Senior adults

Health conditions associated with PI

If PI goes undiagnosed or undertreated, infections, autoimmunity, or chronic inflammation can lead to permanent organ damage. Even after diagnosis, some health issues may continue to get worse. Be aware of health conditions that are common complications of PI and work with your healthcare provider to maintain treatment.

Common lung issues include [3,4]:

• Bronchiectasis: Damaged, permanently widened airways caused by repeated infections like pneumonia, leading to mucus buildup, further infection risk, persistent cough, and trouble breathing.
• Chronic obstructive pulmonary disease (COPD): Ongoing lung inflammation that makes breathing difficult.
• Pulmonary fibrosis with hypoxemia: Scarring and thickening of lung tissue that restricts breathing and reduces oxygen in the blood.
• Granulomatous lung disease: Immune cell clusters in the lungs that can cause cough and shortness of breath.
• Autoinflammatory lung disease: Chronic, low-grade inflammation that, over a period of time, causes lung damage.

Early diagnosis and treatment can slow these conditions, but some may eventually require surgery or use of supplemental oxygen. Make sure your healthcare provider monitors you for these conditions and tell your provider about any new respiratory symptoms.

Gastrointestinal (GI) issues, or problems with your digestive tract, are also common [5]. These infections can cause:

• Malnutrition.
• Protein and fluid loss from chronic diarrhea.
• Loss of immunoglobulin G (IgG).
• Conditions like inflammatory bowel disease, autoimmune hepatitis, malabsorption, and bacterial overgrowth can also happen.

Cancer in general is more common with age. Some cancers are also associated with certain types of PI, especially CVID and WAS [6]. Make sure your healthcare provider monitors you for blood cancers like lymphoma, myeloma, and leukemia and for GI cancers if you have had certain GI infections or conditions.

Cancers or blood disorders may lower antibody levels, which can cause secondary immunodeficiency. Chemotherapy and other cancer treatments can further weaken immunity. It is important to check your IgG levels before cancer treatment to understand whether low Ig levels are due to PI, cancer, or treatment.

Considerations for Ig replacement therapy and other medications

Health problems that come with age, like diabetes, chronic kidney or liver disease, nerve damage, dementia, arthritis, and high blood pressure, can affect Ig replacement therapy. Providers must consider Ig dose, how often it’s given, how it’s given, which product to use, and where treatment will happen (ex., at home or at an infusion center). 

The two main options for infusing Ig are intravenous immunoglobulin (IVIG) replacement therapy (through a vein) and subcutaneous immunoglobulin (SCIG) replacement therapy (under the skin). With both IVIG and SCIG, seniors generally should receive lower doses of Ig at a slower infusion rate. Beginning with a lower dose minimizes rare but serious side effects like kidney failure and blood clots, particularly for those with other health problems. Healthcare providers can then increase the dose if needed.

Some senior adults choose IVIG because infusions are less frequent, and they do not have to self-infuse. Going to an infusion center for IVIG also lessens social isolation for some senior adults.

However, the supervising healthcare provider and infusion center or home nurse need to have experience with IVIG infusions in senior adults. Large volumes of Ig, if infused rapidly, could have dangerous side effects. IVIG can also increase blood thickness (viscosity), causing clotting and poor kidney function. Challenges with IVIG in senior adults include:

• Decreased vein flexibility or access.
• More frequent and serious side effects from IVIG infusion.
• Vein inflammation from long-term use of blood thinners and steroids.
• Too much fluid in the body (fluid overload), leading to high blood pressure and stress on the heart.
• Not being able to travel to infusion clinics or access home nursing care.

Those with kidney disease are at particular risk of serious side effects. However, all senior adults have an increased risk for blood clots, including inflammation of surface veins (thrombophlebitis), heart attack, stroke, and clots in the lungs (pulmonary embolism). The risk is higher in individuals with other blood-clotting risks or previous clotting events, particularly those with limited mobility. Healthcare providers should measure Ig serum levels, check kidney function, and adjust Ig therapy if needed.

