Common Health Concerns as You Get Older

Hepatitis is a common cause of liver disease. Six types of viruses cause hepatitis. The most prevalent are hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). The hepatitis A virus is transmitted by stool and rarely blood, but does not typically lead to chronic (long-term) disease. In contrast, HBV and HCV, which are primarily transmitted by blood, semen, and other bodily fluids, do cause chronic disease. Chronic disease is much more common with HCV than HBV. The course of chronic HBV or HCV infection varies from person to person. Some people have no symptoms at all, while others develop cirrhosis, liver cancer, and/or liver failure.

As many as 98% of people who received plasma-derived clotting factor in the 1970s and 1980s were infected with HCV. Between 1987 and 1991 people were no longer being infected with HIV, however 3000 individuals were still infected with Hepatitis C. If you have not done so already, you should also be vaccinated against HAV and HBV; unfortunately, there is no vaccine for HCV.

If you have been infected with the hepatitis virus, your healthcare provider (HCP), usually a liver specialist, can determine the right treatment for you. Hepatitis A does not have any specific treatment, aside from rest and avoiding alcohol and other substances or medications that are toxic to the liver. Hepatitis A does not become chronic. Hepatitis B and hepatitis C, however, can become chronic. They are usually treated with a combination of antiviral medications. Recently, new and more effective medications for HCV have become available. Your HCP may also recommend a liver biopsy to assess the extent of any damage to your liver from these viruses. With proper treatment, liver biopsies, especially in the transjugular route (through an IV in the jugular vain in the neck) are safer than standard biopsy by a needle in the abdomen to evaluate the extent of liver damage in people with bleeding disorders. Some physicians use blood tests that can help assess the amount of fibrosis in your liver.

Many people with a bleeding disorder who received plasma-based blood products during the late 1970s and early 1980s became infected with human immunodeficiency virus (HIV). Today, about 10% to 15% of people with hemophilia are infected with HIV.

Treatments for HIV infection have improved dramatically in the years since the virus was first identified. Currently, highly active anti-retroviral therapy (HAART) is the standard treatment for people infected with HIV. HAART involves taking a combination of drugs (sometimes in a single pill) to stop or slow the virus from multiplying. HAART may prevent or delay the development of acquired immunodeficiency syndrome (AIDS) and complicating infections.

The National Institutes of Health (NIH) recommends HAART for all HIV-infected people, the strength of the recommendation varies depending on CD4 count, which is a measure of how well the immune system is working. The lower the CD4 count, the less able the body is able to fight infection. Currently, there is the belief that because of the chronic damage the HIV virus does to the immune system and organs over time, that HAART should be given to all those infected. Research studies are evaluating this question.

Managing HIV becomes more complex with advancing age due to changes in the body that may increase the risk of negative side effects from medications. If you are older than 50 years of age and are receiving HAART, your bone, kidney, metabolic, cardiovascular, and liver health should be monitored carefully by your healthcare team (primary care provider [PCP], infectious disease specialist, and Hemophilia Treatment Center [HTC]). If you are taking medications to treat other health conditions, you may be at an increased risk of interactions between drugs. Inform each of your HCPs about any medication you're taking so that they can make appropriate treatment choices.

Healthy teeth and gums are important for everyone. People with bleeding disorders, however, need to be extra vigilant when it comes to oral care. Oral disease may cause serious bleeding, and some dental procedures may result in significant bleeding during and immediately afterward.

Plaque, the thin, colorless, sticky film containing bacteria that constantly forms on the teeth, can contribute to cavities and gum disease. Plaque must be removed each day to avoid its building up, hardening, and forming tartar, which can't be removed by simple tooth brushing. Plaque buildup can lead to more serious problems such as gingivitis, which can cause the gums to bleed, or chronic periodontitis, which damages the membrane attaching the teeth to the jaw and can lead to tooth loss. Gum disease may be worsened by other health conditions, such as human immunodeficiency virus (HIV) infection and diabetes, and by smoking.

