-malignant diseases of the upper and lower gastrointestinal tract Although malignant gastrointestinal diseases are numerically very important causes of cancer overall, and important causes of gastrointestinal disease, non-malignant disease predominates in both primary and secondary care of gastrointestinal disease. Oesophagitis and gastro-oesophageal reflux disease Symptoms of oesophagitis and of gastro-oesophageal reflux, heartburn and acidic regurgitation, are very common. In a population-based prevalence survey of gastro-oesophageal reflux in England, it was reported that about 30% of the population had had such symptoms in the previous year [21]. At least up to the age of 69 years (the upper limit of the study), the age-specific prevalence rates were very similar across age groups; and they were also similar in men and women. As seen in specialist practice, too, rates from 60 years of age for hospital care of gastro-oesophageal reflux disease do not show any striking association with advancing age (Table 3). Rates are also similar in men and women. Peptic ulcer Hospital admission rates for peptic ulcer disease rise steeply with advancing age (Table 3). In this English population, age-specific rates for gastric ulcer and for duodenal ulcer were similar in men; rates
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for gastric ulcer were higher than those for duodenal ulcer in women. Epidemiological studies have demonstrated a very strong association between H. pylori infection and duodenal and gastric ulcer; and proof that the association was causal was demonstrated by the permanent cure of ulcers following eradication of H pylori infection [19]. Eradication of H. pylori by treatment has been a major factor in the decline of peptic ulcer disease. Other important causal or aggrevating factors for peptic ulcer include the use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, smoking and heavy alcohol consumption. In the United Kingdom gastric ulcer became common in young adults, particularly women, in the early part of the 20th century but, following a rise, its occurrence in the young has declined substantially. It is now predominantly a disease of elderly men and women. In Europe and North America duodenal ulcer was uncommon at the turn of the 20th century, as evidenced from medical and autopsy reports, but its prevalence rose substantially from the 1920s and 1930s to the 1950s [17]. In recent decades it has declined in western urban communities. In the period of increase, it seemed to be more common in some occupations than others and, for a time, it was considered a disease related to occupational stress in professional and executive staff. Stress is hard to define and, if anything, nowadays duodenal ulcer is more common in low than high socio-economic groups. Smoking and high alcohol consumption are risk factors, as are elements of diet but the precise identification of dietary risk factors has been elusive. Its prevalence is increasing in the urban areas of the developing world. Non-steroidal anti-inflammatory drugs (NSAIDs), and aspirin, are particularly important causes of peptic ulcer in the elderly; and have become increasingly important in recent decades. As the average age of the population increases, the prevalence of arthropathies and other causes of chronic pain increases, and so does the consumption of NSAIDs by the elderly. This has led to the emergence of NSAID-associated peptic ulcer and to increased risks of perforation and haemorrhage. Acid suppression has been the mainstay of management of NSAID-associated ulcer disease. The pathophysiology and management of NSAID-associated ulcer disease, and its relationship with H pylori ulcer disease, have recently been reviewed [19]. Ulceration in the absence of H pylori, or NSAIDs or aspirin, is uncommon. However, the fall in prevalence of H pylori ulcer disease means that the relative importance of H pylori-negative NSAIDnegative disease has been increasing. Gastritis and duodenitis Prevalence studies show that the major forms of gastritis are very common in the elderly. Hospital admission rates with a hospital discharge diagnosis of gastritis or duodenitis are also high in the elderly. In the English hospital data, hospitalization rates were 297 per 100,000 men aged 60–64 and 381 per 100,000 men aged 80–84 (Table 3). In women the corresponding rates were 302 and 327. Appendicitis Acute appendicitis is a disease that is closely associated with economic development and a westernised lifestyle. It was uncommon until the last part of the 19th century. Its incidence rose steeply in the fist half of the 20th century in Europe and North America. Its incidence has declined considerably in recent years. The cause of the rise, and of the subsequent decline, is unknown. Appendicitis is very uncommon in the developing world. Its peak incidence is in children and young adults and, even in the elderly, its incidence continues to decline with advancing old age (Table 3). However, it remains a disease that can occur at any age and it is an important surgical emergency in the elderly. Crohn’s diseases and ulcerative colitis Crohn’s disease and ulcerative colitis are inflammatory bowel diseases of unknown aetiology. Crohn’s disease was first described in 1932 and, in the few decades that followed, it has been reported with increasing frequency in Europe and North America [17,20]. While some of the increase may result from improved recognition and diagnosis, it is generally accepted that the increase in incidence and prevalence has been real. It seems likely that there is some geographical variation in the times at which the diseases have increased: studies in some places have reported increases that have continued while others have reported increases that then stabilized [20]. Ulcerative colitis, first recognised in the late 19th century, has also become more common in the past 50 years but in recent decades its incidence
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has generally been more stable that that of Crohn’s disease [20]. A European collaborative study on inflammatory bowel disease reported incidence rates across Europe, albeit confined to people aged under 65 years, of 5.6 new cases of CD per 100,000 population per year and 10.4 new cases of UC per 100,000 [22]. Rates were higher in northern than southern Europe [22,23]. For CD, the highest rates were in Holland and north-west France (9.2 per 100,000) and the lowest (0.9) was in north-west Greece. For UC, the highest reported rate was in Iceland (24.5) and the lowest in southern Portugal (1.6). CD and UC are uncommon in the black African population and in India. CD is typically a disease of young people, a little more common in women than men, and its incidence declines with increasing age. UC, too, affects young people but its incidence is more evenly spread across the age range and it is more common in men than women. There is a secondary late peak, albeit small, in the incidence of CD and UC at about 60–70 years of age. As chronic diseases, their prevalence is far higher than their annual incidence; and prevalent cases of disease acquired at an earlier age are an important cause of morbidity into old age (Table 3). The aetiologies of CD and UC are unknown but their higher prevalence in western countries, and their emergence and rise in them in recent decades, suggests a link with aspects of western lifestyle and perhaps in particular with diet or food additives. Diverticular disease Multiple diverticula of the colon are very common in elderly people in countries with western lifestyles. Inflammatory changes in the diverticula cause clinical disease. The prevalence of diverticula rises with age and in many western countries over half the population have them. Diverticular disease has become much more common in western populations over the