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The “scope” of the problem
Gastrointestinal symptoms are common in patients aged 65 and older and can range from mild self-limited episodes of constipation or acid reflux to life-threatening episodes of infectious colitis or bowel ischemia. According to data from the US Census Bureau in 2005, 45–50 million people over age 65 had at least one gastrointestinal (GI) complaint that impacted their daily life and that might result in a medical visit. Geriatric-aged patients may present with unusual or subtle symptoms of serious GI disease due to alterations in physiology with aging. This chapter highlights common GI problems in older patients, with an emphasis on practical management and goals of care in this population.
Disorders of the esophagus
Gastroesophageal reflux disease
Gastroesophageal reflux disease (GERD) is one of the more common GI disorders affecting the elderly.[1] Population studies have indicated that more than 20% of adults over age 65 have heartburn at least weekly. This may actually underestimate the true prevalence of GERD due to the finding that, while symptoms appear to decrease in intensity with age, the severity of reflux and the risk of complications increase. The ubiquitous use of proton pump inhibitors (PPIs) in clinical practice has probably resulted in treatment of unsuspected GERD, but chronic PPI use comes with its own set of problems, including accelerated osteoporosis, decreased efficacy of Plavix, and potential increase in risk of developing serious respiratory infections. Hence, there has been a recent focus on decreasing chronic use of PPIs in patients who do not appear to have an indication for their use.
Presentation
GERD is straightforward to diagnose if it presents with the classic symptoms of pyrosis (substernal burning with radiation to the mouth and throat) and sour regurgitation. Geriatric patients may present with more subtle symptoms, such as a chronic cough, difficult-to-control asthma, laryngitis, or recurrent chest pain. They may also be completely asymptomatic and present with a complication such as anemia or dysphagia due to dysmotility or stricture. Patients taking multiple medications – particularly nonsteroidal anti-inflammatory drugs (NSAIDs) or bisphosphonates – are at increased risk for pill-induced esophagitis or erosions, which can present with symptoms similar to GERD and should be investigated in a similar way.
Diagnosis
If GERD is suspected from the history, patients should be tested for anemia and low iron levels, which may be due to esophagitis. Upper endoscopy (EGD) should be performed in all patients with new-onset GERD over age 50, persistent symptoms of reflux despite medical therapy, patients with a history of acid reflux longer than five years, and those with possible complications from acid reflux. These groups have an increased risk of malignancy. EGD is safe to perform even in the very elderly frail patient – the main contraindication is end-stage chronic obstructive pulmonary disease (COPD) or other situation where sedation is contraindicated. Other testing is typically reserved for patients who do not respond to therapy or who have atypical symptoms. Patients presenting with hoarseness or cough that is suspected to be related to GERD can undergo ambulatory evaluation with a 24-hour pH monitoring after a negative workup (including EGD and other tests for malignancy) and failure of empiric treatment with PPIs and lifestyle changes. Esophageal manometry is typically reserved for the elderly patient with a suspected motility disturbance or to rule out a motility disturbance prior to the consideration of reflux surgery.
Differential diagnosis
In older patients presenting with heartburn and dysphagia, malignancy in the esophagus and/or stomach should be considered and excluded. Patients with hoarseness and cough may require evaluation by imaging or referral to specialists to exclude oropharyngeal causes of vocal cord dysfunction such as stroke or malignancy.
