Immunosupportive therapies in aging

Aging and chronic inflammation: highlights from a multidisciplinary workshop

Aging is a gradual, continuous series of natural changes in biological, physiological, immunological, environmental, psychological, behavioral, and social processes. Aging entails changes in the immune system characterized by a decrease in thymic output of naïve lymphocytes, an accumulated chronic antigenic stress notably caused by chronic infections such as cytomegalovirus (CMV), and immune cell senescence with acquisition of an inflammatory senescence-associated secretory phenotype (SASP). For this reason, and due to the SASP originating from other tissues, aging is commonly accompanied by low-grade chronic inflammation, termed "inflammaging". After decades of accumulating evidence regarding age-related processes and chronic inflammation, the domain now appears mature enough to allow an integrative reinterpretation of old data. Here, we provide an overview of the topics discussed in a recent workshop "Aging and Chronic Inflammation" to which many of the major players in the field contributed. We highlight advances in systematic measurement and interpretation of biological markers of aging, as well as their implications for human health and longevity and the interventions that can be envisaged to maintain or improve immune function in older people.

Immunomodulation in age-related disorders and nanotechnology interventions

Recently, the aging population has increased exponentially around the globe bringing more challenges to improve quality of life in those populations while reducing the economic burden on healthcare systems. Aging is associated with changes in the immune system culminating in detrimental effects such as immune dysfunction, immunosenescence, and chronic inflammation. Age-related decline of immune functions is associated with various pathologies including cardiovascular, autoimmune, neurodegenerative, and infectious diseases to name a few. Conventional treatment addresses the onset of age-related diseases by early detection of risk factors, administration of vaccines as preventive care, immunomodulatory treatment, and other dietary supplements. However, these approaches often come with systemic side-effects, low bioavailability of therapeutic agents, and poor outcomes seen in the elderly. Recent innovations in nanotechnology have led to the development of novel biomaterials/nanomaterials, which explore targeted drug delivery and immunomodulatory interactions in vivo. Current nanotechnology-based immunomodulatory approaches that have the potential to be used as therapeutic interventions for some prominent age-related diseases are discussed here. Finally, we explore challenges and future aspects of nanotechnology in the treatments of age-related disorders to improve quality of life in the elderly. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Cardiovascular Disease Therapeutic Approaches and Drug Discovery > Nanomedicine for Neurological Disease Therapeutic Approaches and Drug Discovery > Emerging Technologies.

Humoral immunoresponse elicited against an adenoviral-based SARS-CoV-2 coronavirus vaccine in elderly patients

The early sequencing of the SARS-CoV-2 viral genome allowed for a speedy development of effective vaccines against the virus. Nevertheless, age-related immunosenescence, the inability to mount strong immune responses, still represents a major obstacle. Here, in a group of 149 elderly volunteers (70-96 years old), evolution of the humoral immune response over time to Gam-COVID-Vac (Sputnik V), a vaccine based on heterologous recombinant adenovirus-26 (Ad26) and adenovirus-5 (Ad5) carrying the Spike genome, was analyzed by an anti-RBD ELISA. At 28 days post vaccination (dpv), a seroconversion rate of 91% was achieved, showing the importance of administering at least two doses of Gam-COVID-Vac to elicit a robust immune response, especially in elderly individuals without previous SARS-CoV-2 infection. Interestingly, IgG specific antibodies that reached their highest titers around 28 dpv (median = 740), persisted without significant decrease after 60 dpv (median = 650). After 90 dpv, IgG titers began to drop, and at 180 dpv only 44.7% of the elderly individuals remained with detectable anti-RBD IgG antibodies. No significant differences were observed in specific humoral immune responses between genders at early times point. However, at 60 dpv anti-RBD titers were more persistent in elderly females, and only dropped at 90 dpv (p < 0.0001). As expected, the highest antibodies titers were elicited in the youngest subgroup (70-74 years). Our results show that Gam-COVID-Vac was able to deal with the ageing of the immune system, eliciting a robust immune response in an elderly cohort, which lasted approximately 90 dpv at high levels, and protected against COVID-19.