course of the past century. Diverticular disease is one of the most common reasons for hospital admission in elderly people and, as the tables show, it is the single most common diagnostic reason for hospital admission in people aged 75 years and over. Hospitalization rates increased from 173 per 100,000 population in men aged 60–64 to 432 in men aged 80–84 (Table 3). In women the corresponding rates were 235 and 528. It is generally accepted that diverticula are formed as a result of high intracolonic pressures, leading to protrusion of mucosa through weak points in the muscle wall, associated with straining at defaecation. In rural African and Indian communities, where diverticular disease is very uncommon, people have soft bulky stools and short bowel transit times. The typical smaller stool weight and longer bowel transit times in westernized populations are generally considered to be a consequence of the lower proportion fibre in typical western diets. Other gastrointestinal disorders Irritable bowel syndrome is very common in the general population. It is more common in women than in men and its prevalence declines with age. In a population-based prevalence survey in the UK, it was reported in 28% of women and 12% of men aged 20–29, and in 10% of women and 8% of men aged 60–69 years [24]. It is a relatively uncommon reason for hospital admission and one that declines with advancing age in the elderly (Table 3). Vascular disorders of the intestine are increasingly common causes of hospital admission with advancing age. Age-specific rates in the English data showed about a ten-fold increase in admission rates from about seven per 100,000 population aged 55–59 to 70 per 100,000 by the age of 85 and over (Table 3). Admission rates with a diagnosis of peritonitis also show a considerable increase with advancing age with almost a ten-fold increase from age 55–59 to age 85 and over (Table 3). Disorders of liver, gallbladder, pancreas Liver diseases Age-specific admission rates for liver diseases are shown in Table 4. Up to the age of 70, the figures are dominated by alcohol-related disease. Admission rates for alcoholic liver disease decline with advancing age. A similar age-related fall with advancing age is seen in English mortality rates for alcohol-related diseases: for example, age-specific rates per million in 1984–1992 were 136 in men aged 55–64 and 78 in men aged 75 and over, and they were 94 in women aged 55–64 and 47 in women
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Table 4 Non-malignant diseases of liver, gallbladder and pancreas: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
K70
Alcoholic liver disease
K71
Toxic liver disease
K72
K80
Hepatic failure, not elsewhere classified Chronic hepatitis, not elsewhere classified Fibrosis and cirrhosis of liver Cholelithiasis
K81
Cholecystitis
K85
Acute pancreatitis
K86
Other diseases of pancreas
M F M F M F M F M F M F M F M F M F
K73 K74
a
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
53.9 25.5 0.7 0.8 8.8 5.7 1.6 3.3 10.3 11.3 100.9 279.0 26.3 56.6 32.1 29.7 18.1 9.4
48.1 21.8 0.6 0.5 9.3 6.1 1.6 3.8 12.0 12.8 129.8 293.8 35.8 59.7 37.6 35.2 17.9 10.1
36.5 16.4 0.6 0.6 10.9 6.8 1.6 4.2 13.3 16.4 179.4 288.4 47.7 59.6 44.6 39.5 16.1 10.4
23.3 10.8 0.7 0.7 10.0 7.2 1.5 3.2 13.6 16.0 221.8 274.7 55.0 53.8 50.9 42.9 15.0 11.6
15.4 6.4 0.7 0.7 11.1 6.9 1.5 2.7 12.9 13.1 245.3 255.9 56.0 49.6 59.2 51.5 14.3 10.6
9.2 3.6 0.6 0.7 10.2 5.9 1.2 1.6 12.6 9.5 258.1 251.9 55.9 46.1 65.7 61.3 11.9 10.2
5.5 1.3 0.8 0.4 9.2 6.1 0.5 0.4 9.0 5.7 281.5 269.7 56.6 53.6 76.9 78.0 12.0 9.5
International Classification of Diseases, tenth Revision.
aged 75 and over [25]. These apparent declines with age are likely to be largely attributable to cohort effects and, specifically, to the very substantial increase in alcohol-related disease in young and middleaged adults in recent times in England [26]. Alcohol-related deaths in Britain have risen very substantially in recent decades [25,26]. Trends in alcohol-related morbidity and mortality show considerable differences between countries: by contrast with Britain, mortality rates are generally falling in southern European countries [26]. Gallbladder disease Admissions with a principal diagnosis of gallbladder disease increase sharply with increasing age. As Table 4 shows, it is a common reason for admission of the elderly. It is more common in women than men up to the age of about 75 and thereafter male and female rates are similar. The prevalence of gallstones, as measured by population-based ultrasound surveys, varies across Europe from about five to 25% of the population. Diseases of the pancreas Acute pancreatitis is becoming increasingly common in Britain [27,28]. The great majority of diagnosed case of acute pancreatitis are admitted to hospital and so hospital admission rates are a good proxy for incidence rates. Its incidence is broadly similar in men and women. It increases with increasing age: for example, admission rates in men rose from 32 per 100,000 at age 55–59 to 77 at ages of 85 and over, and those for women rose from 30 to 78 (Table 4). The two main causes of acute pancreatitis are blockage of the pancreatic duct by gallstones and heavy alcohol consumption. The percentage of cases of acute pancreatitis that are gallstone related, and that are alcohol related, vary between European populations and may change over time [20]. Other diseases of the pancreas notably include chronic pancreatitis. Chronic pancreatitis is less common than acute pancreatitis. Its prevalence declines with increasing age. Gastrointestinal symptoms Many patients who are hospitalized for gastrointestinal problems leave hospital without a definitive diagnosis. Table 5 shows hospitalization rates for elderly people whose discharge diagnosis was simply abdominal or pelvic pain, nausea and vomiting, or dysphagia. Rates are high, particularly in the very old, and they rise substantially with advancing age.
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Table 5 Non-specific gastrointestinal disorders: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
R10
Abdominal and pelvic pain
R11
Nausea and vomiting
R13
Dysphagia
M F M F M F
270.4 412.5 30.4 46.1 44.4 51.4
322.4 429.3 39.4 59.0 60.6 62.9
358.8 428.8 52.7 72.1 75.4 72.4
372.1 424.5 68.3 91.2 97.7 88.2
393.9 420.3 84.9 116.7 124.1 103.1
412.5 427.1 102.9 147.4 142.1 123.3
481.8 466.6 150.4 205.4 175.6 146.8
a
International Classification of Diseases, tenth Revision.
Summary Most but not all of the common and important gastrointestinal diseases show increased age-specific rates with increasing age. Most but not all are more common in men than women. Many show substantial international variation in incidence and prevalence rates. Some are strongly related to economic development and the adoption of westernized lifestyles. The surgeon and epidemiologist Denis Burkitt wrote extensively about diseases that are associated with ‘modern western civilisation’ [29] and, in this group, he included appendicitis, diverticular disease, colorectal cancer, inflammatory bowel disease and gallstones. Western diet, and factors closely associated with it such as methods of food preservation, additives and food preparation are strongly implicated, although much of the detail remains to be unravelled. The importance of H. pylori as a cause of gastrointestinal disease is undoubted; and its treatment has led to a substantial decline in peptic ulcer disease and gastric cancer. Some diseases associated with western civilization are now in decline in countries where they had become common – the most notable example is appendicitis. Some diseases associated with western civilization, uncommon in the rural developing world, will become more common as developing nations undergo urbanisation and lifestyle changes. Conflict of interest statement None.