Here are some tips to help keep your teeth and gums healthy:

• Avoid drinking or eating a lot of sugary or acidic foods and beverages.
• Avoid smoking or chewing tobacco.
• Brush and floss at least twice a day. Use a medium-textured brush and fluoride toothpaste. You can also rinse with fluoride mouthwashes or apply fluoride gels daily or weekly.
• Visit the dentist regularly. Your primary care provider (PCP) or Hemophilia Treatment Center (HTC) can advise you about how frequently you should get dental checkups.
• In addition, if you wear dentures, be sure they fit properly and don't irritate your mouth or gums. Poor-fitting dentures can cause your gums to bleed.

Diabetes is a disease in which sugar (called glucose) levels in the blood are too high. Normally, the body uses the hormone insulin to carry glucose from the foods we eat into the cells, where it's used for energy. In people with diabetes, the body doesn't produce enough or any insulin at all, and/or the body isn't able to use the insulin properly. This results in glucose building up in the blood, which can damage blood vessels.

Diabetes may cause serious health problems, including heart disease, blindness, kidney failure, poor circulation, and loss of sensation in the legs (called peripheral neuropathy). The poor circulation combined with neuropathy can lead to infections and, ultimately, to amputation.

Here are the most common signs and symptoms of diabetes:

• Frequent urination
• Excessive thirst
• Unexplained weight loss
• Extreme hunger
• Sudden vision changes
• Tingling or numbness in the hands or feet
• Tiredness
• Very dry skin
• Slow healing sores
• Increased frequency of infections

The risk of diabetes increases with age. People who are sedentary and/or obese are also at increased risk of diabetes. Maintaining a healthy weight and staying active may decrease this risk.

If you have diabetes, good blood glucose control is critical to avoid serious health complications. Treatment for diabetes involves regular monitoring of blood glucose levels, a healthy diet, and exercise. In addition, oral medications and/or insulin may be necessary to keep sugar levels in check. Subcutaneous insulin injections may be given safely without causing bleeding complications.

Having a bleeding disorder places you at a significantly increased risk of death from kidney (called renal) disease compared with the general population. Therefore, it's important to know the signs and symptoms of and risk factors for renal disease. Hematuria, which is blood in the urine, is usually not significant in younger people with a bleeding disorder, even when clotting factor is needed to stop it. However, in older adults with a bleeding disorder and diabetes, hematuria may be a sign of chronic renal disease.

Here are some important risk factors for renal disease:

• High blood pressure (called hypertension)
• Human immunodeficiency virus (HIV) infection
• Kidney bleeds
• Diabetes

The process of screening for and managing kidney disease in people with a bleeding disorder is similar to that used in the general population. You and your primary care provider (PCP) should monitor and control your blood pressure, as well as other risk factors for cardiovascular disease. If your PCP suspects that you have kidney disease, you may be referred to a nephrologist.

People with end-stage renal disease (ESRD) typically undergo dialysis, which may be performed safely in people with a bleeding disorder. Two main types of dialysis are available: hemodialysis, which uses a machine to filter the blood, and peritoneal dialysis, which uses the thin lining around the abdomen as the filter. Peritoneal dialysis may be the better option for people with a bleeding disorder because it's less likely to require the use of blood-thinning agents or infusions of factor. Kidney transplantation is another treatment for some individuals with ESRD; it, too, may be performed safely in people with a bleeding disorder.

In the general population, the incidence of many types of cancer increases with age. For people with a bleeding disorder, many aspects about the incidence and management of cancer remain unclear.

People infected with the human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) need to be particularly watchful for certain types of cancers, including non-Hodgkin's lymphoma; basal cell cancer, a type of skin cancer; Kaposi's sarcoma; and hepatocellular carcinoma (HCC), a type of liver cancer.

