Liver disease is also an illness that has a major impact on blood clotting and coagulation as the liver has an important role in the coagulation process and thus clotting abnormalities are a prominent feature of acute and chronic liver disease. Liver disease, in particular chronic liver disease is seen more in older patients, in particular the elderly. This can be due to many reason such as long term alcohol abuse, cardiac dysfunction, diabetes and hepatitis. The key point to note here is that even though younger individuals may suffer from these illnesses, it is the long-term effects of them that tend to cause major complication and they only normally tend to manifest after many years or in later life. In patients with chronic liver disease, particularly the elderly, bleeding can reflect primarily anatomic or specific abnormalities of the coagulation system (Mancuso et al 2003). The outcome is often portal hypertension eventually leading to esophageal and gastric varices, hemorrhagic gastritis and volume overload in the portal system. These conditions may lead to severe gastrointestinal hemorrhage and bleeding due to quantitative and qualitative platelet and coagulation factor abnormalities, for example, normally 30% of the platelet pool is sequestered in the spleen, however, in the presence of portal hypertension this figure can rise to as much as 90% leading to a large reduction in the circulating platelet count. Other factors that can lead to defective haemostasis in patients with liver disease include decreased synthesis of pro-coagulant and anti-coagulant proteins, impaired clearance of activated coagulation factors, synthesis of functionally abnormal fibrinogen, splenomegaly, qualitative platelet defects and in some cases bone marrow suppression of thrombopoiesis, each leading to impaired coagulation efficiency (John et al 2003). It is important to note that in general, the elderly normally have a decreased haemoglobin level and a decreased physical and mental ability to deal with any kind of trauma and thus any kind of hemorrhage will not only be traumatic but will also be life threatening.
Another illness that is common amongst the elderly and that directly affects blood coagulation is autoimmune haemolytic anaemia, in particular Cold-Reactive Autoimmine Haemolytic Anaemia (Cold Haemagglutinin Disease, CHAD). Even though this normally affects the elderly, it can also occur at any age; however, elderly patients may be more effected by the illness and may become more and severely anaemic since the elderly have a decreased ability of the bone marrow to compensate for the loss. CHAD normally occurs in the recovery stage after disease, (Sokol et al 2000). This by itself increases the chances of the elderly acquiring the disease due to the simple fact that the elderly are more prone to disease in general. It occurs when the bodies extremities i.e. fingers and toes, are subjected to cold temperature over a long period of time, which causes precipitation of haemoglobinuria. This causes agglutination of the blood that can decrease or completely block the circulation of blood to that area and can cause the onset of vasospastic attacks, which cause the blood vessels in the extremeties to constrict known as Raynaud’s phenomenon (www.ohiohealth.com). This again increases the chances of the elderly acquiring the disease for several reasons. Firstly, the elderly are more sensitive to the cold and their body temperature drops quicker due to natural mitochondrial abnormalities/deficiencies. It is also a sad fact that the majority of the elderly population do not live their lives under proper care and many of them live in homes where either proper heating is not available or they just cannot afford to heat their homes sufficiently. This not only increases the risk of CHAD but in general causes increased risk of other illnesses and affects general immunity, which again can be more threatening to the elderly.
It is also important to note that since the elderly population is at increased risk of many illnesses such as cardiovascular disease including myocardial infarction and stroke, and many elderly people are already sufferers of these conditions, a high number of the population will be taking drugs or drug therapies to treat their conditions or as preventative measures. Apart from specific drugs to treat specific illnesses, in general, people that are at increased risk of certain illnesses such as cardiovascular problems, heart attack and stroke are normally given anticoagulation therapy to reduce their risk. In the UK, this is normally in the form of Warfarin therapy and occasionally Aspirin or Heparin therapy. Warfarin causes the ineffective production of clotting factors II, VII, IX and X and anticoagulant proteins C and S by inhibiting Vitamin K (www.cardioliving.com). This causes an increase in the prothrombin time and INR thus reducing the chances of blood clot formation. Aspirin has an anti-thrombotic effect caused by inhibition of platelet cyclo-oxygenase as well as other platelet pathways. With warfarin, the dose varies from person to person as each individual metabolises it at a different rate and for this reason it is important to set the dose in the first 6 – 8 weeks of the therapy being started. This unfortunately means daily visits to the hospital to check INR values and changing the dose as need be, however, in the case of the elderly, many of them are unable to attend clinics regularly due to either physical problems or simple problems such as transport to the hospital. For this reason many of the elderly people taking this drug may not be receiving the correct dose which could mean that they have an increased or decreased INR which could mean that they are still at increased risk of certain illnesses or they are at increased risk of bleeding.
Other regularly used drugs can also have a direct effect on coagulation and clotting in the elderly such as long term use of steroids in angina which can lead to eventual hemorrhage caused by both qualitative and quantitative disorders of platelets and clotting factors. Long term steroidal use in angina, particularly the use of steroidal inhalers can also lead to Angina bullosa hemorrhagica (ABH), (Poskitt 1991). Cardiovascular drugs are also commonly used in the elderly due to the high frequency of cardiovascular disease in the population. This can also lead to further problems and complications as age and disease processes decrease the bodies elimination of most cardiovascular agents, causing an increase in serum concentration levels. Increased drug levels increase the patients sensitivity to the medication, exaggerate response and potentiate adverse reactions. For this reason, there is also an increased potential for drug-drug interactions in the elderly, for example, taking warfarin treatment at the same time as certain macrolide antibiotics, such as clarithromycin, can rapidly increase INR which could lead to severe hemorrhage.
Diet also plays a pivotal role in the onset of diseases that can cause coagulation problems in the elderly. Apart from the fact that nowadays the general population consume too many foods that are high in fats and sugars leading to diseases such as coronary heart disease, stroke and diabetes in later life, the elderly do not tend to have a balanced, nutritional diet. This means that they do not receive all the nutrients and nourishment which they should be getting to be ‘healthy’, which can eventually lead to coagulation problems, as well as other illnesses such as diabetes. An example of this can be seen in case of Vitamin K deficiency as this causes decreased production of clotting factors leading to decreased coagulation.
Overall, coagulation is a very sensitive matter especially in the elderly. It can simply be said that ‘time takes its toll’ on the body and the problems associated with this tend to manifest in later life. It is very important to be able to rapidly control or treat any coagulation problems in the elderly since even small variation in the homeostasis of haemostasis can have drastic consequences due to the physical and mental frailness of the elderly and due to the decreased ability of their bone marrow to compensate for any changes or loss.
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