References [1] United Nations Statistics Division. Demographic yearbook, Table 1, http://unstats.un.org/unsd/demographic/products/dyb/ dyb2007/Table01.pdf. [2] World health Organisation. Ageing and lifecourse, http://www.who.int/ageing/en/. [3] Office for National Statistics. National Statistics Online. Ageing, http://www.statistics.gov.uk/cci/nugget.asp?id¼2157. [4] Dini E, Goldring S. Estimating the changing population of the oldest old, http://www.statistics.gov.uk/articles/population_ trends/PT132OldestOldArticle.pdf. [5] United Nations Statistics Division. Demographic yearbook, Table 2, http://unstats.un.org/unsd/demographic/products/dyb/ dyb2007/Table02.pdf. [6] United Nations Statistics Division. Demographic yearbook, Table 4, http://unstats.un.org/unsd/demographic/products/dyb/ dyb2007/Table04.pdf. [7] Office for National Statistics. Life expectancy at birth in longest in the South of England, http://www.statistics.gov.uk/ pdfdir/leb1008.pdf. [8] United Nations Population Fund. State of World Population. – online report, http://www.unfpa.org/swp/2007/english/ introduction.html; 2007. [9] Webb PM, Knight T, Greaves S, et al. Relation between infection with Helicobacter pylori and living conditions in childhood: evidence for person to person transmission in early life. BMJ 1994;308:750–3. [10] Sonnenberg A, Muller H, Pace F. Birth-cohort analysis of peptic ulcer mortality in Europe. J Chronic Dis 1985;38:309–17. [11] Westbrook JI, Rushworth RL. The epidemiology of peptic ulcer mortality 1953–1989. A birth cohort analysis. Int J Epidemiol 1993;22:1085–92. [12] Primatesta P, Goldacre MJ, Seagroatt V. Changing patterns in the epidemiology and hospital care of peptic ulcer. Int J Epidemiol 1994;23:1206–17.
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[13] Nguyen-Van-Tam J, Logan R. In: Charlton J, Murphy M, editors. The health of Adult Britain 1841–1994 Digestive disease, vol. 2. London: The Stationery Office; 1997 p. 129–39, http://www.statistics.gov.uk/STATBASE/Product.asp?vlnk¼1548. [14] International Agency for Research on Cancer. Cancer Incidence in Five Continents.Summary tables by site (3-digit rubrics), http://www-dep.iarc.fr/. [15] World Health Organisation. Health statistics and health information systems. WHO Mortality Database: Tables, http:// www.who.int/healthinfo/morttables/en/index.html. [16] World Health Organisation. Health statistics and health information systems. Global burden of disease, http://www.who. int/healthinfo/global_burden_disease/metrics_daly/en/index.html. [17] Hutt MSR, Burkitt DP. The geography of non-infectious disease. Chapters 2 and 3. Oxford: Oxford University Press; 1986. [18] James OFW (ed). Section 8: Gastroenterology. In: Grimley Evans J, Williams TF, editors. Oxford textbook of geriatric medicine. Oxford: Oxford University Press; 1992. [19] Malfertheiner P, Chan FKL, McColl KEL. Peptic ulcer disease. Lancet 2009;374:1449–61. [20] Williams JG, Roberts SE, Ali MF, et al. Gastroenterology services in the UK. The burden of disease, and the organisation and delivery of services for gastrointestinal and liver disorders: a review of the evidence. Gut 2007;56:1–113. [21] Kennedy T, Jones R. The prevalence of gastro-oesophageal reflux symptoms in a UK population and the consultation behaviour of patients with these symptoms. Aliment Pharmacol Ther 2000;14:1589–94. [22] Shivananda S, Lennard-Jones J, Logan R, et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut 1996;39:690–7. [23] Frangos CC, Frangos CC. Inflammatory bowel disease: reviewing an old study under a new perspective. Gut 2007;56: 1638–9. [24] Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. Br J Surg 2000;87:1658–63. [25] Goldacre MJ, Duncan M, Griffith M, Cook-Mozaffari P. Alcohol as a certified cause of death in a ‘middle England’ population 1979-1999: database study. J Public Health 2004;26:343–6. [26] Leon DA, McCambridge J. Liver cirrhosis mortality rates in Britain from 1950 to: an analysis of routine data. Lancet 2006; 367:52–6. [27] Goldacre MJ, Roberts SE. Hospital admission for acute pancreatitis in an English population, 1963–1998: database study of incidence and mortality. BMJ 2004;328:1466–9. [28] Wilson C, Imrie CW. Changing patterns of incidence and mortality from acute pancreatitis in Scotland, 1961–1985. Br J Surg 1990;77:731–4. [29] Burkitt DP. Some diseases characteristic of modern western civilisation. BMJ 1973;1:274–8.
Contents lists available at ScienceDirect
Best Practice & Research Clinical Gastroenterology
1
Demography of aging and the epidemiology of gastrointestinal disorders in the elderly Michael J. Goldacre, MA, MSc, BM, BCh, FFPHM, FRCP, Professor of Public Health * Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
Keywords: aging demography epidemiology gastrointestinal digestive cancer
Population aging is a global phenomenon. It is estimated that there were 600 million people in the world aged 60 and over in 2000 and that there will be 1.2 billion by 2025. People aged 65 and over comprise 16% of the population of Europe. About half of the world’s elderly population live in the developing world. Many of the gastrointestinal disorders seen in specialist practise show age-specific incidence and prevalence rates that increase substantially with increasing age. In this review, hospitalization rates for gastroenterological disorders in England are presented by age to demonstrate gradients with age. Some of the disorders, such as colorectal cancer, appendicitis, diverticular disease and inflammatory bowel disease, became common in developed countries in association with economic development and changes in lifestyle. As the developing world becomes more urbanised and westernised, disorders that are now rare in the developing world will probably become much more common. Ó 2009 Published by Elsevier Ltd.