Complications
Complications that have been associated with GERD include esophagitis, esophageal ulceration, bleeding, strictures, Barrett’s esophagus, and esophageal adenocarcinoma, all of which are increased in patients over 65 years of age.[2]
Treatment and prevention
Treatment of GERD in the elderly is essentially the same as that in younger patients. Although the “step-up” approach of lifestyle changes followed by acid-reducing drugs may work, immediate initiation of a PPI with lifestyle modifications usually results in fewer office visits, a reduction in procedures, improved patient satisfaction, and reduced overall costs. Histamine2 receptor antagonists (H2RAs) are also effective for mild symptoms, and avoid the side effects of PPIs such as accelerated osteoporosis and drug interactions. (See Table 22.1.) Cimetidine is generally not recommended in older patients because of potential drug interactions and a higher incidence of adverse side effects compared with other H2RAs. Although effective, chronic PPI use has been associated with an increased relative risk of osteoporosis of 1.97 with long-term use of PPIs (>7 years).[3] There have been reports of other concerns, such as decreased efficacy of clopidogrel anticoagulation for prophylaxis against coronary stent occlusion when clopidogrel is used in conjunction with PPIs. (See Table 22.2.)
| Osteoporosis |
| Small intestinal bacterial overgrowth |
| Increased susceptibility to infection with enteric pathogens |
| Traveler’s diarrhea |
| C. difficile |
| Drug–drug interactions |
| Cytochrome P450 interaction with clopidogrel |
| Reduced absorption of Atazanavir |
| Increased susceptibility to aspiration pneumonia |
| Vitamin B12 and iron malabsorbtion |
| Increased risk of Helicobacter pylori gastritis |
| Acute interstitial nephritis |
For this reason, it is recommended to reevaluate the need for PPIs in patients who have been taking them for longer than six months or who had PPIs started for ulcer prophylaxis during hospitalization. Antireflux surgery should be reserved for patients with severe refractory GERD with complications. Results from high-volume centers indicate that mortality and morbidity are not increased in patients over 70 who are deemed low surgical risk for complications. However, as in younger patients undergoing reflux surgery, there is an immediate decrease in patients with symptoms post-surgery to 10%–15%, yet some 60% of patients are taking acid suppressive medications 5–15 years later.
Dysphagia
Dysphagia, or difficulty swallowing, is a common complaint in older individuals.[4] (See Box 22.1.) Dysphagia is classified as oropharyngeal (transfer) or esophageal (transit).
Dysphagia in the elderly is common and should always be investigated
Check history of smoking, alcohol use, review medications, do neurologic exam
Dysphagia may be oropharyngeal (mostly caused by neurological disorders) or esophageal; the causes of esophageal dysphagia can generally be determined by history
Common causes of dysphagia
Neuromuscular: strokes, Parkinson’s disease, dementia
Mechanical: strictures, Zenker’s diverticulum, Shatski’s ring, tumors of the head, neck, esophagus
Motility: achalasia, paraneoplastic, diffuse esophageal spasm, hypertonic LES, diffuse motility disorder with ineffectual peristalsis
Inflammatory esophagitis: pill esophagitis, acid reflux, radiation, caustic ingestion
Dysphagia is associated with aspiration, weight loss, and poor quality of life
Patients considered for a feeding tube should be able to participate in the decision
Esophageal cancer usually presents in an advanced stage in the elderly, with symptoms of progressive dysphagia and weight loss.
Surveillance of Barrett’s esophagus should be performed at one-to-three-year intervals to detect early adenocarcinoma
Oropharyngeal dysphagia refers to impaired movement of liquids or solids from the oral cavity to the upper esophagus. Changes with aging affecting the ability to chew and swallow food include painful or diseased teeth, xerostomia (dry mouth), poorly fitting dentures, and loss of mandibular bone density. Muscle function slows with aging, resulting in slower transfer of food into the pharynx, and delayed relaxation of the upper esophageal sphincter (UES). The resultant inability to move food into the esophagus can cause penetration of food into the area above the vocal cords, and possibly aspiration into the trachea. Studies of normal healthy adults over age 85 demonstrate that approximately 10% have silent aspiration documented on barium cinefluoroscopy. Neuromuscular disorders affecting the tongue, soft palate, oropharynx, and upper esophageal sphincter such as cerebrovascular disease, Parkinson’s disease, multiple sclerosis, Alzheimer’s disease, and upper motor neuron diseases exacerbate the problem, as do muscular disorders such as myasthenia gravis, polymyositis, and amyloidosis. Finally, patients with a history of surgery or radiation to the oral cavity or neck are at risk for transfer dysphagia. This can occur many years later due to structuring or fibrosis in the irradiated muscles. In this group, recurrence of cancer should be part of the differential diagnosis.