It is unclear whether people with a bleeding disorder who are not infected with HIV and/or HCV are more likely to develop or die from cancer than people without a bleeding disorder. If you have been diagnosed with cancer of any type, you should work closely with your healthcare team (primary care providers [PCPs], oncologist, and Hemophilia Treatment Center [HTC]) to determine the best course of treatment. Standard procedures for the diagnosis and treatment of cancer, such as biopsy, surgery, chemotherapy, and radiotherapy, may require infusion with factor.

As people age, so do their joints. In people with a bleeding disorder, the wear-and-tear joint damage seen in many people as they get older may start earlier and be compounded by previous bleeding episodes. For example, a form of arthritis (called chronic hemophilic arthropathy) may occur in teenagers and young adults because of previous joint bleeds. The incidence of chronic hemophilic arthropathy is particularly pronounced in older people with a bleeding disorder because most of them did not have the benefit of early prophylaxis. In addition, just like the general population, people with bleeding disorders are at risk for osteoarthritis (arthritis resulting from wear and tear on the joints) as they age.

Arthritis may take a toll on your physical and emotional health. It can cause pain, deformity, and loss of function—which increase the risk of falling. Although joint damage from arthritis is not reversible, some treatments may help reduce pain and keep you active. Several treatments are available to manage chronic pain, including over-the-counter and prescription pain relievers, and physical therapy.

Some surgical options are available for joint damage:

• Arthroscopy—a procedure in which a fiber-optic instrument is introduced through a small incision into the joint and the damaged tissue or fluid is removed.
• Synovectomy—an operation or arthroscopic procedure in which part or all the synovial membrane around the joint is removed.
• Joint replacement—an operation that replaces a damaged joint with a prosthetic one.

The term cardiovascular disease (CVD) refers to a broad range of conditions related to the heart and blood vessels, including:

• Heart attack
• Stroke
• Heart failure
• Arrhythmia
• Heart valve defects

Some studies indicate that bleeding disorders may lower the risk of death from certain forms of CVD — but the data are controversial. The overall the number of deaths is increasing. In individuals with a bleeding disorder, the prevention, treatment, and even diagnosis of certain CVDs, such as a heart attack or stroke, requires special consideration. This is because some of these approaches may require insertion of a needle or other device into a vein or artery, or the use of drugs to prevent or destroy blood clots.

Risk factors for CVD are more common in people with bleeding disorders, particularly high blood pressure (called hypertension); obesity; and metabolic syndrome, which is a combination of high blood pressure, abdominal obesity, high cholesterol levels, and high blood glucose levels.

Treatment with highly active anti-retroviral therapy (HAART) also increases the risk for adverse cardiovascular events in people with bleeding disorders.

You and your primary care provider (PCP) may also decide that certain medications are right for you, including those that decrease cholesterol levels and reduce blood pressure. These treatments must be taken carefully and be monitored by your PCP.

Because people with a bleeding disorder are less likely to engage in physical activity, obesity is common. Obesity worsens existing joint problems, including the damage and pain from arthritis. It also increases the risk of other health conditions, including diabetes and cardiovascular disease (CVD).

If you're overweight, ask your primary care provider (PCP) or Hemophilia Treatment Center (HTC) to work with you to develop a diet and exercise program tailored to your needs and abilities.

Anemia can occur when the body loses blood and/or does not produce enough red blood cells. Because one of the major functions of these cells is to carry oxygen, low levels of red blood cells may prevent the body from maintaining the oxygen levels it requires.

Mild anemia may have no signs or symptoms. However, in some people it may cause:

• Tiredness
• Weakness
• Headache
• Pale or yellowish skin (called pallor)

Moderate to severe anemia may lead to more serious problems, including:

• Faintness or dizziness
• Sweating
• Weak or rapid pulse
• Rapid breathing or shortness of breath
• Lower leg cramps during exercise
• Brain damage
• Heart disorders (for example, an irregular heart beat [called arrhythmia]; heart murmur, enlarged heart, or heart failure)

Although there are several types of anemia, the one most common in people with a bleeding disorder is iron-deficiency anemia.