In this paper, I outline some of the major characteristics of the demography of the elderly, consider the gastrointestinal disorders that commonly afflict the elderly, and summarise some of the main epidemiological characteristics of these disorders. Demography: the global phenomenon of aging populations The fact that the world’s population is growing fast, and that the elderly population is expanding substantially, is well recognised but the extent of growth is phenomenal. The world population has
* Tel.: þ44 1865 289377; fax: þ44 1865 289379. E-mail address: [email protected] 1521-6918/$ – see front matter Ó 2009 Published by Elsevier Ltd. doi:10.1016/j.bpg.2009.10.008
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been estimated as 2.5 billion people in 1950 and 6.7 billion in 2007 [1]. The elderly population has expanded considerably both in sheer size and as a percentage of total population. The World Health Organisation (WHO) estimates that, globally, there were 600 million people aged 60 years and over in 2000, that there will be 1.2 billion by 2025, and two billion by 2050 [2]. The factors that drive population growth and aging are different in different parts of the world. However, in general, growth reflects, in part, increases in numbers of births 60 and more years ago; increased survival through the hazardous years of infancy and early childhood; and, in most countries, continuing improvements in life expectancy thereafter at every age through life up to and including old age [3,4]. People aged 60 years and over in 2010 are the survivors of the cohorts born in the population of 2.5 billion people in 1950 and earlier; people aged 60 years and over in 2067 will be the survivors of the cohorts born in the population of 6.7 billion people in 2007 and earlier. It is estimated that people aged 65 years and over currently comprise 7.4% of the world population, 3.4% of the population of the continent of Africa, 5.6% of south east Asia, 12.6% of northern America, 13.1% of Australasia and 16.1% of Europe [5]. Projections of future population size and age structure are inherently uncertain but in the UK, for example, it is projected that the percentage of the population aged 65 and over will rise from 16% in 2006 to 22% by 2031. In many parts of the developed world, the sharpest rises in the elderly have been in the very elderly. In the UK, the population aged 80 and over rose from 2.8% of the total population in 1981 to 4.5% by 2006. Expressed as percentages, the aging of the population is seen as particularly striking in the developed world at present. However, the median age of the population is rising in almost every country whether in the developed or developing world. Expressed as numbers, the huge rise in the elderly population is a global phenomenon. The WHO estimates that there are about 492 million people aged 65 and over globally, 117 million in Europe, 43 million in northern America, and 258 million in the much bigger total population of Asia [5]. Today, about two-thirds of all older people in the world are living in the developing world; by 2025, it will be 75% [2]. Life expectancy Figures for life expectancy from birth for selected countries are shown in Table 1, obtained from the WHO Demographic Yearbook [6]. The figures show that babies born now in the developed world can be expected to live, on average, to ages in the mid to late 70s for males and to the late 70s to mid 80s for females. Life expectancy calculations from birth do, of course, include loss of life in infancy, childhood and young adult life; and actuarial calculations can be made from any age. In the UK, for example, current life expectancy for people who reach the age of 65 is now, on average, 17.2 further years of life for men and 19.9 for women [7]. Implications of an aging population are manifold. The dependency ratio – the ratio of the number of people who do not work to those who do – increases. Typically, women outlive men in almost all societies and by very old age the female:male ratio is close to 2:1 [2]. Needs for social support and medical care increase with advancing age. Some of the implications for professionals concerned with the prevention, treatment and care for gastrointestinal disorders in the elderly are as follows. The larger number of elderly will, of course, substantially increase the need for services for, and expertise in the care of, gastrointestinal disorders in the elderly. The total burden of disease will increase for those disorders that are strongly related to increasingly old age – such as gastric, colorectal and pancreatic cancer. Elderly patients with gastrointestinal disorders will also tend to have the complication of higher levels of other clinical co-morbidity. Higher levels of dependency with advancing old age, and increasing numbers of elderly lone women, will create challenges for after-care in patients who are treated successfully for acute and acute-on-chronic illnesses. Urbanisation Another worldwide demographic phenomenon deserves brief mention for its likely future impact: urbanisation. There have been major population shifts in recent decades from rural to urban areas. Throughout human history, the majority of people have lived in rural settings. It is estimated that by 2008, for the first time in history, the majority of humankind were urban dwellers [8]. Urbanisation, and the
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Table 1 Life expectancy for males and females in selected countries. Country
Males
Females
United Statesa Canadab Mexico Egyptc Indiad Hong Kongd Singapore Japan England Finland Franced Germany Greecea Israel Italya Netherlands Norway Portugal Spainb Russia Sweden Switzerland Australia New Zealand
74.9 77.8 72.6 67.9 62.6 79.4 78.1 79.2 77.2 75.8 77.2 76.9 77.0 78.8 78.1 78.0 78.2 75.2 77.0 61.4 78.9 79.2 79.0 78.0
79.9 82.6 77.4 72.3 64.2 85.5 82.9 86.0 81.5 82.9 84.2 82.3 82.0 82.5 83.7 82.3 82.7 81.6 83.5 73.9 83.0 84.1 83.7 82.2
Life expectancy data for 2007 except where otherwise indicated as a2005, b2004, c2003, d2006.
adoption of western lifestyles, are likely to bring behavioural and environmental changes on an unprecedented scale. Some of the chronic gastrointestinal disorders that are now common in westernised countries became common in association with urbanisation, economic growth, and lifestyle changes. These disorders remain uncommon in low income countries with traditional rural ways of life. Time will tell whether these chronic gastrointestinal diseases that are familiar in western countries, but rare in rural populations in low income countries, will become more common in these newly urbanised populations. Age and cohort effects As indicated above, chronological age is a function of calendar time and birth cohort: people aged, for example, 80 in the year 2010 are also people who were born in 1930. Some of their characteristics in 2010 will be attributable to age and aging; others may be a function of having been born in 1930, having been a child in the 1930s, a teenager in the 1940s, a young adult in the 1950s, and so on. As an example, the age-specific prevalence of Helicobacter pylori infection is higher in older than in younger people in Europe and North America. The risk of H. pylori infection is associated with socio-economic deprivation in childhood, and it is relatively high in unsanitary or overcrowded living conditions. The current age-related prevalence of infection is, at least in part, a cohort effect: successive birth cohorts have had a successively lower risk of chronic childhood infection with H. pylori [9]. There is also evidence of a birth cohort effect in the rise and fall of peptic ulcer disease during the course of the 20th century – an effect whereby individuals born at certain times were exposed to causative factors that preceding and succeeding cohorts did not experience on such a scale [10–13]. Some measures of population ‘burden’ of gastrointestinal disease Some of the standard sources of routinely collected information about disease occurrence include national and regional collections of mortality statistics; hospital admission statistics; cancer registration statistics; in some countries, data from general practices that choose to collect and share anonymised data about patients’ contacts with primary care services; and population prevalence