Dysphagia occurring in the esophagus distal to the UES is transit dysphagia, and is even more common than transfer dysphagia. In a review of patients presenting with dysphagia in a primary care setting, the most common diagnoses were esophageal reflux (44%), benign strictures (36%), esophageal motility disorder (11%), neoplasm (6%), infectious esophagitis (2%), and achalasia (1%).
Presentation
Patients with oropharyngeal dysphagia typically cough, gag, choke, or aspirate their food during the initiation of a swallow. Patients may also complain of odynophagia, or painful swallowing. (See Table 22.3.) Those with transit dysphagia often complain of solid foods or liquids “sticking,” “catching,” or “hanging up” in their esophagus, and may point to their substernal area as the problem location. This does not always indicate the true location of the problem, as patients with distal esophageal obstruction may have sensations referred higher up in the chest. Using a series of questions, the cause of esophageal (transit) dysphagia can be identified in nearly 90% of cases. Dysphagia to solids usually reflects an underlying mechanical obstruction, whereas dysphagia to both liquids and solids starting simultaneously usually reflects an underlying neuromuscular disorder (motility disorder). It is helpful in this age group to ask about risk factors that predispose patients to infection, inflammation, or malignancy and whether the patient is experiencing odynophagia.
NSAIDs – nonsteroidal anti-inflammatory drugs; ASA – acetylsalicylic acid; HSV – herpes simplex virus; CMV – cytomegalovirus; VZV – varicella zoster virus.
Patients with odynophagia may have underlying infection (such as esophageal candidiasis) or obstruction. Use of steroid inhalers for COPD can result in yeast colonization of the mouth and throat. History of smoking or heavy alcohol use is associated with increased risk of squamous cell esophageal cancer. The physician should look for evidence of anemia and unintentional weight loss due to inability to eat, either of which could indicate a serious disorder such as malignancy. Finally, associated symptoms of chest pain or acid reflux should be elicited, as GERD is a risk for peptic strictures and development of Barrett’s esophagus and subsequent adenocarcinoma.[2]
Diagnosis
In the elderly a barium esophagogram is often ordered as the initial test to evaluate dysphagia, but an EGD should also be performed to check for malignancy and take biopsies.[5] Patients with oropharyngeal symptoms of transit dysphagia should be evaluated by a speech-language pathologist who can coordinate a swallowing study (modified barium swallow or videofluoroscopy) using thin, thick, and solid food materials. If upper endoscopy is normal and complaints of dysphagia persist, then esophageal manometry should be performed. This is a safe and readily performed procedure that can accurately identify neuromuscular disorders that cause dysphagia.
Treatment
Treatment is directed toward the underlying disorder in addition to ensuring adequate nutrition and preventing aspiration. Patients with transfer dysphagia are taught which foods can be safely swallowed, proper swallowing techniques, and how to modify their posture to improve their swallowing. Patients with transit dysphagia due to decreased esophageal contractility and increased lower esophageal sphincter (LES) pressure (achalasia) may benefit from lower esophageal sphincter (LES) dilation or botulinum toxin injection. Drugs that decrease smooth muscle contractions (anticholinergics, calcium antagonists, nitrates) may decrease diffuse esophageal spasm. Laparoscopic Heller myotomy to open the LES has been performed in elderly patients with achalasia with reasonable safety and efficacy. If aspiration occurs or the nutritional status of the patient suffers, a feeding jejunostomy or gastrostomy should be considered. The patient should participate in the decision to proceed with a feeding tube as part of long-term management. Current recommendations are to avoid placing G tubes in demented patients, as those have not been shown to improve quality of life.
