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Aging and GI Disorders

Aging and GI Disorders. Karen E. Hall, MD, PhD Associate Professor Department of Internal Medicine Division of Geriatric Medicine University of Michigan/VAMC Ann Arbor, MI. Hurley Medical Center 2007. Disclosures. I have received honoraria from: TAP Pharmaceuticals

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Aging and GI Disorders

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  1. Aging and GI Disorders Karen E. Hall, MD, PhD Associate Professor Department of Internal Medicine Division of Geriatric Medicine University of Michigan/VAMC Ann Arbor, MI Hurley Medical Center 2007

  2. Disclosures • I have received honoraria from: • TAP Pharmaceuticals • Sucampo Pharmaceuticals • Takeda Pharmaceuticals North America

  3. Increase in the Number of Persons Aged 65+ Years in the United States 72 (20%) 55 (17%) Number (millions) Percent of population 40 (13%) Population 35 (12%) 31 (13%) 26 (11%) 20 (10%) 17 (9%) 12 (8%) 9 (7%) 7 (5%) 5 (5%) 4 (4%) 3 (4%) Year The “Age Wave” He W, et al. US Census Bureau. Current Population Reports, P23-209. 65+ in the United States: 2005. US Government Printing Office. Washington DC, 2005.

  4. Population Aged ≥ 65 by Race in 2003, 2030, and 2050 Percent total population aged ≥65 *Includes American Indian and Alaska Native alone, Native Hawaiian and Other Pacific Islander alone, and all other who reported 2 or more races He W, et al. US Census Bureau. Current Population Reports, P23-209. 65+ in the United States: 2005. US Government Printing Office. Washington DC, 2005.

  5. Epidemiology and Costs • 35% to 40% (45-50 million) of geriatric patients will have at least one GI symptom in any year • Common problems in this age group include constipation, fecal incontinence, diarrhea, reflux disease, and swallowing disorders • $300 million to treat GI disease in older patients today • Individuals aged 65 years or older account for 60% of all medical expenditures He W, et al. US Census Bureau. Current Population Reports, P23-209. 65+ in the United States: 2005. US Government Printing Office. Washington DC, 2005. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  6. The Geriatric Patient Profile • Increasing age = increased heterogeneity in functional status, cognition, and co-morbidities • “Baby boomers” more proactive about maintaining independence? • Older patients are at high risk of iatrogenic complications • Especially true when the patient is seeing multiple specialists who may be prescribing treatments without coordination of care • Increased potential for complications if interventions of other medical providers are not considered Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  7. Age-related Changes in the Gastrointestinal Tract • Areas identified as important to aging are: • Pathophysiology of swallowing disorders • Esophageal reflux • Dysmotility symptoms • GI immunobiology • Cellular mechanisms of neoplasia in the GI tract • Decreased visceral sensitivity Motility Hormone responsiveness Visceral sensitivity Drug metabolism Liver sensitivity to stress Pancreas structure and function Immunity Lithogenic bile Colonic function Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Robins J, et al. GI Motility Online. 2006

  8. Cellular Mechanisms of Aging • Most people experience a rapid change in physiologic function between the ages of 60-75 years that results in impaired function represented by: • Cellular aging • Acquisition of genetic errors • Oxidant damage • Alterations in pathways in growth and repair • Immunobiology of aging • Decreased ability to generate immune response to new stimulus • Loss of immunocompetent B cells • Immunosuppressive/cytotoxic T cells increased in animal models • Neurodegenerative disease • Dementia rises steeply after age 65 • Visceral autonomic function impaired • Pain sensitivity decreased Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  9. Decreased Autonomic Sensitivity • “Painless GERD” • “No Peritonitits”

  10. CT scan for Acute Abdomen

  11. Effect of Aging on Swallowing • Oro-pharyngeal dyskinesia • Slow Transit past pharynx and upper esophageal sphincter (UES) • Aspiration • Zenker’s Diverticulum • Decreased lower esophageal sphincter (LES) pressure • Gastroesophageal reflux (GERD) • Esophagitis • Bleeding • Atypical symptoms (nausea, aspiration, not pain) • Secondary Esophageal Dysmotility • “Tertiary contractions” - poor acid clearance • Spasm • Presbyesophagus (long tortuous esophagus) Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  12. Effect of Disease on Swallowing • Oro-pharyngeal dyskinesia • Neurodegenerative disease • Stroke • Dementia • Parkinson’s Disease • Others • Tumor • Head and neck (extrinsic to gut) • Esophageal • Paraneoplastic (lung) • Brain and spinal cord • Benign “Stricture” • Peptic • Achalasia Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  13. Peptic Esophageal Stricture Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  14. Achalasia • Impaired relaxation of the LES • Loss of inhibitory myenteric neurons • Idiopathic • Paraneoplastic • Chagas Disease (parasitic infection) • Tumor can present in same way • Get endoscopy • LES is distensible • Tumor or peptic stricture is fixed • Balloon dilation • Botulinum toxin injection • Myotomy