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surveys. Each source has its strengths and weaknesses. Important international collections of pooled national and sub-national data notably include cancer incidence data, compiled and disseminated for many years, as Cancer Incidence in Five Continents, by the International Agency for Research on Cancer (IARC) [14]; mortality data published by the WHO [15]; and data on the ‘burden’ of disease, also published by the WHO, measured by Disability-Adjusted Life-Years (DALYs) [16]. DALYs are time-based measures that combine years of life lost due to premature mortality and years of ‘quality of life’ lost as a result of years of life spent in states of less than full health. In DALY calculations for a specific disease, the component of ‘years of life lost’ is calculated as the difference between age at death from the disease and achievable longevity. Typically, Japanese life expectancy statistics are used as the standard for measuring premature death, as, among the world’s large countries, the Japanese have the longest life expectancy. The disability component is based on calculations of years of life spent disabled by the disease. The years of life lost and the years spent disabled by the disease, taken together, give a measure that combines the population ‘burden’ of mortality and morbidity. DALYs are typically calculated on an all-ages basis but, as with the life expectancy figures described above, could in principle be calculated as from any age. If calculated from the age of (say) 60, they can provide estimates of the burden of gastroenterological diseases in the elderly that combines mortality and morbidity. The WHO has published DALY data for all ages, and for people aged 60 and over, for selected disorders including some gastroenterological disorders, for a wide range of countries [16]. Presentation of age- and sex-specific hospitalization rates and basic epidemiology In the sections that follow, I show disease rates measured as hospital admission rates, which include both overnight stays and admissions for ambulatory day case care, in England by age group. These are the only measures of rates of morbidity that are routinely available for the elderly for all diseases for the country as a whole. The use of one main source of data also means that disease rates and age gradients between different diseases can easily be compared. The rates provide a profile of gastrointestinal disease as seen in specialist gastroenterological practice. The data are shown, below, in five-year age groups from 55 years of age, to show how rates in people aged 65 and over compare with those in the preceding two younger quinquennia. They are shown separately for males and females to compare the sexes. The measures given are average annual admission rates for people admitted for each disease in each age group and sex, expressed per 100,000 people in the general English population in the same age group and of the same sex (i.e. they are age-specific and sex-specific rates). The diagnoses are those given on the hospital record as the principal diagnostic reason for the hospital stay as recorded at the time of the patient’s discharge. The hospital data are linked – that is, successive admissions for the same person are brought together – so that anyone admitted more than once for the same disease in the year is counted once only. Some of the international comparisons, below, are made using all-ages rates. This is because, generally, rates confined to the elderly are not routinely available for such international comparisons. For most diseases described, there is a substantial increase in rates with increasing age and, in practice, the all-ages rates will generally be dominated numerically by international differences in disease incidence and prevalence of the disease in the elderly. The following sections cover the basic descriptive epidemiology of common gastroenterological diseases with comments on known aetiological risk factors. It is noteworthy that, where aetiological risk factors have been established, they are generally not strong: they account for only a small fraction of disease risk. Nonetheless, many common and important gastrointestinal diseases show substantial international geographical variation; and some have shown striking trends over time. This means that there must be important behavioural and environmental factors that influence the aetiology of gastrointestinal diseases that are yet to be identified. Interested readers may also wish to consult the epidemiological sections of other publications [13,17–20]. Gastrointestinal malignancies Most gastrointestinal malignancies show a steep gradient of increasing frequency with increasing age. The hospital admission rates show approximately a doubling of rates between ages 60–64 and
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Table 2 Gastrointestinal malignancies: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
C15
Malignant neoplasm of oesophagus Malignant neoplasm of stomach Malignant neoplasm of small intestine Malignant neoplasm of colon Malignant neoplasm of rectosigmoid junction Malignant neoplasm of rectum Malignant neoplasm of liver and intrahepatic bile ducts Malignant neoplasm of gallbladder Malignant neoplasm of pancreas
M F M F M F M F M F M F M F
47.5 13.8 28.6 10.4 3.3 2.6 63.6 50.5 15.4 9.0 51.5 25.2 10.8 5.1
68.2 22.9 52.7 18.4 4.7 3.3 112.2 79.1 26.1 14.3 81.9 36.5 15.6 7.9
91.9 33.1 85.0 28.8 6.1 4.1 173.1 119.5 37.5 19.9 116.7 51.1 22.9 11.5
120.3 49.6 121.9 44.7 6.9 5.3 244.8 158.5 48.0 22.4 141.9 66.7 28.7 14.7
150.6 66.2 153.6 59.7 8.3 6.3 303.4 197.0 50.9 27.1 166.1 78.2 38.6 17.4
161.6 80.1 178.1 76.6 9.8 6.5 327.6 221.1 48.7 23.5 172.0 87.6 37.1 23.6
162.7 91.5 200.9 89.2 9.2 5.5 323.4 219.7 42.4 22.7 171.1 92.2 38.6 21.7
M F M F
0.8 1.8 21.0 15.1
1.1 2.6 33.0 25.1
2.0 3.7 46.5 35.3
2.6 4.5 59.9 47.6
3.7 4.7 74.1 59.8
3.5 5.1 85.4 71.1
4.6 5.5 92.2 80.4
C16 C17 C18 C19 C20 C22
C23 C25 a
International Classification of Diseases, tenth Revision.