Disorders of the stomach
Peptic ulcer disease
Peptic ulcer disease (PUD) refers to both gastric ulcers (GUs) and duodenal ulcers (DUs). Approximately five million cases of PUD will occur this year in the United States, and the demographics are shifting towards an older age of presentation. This may be due to increased use of NSAIDs, H. pylori infection, and longer lifespan. The elderly are more likely to suffer complications of PUD, including hospitalization, need for blood transfusions, emergency surgery, and death. The two most common causes of PUD are NSAIDs and H. pylori.[6] (See Box 22.2.)
Peptic ulcer disease is usually caused by NSAIDs or H. pylori.
Complications of peptic ulcer disease are more common in the elderly and morbidity and mortality are higher in this age group.
PUD in the elderly may present without pain, particularly with NSAID use, and hemorrhage or perforation may be the first sign of an ulcer.
Dyspepsia is a common complaint in the elderly and requires endoscopy to rule out ulcer or cancer.
Consider depression as a cause of dyspepsia in an older patient with a negative workup and other symptoms of depression
A CT scan of the abdomen may be helpful to diagnose abdominal pain, as elderly patients often present with atypical symptoms of diseases such as cholecystitis, appendicitis, and renal stones
Mesenteric ischemia is a diagnosis often missed in older adults
Presentation
Patients may have bleeding with hematemesis or coffee-ground emesis, or present with anemia. Elderly patients are less likely to have epigastric pain with PUD than younger patients, with as many as 50% of patients without significant pain from either a GU or a DU. Because elderly patients may have little or no symptoms of significant ulceration, complications such as perforation are also more common in this age group.[7]
Diagnosis
Patients should be asked about a history of PUD; their use of aspirin, NSAIDs, and warfarin; and previous diagnostic studies (upper GI series, testing for H. pylori). Upper endoscopy should be performed in older patients suspected of having PUD to identify the lesion, perform a biopsy in the stomach for H. pylori, rule out a malignancy, and initiate endoscopic therapy for a bleeding ulcer, if necessary.[8] Morbidity and mortality of GI bleeding is higher in patients over 70; this has been correlated with delayed endoscopy and continued hemorrhage causing hypotension and cardiac ischemia. Current recommendations in this population are to perform endoscopy within 12 hours of presentation if possible and transfuse if the hemoglobin falls below 7.
Treatment
If the patient is found to be H. pylori positive, double or triple antibiotic therapy should be started. In the case of a GU, healing should be documented eight to twelve weeks later, with follow-up EGD to make sure that the ulcer is not malignant. The most common issue is what to do about using ASA or NSAIDs in patients with prior ulceration or bleeding. Patients with a prior history of PUD who did not have a significant bleed, and who require chronic NSAID or aspirin use should be treated concurrently with a PPI or misoprostol. Both agents are effective in reducing the risk of PUD in chronic NSAID users, although, as a group, the PPIs are generally better tolerated than misoprostol. Older patients with serious complications such as hemorrhage or perforation should avoid NSAIDs and ASA, as risk of recurrent bleeding is so high, even with prophylaxis with PPIs or misoprostol, that it outweighs any potential benefit.
Dyspepsia
Dyspepsia is defined as chronic or recurrent pain or discomfort in the upper abdomen that is thought to arise in the upper GI tract. It is exceedingly common in clinical practice, affecting an estimated 20%–30% of older adults. It can sometimes be difficult to distinguish abdominal pain due to gastric or esophageal irritation from colonic spasm, but the latter is usually “spasmodic” in that it waxes and wanes within minutes, whereas dyspepsia lasts for a longer time (hours). There is overlap with the symptoms of cholecystitis, and patients often end up being evaluated for gallbladder disease.