Cytomegalovirus Serostatus and Functional Impairment in Liver Transplant Recipients in the Current Era

BACKGROUND

Whether donor (D+) or recipient (R+) cytomegalovirus (CMV) seropositivity is associated with functional impairment in liver transplant recipients is not known.

METHODS

Patients included adult liver transplant recipients in the Organ Procurement and Transplantation Network database transplanted over a five-year period from 1 January 2014-31 December 2018. Functional status in the database was assessed using Karnofsky performance scale. A logistic regression model that controlled for potential confounders was used to examine the association of CMV serostatus and functional status. Variables significantly associated with functional status (p < 0.05) were then used to develop propensity score and propensity score matched analysis was conducted where each patient was compared with a matched-control with the same propensity score.

RESULTS

Among 30,267 adult liver transplant recipients, D+ or R+ patients had significantly lower functional status at last follow-up than the D-R- cohort (OR 0.88, 95% CI 0.80-0.96, p = 0.007). In propensity score matched model, D+ or R+ patients had significantly lower functional status than matched-controls (p = 0.009). D+ or R+ CMV serostatus (p = 0.018) and low functional level (p < 0.001) were also independently associated with infections as cause-of-death.

CONCLUSIONS

D+ or R+ liver transplant recipients had lower functional status and higher risk of deaths due to infections. Future studies are warranted to examine the mechanistic basis of these findings in the setting of transplantation.

Biomodulina T partially restores immunosenescent CD4 and CD8 T cell compartments in the elderly

The changes that occur in the immune system with aging are commonly termed immunosenescence. Immunosenescence affects almost all components and functions of the immune response. The most commonly described change is a decrease in numbers and proportions of naïve T cells combined with the increase of terminally differentiated T lymphocytes, mainly affecting CD8+ T cells. The changes in the naïve T cell compartment are principally attributed to thymic involution and lifelong chronic antigen stimulation, among other triggers. Several strategies such as hormonal products, thymic peptides, or cytokines have been proposed for the restoration of the immune system. Here we show the effects of Biomodulina T (BT) on several populations of the immune system when administered to elderly patients diagnosed with recurrent respiratory infections. BT is a polypeptide fraction of bovine thymus, a Cuban product that obtained sanitary registration in 1994 for its immunomodulatory effects. We found that CD4+ naïve T, CD8+ stem cell-like memory (SCM) T, CD4+ recent thymic emigrants (RTE) T and CD4+ CD31+ naïve T cells increased with the administration of BT, whereas CD4+ and CD8+ T cells expressing PD1 decreased after the treatment with BT. Additionally, the proliferative capacity of CD4+ T cells measured by Ki67 expression, and the CD4+ T cell ability to produce IFN-γ were also improved by BT. Moreover, BT did not increase CD4+ Tregs. Altogether, these findings suggest that BT administration is a promising strategy for immune restoration in elderly patients and improvement of immunotherapeutic potential in cancer patients.

Frontline Science: Functionally impaired geriatric CAR-T cells rescued by increased α5β1 integrin expression

Chimeric antigen receptor expressing T cells (CAR-T) are a promising form of immunotherapy, but the influence of age-related immune changes on CAR-T production remains poorly understood. We showed that CAR-T cells from geriatric donors (gCAR-T) are functionally impaired relative to CAR-T from younger donors (yCAR-T). Higher transduction efficiencies and improved cell expansion were observed in yCAR-T cells compared with gCAR-T. yCAR-T demonstrated significantly increased levels of proliferation and signaling activation of phosphorylated (p)Erk, pAkt, pStat3, and pStat5. Furthermore, yCAR-T contained higher proportions of CD4 and CD8 effector memory (EM) cells, which are known to have enhanced cytolytic capabilities. Accordingly, yCAR-T demonstrated higher levels of tumor antigen-specific cytotoxicity compared with gCAR-T. Enhanced tumor killing by yCAR-T correlated with increased levels of perforin and granzyme B. yCAR-T had increased α5β1 integrin expression, a known mediator of retroviral transduction. We found that treatment with M-CSF or TGF-β1 rescued the impaired transduction efficiency of the gCAR-T by increasing the α5β1 integrin expression. Neutralization of α5β1 confirmed that this integrin was indispensable for CAR expression. Our study suggests that the increase of α5β1 integrin expression levels enhances CAR expression and thereby improves tumor killing by gCAR-T.