• Iron-deficiency anemia occurs when there is not enough iron to make red blood cells. In people with a bleeding disorder, iron deficiency usually results from repeated bleeding episodes, say from the stomach or gastrointestinal tract. It may also be caused by poor diet or other factors. Women with von Willebrand's disease (VWD), and other bleeding disorders, may develop iron deficiency as a result of heavy menstrual periods. When iron levels are low, the body makes fewer red blood cells, which also consequently contain less hemoglobin, the oxygen-carrying portion of red blood cells.
• People with other medical conditions such as infection with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) often have mild anemia. This may be due to several factors. A common diagnosis is anemia of chronic disease, which results when inflammation affects the ability of the red blood cells to take up iron, even when it is present.

Anemia is easily diagnosed with a blood test and physical exam. If you have iron-deficiency anemia, your primary care provider (PCP) may recommend changing your diet and/or supplementing with iron. You should also be sure to manage any bleeding episodes quickly and adequately. If the reason for iron deficiency is unknown, the source of bleeding should be found. Your healthcare provider (HCP) may consider looking for a source of bleeding. Particularly in older individuals, blood in the stool or in the urine should raise concern for possible cancer. For more severe anemia, a blood transfusion may be needed. For those who have anemia due to causes other than iron deficiency, treatment should be focused on the cause of the anemia, if possible.

In people with a bleeding disorder, fatigue may be caused by such a broad array of factors that it may be difficult to identify the origin. For example, fatigue may result from chronic pain or anemia, or may even be a side effect of a medication. It could also be a sign of a more serious health problem. If you're fatigued, don't ignore it. Fatigue may impair your ability to work and enjoy the good things in life. Let your primary care provider (PCP) know if you are experiencing fatigue so you can work together to identify its cause and determine the best way to manage it.

Despite many advances in treatment, living with a bleeding disorder can still be extremely challenging. But turning to drugs and alcohol to escape from the fears, frustrations, and pain that accompany a chronic health condition isn't wise. Substance abuse is harmful to any person, and for those living with a bleeding disorder, there are additional reasons to stay sober.

Drugs and alcohol may impair judgment, coordination, and reaction time, leading to an increased risk of accidents and an inability to appropriately respond to an injury. Additionally, alcohol consumption may hamper the blood's ability to clot and can cause dehydration, which makes self-infusion more difficult. Alcohol abuse can also damage the liver or increase the likelihood that some anti-retroviral drugs will damage the liver.

Addiction to drugs or alcohol is not something to be ashamed of, but it is something for which you should seek help. If you are having problems with drugs or alcohol, contact your primary care provider (PCP) or Hemophilia Treatment Center (HTC). You may also wish to enlist the aid of a close friend or family member who can support you on your journey to sobriety.

Like other individuals dealing with a chronic health problem, adults with a bleeding disorder are more likely to experience depression. About 1 in 3 adult men with hemophilia meet the criteria for depression. In depressed males with hemophilia, more than half have symptoms that are moderate to severe and three-quarters report that depression interferes with their ability to function.

Here are some of the signs and symptoms of depression:

• Persistent sad, anxious, or empty feelings
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Irritability and restlessness
• Loss of interest in activities or hobbies once considered pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details, and making decisions
• Unusual sleeping patterns, including insomnia, early morning wakening, or excessive sleeping
• Overeating or loss of appetite
• Thoughts of suicide or suicide attempts
• Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment

If you experience the symptoms of depression, contact your primary care provider (PCP) or Hemophilia Treatment Center (HTC). They may recommend a psychologist or psychiatrist. Treatments for depression include medication and psychotherapy. Your PCP may recommend a combination of both.

