Age Changes
1. Impairment of smell and taste can further reduce poor appetite.
2. Older people cannot open their mouths as wide and chew with less power than younger people.
3. Loss of teeth (see Chapter 15) and/or poorly fitting dentures secondary to alveolar margin atrophy impair mastication.
4. Tongue atrophy means older people can only manage smaller boluses of food.
5. Impaired coordination of swallowing and uncoordinated or reduced oesophageal peristalsis (presbyoesophagus).
6. Reduced pressure of the upper oesophageal sphincter plus delayed relaxation after swallowing lead to problems with the oeosophageal phase of swallowing.
7. Slower gastric emptying of fluids, but not solids.
8. Reduced pancreatic function due to duct and parenchymatous changes.
9. Reduced splanchnic blood flow.
10. Reduced small bowel surface area.
11. Changes in intestinal microflora including a decrease in anaerobes and bifidobacteria and an increase in enterobacteria reduce immunity to Clostridium difficile.
12. Diverticula develop in the bowel.
13. Reduced large bowel motility predisposes to constipation.
14. Reduced rectal wall elasticity increases the risk of faecal incontinence.
Loss of 5 >kg of weight in 6–12 months is clinically significant, associated with increased morbidity and mortality, and affects:
- 20% of over 65s living in the community
- 50% of those in nursing homes.
1. Ageing changes: account for only 0.1–0.2 >kg weight loss per year. There is a tendency to weight loss in old age (in contrast to the weight gain common in middle age) due to reduced body-water content, bone loss (osteoporosis), thinning of connective tissue and the conversion of muscle to fat. Those who maintain their lean body mass into old age have a better life expectancy than their shrinking peers.
2. Oral and dental disease: see Chapter 15.
3. Systemic disease: weight loss is associated with all chronic disorders, e.g. COPD, cardiac failure, kidney disease, poorly controlled diabetes mellitus, thyrotoxicosis and Addison’s disease.
4. Malignancy: GI malignancy accounts for 50% of cancers presenting with severe weight loss.
5. Psychiatric disease: the apathy of depression and self-neglect in some people with dementia lead to weight loss. The paranoia of a psychosis may make food unacceptable. The hyperactivity of some demented and hypomanic patients may result in weight loss. Alcohol abuse should also be considered.
6. Iatrogenic disease: impaired appetite may be due to unpalatable treatments, side-effects, e.g. antibiotics (especially metronidazole and erythromycin), opiates, antidepressants, metformin, levodopa or toxicity, e.g. digoxin. ACE inhibitors may cause loss of taste or an unpleasant taste. Diarrhoea may be due to proton pump inhibitors, anti-cholinesterase inhibitors, misoprostol or antibiotics. The burden of too many tablets may suppress appetite. Do not forget how unpleasant it is for patients in hospital to have to eat where they sleep, open their bowels, etc. and their proximity to others performing the same functions.
7. GI disease:
- Dysphagia.
- Dyspepsia.
- Malabsorption.
Diagnosing weight loss
• History: diet, appetite, taste, nausea, vomiting, dysphagia, abdominal pain, diarrhoea, change in bowel habit.
• Examination: cachexia, anaemia, teeth, tongue, jaundice, lymphadenopathy, goitre, gross oedema, severe heart failure, obvious masses, organomegaly, rectal examination.
• Assess mood and cognitive function.
• Baseline tests:
FBC: micro- or macrocytic anaemia.
LFTs: high alkaline phosphatase (ALP) may represent bone or liver metastases.
TSH suppressed in hyperthyroidism.
CRP and ESR: if normal, the cause is unlikely to be organic.
CXR: may demonstrate unexpected primary or secondary tumours.
Other tests as indicated by the features above.
• Refer to the dietician.
• Treat underlying causes where possible.
• Explain to patient and family if this is an end of life event (see Chapter 17).
- Dysphagia is increasingly common in older age affecting:
10% of over 60s
30–60% of nursing home residents
Up to 60% of post-stroke patients.
- Patients with dysphagia have a worse 6-month mortality than those without.
- There are three stages of swallowing and dysfunction results from a combination of age-related problems and pathology.
- Dysphagia can affect the oropharynx or oesophagus and be due to structural changes or neuromuscular disease (Table 11.1).
Table 11.1 Causes of dysphagia
|
Structural |
Zenker’s diverticulum, pharyngeal pouch |
Peptic stricture, rings or webs |
|
| Severe oesophagitis |
| Carcinoma of palate or tongue |
Intrinsic oesophageal carcinoma |
| Infection, abscess |
Severe candidiasis |
|
| Compression from extrinsic carcinoma, e.g. bronchial |
|
| Vascular compression, e.g. aortic aneurysm |
|
| Foreign body |
Neuromuscular |
Stroke |
Achalasia |
| Bulbar palsy, e.g. MND, pseudobulbar palsy |
Diffuse muscle spasms of presbyoesophagus |
| Brain stem lesion including tumour |
Motility disorder secondary to GORD |
| Polymyositis, dermatomyositis |
Motility disorder secondary to systemic diseases such as diabetes, CREST |
| Myasthenia gravis |
|
|
Assessing Dysphagia
History
- Is it difficult to swallow liquids (suggests neurological problem), solids (suggests obstruction) or both?