Good's Syndrome Accompanied by Agranulocytosis Following a Rapid Clinical Course

Good's syndrome is an immunodeficiency disease involving thymoma accompanied by hypogammaglobulinemia. We encountered a case of Good's syndrome accompanied by agranulocytosis that followed a rapid clinical course. A 72-year-old man visited our hospital with a two-week history of a sore throat. Candida albicans was detected in the pharynx, and hypogammaglobulinemia was detected in addition to granulocytopenia. The patient subsequently developed septic shock and followed a rapid clinical course which ended in death. Good's syndrome with agranulocytosis was diagnosed at autopsy. Good's syndrome accompanied by agranulocytosis can follow a rapid clinical course and some cases remain asymptomatic until old age. Its prompt treatment is crucial.

Prognostic impact of circulating Her-2-reactive T-cells producing pro- and/or anti-inflammatory cytokines in elderly breast cancer patients

Background

Treating elderly breast cancer patients remains a challenge but the increasing availability of immunotherapeutic approaches instills optimism that these tumours may also be susceptible to immune control. Because aging leads to a number of alterations in the immune system (“immunosenescence”) reflecting potential exhaustion which could compromise immunomodulatory antibody therapy, here we have assessed the immunocompetence of elderly breast cancer patients compared with a group of younger patients, and related this to the 5-year survival of the former.

Methods

T-cell responses to Her-2 peptide pools in vitro were assessed by analyzing pro- and anti-inflammatory cytokine production by CD4+ and CD8+ T-cells in 40 elderly and 35 younger breast cancer patients.

Results

The proportions of older and younger patients whose peripheral T-cells responded to Her-2 peptides in vitro were found to be similar, although a significantly higher fraction of younger patients possessed IL-2-producing CD4+ Her-2-reactive T-cells than in the elderly (p = 0.03). However, IL-2 production did not impart a survival benefit to the latter. In contrast, there was a survival benefit of possessing Her-2-reactive CD8+ T-cells, but this was abrogated in patients if they also had CD4+ Her-2-responsive T-cells that producedIL-5 and/or IL-17 (p = 0.01). This resulted in a 5-yr survival rate of only 29 % compared to 76 % for patients whose her-2-reactive CD4+ T-cells did not produceIL-5 and/or IL-17. Additionally, patients whose CD8+ T-cells produced TNF had a significantly better survival than those that did not (93 % compared to 52 %, p = 0.01), whereas no survival benefit was attributable to possessing IFN-γ-producing cells.

Conclusions

Elderly breast cancer patients appear perfectly immunocompetent to respond to Her-2 peptide pools in vitro, with response patterns very similar to younger patients. The nature of this response is associated with 5-year survival of these elderly patients, suggesting that boosting anti-tumor responses and modulating the nature of the T-cell response is likely to be effective even in potentially immunosenescent elderly breast cancer patients, and might be useful for predicting which patients are most likely to benefit from such treatments.

Electronic supplementary material

The online version of this article (doi:10.1186/s40425-015-0090-0) contains supplementary material, which is available to authorized users.

Evaluation of a Unani polyherbal formulation (Tiryaqe wabai) as an immunostimulator in elderly persons

Background and Aims:

Elderly subjects have a dysregulation of immune response mainly due to the changes in cell - mediated immunity. Due to their weakened immune response, the elderly are at increased risk of infection and related complications. In Unani medicine Tiryaq wabai was used for the prevention of epidemic diseases during outbreaks, but it has not been explored scientifically so far. The study was aimed to evaluate the immune-stimulating effect of Tiryaq wabai in elderly.