70–74 years (Table 2). Most show striking variation between countries. International comparative data, published in considerable detail, can be found at the IARC website [14]. Cancer of the oesophagus In most populations, male rates are considerably higher than those in females and there is a strong gradient of increased incidence with increasing age. For example, hospitalization rates increased from 68 per 100,000 population in men aged 60–64 to 162 in men aged 80–84 (Table 2). In women the corresponding rates were 23 and 80. Oesophageal cancer is characterized by substantial geographical variation in rates throughout the world. Age-standardised cancer registration rates for oesophageal cancer in men are four per 100,000 population in Los Angeles, five in New Delhi, nine in Hong Kong and Shanghai, and 20 in the Jiashan province of China [14]. European rates range from two per 100,000 in parts of Italy, three in Finland Norway and Sweden, seven in the Netherlands and eight in London [14]. In some European countries, there is substantial regional variation: in France, rates are six per 100,000 in Herault and 15 in Calvados [14]. In Singapore rates are much higher in ethnic Chinese than in its Indian population. Rates in migrants from high incidence areas to low incidence areas tend, with time, to diminish. For example, residents of Los Angeles with Chinese ancestry have rates that are similar to those of whites in Los Angeles [14]. These changes in risk indicate the importance of modifiable environmental and behavioural risk factors in the aetiology of oesophageal cancer. Risk factors include smoking, high alcohol consumption, and, in all probability, a synergistic effect of the two such that people who both smoke and have high intakes of alcohol are at particularly high risk. It is also likely that there are associations with particular components of diet and food preparation – and perhaps also with carcinogenic food-related toxins or substances chewed for recreational purposes in populations in China and the Caspian with particularly high rates – but these are not yet well defined. Cancer of the stomach Stomach cancer, too, is strongly age-related and much more common in men than women in most populations. Hospitalization rates in England increased from 53 per 100,000 population in men aged
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60–64 to 178 in men aged 80–84 (Table 2). In women the corresponding rates were 18 and 77. Stomach cancer shows substantial variation in incidence between populations. Age-standardised cancer registration rates for men per 100,000 are three in New Delhi, seven in California and in Sweden, ten in London, 11 in Holland, 15 in Hong Kong, and 34 in Shanghai [14]. Its incidence is particularly high in Japan: the rate in men per 100,000 population in Osaka is 51, compared with seven in the white population of Los Angeles and 17 in the Japanese population resident in Los Angeles [14]. The tendency of rates in high-risk populations to move, following migration, towards the rates in the host population indicates the importance of environmental and behavioural factors in the aetiology of stomach cancer. The high levels of risk decline with increasing duration of residence. At least in western populations, stomach cancer incidence tends to show a strong relationship with socio-economic circumstances: it is more common in poor than affluent people. One of the most striking features of the epidemiology of stomach cancer has been its decline over time. Albeit at different rates in different places, it has declined over time in many populations. The decline has been found in all age groups. It is associated with the decline in infection with H. pylori. High levels of salt consumption have been implicated in the aetiology of stomach cancer. Improvements in food preservation methods, including refrigeration, and the decreased use of salting, pickling and smoking food may have contributed to the decline. The increased availability and affordability of fresh fruit and vegetables, perhaps particularly in childhood and young adult life, may also have contributed. Colorectal cancer Cancers of the colon and rectum show a steep gradient of increasing incidence with increasing age. Male rates are higher than those in females, but the male excess is not quite as great as that for cancers of the oesophagus and stomach. Hospitalization rates for colon cancer increased from 112 per 100,000 population in men aged 60–64 to 328 in men aged 80–84 (Table 2). In women the corresponding rates were 79 and 221. Hospitalization rates for rectal cancer increased from 82 per 100,000 population in men aged 60–64 to 172 in men aged 80–84. In women the corresponding rates were 37 and 88. International comparisons of rates show substantial variation, but, contrasting to some extent with oesophageal and stomach cancer, there is a more clearly delineated profile of high rates in the developed world countries and low rates in the developing world. Age-standardised registration rates for colorectal cancer in men per 100,000 population are five in New Delhi, seven in Pakistan and in Uganda, 35 in California, 43 in Canada, 47 in New South Wales in Australia, 30 in Grenada in Spain, 42 in Milan, 32 in London, 40 in the Netherlands and 30 in Sweden [14]. Dietary factors are probably the major cause of colorectal cancers. Colorectal cancers are associated with high consumption of meat, and of animal or saturated fat more generally, with low levels of dietary fibre intake, and low consumption of fruit and vegetables. Risks of colorectal cancer are increased in people with adenomatous polyps of the colon and rectum, and in people with inflammatory bowel disease. Cancer of gallbladder and pancreas Cancer of the gallbladder is rare (Table 2). Like gallstone disease, and unlike other gastrointestinal cancers, it is more common in women than men. Cancer of the pancreas is reasonably common in elderly people. Its incidence is higher in men than in women but the sex difference is not as striking as that for several other gastrointestinal cancers. Hospitalization rates increased from 33 per 100,000 population in men aged 60–64 to 85 in men aged 80–84 (Table 2). In women the corresponding rates were 25 and 71. Smoking is the main known risk factor for pancreatic cancer but the attributable risk is far lower than that for smoking and lung cancer. Its incidence in the developed world has been fairly stable over time. It seems to exhibit much less geographical variation than oesophageal, stomach and colorectal cancer. For example, age-standardised cancer registration rates in males are reported as two in New Delhi, six in Holland, seven in Canada, California, London and Australia, eight in Shanghai and in Denmark, and nine in Osaka and in Milan and Finland.
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Table 3 Non-malignant diseases of the upper and lower gastrointestinal tract: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
K20
Oesophagitis
K21
Gastro-oesophageal reflux disease
K25
Gastric ulcer
K26
Duodenal ulcer
K27 K28
Peptic ulcer, site unspecified Gastrojejunal ulcer
K29
Gastritis and duodenitis
K30
Dyspepsia
K35
Acute appendicitis
K36
Other appendicitis
K37
Unspecified appendicitis
K50
Crohn’s disease
K51
Ulcerative colitis
K55
K58
Vascular disorders of intestine Diverticular disease of intestine Irritable bowel syndrome
K65
Peritonitis
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
105.7 88.5 192.2 197.4 50.6 45.7 51.6 24.4 3.2 2.3 0.6 0.3 223.6 242.1 94.2 144.2 30.8 29.7 0.7 0.8 3.2 3.0 19.6 25.9 60.7 45.2 6.5 7.0 118.0 151.8 8.4 22.8 9.5 6.9
129.4 109.6 216.6 231.8 72.7 62.2 66.9 33.0 4.4 2.9 1.0 0.5 297.4 301.5 110.6 160.8 26.8 25.0 0.4 0.7 2.5 2.3 18.9 24.9 61.2 45.3 10.6 11.1 172.8 234.7 7.4 19.4 12.4 9.8
139.5 115.9 226.2 229.8 94.6 81.3 85.8 42.1 5.2 3.5 1.1 0.6 343.3 325.9 119.9 150.6 24.8 21.5 0.4 0.7 2.0 2.2 17.3 22.9 64.1 45.8 16.3 18.1 245.4 333.8 6.1 14.6 17.2 14.2
141.7 120.8 214.1 211.6 115.5 101.9 111.9 55.7 7.0 4.7 1.6 0.8 361.3 347.1 107.6 132.2 22.0 18.7 0.4 0.6 1.9 1.8 16.7 23.1 65.1 46.3 26.0 26.1 325.2 431.0 5.0 12.5 25.3 20.9
145.9 121.9 205.9 195.0 147.1 128.6 140.3 75.9 9.5 6.9 1.7 1.1 389.0 346.8 103.7 107.9 18.2 16.3 0.4 0.3 1.7 1.4 15.7 20.4 55.7 42.5 37.2 41.4 402.1 504.5 4.7 9.7 35.1 33.4
139.7 115.3 189.8 168.7 162.5 144.3 172.5 99.4 11.6 9.4 2.3 1.3 380.8 326.5 83.6 79.1 17.2 14.0 0.4 0.3 1.7 1.3 14.4 17.7 42.2 33.9 50.3 55.3 432.2 527.9 3.8 7.5 48.3 53.8
136.3 97.2 167.9 124.1 177.0 149.6 219.7 129.6 19.9 15.1 2.7 1.1 337.4 256.3 60.5 42.9 13.4 10.0 0.3 0.2 2.2 1.2 10.4 10.7 29.6 22.1 70.7 77.0 417.0 466.7 3.4 5.7 71.2 87.2
K57
a
International Classification of Diseases, tenth Revision.