- Is there evidence of inflammation – indigestion, acid burn?
- Does the food stick at one level?
- Is there a sensation of fatigue? ‘Yes’ suggests myasthenia gravis.
Examination
Check dentition and fit of dentures and look for candidiasis. Are there tongue fasiculations suggestive of MND?
Investigation
If there is concern that endoscopy may perforate the oesophagus, arrange a barium swallow first. This will demonstrate a pharyngeal pouch, corkscrew contractions secondary to achalasia or shouldering characteristic of oesophageal carcinoma. Gastroscopy allows direct visualization and biopsy of abnormal tissue. Active bleeding can be treated, a benign stricture can be dilated and a malignant stricture can be stented.
Management
Specific management depends on the cause, but is often multidisciplinary involving dieticians and speech and language therapists.
Neuromuscular Dysphagia
1. Presbyoesophagus.
2. Pseudobulbar palsy is bilateral upper motor neuron spastic weakness of muscles supplied by V, VII, X, XI and XII secondary to lesions of the corticobulbar tracts in the mid-pons, e.g. bilateral internal capsule strokes or MS.
3. Bulbar palsy is the impairment of function of the cranial nerves due to a lower motor lesion. A posterior inferior cerebellar artery infarct results in ipsilateral pharyngeal paralysis with contralateral paresis of the arm and leg (Wallenberg’s syndrome).
4. Parkinson’s disease. Akinesia impairs swallowing; up to 50% of PD patients have dysphagia. Levodopa and speech therapy may help.
5. Myasthenia gravis. Rare but important, because of good response to anticholinesterases, e.g. pyridostigmine.
6. Achalasia. More of a problem in younger patients but may be an aspect of presbyoesophagus.
NB: Nasogastric (NG) tube feeding is usually only justified short term when recovery is anticipated. Fine-bore tubes should be used, ideally when the patient can cooperate. Bridled loop NG tubes can be useful for patients with dementia who are likely to pull the tube out, but again use should be short term. If long-term treatment is contemplated, consider percutaneous endoscopic gastrostomy (PEG) feeding. See Chapter 7.
External Pressure on the Oesophagus
1. Pharyngeal pouches. All pouches become more common with increasing age. Zenker’s diverticulum, through the posterior pharyngeal wall at the upper level of cricopharyngeus, may result from incoordinated contractions. When large and full, it may hinder passage of a food bolus. Symptomatic pouches can be removed surgically and endoscopic techniques permit operations on frailer patients. More rarely, pouches occur lower in the oesophagus.
2. Superior mediastinal obstruction – malignancy (usually carcinoma of the bronchus).
3. Dilated left atrium, in severe heart disease. A CXR, in conjunction with clinical signs, will usually be sufficient to make the diagnosis.
4. Aortic-arch dilatation.
5. Posterior pressure from spinal osteophytes (very rare).
Inflammatory Lesions of the Oesophageal Epithelium
Oesophagitis
Inflammation in the lower oesophagus is associated with hiatus hernia and acid reflux. The patient often gives a long history of indigestion. Chronic inflammation can lead to strictures. Endoscopy is the best diagnostic modality as biopsies can be taken (essential if there is any suspicion of malignant change), and Barrett’s oesophagus (see below) may be noted. Symptoms respond to antacids, but H2 antagonists (e.g. ranitidine) or proton-pump inhibitors (e.g. omeprazole) are necessary for healing. Strictures should be dilated.
Oesophageal Candidiasis
Frail elderly people are at risk, especially if immunosuppressed, users of steroid inhalers or after antibiotics. The typical white patches of thrush are often (but not always) present in the mouth. Endoscopy confirms oesophageal involvement. Oral fluconazole is the treatment of choice.
Barrett’s Oesophagus
This is the development of intestinal metaplasia usually affecting the lower one-third of the oesophagus. Risk factors include being male, over 60, smoking and alcohol. It usually develops in combination with hiatus hernia, low oesophageal tone and duodenal reflux. It is premalignant and may progress to adenocarcinoma. Most elderly patients will die of other diseases, but fit elderly people without significant other pathologies should be offered regular surveillance.
Carcinoma of the Oesophagus
- Commonly occurs in the sixth and seventh decades; 20 times more common in those aged over 65 compared with the younger population.
- UK incidence in men is 17.5 per 100,000; 8.8 per 100,000 women.