Materials and Methods:

A randomized placebo controlled trial was conducted at National Institute of Unani Medicine Hospital, Bangalore. Thirty immunocompromised elderly persons were selected on the basis of clinical examination considering parameters like history of recurrent infection, unexplained weight loss, persistent diarrhea etc. They were randomly assigned, 20 in test and 10 in the control group. Tiryaq wabai was given to test group 500 mg orally thrice in a week for 45 days. Placebo was given orally to the control group at a dose of 500 mg thrice in a week for 45 days. Response was assessed by total leucocyte count (TLC), lymphocyte percentage, absolute lymphocyte count (ALC), CD4 and CD8 count. The results were analyzed statistically using Graph Pad InStat 3.

Results:

The test drug showed statistically significant increase in TLC (P < 0.001), lymphocyte percentage (P < 0.001),ALC (P < 0.001), CD4 count (P < 0.001) in comparison to control group, but increase in CD8 count was not statistically significant. No major adverse effect was observed throughout the study.

Conclusion:

The findings outlined above indicate immune- stimulating activity of Tiryaq wabai and supports its use in conditions where immunostimulation is required and thus is suggestive of therapeutic usefulness.

Influence of oral supplementation with sesamin on longevity of Caenorhabditis elegans and the host defense

PURPOSE

Nutritional control has been proposed as a potential therapy for slowing the senescence of immune function and decreasing mortality. This study investigated whether sesamin could modify host defense systems and extend the lifespan of the nematode Caenorhabditis elegans.

METHODS

Nematodes were fed standard food (the bacterium Escherichia coli strain OP50) supplemented with various doses of sesamin/γ-cyclodextrin inclusion compounds starting from young adulthood. The mean lifespan, muscle function, lipofuscin accumulation, protein carbonyl content, and stress resistance of the worms were examined. Then, C. elegans mutants harboring loss-of-function lesions in longevity- and host defense-related signaling pathways were supplemented with sesamin to identify the genes involved in the longevity effects.

RESULTS

Worms supplemented with sesamin displayed higher locomotion and prolongevity and produced offspring at levels similar to unsupplemented control animals. The growth curves of nematodes were similar to those of controls, suggesting that sesamin did not induce prolongevity effects through dietary restriction. Notably, sesamin made the worms more resistant to infection by Legionella pneumophila and more resistant to oxidative stressors such as paraquat and hydrogen peroxide and prolonged the lifespan of a mev-1 mutant that produces abundant superoxide anions. However, the accumulation of protein carbonyls and lipofuscin was similar in sesamin-exposed and control worms, suggesting that sesamin is unlikely to work simply as an antioxidant. Sesamin supplementation failed to extend the lifespan of loss-of-function mutants of daf-2, daf-16, pmk-1, and skn-1.

CONCLUSIONS

Sesamin enhances the host defense of C. elegans and increases the average lifespan via activation of both skn-1 (encoding a component of the p38 MAPK pathway) and daf-16 (encoding a component of the IGF-1 pathway).

Immunosenescence and immune response in organ transplantation

The immune system undergoes a complex and continuous remodeling with aging. Immunosenescence results into both quantitative and qualitative changes of specific cellular subpopulations that have major impact on allorecognition and alloresponse, and consequently on graft rejection and tolerance. Here, we are going to review the immunological changes associated with the aging process relevant for transplantation. Interventions to selectively target changes associated with the senescence process seem promising therapeutic strategies to improve transplantation outcome.

Management of the elderly patients with inflammatory bowel disease: practical considerations

The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.

Altered molecular repertoire of immune system by renal dysfunction in the elderly: is prediction and targeted prevention in the horizon?