As people age, the lenses in their eyes become less flexible, which may result in long-term changes in vision. Many adults begin to experience problems focusing at close distances (called presbyopia) in their early-to-mid-40s. This condition usually worsens before stabilizing around the age of 60 years. The vision impairment stemming from presbyopia may be managed with eyeglasses, contact lenses, or laser surgery.

Here are some other vision changes that may occur with aging:

• A need for more light in order to see
• Increased glare
• Changes in color perception
• Dry eyes due to a decrease in tear production

More serious eye problems also become more common as people age, including retinal detachment, glaucoma, cataracts, and age-related macular degeneration (AMD), all of which can lead to blindness.

Here are some warning signs and symptoms for these and other eye problems:

• Frequent changes in how clearly you see
• Spots, floaters, and flashes in your visio
• Loss of peripheral (side) vision
• Distorted vision

Regardless of any symptoms, you should have a comprehensive dilated eye exam (an exam that includes dilation of the pupil so that the retina can be examined) at the age of 50 years.

There are two types of stroke:

• Ischemic stroke, which occurs when blood flow to the brain is blocked
• Hemorrhagic stroke, which results from bleeding into the brain or surrounding spaces.

Both forms of stroke may cause a harmful lack of oxygen to the brain.

People with bleeding disorders face an increased risk of hemorrhagic stroke throughout their lives. With increasing age, the potential for either form of stroke is compounded by additional risk factors. While some of these risk factors, such as gender, race, and family history, are beyond our control, we may be able to avoid or treat others.

Here are some risk factors for stroke:

• High blood pressure (called hypertension)
• Smoking
• Heart disease
• Diabetes
• High cholesterol levels
• Atherosclerosis
• Physical inactivity
• Obesity

Here are some of the signs and symptoms that may point to a stroke:

• Trouble walking
• Trouble speaking and understanding
• Paralysis or numbness of the face, arm, or leg
• Trouble seeing in one or both eyes
• Sudden, severe headache

The word FAST can help you remember the warning signs of a stroke and the action you should take if you see them.

• Face: Check to see if one side of the face droops when smiling.
• Arms: When both arms are raised, check to see if one drifts downward.
• Speech: Check to see if speech is slurred or strange.
• Time: Call 9-1-1 immediately if any of these signs are observed.

In a patient with a bleeding disorder, a stroke may present as a very bad headache. Whenever a patient with a bleeding disorder has a severe headache, he should seek emergency room evaluation immediately.

The impact of a stroke depends on the part of the brain affected and the length of time before proper blood flow is restored. The temporary or permanent disabilities caused by stroke include paralysis, difficulty talking, cognitive impairment, emotional difficulties, physical pain, and behavioral changes. Treatment following a stroke requires a team of healthcare providers and varies from person to person.

Osteoporosis is a condition in which the body's bones become weak, porous, and fragile—a consequence of the body breaking down bone tissue faster than it produces it. Osteoporosis is more common among older people, especially women. People with a bleeding disorder have lower bone mineral density, possibly as a result of decreased activity, which puts them at an even greater risk for osteoporosis.

Osteoporosis has no outward symptoms but increases the risk for bone fractures. Osteoporosis is diagnosed using a bone density test, which is a painless and safe procedure that measures the strength of the bones.

As you get older, it's important that you actively protect the health of your bones. You may do this by regularly exercising and eating a diet rich in calcium and vitamin D. Men between the ages of 51 and 70 years should consume at least 1000 mg of calcium each day; those more than 70 years of age should consume at least 1200 mg of calcium each day. Women older than 50 years of age should consume at least 1200 mg of calcium each day. Although dietary sources of calcium are more effective, calcium supplements may be helpful. The requirements for vitamin D intake are at least 600 international units (IUs) per day in people aged 51 to 70 years, and at least 800 IUs per day in people more than 70 years of age. Osteoporosis may be treated with one of several medications. Your primary care provider (PCP) can help you decide which one is right for you.