Presentation
Patients may complain of upper abdominal pain, nausea, bloating, early satiety, or reflux symptoms. It is important to distinguish patients with structural damage due to problems such as an ulcer from those with “functional” or non-ulcer dyspepsia, because treatment approaches are different.
Patients should be asked about unintentional weight loss, odynophagia, dysphagia, prior PUD, pancreatitis, biliary tract disease, bleeding, prior trauma, a family history of GI tract cancer, and evidence of blood loss or jaundice. H. pylori infection is a risk factor for PUD and accounts for a significant number of cases of dyspepsia in younger patients (aged <60). Older patients may be more likely to be infected but most are asymptomatic. Noninvasive tests for active H. pylori infection include urease breath testing and stool antigen. Patients undergoing endoscopy for dyspepsia should be tested for H. pylori and treated if positive.
Laboratory tests – including a CBC, erythrocyte sedimentation rate (ESR), liver function tests (LFTs), electrolytes, amylase, and lipase – should be performed. Older patients should be evaluated by upper endoscopy to rule out an ulcer or cancer rather than simply initiating treatment with triple therapy. If endoscopy is normal and symptoms persist, then it is reasonable to get a right upper quadrant (RUQ) ultrasonogram to check for evidence of cholecystitis (gallbladder wall thickening and fluid around the gallbladder). If this is normal and complaints persist, a solid-phase gastric emptying scan can be performed to check for gastroparesis. In an older patient with persistent symptoms, concerns about occult malignancy should prompt a CT scan of the abdomen with both oral and intravenous contrast if the patient’s renal function will allow this.
Treatment
Patients with persistent dyspeptic symptoms and a normal evaluation are categorized as having non-ulcer dyspepsia. Although this is more often seen in patients younger than 65, there are geriatric patients who fall into this group. There is not much data to support the routine use of antacids, antimuscarinic agents, or sucralfate. Routine treatment with H2RAs has shown a slight benefit, but better results have been obtained with the use of once-or twice-daily PPIs in patients with burning pain or pain relieved by food. This suggests that these patients likely have GERD or some effect of acid on gastroesophageal motility.
It is important to consider depression with somatization as a potential underlying cause of dyspepsia, as recent studies have shown a correlation between chronic abdominal pain and depression. The Rome III classification of gastrointestinal motility disorders is based on evidence that patients with chronic abdominal pain without irritable-bowel-type relief with defecation actually respond better to antidepressants than GI-directed medications such as PPIs. This is particularly worth remembering in older patients, as they may have somatic manifestations of depression, such as chest pain, abdominal pain, nausea, and early satiety. There are no controlled, published studies to date on the use of selective serotonin reuptake inhibitors in the treatment of dyspepsia in older patients; however, if the patient has other symptoms and signs of depression, use of SSRIs should be considered. Antidepressants that have been used to treat chronic pain include tricyclic antidepressants, fluoxetine, paroxetine, venlafaxine, and duloxetine.
Gastric cancer
In 2002, the number of new cases of gastric cancer diagnosed reached 900,000, with the highest incidence in China, Japan, Korea, and Eastern Europe; most were diagnosed in patients older than 60.[9] The incidence of gastric cancer is increasing in the elderly worldwide, while it is decreasing in younger cohorts. The overall five-year survival rate is estimated at 16%. Nearly 95% of gastric cancers are adenocarcinomas, followed by lymphoma at 4%. Gastrointestinal stromal tumors (GISTs), carcinoids, and sarcomas make up the remaining 1%. Risk factors for gastric cancer include chronic atrophic gastritis, H. pylori, pernicious anemia, family history of gastric cancer, partial gastrectomy, tobacco use, alcohol use, and consumption of large quantities of salted or smoked foods containing nitrites and nitrates. (See Box 22.3.)
Symptoms of gastric cancer are nonspecific, and diagnosis is often delayed.
Gastric cancer is most common in China, Japan, Korean, and Eastern Europe, therefore consider this diagnosis in patients from those areas.