Background

Patients on chronic hemodialysis (HD) have impaired cellular and humoral immunity. The percentage of elderly people among the total population in Taiwan is increasing dramatically, and HD is the primary alternative for renal replacement therapy when renal function declines. Activated vitamin D is widely used in HD patients with secondary hyperparathyroidism (SHPT) and is a well-known immunomodulatory agent. Personalized medicine and integrative medical approach has been a trend in current clinical practice. Can we improve their immune function using vitamin D in spite of the mineral aspect? Here, we investigated the relationship between serum 25-hydroxyvitamin D (25(OH)D) level and T cell differentiation in chronic HD patients.

Methods

Forty patients with chronic HD were enrolled. HD patients with SHPT had been treated with activated vitamin D for 3 months. Peripheral blood mononuclear cells obtained from the patients were cultured and stimulated by mitogens, and T cells were analyzed by flow cytometry. Serum 25(OH)D levels were detected by enzyme-linked immunosorbent assay.

Results

The incidence of T cell differentiation to the T helper cell (Th)2 subtype was more prevalent in the elderly group than in the controls (p = 0.001). Th2 differentiation was also correlated with age (p = 0.004) and serum 25(OH)D levels (p < 0.05). After treated with activated vitamin D, the level of Th1 cytokines decreased while the Th2 cytokine level increased in the sera (p < 0.05). The T cell differentiation tended toward the Th2 subtype (p = 0.027) after treatment of activated vitamin D in SHPT patients.

Conclusions

These results demonstrated that Th2 differentiation is correlated with age and the serum 25(OH)D level of patients. Treatment with activated vitamin D influenced T cell differentiation and cytokine expression in SHPT patients. Taking vitamin D is the possible prediction and targeted treatment in the immune dysfunction in chronic HD patients.

The safety of systemic treatments that can be used for geriatric psoriasis patients: a review

Background. Patients with moderate-to-severe psoriasis are often treated with systemic immunosuppressant agents that decrease immune system function. For the elderly, these medications are often problematic due to their already immunosuppressed state and comorbidities. However, there are few studies examining the effects of these medications on the elderly age group. Therefore, there is often discomfort among dermatologists treating elderly patients with psoriasis in utilizing systemic agents, frequently resulting in inadequate treatment. Objective. We review the safety profiles of systemic treatments often used to treat psoriasis and their possible adverse risks to the geriatric population. Methods. We conducted a search of PubMed's Medline database of articles published from 2000 to 2011, which resulted in 14 articles. Conclusion. Treating geriatric patients with moderate-to-severe psoriasis remains a challenge due to immunosenescence and comorbidities. More studies focusing on psoriasis treatment safety in the geriatric population are needed.

Cancer surgery in the elderly

The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.

A molecular mechanism for TNF-α-mediated downregulation of B cell responses

B cell function with age is decreased in class switch recombination (CSR), activation-induced cytidine deaminase (AID), and stability of E47 mRNA. The latter is regulated, at least in part, by tristetraprolin (TTP), which is increased in aged B cells and also negatively regulates TNF-α. In this study, we investigated whether B cells produce TNF-α, whether this changes with age, and how this affects their function upon stimulation. Our hypothesis is that in aging there is a feedback mechanism of autocrine inflammatory cytokines (TNF-α) that lowers the expression of AID and CSR. Our results showed that unstimulated B cells from old BALB/c mice make significantly more TNF-α mRNA and protein than do B cells from young mice, but after stimulation the old make less than the young; thus, they are refractory to stimulation. The increase in TNF-α made by old B cells is primarily due to follicular, but not minor, subsets of B cells. Incubation of B cells with TNF-α before LPS stimulation decreased both young and old B cell responses. Importantly, B cell function was restored by adding anti-TNF-α Ab to cultured B cells. To address a molecular mechanism, we found that incubation of B cells with TNF-α before LPS stimulation induced TTP, a physiological regulator of mRNA stability of the transcription factor E47, which is crucial for CSR. Finally, anti-TNF-α given in vivo increased B cell function in old, but not in young, follicular B cells. These results suggest new molecular mechanisms that contribute to reduced Ab responses in aging.