  15. GERD and Barrett’s Esophagus • Barrett’s Esophagus • Intestinal metaplasia with potential for adenocarcinoma • ?Acid exposure • Endoscopic monitoring • How often? 1-3 years • Multiple biopsies every cm • Dysplasia can regress or progress • Proton pump inhibitor (PPI) treatment • Not clear if beneficial • High grade dysplasia or cancer • Esophagectomy • Endoscopic mucosal stripping or laser ablation • ?DNA testing – experimental Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  16. Nutrition • Geriatric patients, especially aged >85 years are at risk for decreased food intake due to several factors: • Mobility impairment • Ability to obtain food • Loss of taste, may be due to decreased olfaction • Poor dentition • Decreased appetite • “Anorexia of aging”, may be related to neuroendocrine changes • Depression Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  17. Weight Loss • Assess amount of food eaten – HISTORY • Screen for depression and dementia • Get labs • CBC, basic renal, hepatic, TSH level, folate, B12, iron • Trial of increased calories with prompting by caregivers • If patient will not eat consider further tests • CT or referral • Consider treatment of depression Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:288-295. Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11.

  18. Depression Affects the Elderly • 1% of the general population • Most common psychiatric disorder • 3%-12% of community-dwelling elderly patients • More common (>26%) in nursing home residents • Social withdrawal more common than sad mood • Somatic symptoms common in elderly • Nausea, chronic abdominal pain, and weight loss) Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:288-295. Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11.

  19. Aging and the Stomach Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Cullen DJE, et al. Gut. 1997;41:459-462.

  20. Gastritis • NSAIDs >> H. pylori: use low dose PPI for prophylaxis • ASA 81 mg increases risk of bleeding from 1% to 6% • use low dose PPI with ASA in older pt with prior PUD or GI bleed Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  21. Gastroparesis • Diabetes – 12% of population is diabetic • Medications (anticholinergic) • Obstructive (benign or malignant) • Endoscopy • UGI series • Gastric emptying study (abnormal if >3 hours) • Prokinetics • Metoclopramide • Erythromycin (motilin analog) • (Domperidone in Canada) • (Cisapride)

  22. Gastrointestinal Bleeding is Common in the Elderly • 70% GI bleeding in the upper tract • Esophagus • Stomach • Small bowel • 30% GI bleeding in the lower tract • Terminal ileum • Colon • Rectum Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  23. Gastrointestinal Bleeding in the Elderly • Upper tract • 50% bleeding is due to NSAID use • 50% bleeding is due to ulceration or erosions (peptic or esophageal) • Females are at higher risk than males (older, NSAID use) • Continued bleeding or rebleeding are the highest predictors of mortality and morbidity in older patients • (Just like younger patients) Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Image courtesy of David C. Metz, MD.

  24. Gastrointestinal Bleeding in the Elderly • Visible vessel – laser or bicap coagulation • In patients with risk for cirrhosis • Esophageal varicies • usually Grade II-IV • Gastric varicies • Rarely small bowel or biliary source of bleeding Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Image courtesy of David C. Metz, MD.

  25. Celiac Disease – Malabsorbtion and Anemia • Small bowel mucosal atrophy • Weight loss and malabsorbtion – diarrhea • Anemia • IgA and/or IgG antibodies: • Anti-tissue transglutamidase – most sensitive and specific • Anti-endomysial • Anti-gliadin • Vitamin deficiencies (fat soluble and B vitamins) • May present for first time in geriatric age • Get serology, imaging (UGI + SBFT), duodenal biopsy • If diet-resistant: oral steroid and workup for small bowel lymphoma

  26. Colonic Bleeding in the Elderly • Angiodysplasia in the colon • Colitis (medications, ischemic, inflammatory)

  27. Colorectal Cancer in the Elderly • An estimated 106,680 cases of colon and 41,930 cases of rectal cancer are expected to occur in 2006 • 90% of all cases occur in individuals older than aged 50 years ACS Cancer Facts and Figures 2006. Burt RW. Gastroenterology. 2000;119:837-853. Image courtesy of Subhas Banerjee, MD.

  28. Colorectal Cancer in the Elderly • In a study of 1244 participants divided into three age groups who underwent screening colonoscopy, increasing age was associated with an increased prevalence of neoplasia Prevalence of neoplasia (%) n = 147 n = 63 n = 1034 Age group (years) Lin OS, et al. JAMA. 2006;295:2357-2365.

  29. Colonic Polyps • Most colon cancer (>90%) originates in adenomatous polyp • >60% of polyps are right sided (cecal and transverse) • 1-5% of low risk patients undergoing colonoscopy have a carcinoma-in-situ (CIS) • 8% of low risk patients aged 85+ have CIS • 60% of aged 85+ patients have Dukes A tumors (no extension out of the polyp) • Virtual colonoscopy not sensitive or specific enough (?insurance reimbursement?) • No “age cutoff” – “less than 5 year life expectancy” ACS Cancer Facts and Figures 2006. Burt RW. Gastroenterology. 2000;119:837-853.MD.