Non-malignant diseases of the upper and lower gastrointestinal tract Although malignant gastrointestinal diseases are numerically very important causes of cancer overall, and important causes of gastrointestinal disease, non-malignant disease predominates in both primary and secondary care of gastrointestinal disease. Oesophagitis and gastro-oesophageal reflux disease Symptoms of oesophagitis and of gastro-oesophageal reflux, heartburn and acidic regurgitation, are very common. In a population-based prevalence survey of gastro-oesophageal reflux in England, it was reported that about 30% of the population had had such symptoms in the previous year [21]. At least up to the age of 69 years (the upper limit of the study), the age-specific prevalence rates were very similar across age groups; and they were also similar in men and women. As seen in specialist practice, too, rates from 60 years of age for hospital care of gastro-oesophageal reflux disease do not show any striking association with advancing age (Table 3). Rates are also similar in men and women. Peptic ulcer Hospital admission rates for peptic ulcer disease rise steeply with advancing age (Table 3). In this English population, age-specific rates for gastric ulcer and for duodenal ulcer were similar in men; rates
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for gastric ulcer were higher than those for duodenal ulcer in women. Epidemiological studies have demonstrated a very strong association between H. pylori infection and duodenal and gastric ulcer; and proof that the association was causal was demonstrated by the permanent cure of ulcers following eradication of H pylori infection [19]. Eradication of H. pylori by treatment has been a major factor in the decline of peptic ulcer disease. Other important causal or aggrevating factors for peptic ulcer include the use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, smoking and heavy alcohol consumption. In the United Kingdom gastric ulcer became common in young adults, particularly women, in the early part of the 20th century but, following a rise, its occurrence in the young has declined substantially. It is now predominantly a disease of elderly men and women. In Europe and North America duodenal ulcer was uncommon at the turn of the 20th century, as evidenced from medical and autopsy reports, but its prevalence rose substantially from the 1920s and 1930s to the 1950s [17]. In recent decades it has declined in western urban communities. In the period of increase, it seemed to be more common in some occupations than others and, for a time, it was considered a disease related to occupational stress in professional and executive staff. Stress is hard to define and, if anything, nowadays duodenal ulcer is more common in low than high socio-economic groups. Smoking and high alcohol consumption are risk factors, as are elements of diet but the precise identification of dietary risk factors has been elusive. Its prevalence is increasing in the urban areas of the developing world. Non-steroidal anti-inflammatory drugs (NSAIDs), and aspirin, are particularly important causes of peptic ulcer in the elderly; and have become increasingly important in recent decades. As the average age of the population increases, the prevalence of arthropathies and other causes of chronic pain increases, and so does the consumption of NSAIDs by the elderly. This has led to the emergence of NSAID-associated peptic ulcer and to increased risks of perforation and haemorrhage. Acid suppression has been the mainstay of management of NSAID-associated ulcer disease. The pathophysiology and management of NSAID-associated ulcer disease, and its relationship with H pylori ulcer disease, have recently been reviewed [19]. Ulceration in the absence of H pylori, or NSAIDs or aspirin, is uncommon. However, the fall in prevalence of H pylori ulcer disease means that the relative importance of H pylori-negative NSAIDnegative disease has been increasing. Gastritis and duodenitis Prevalence studies show that the major forms of gastritis are very common in the elderly. Hospital admission rates with a hospital discharge diagnosis of gastritis or duodenitis are also high in the elderly. In the English hospital data, hospitalization rates were 297 per 100,000 men aged 60–64 and 381 per 100,000 men aged 80–84 (Table 3). In women the corresponding rates were 302 and 327. Appendicitis Acute appendicitis is a disease that is closely associated with economic development and a westernised lifestyle. It was uncommon until the last part of the 19th century. Its incidence rose steeply in the fist half of the 20th century in Europe and North America. Its incidence has declined considerably in recent years. The cause of the rise, and of the subsequent decline, is unknown. Appendicitis is very uncommon in the developing world. Its peak incidence is in children and young adults and, even in the elderly, its incidence continues to decline with advancing old age (Table 3). However, it remains a disease that can occur at any age and it is an important surgical emergency in the elderly. Crohn’s diseases and ulcerative colitis Crohn’s disease and ulcerative colitis are inflammatory bowel diseases of unknown aetiology. Crohn’s disease was first described in 1932 and, in the few decades that followed, it has been reported with increasing frequency in Europe and North America [17,20]. While some of the increase may result from improved recognition and diagnosis, it is generally accepted that the increase in incidence and prevalence has been real. It seems likely that there is some geographical variation in the times at which the diseases have increased: studies in some places have reported increases that have continued while others have reported increases that then stabilized [20]. Ulcerative colitis, first recognised in the late 19th century, has also become more common in the past 50 years but in recent decades its incidence
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has generally been more stable that that of Crohn’s disease [20]. A European collaborative study on inflammatory bowel disease reported incidence rates across Europe, albeit confined to people aged under 65 years, of 5.6 new cases of CD per 100,000 population per year and 10.4 new cases of UC per 100,000 [22]. Rates were higher in northern than southern Europe [22,23]. For CD, the highest rates were in Holland and north-west France (9.2 per 100,000) and the lowest (0.9) was in north-west Greece. For UC, the highest reported rate was in Iceland (24.5) and the lowest in southern Portugal (1.6). CD and UC are uncommon in the black African population and in India. CD is typically a disease of young people, a little more common in women than men, and its incidence declines with increasing age. UC, too, affects young people but its incidence is more evenly spread across the age range and it is more common in men than women. There is a secondary late peak, albeit small, in the incidence of CD and UC at about 60–70 years of age. As chronic diseases, their prevalence is far higher than their annual incidence; and prevalent cases of disease acquired at an earlier age are an important cause of morbidity into old age (Table 3). The aetiologies of CD and UC are unknown but their higher prevalence in western countries, and their emergence and rise in them in recent decades, suggests a link with aspects of western lifestyle and perhaps in particular with diet or food additives. Diverticular disease Multiple diverticula of the colon are very common in elderly people in countries with western lifestyles. Inflammatory changes in the diverticula cause clinical disease. The prevalence of diverticula rises with age and in many western countries over half the population have them. Diverticular disease has become much more common in western populations over the course of the past century. Diverticular disease is one of the most common reasons for hospital admission