Vaccination in the elderly

There is a general consensus that the elderly do not respond as well to vaccination as the young, but robust studies are few and far between. Most refer to influenza vaccination, but even here, adequate immunological and clinical data are surprisingly thin on the ground. The meta-analysis by Goodwin et al. from 2006 is still the most comprehensive that we have. They reviewed 31 antibody response studies comparing influenza vaccination efficacy in groups of elderly and younger adults. They reported that the adjusted odds ratio (OR) of responses in elderly versus young adults ranged from 0.24 to 0.59 for the three influenza antigens used in the vaccines. They concluded that rather than the estimated 70-90% clinical vaccine efficacy in younger adults, this figure was only 17-53% in the elderly, depending on which viruses were prevalent that year. They stated that 'this highlights the need for more immunogenic vaccine formulations for the elderly'. How to achieve this? There are three areas where we may consider alterations to increase vaccine efficacy: (i) make the vaccine more potent; (ii) use adjuvants to enhance immunity; and (iii) apply immune modulators or other interventions to alter host immunity generally. We will consider these three options, focusing on influenza vaccination, in this mini-review.

Aging and immune function: molecular mechanisms to interventions

Abstract The immune system of an organism is an essential component of the defense mechanism aimed at combating pathogenic stress. Age-associated immune dysfunction, also dubbed "immune senescence," manifests as increased susceptibility to infections, increased onset and progression of autoimmune diseases, and onset of neoplasia. Over the years, extensive research has generated consensus in terms of the phenotypic and functional defects within the immune system in various organisms, including humans. Indeed, age-associated alterations such as thymic involution, T cell repertoire skewing, decreased ability to activate naïve T cells and to generate robust memory responses, have been shown to have a causative role in immune decline. Further, understanding the molecular mechanisms underlying the generation of proteotoxic stress, DNA damage response, modulation of ubiquitin proteasome pathway, and regulation of transcription factor NFκB activation, in immune decline, have paved the way to delineating signaling pathways that cross-talk and impact immune senescence. Given the role of the immune system in combating infections, its effectiveness with age may well be a marker of health and a predictor of longevity. It is therefore believed that a better understanding of the mechanisms underlying immune senescence will lead to an effective interventional strategy aimed at improving the health span of individuals. Antioxid. Redox Signal. 14, 1551-1585.

Potential role of immunosenescence in cancer development

The incidence and prevalence of most cancers increase with age. The reasons for this may include tumor escape mechanisms and decreased immunosurveillance, but most are caused by the time required for carcinogenesis, according to most scientists. The immune system is a unique mechanism of defense against pathogens and possibly cancers; however, there is a body of evidence that the immune system of the aged is eroded, a phenomenon termed immunosenescence. There is a growing interest in immunosenescence and how it may contribute to the increased number of cancers with aging. Each arm of the immune system, innate and adaptive, is altered with aging, contributing to increased tumorigenesis. Understanding the contribution of immunosenescence to cancer development and progression may lead to better interventions for the elderly.

Rejuvenation of the aging thymus: growth hormone-mediated and ghrelin-mediated signaling pathways

One of the major fundamental causes for the aging of the immune system is the structural and functional involution of the thymus, and the associated decline in de novo naïve T-lymphocyte output. This loss of naïve T-cell production weakens the ability of the adaptive immune system to respond to new antigenic stimuli and eventually leads to a peripheral T-cell bias to the memory phenotype. While the precise mechanisms responsible for age-associated thymic involution remain unknown, a variety of theories have been forwarded including the loss of expression of various growth factors and hormones that influence the lymphoid compartment and promote thymic function. Extensive studies examining two hormones, namely growth hormone (GH) and ghrelin (GRL), have demonstrated their contributions to thymus biology. In the current review, we discuss the literature supporting a role for these hormones in thymic physiology and age-associated thymic involution and their potential use in the restoration of thymic function in aged and immunocompromised individuals.