Other seniors choose SCIG and self-infuse at home because it’s easier, has a lower risk of serious side effects, and is covered by their health insurance. SCIG may be necessary for seniors with kidney disease, severe heart disease, clotting disorders, hypertension, or other conditions. According to research, senior adults, even those on blood thinners (anticoagulants), can tolerate and self-administer SCIG safely [11]. 

While SCIG may be convenient for some, it may cause problems for seniors with physical limitations. SCIG self-infusion requires several steps, which may be hard for those with arthritis, poor eyesight, muscle weakness, or nerve damage. Often, a caregiver needs to help with the infusions. Note that, unlike IVIG, Medicare generally does not pay for nursing support for SCIG after initial training sessions. Exceptions include facilitated SCIG or when an individual has documented manual dexterity issues.

Besides Ig, other medications might need to be adjusted for seniors because the body’s sensitivity to and ability to break down medications change with age [12]. Healthcare providers should consider chronic conditions besides PI, kidney and liver health, and chronic infections. 

Adjusting medication for age is especially important for seniors who take many medications daily, prescribed by different healthcare providers. Even with electronic medical records and pharmacies keeping track, seniors can still be hurt by mistakes with medicine. It’s important for you or your caregiver to know what medicines you are taking and their side effects. Don’t hesitate to ask your healthcare provider or pharmacist questions. 

Health coverage for senior adults with PI

Adults 65 and over are eligible for Medicare coverage and should discuss the different plan options with a trusted advisor [13]. Medicare offers many options, and understanding a plan’s coverage is important. Choosing the wrong plan can impact both your health and finances. 

Your options are:

• Original Medicare 
  • Part A: Covers 80% of costs for inpatient hospital stays, skilled nursing facilities (SNFs), hospice care, and some home healthcare.
  • Part B (optional): Covers 80% of costs for healthcare provider visits, preventative care, medical tests and imaging, and some prescription drugs, including immunoglobulin (Ig) replacement therapy for certain PI diagnoses.
  • Part D (optional): Privately run prescription drug plans that include Ig replacement therapy for all PI diagnoses not covered under Part B. After the $615 deductible, plans cover 75% of costs up to the out of pocket cap of $2,100/year (note that these are 2026 levels and may change).
  • Parts F & G (optional; not available for those with secondary insurance): Medigap plans that provide supplemental coverage for the 20% of costs that Parts A and B do not cover.

-OR-

• Medicare Advantage
  • Part C: Privately run plans that must cover Part A and Part B services and benefits but can impose their own rules, including preferred provider networks, drug formularies, cost-sharing, prior authorization, step therapy, and referral requirements. Many include prescription drug coverage and coverage for other services not covered by original Medicare. 
  • Part D (optional; not available if your Part C plan includes prescription drug coverage): Privately run plans for prescription drug coverage that include Ig replacement therapy for all PI diagnoses not covered under Part B. After the $615 deductible, plans cover 75% of costs up to the out of pocket cap of $2,100/year (note that these are 2026 levels and may change).

Based on the experiences of senior adults with PI on Ig or other specialty medications, original Medicare with Part B, Part D, and a Medigap plan (if needed) provides coverage for most medications. Medicare Advantage plans can set their own formularies, so they may not cover all Ig products. People with Medicare Advantage plans have reported that most cover only 70-80% of the costs for Ig replacement therapy. Because those with Medicare Advantage are not eligible for Medigap plans, people on Medicare Advantage plans can end up paying significantly more out of pocket for Ig therapy.

Note that people with original Medicare and Medicare Advantage have reported problems getting Ig replacement therapy during stays in a skilled nursing facility (SNF). SNFs receive a single bundled payment under Part A, which is not enough to cover the cost of Ig therapy. As a result, many SNFs do not accept patients who need Ig therapy or refuse Ig therapy once someone is admitted.

Medicare coverage is complicated. Since Medicare plans vary from state to state and even by counties within a state, you need to research what plans you are eligible for. Contact your State Health Insurance Assistance Program (SHIP) to find trained counselors who can tell you which plans you are eligible for and assist you in finding the answers to your coverage questions [14].