in elderly people and, as the tables show, it is the single most common diagnostic reason for hospital admission in people aged 75 years and over. Hospitalization rates increased from 173 per 100,000 population in men aged 60–64 to 432 in men aged 80–84 (Table 3). In women the corresponding rates were 235 and 528. It is generally accepted that diverticula are formed as a result of high intracolonic pressures, leading to protrusion of mucosa through weak points in the muscle wall, associated with straining at defaecation. In rural African and Indian communities, where diverticular disease is very uncommon, people have soft bulky stools and short bowel transit times. The typical smaller stool weight and longer bowel transit times in westernized populations are generally considered to be a consequence of the lower proportion fibre in typical western diets. Other gastrointestinal disorders Irritable bowel syndrome is very common in the general population. It is more common in women than in men and its prevalence declines with age. In a population-based prevalence survey in the UK, it was reported in 28% of women and 12% of men aged 20–29, and in 10% of women and 8% of men aged 60–69 years [24]. It is a relatively uncommon reason for hospital admission and one that declines with advancing age in the elderly (Table 3). Vascular disorders of the intestine are increasingly common causes of hospital admission with advancing age. Age-specific rates in the English data showed about a ten-fold increase in admission rates from about seven per 100,000 population aged 55–59 to 70 per 100,000 by the age of 85 and over (Table 3). Admission rates with a diagnosis of peritonitis also show a considerable increase with advancing age with almost a ten-fold increase from age 55–59 to age 85 and over (Table 3). Disorders of liver, gallbladder, pancreas Liver diseases Age-specific admission rates for liver diseases are shown in Table 4. Up to the age of 70, the figures are dominated by alcohol-related disease. Admission rates for alcoholic liver disease decline with advancing age. A similar age-related fall with advancing age is seen in English mortality rates for alcohol-related diseases: for example, age-specific rates per million in 1984–1992 were 136 in men aged 55–64 and 78 in men aged 75 and over, and they were 94 in women aged 55–64 and 47 in women
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Table 4 Non-malignant diseases of liver, gallbladder and pancreas: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
K70
Alcoholic liver disease
K71
Toxic liver disease
K72
K80
Hepatic failure, not elsewhere classified Chronic hepatitis, not elsewhere classified Fibrosis and cirrhosis of liver Cholelithiasis
K81
Cholecystitis
K85
Acute pancreatitis
K86
Other diseases of pancreas
M F M F M F M F M F M F M F M F M F
K73 K74
a
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
53.9 25.5 0.7 0.8 8.8 5.7 1.6 3.3 10.3 11.3 100.9 279.0 26.3 56.6 32.1 29.7 18.1 9.4
48.1 21.8 0.6 0.5 9.3 6.1 1.6 3.8 12.0 12.8 129.8 293.8 35.8 59.7 37.6 35.2 17.9 10.1
36.5 16.4 0.6 0.6 10.9 6.8 1.6 4.2 13.3 16.4 179.4 288.4 47.7 59.6 44.6 39.5 16.1 10.4
23.3 10.8 0.7 0.7 10.0 7.2 1.5 3.2 13.6 16.0 221.8 274.7 55.0 53.8 50.9 42.9 15.0 11.6
15.4 6.4 0.7 0.7 11.1 6.9 1.5 2.7 12.9 13.1 245.3 255.9 56.0 49.6 59.2 51.5 14.3 10.6
9.2 3.6 0.6 0.7 10.2 5.9 1.2 1.6 12.6 9.5 258.1 251.9 55.9 46.1 65.7 61.3 11.9 10.2
5.5 1.3 0.8 0.4 9.2 6.1 0.5 0.4 9.0 5.7 281.5 269.7 56.6 53.6 76.9 78.0 12.0 9.5
International Classification of Diseases, tenth Revision.
aged 75 and over [25]. These apparent declines with age are likely to be largely attributable to cohort effects and, specifically, to the very substantial increase in alcohol-related disease in young and middleaged adults in recent times in England [26]. Alcohol-related deaths in Britain have risen very substantially in recent decades [25,26]. Trends in alcohol-related morbidity and mortality show considerable differences between countries: by contrast with Britain, mortality rates are generally falling in southern European countries [26]. Gallbladder disease Admissions with a principal diagnosis of gallbladder disease increase sharply with increasing age. As Table 4 shows, it is a common reason for admission of the elderly. It is more common in women than men up to the age of about 75 and thereafter male and female rates are similar. The prevalence of gallstones, as measured by population-based ultrasound surveys, varies across Europe from about five to 25% of the population. Diseases of the pancreas Acute pancreatitis is becoming increasingly common in Britain [27,28]. The great majority of diagnosed case of acute pancreatitis are admitted to hospital and so hospital admission rates are a good proxy for incidence rates. Its incidence is broadly similar in men and women. It increases with increasing age: for example, admission rates in men rose from 32 per 100,000 at age 55–59 to 77 at ages of 85 and over, and those for women rose from 30 to 78 (Table 4). The two main causes of acute pancreatitis are blockage of the pancreatic duct by gallstones and heavy alcohol consumption. The percentage of cases of acute pancreatitis that are gallstone related, and that are alcohol related, vary between European populations and may change over time [20]. Other diseases of the pancreas notably include chronic pancreatitis. Chronic pancreatitis is less common than acute pancreatitis. Its prevalence declines with increasing age. Gastrointestinal symptoms Many patients who are hospitalized for gastrointestinal problems leave hospital without a definitive diagnosis. Table 5 shows hospitalization rates for elderly people whose discharge diagnosis was simply abdominal or pelvic pain, nausea and vomiting, or dysphagia. Rates are high, particularly in the very old, and they rise substantially with advancing age.
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803
Table 5 Non-specific gastrointestinal disorders: age- and sex-specific hospital admission rates per 100,000 resident population in each age and sex group, English national rates. ICD Codea
Condition
Sex
Age group (years) 55–59
60–64
65–69
70–74
75–79
80–84
85þ
R10
Abdominal and pelvic pain
R11
Nausea and vomiting
R13
Dysphagia
M F M F M F
270.4 412.5 30.4 46.1 44.4 51.4
322.4 429.3 39.4 59.0 60.6 62.9
358.8 428.8 52.7 72.1 75.4 72.4
372.1 424.5 68.3 91.2 97.7 88.2
393.9 420.3 84.9 116.7 124.1 103.1
412.5 427.1 102.9 147.4 142.1 123.3
481.8 466.6 150.4 205.4 175.6 146.8
a
International Classification of Diseases, tenth Revision.
Summary Most but not all of the common and important gastrointestinal diseases show increased age-specific rates with increasing age. Most but not all are more common in men than women. Many show substantial international variation in incidence and prevalence rates. Some are strongly related to economic development and the adoption of westernized lifestyles. The surgeon and epidemiologist Denis Burkitt wrote extensively about diseases that are associated with ‘modern western civilisation’ [29] and, in this group, he included appendicitis, diverticular disease, colorectal cancer, inflammatory bowel disease and gallstones. Western diet, and factors closely associated with it such as methods of food preservation, additives and food preparation are strongly implicated, although much of the detail remains to be unravelled. The importance of H. pylori as a cause of gastrointestinal disease is undoubted; and its treatment has led to a substantial decline in peptic ulcer disease and gastric cancer. Some diseases associated with western civilization are now in decline in countries where they had become common – the most notable example is appendicitis. Some diseases associated with western civilization, uncommon in the rural developing world, will become more common as developing nations undergo urbanisation and lifestyle changes. Conflict of interest statement None.
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