- Two main types: adenocarcinoma and squamous cell carcinoma.
Adenocarcinoma is becoming more common in the West, is more common in men, affects slightly younger patients, and tends to affect the lower third of the oesophagus. The strongest risk factor is reflux and Barrett’s oesophagus is a premalignant stage.
Worldwide, squamous cell carcinoma is more common and is related to smoking, alcohol and vitamin deficiencies. The increased incidence in China is attributed to riboflavin deficiency.
- Symptoms: the patient complains of dysphagia, first for solids and then liquids. Weight loss is extremely common. Some patients experience retrosternal pain. Hoarseness indicates invasion of the left recurrent laryngeal nerve. Cough and breathlessness may be due to aspiration or direct invasion of the bronchial tree.
- Barium swallow is safest for initial evaluation and great care is needed during endoscopy because of risk of perforation.
- Endoscopy allows biopsy.
- CT scanning is useful for staging.
Management
Curative treatment is rare; tumours are discovered late and have often already spread, so palliation is the aim.
1. Patient should be discussed by a multidisciplinary upper GI team.
2. Oesophagectomy, for lesions at the lower end, is a massive undertaking unlikely to improve quality of life of frail older people.
3. Combinations of chemotherapy and radiotherapy may be an option for biologically fit patients with high performance status and localized disease.
4. Dysphagia can be reduced by debulking with endoluminal brachytherapy or photodynamic therapy.
5. Stent insertion: the treatment of choice for obstructive symptoms when other measures are not justified; pain and complications are common. If tumour blocks the stent, this can be debulked with a Yittrium Aluminium Garnet (YAG) laser or photodynamic therapy.
6. Patient support: patients and their families should be given the support of a specialist nurse and contact details for support networks (e.g.
www.macmillan.org).
7. Nutrition: do not forget to optimize patient’s oral intake by referring to the dietician for supplements where indicated and consider thickened fluids if there is risk of aspiration.
8. Palliative care: refer early for help with symptoms and further support (Chapter 17).
Intraluminal Obstruction
Impacted objects may include food (especially if not properly chewed), missing dentures and other foreign bodies. Cognitively impaired patients are particularly at risk.
Complications of Dysphagia
- Malnutrition.
- Aspiration pneumonia.
- Oesophageal rupture.
1. Indigestion is common at all ages (30% of the population); 2–3% of prescribed drugs are antacids.
2. In many elderly patients diagnosis is difficult as the symptoms are vague and non-specific.
3. As many drugs cause dyspepsia; a drug history is essential. Avoid NSAIDs, bisphosphonates and calcium channel blockers, and co-prescribe proton pump inhibitors (PPIs) with steroids.
4. Helicobacter pylori infection rises with age (up to 60% of elderly people are infected) and should be treated if demonstrated by biopsy, culture, breath test or serology.
5. The pathologies potentially responsible for indigestion become more common in old age. See box below.
6. Many patients will have more than one possible cause for their non-specific indigestion. A therapeutic trial may identify the responsible lesion as many of the conditions can be asymptomatic, e.g. 20% of hiatus hernia and up to 50% of gallstones.
7. Late-onset dyspepsia should be investigated. Endoscopy is the investigation of choice (except in the presence of dysphagia) and acceptable for most elderly patients; extra care is needed with pre-medication in those with poor respiratory reserve. Magnetic resonance cholangiopancreatography (MRCP) is useful in diagnosis in frail patients with biliary-tract disease. However, they may subsequently need ERCP for biopsies and treatment, e.g. to remove small biliary stones or insert stents.
8. Ultrasound examination is the best technique for suspected gallbladder and pancreatic disease.
9. Watch out for side-effects from medication, for example:
Metoclopramide may precipitate or worsen extra-pyramidal syndromes.
Cimetidine can cause delirium.
Avoid aluminium salts in constipated patients and magnesium in those with diarrhoea.
Bile salts have proved disappointing for dissolving gallstones and side-effects, especially diarrhoea, can be troublesome.
PPIs can cause hyponatraemia, diarrhoea, increase the risk of
Clostridium difficile and long-term use has been linked to increased risk of malignant change. There is uncertainty as to whether their interaction with clopidogrel is clinically relevant.
Patients with osteoporotic kyphosis are at increased risk of oesophageal perforation with bisphosphonates.
Lesions potentially responsible for ’indigestion’
• Hiatus hernia (affects 60% of over 70 >year olds).
• Gastritis (especially drug-induced).
• Peptic ulceration (found in 20% of over 70 >year olds).
• Carcinoma of the stomach.
• Gallstones (found in 38% of over 70 >year olds).
• Pancreatic disease.
• Mesenteric ischaemia.
• Carcinoma of large bowel.