MALT lymphoma, although uncommon, has a relatively good prognosis and appears to be sequelae of chronic H. pylori infection.
Patients need continued endoscopic and EUS surveillance for at least five years after surgical resection of gastric cancer.
Diagnosis
Presenting symptoms of gastric cancer are often vague. Patients may complain of nausea, early satiety, epigastric fullness, intermitted vomiting, weight loss, and abdominal pain. Physical examination may reveal a mass, a succussion splash from gastric outlet obstruction, or evidence of peripheral lymphadenopathy. Unfortunately, by the time symptoms are severe or physical examination findings are apparent, patients usually have widespread disease.
Gastric cancer is best detected by upper endoscopy. CT scanning is useful to assess the depth of tumor invasion and the presence of lymphadenopathy. Both endoscopic ultrasonography and positron emission tomography scans are used to improve tumor staging. Mucosal-associated lymphoid tissue (MALT lymphoma), which is confined to the gastric mucosa, has the best prognosis of all gastric cancers. There appears to be an association between development of this tumor and infection with H. pylori, and treatment of H.pylori (if present) is the first-line treatment-grade MALT lymphoma. There are no specific lab tests for gastric cancer, although levels of CEA are often elevated, which can be useful to monitor efficacy of treatment.
Treatment
Surgical therapy offers the only cure for gastric cancer; however, the overall five-year survival is poor (20%–40%), and operative mortality high (15%–25%). Endoscopic resection of large masses, laser therapy, and stent placement may provide palliation for some patients with obstructive symptoms. Neo-adjuvant chemotherapy has been shown to improve survival. Palliative chemotherapy should be considered, as this has been shown to prolong survival and preserve quality of life. Both chemotherapy and radiation are used for treatment of high-grade MALT lymphoma. Patients undergoing surgery should have EGD and EUS surveillance at frequent intervals (at least yearly) until at least five years after surgery.
Disorders of the colon
Diarrhea
Patients with diarrhea most often complain of frequent stools (>3/day) or loose stools. However, other patients use the term “diarrhea” to describe fecal incontinence or fecal urgency. The etiology of acute diarrhea (lasting <2 weeks) in the elderly is similar to that of younger adults. Most cases of acute diarrhea are related to viral or bacterial infections, but it can also be caused by medications, medication interactions, or dietary supplements. Clostridium difficile colitis is more prevalent in the elderly because of more frequent hospitalizations, increased antibiotic use, and increased numbers of patients in institutional settings. C. difficile colonization in long-term care facilities has been estimated to be at least 50% in the United States. Chronic diarrhea, lasting more than two weeks, may result from fecal impaction, medications, irritable bowel syndrome, microscopic or lymphocytic colitis, inflammatory bowel disease, obstruction from colon cancer, malabsorption, small bowel bacterial overgrowth, thyrotoxicosis, or lymphoma. Patients with underlying neuromuscular disease such as Parkinson’s disease who use anticholinergic medications that slow GI transit may be at much higher risk of small bowel bacterial overgrowth. (See Box 22.4.)
Acute diarrhea is usually self-limited and caused by infections. Chronic diarrhea has many causes, and an extensive workup may be needed.
Consider early hospitalization or admission to an observation unit for older patients with diarrhea due to increased risk of dehydration, falls, and inability to perform activities of daily living.
Diverticulosis increases with age. Complications include bleeding, diverticulitis, and perforation.
Most patients with diverticulitis respond to outpatient treatment. Elderly patients may develop abscess or perforation without significant peritonitis – consider early admission if decreased bowel sounds or WBC >12,000.
Inflammatory bowel disease (IBD) may present for the first time in older people and is often more limited in distribution compared to younger patients.
Treatment of IBD in older patients may be limited by side effects of immunosuppressive drugs and have higher risk of infection.
Surgical treatment of IBD in the elderly has higher risk of morbidity.
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