Bladder cancer in the elderly

INTRODUCTION

Age is now widely accepted as the greatest single risk factor for developing bladder cancer, and bladder cancer is considered as primarily a disease of the elderly. Because of the close link between age and incidence of bladder cancer, it can be expected that this disease will become an enormous challenge with the growth of an aging population in the years ahead.

METHODS

Using MEDLINE, a search of the literature between January 1966 and July 2007 was performed to describe normative physiologic changes associated with aging, elucidate genetic and epigenetic alterations that associate aging with bladder cancer and its phenotypes; and to characterize how aging influences efficacies, risks, side effects, and potential complications of the treatments needed for the various stages of bladder cancer.

RESULTS

We discuss influence of aging on host physiology, genetic and epigenetic changes, environmental influences, and host factors in the development and treatment of bladder cancer. Treatments with intravesical bacille Calmette Guerin, radical cystectomy, and perioperative chemotherapy are less well tolerated and have poorer response in elderly patients compared with their younger counterparts. Elderly patients face both clinical and broader institutional barriers to appropriate treatment and may receive less aggressive treatment and sub-therapeutic dosing. However, when appropriately selected, elderly patients tolerate and respond well to cancer treatments.

CONCLUSIONS

The decision to undergo treatment for cancer is a tradeoff between loss of function and/or independence and extension of life, which is complicated by a host of concomitant issues such as comorbid medical conditions, functional declines and "frailty", family dynamics, and social and psychologic issues. Chronological age should not preclude definitive surgical therapy. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus efforts towards gaining a better understanding of what the consequences of bladder cancer and its treatments are for older adults and how to appropriately meet the multifaceted medical and psychosocial needs of this growing population.

Immunity, ageing and cancer

Compromised immunity contributes to the decreased ability of the elderly to control infectious disease and to their generally poor response to vaccination. It is controversial as to how far this phenomenon contributes to the well-known age-associated increase in the occurrence of many cancers in the elderly. However, should the immune system be important in controlling cancer, for which there is a great deal of evidence, it is logical to propose that dysfunctional immunity in the elderly would contribute to compromised immunosurveillance and increased cancer occurrence. The chronological age at which immunosenescence becomes clinically important is known to be influenced by many factors, including the pathogen load to which individuals are exposed throughout life. It is proposed here that the cancer antigen load may have a similar effect on "immune exhaustion" and that pathogen load and tumor load may act additively to accelerate immunosenescence. Understanding how and why immune responsiveness changes in humans as they age is essential for developing strategies to prevent or restore dysregulated immunity and assure healthy longevity, clearly possible only if cancer is avoided. Here, we provide an overview of the impact of age on human immune competence, emphasizing T-cell-dependent adaptive immunity, which is the most sensitive to ageing. This knowledge will pave the way for rational interventions to maintain or restore appropriate immune function not only in the elderly but also in the cancer patient.

Multiparameter flow cytometric analysis of CD4 and CD8 T cell subsets in young and old people

Background

T cell-mediated immunity in elderly people is compromised in ways reflected in the composition of the peripheral T cell pool. The advent of polychromatic flow cytometry has made analysis of cell subsets feasible in unprecedented detail.

Results

Here we document shifts in subset distribution within naïve (N), central memory (CM) and effector memory (EM) cells defined by CD45RA and CCR7 expression in the elderly, additionally using the costimulatory receptors CD27 and CD28, as well as the coinhibitory receptors CD57 and KLRG-1, to further dissect these. Although differences between young and old were more marked in CD8 than in CD4 cells, a similar overall pattern prevailed in both. Thus, the use of all these markers together, and inclusion of assays of proliferation and cytokine secretion, may enable the construction of a differentiation scheme applicable to CD4 as well as CD8 cells, with the model (based on Romero et al.) suggesting the progression N→CM→EM1→EM2→pE1→pE2→EM4→EM3→E end-stage non-proliferative effector cells.

Conclusion

Overall, the results suggest that both differences in subset distribution and differences between subsets are responsible for age-related changes in CD8 cells but that differences within rather than between subsets are more prominent for CD4 cells.