Gastro-Oesophageal Reflux Disease (GORD)
This is return of gastric contents into the oesophagus.
- Heartburn is common, but GORD may cause respiratory symptoms such as chronic cough or asthma and non-cardiac chest pain.
- PPIs are the most successful treatment in conjunction with H. pylori eradication plus lifestyle changes (weight-loss, cessation of smoking, raise head of bed).
- Only endoscope if treatment fails to relieve symptoms.
- Oesophagitis, strictures, Barrett’s oesophagus and adenocarcinoma are complications.
Almost every cause of GI bleeding becomes more common with increasing age:
1. Hiatus hernia with oesophagitis.
2. Gastritis and gastric erosions: elderly patients on NSAIDs have a sevenfold increased risk of bleeding compared with the same age group not taking such drugs.
3. Gastric and duodenal ulcers.
4. Carcinoma of the oesophagus and the stomach.
5. Diverticular disease.
6. Ischaemic bowel disease, sometimes difficult to differentiate from chronic inflammatory disease, e.g. Crohn’s disease.
7. Colonic polyps: 40% incidence in the over 65s in a post-mortem study.
8. Colon cancer.
9. Angiodysplasia.
10. Piles.
Acute Blood Loss
This is particularly dangerous in the elderly as the resulting hypotension may precipitate a stroke, MI, acute kidney injury or fracture. Timely treatment is required: initially blood transfusion but with ready access to surgical intervention if the bleeding persists.
Acute upper GI bleeding in the elderly often presents as melaena without haematemesis: endoscopy may therefore be helpful in locating the site of bleeding and mucosal injection may help to stop bleeding.
Acute, severe bowel ischaemia may present as rectal bleeding, and the ischaemia may be secondary to other pathology, e.g. a silent MI. A full assessment is therefore needed.
Chronic Blood Loss
Chronic GI bleeding is the most common cause of iron-deficiency anaemia in old age in the UK (see Chapter 14). The bleeding site is often asymptomatic. Examination of both the upper and lower tract is required in most cases. Discovery of a benign lesion should not prevent further exploration for more serious causes, providing the patient is sufficiently fit and willing to be investigated.
Suggested Plan of Investigation
1. Confirm the anaemia is due to iron-deficiency.
2. Is GI bleeding likely; faecal occult bloods now less commonly performed.
3. Endoscopy of upper GI tract. Barium swallow/meal is indicated for dysphagia.
4. Flexible sigmoidoscopy followed by CT abdomen with oral and IV contrast to study the large bowel. Contrast CT of the abdomen is kinder than and almost as effective as barium enema in frail elderly patients and provides extra information about liver, pancreas and lymph nodes.
5. Colonoscopy, the gold standard, may require the patient to be hospitalized for bowel prep and like barium enema may be poorly tolerated so the caecum may not be seen. It is often used after CT to confirm possible abnormality or reveal angiodysplasia. Biopsies can be taken and polyps can be removed.
6. Radioisotope-labelled red cells may be used to identify the site of GI bleeding in cases of brisk intermittent bleeding of unknown cause.
Treatment
1. Specific treatment for underlying cause.
2. Oral iron supplements: ferrous sulphate if tolerated.
3. Transfuse only if haemoglobin is very low, e.g. less than 8 >g/dL, and causing symptoms; take care if risk of congestive heart failure is present.
This is a difficult diagnostic problem, but even more so in old age. The mortality rate in elderly patients may exceed 50%. There are four possible reasons for such depressing results:
1. Delay in presentation.
2. Atypical presentation (‘silent’).
3. Reluctance to operate on frail elderly patients.
4. Precipitation of other significant pathology during the acute episode, e.g. MI.
The NCEPOD report (2010) into the care received by elderly patients undergoing surgery made several recommendations (see box).
NCEPOD recommendations (2010)
• Review by senior surgeons/physicians, and more input from care-of-the-elderly physicians.
• Better fluid balance, pain relief and nutrition.
• Review of all medications including venous thromboprophylaxis.
• More awareness of prevention of acute kidney injury (see Chapter 13).
• Optimize time to theatre; investigate and stabilize the patient but avoid delaying surgery in life-threatening conditions.
• Plan high level post-operative care, e.g. high dependency or intensive care.
Common pathologies in patients aged over 75 undergoing emergency abdominal surgery are listed in Table 11.2.
Table 11.2 Acute abdomen – pathology in elderly patients undergoing surgery
|
Strangulated hernia |
115 |
16 |
Intestinal obstruction |
103 |
38 |
Perforated peptic ulcer |
22 |
41 |
Perforated large bowel |
22 |
64 |
Ruptured aortic aneurysm |
9 |
78 |
Biliary-tract disease |
22 |
* |
Mesenteric ischaemia |
10 |
* |
|
Useful Pointers in the Elderly Acute Abdomen
