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symptoms such as fatigue, osteoporosis
or unexplained iron, vitamin B12 or folate
Although some patients with coeliac
disease may not have many symptoms
if they ingest small amounts of gluten,
the gluten causes tissue damage in the
small bowel. Untreated coeliac disease,
even in patients with few symptoms,
has associated risks including the
development of lymphoma (e.g. four-
fold increased risk of non-Hodgkin’s
lymphoma), osteoporosis, anaemia, and
other micronutrient deficiencies. The
potentially serious sequelae of coeliac
disease can be prevented by adherence
to a strict lifelong gluten-free diet.
There is a growing incidence of coeliac
disease diagnosis among adults,
particularly in the elderly.
disease can be first diagnosed in the
elderly population, despite the apparent
tolerance of gluten ingestion for the
Not surprisingly, diagnosis
may be delayed for many years due
to limited symptoms, a low index of
suspicion or diagnostic difficulties
related to cognitive impairment.
In contrast with younger patients, in
the elderly, coeliac disease is diagnosed
much more in men, as compared with
women. Older patients may have no
gastrointestinal symptoms and present
with a complication (e.g. anaemia,
osteoporosis) or an associated condition
(e.g. dermatitis herpetiformis).
Micronutrient deficiencies are also
more common with onset in the elderly;
unexplained iron, vitamin B12 or folate
deficiency should prompt screening
for coeliac disease.
symptoms, when present in the
elderly, are often mild, making the
19 Diarrhoea is mild
or intermittent, and occasionally,
the elderly coeliac patient can have
constipation. A common presentation in
the elderly is anaemia, primarily due to
iron deficiency, but potentially also due
to deficiencies of folic acid or vitamin
Osteoporosis and increased risk of
fractures are consequences of calcium
and vitamin D deficiency.
Dermatitis herpetiformis, an
autoimmune blistering skin disease,
may be the only presenting feature
of coeliac disease in adults. It features
intensely itchy, small, clustered papules
and vesicles that generally erupt
symmetrically on the elbows, knees,
buttocks, back, or scalp, as a result
of antibody response to skin antigen
epidermal transglutaminase. Dermatitis
herpetiformis occurs in about 25% of
coeliac patients, mostly middle-aged
and elderly men.
Currently, the only effective treatment
for coeliac disease is a gluten-free diet
A gluten-free diet involves
avoiding foods containing wheat, rye,
barley and oats. There are three main
aspects to the gluten-free diet:9,21
• avoiding cereals and products
containing gluten such as bread,
breakfast cereals, flours, pasta, cakes,
biscuits, and sauces derived from
wheat, barley, rye or oats;
eating naturally occurring gluten-free
foods (all fresh meats, fish, chicken,
eggs, seeds, nuts, fruit, vegetables,
legumes, most dairy products, oils,
margarine and butter) and alternative
sources of starchy foods such as rice,
potatoes, corn and sorghum; and
using commercially prepared gluten-
free substitute foods.
Changing a long-established diet can
be extremely difficult for the elderly.
The availability, palatability and cost
of gluten-free foods, along with social
difficulties related to eating out, can all
present additional barriers.
a dietitian specialising in coeliac disease is
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Table 1. Typical differences between coeliac disease with onset in young or older individuals
(adapted from Cappello et al.6)
anaemia, growth impairment,
diarrhoea, weight loss
diabetes, thyroid disease,
disorders (e.g. ataxia)
refractory coeliac disease,
Response to gluten-free diet
Adherence to gluten-free diet high
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