  30. Prevalence of Constipation Compared to Other Common Diseases Prevalence of Selected Diseases in US Adults 14 Coronary heart disease Asthma 16 Diabetes 16 Migraines 33 Hypertension 49 Constipation 63* 0 20 40 60 80 Prevalence in millions *Prevalence in North Americans Lethbridge-Çejku M, et al. Vital Health Stat 10. 2005;1. Higgins PDR, et al. Am J Gastroenterol. 2004;99:750.

  31. Aging-Associated Changes in Colonic Motility • Common colonic motility disorders in older adults: • Constipation • Diverticular disease • Diarrhea • Fecal incontinence • Age-associated decrease in myenteric neurons, neuronal and myenteric calcium, connective tissue elasticity • No clear effect of age on colonic transit - many constipated older patients appear to have normal transit times Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23:1379-1391.

  32. Constipation in the Elderly • Constipation is the most common chronic digestive complaint in the United States • Age • The incidence increases after age 65 • Prevalence 30% - 40% among people aged > 65 years • Gender • 2-3x more common in females • Impaired evacuation a significant factor in elderly women • Community-residing elderly patients - 30% report that they suffer from constipation at least monthly Talley NJ, et al. Am J Gastroenterol. 1996;91:19. Johanson JF, et al. J Clin Gastroenterol. 1989;11:525. Pekmezaris R, et al. J Am Med Dir Assoc. 2002;3:224. Higgins PDR, et al. Am J Gastroenterol. 2004;99:750. Muller-Lissner S. Best Pract Res Clin Gastroenterol. 2002;16:115-133.

  33. Geriatric Risk Factors for Constipation • Immobility (bed-bound) • Pain • Musculoskeletal in spine, pelvis, hips • Abdominal • Severe generalized pain • Medications (opiates, anticholinergic) • Deconditioning/Muscle weakness • Neurodegenerative disease • Thyroid disease • Hypercalcemia (metabolic, neoplastic) • Higgins PDR, et al. Am J Gastroenterol. 2004;99:750. • Muller-Lissner S. Best Practice Res Clin Gastroenterol. 2002;16:115-33. • Hall KE, et al. Gastroenterology. 2005;129:1305-1338. • De Lillo AR, et al. Am J Gastroenterol. 2000;95:901.

  34. Atypical Presentation of Constipation in the Elderly • Anorexia • Nausea • Behavioral changes • Abdominal discomfort/distension • Fecal impaction • Overflow incontinence - “diarrhea” • Get an abdominal xray • if stool proximal to descending colon – not “normal” De Lillo AR, et al. Am J Gastroenterol.2000;95:901. Leonard R, et al. Arch Intern Med. 2006. Jun 26;166(12):1295-1300.

  35. Patient and Physician Descriptions of Constipation • Patient description • “I haven’t had a bowel movement today” • “My stools are hard and lumpy” • “It’s hard to have a bowel movement” • Physician description • Infrequent bowel movements • Difficulty during defecation (straining) • Sensation of incomplete bowel evacuation • Abnormal stool form • Smaller bowel movements Herz MJ, et al. Fam Pract. 1996;13:156.

  36. Bristol Stool Chart • “More than 25% of the time” • Types 1-7 • Correlates with colonic transit – type 1 slow; type 7 fast Lewis SJ, Heaton KW. Scan J Gastroenterol 2007; 32:920

  37. Constipation: Myths and Facts • No evidence that fiber or hydration alone is effective in patients >70 years without dehydration • Only RTC evidence for psyllium, osmotic agents (PEG solution) and newer drugs (tegaserod, lubiprostone) • Tegaserod recently withdrawn (April 2007) due to cardiac events (0.11% vs 0.03% placebo) • Consider stimulant laxative (senna, bisacodyl, milk of magnesia, lubiprostone) • No evidence of myenteric damage with these agents • Osmotic agents (lactulose, sorbital, PEG) also effective but may cause bloating or vomiting Muller-Lissner S. Best Practice Res Clin Gastroenterol. 2002;16:115-33.

  38. Enema v.s. Oral agents • “Get patient moving from below before given meds from above” • If no BM in 1-2 days - use suppository then enema • Use tap water or milk and molasses (1 liter: 0.5 cups) enemas for severely constipated • Mineral oil enema may work but some cases of oil absorption and pneumonia • May need multiple enemas • > 3 may increase risk of colitis • Avoid soapsuds enemas (ischemic colitis)

  39. Diverticular Disease • An abnormality in the aging colon involving decreased tensile strength of the muscle wall • By aged 50 years one third of Americans will have diverticulosis coli; by aged 80 years, two-thirds will be affected • Incidence less than 5% <40 years • Incidence greater than 60% by aged 85 years • Mean age at presentation is age 60 years • The majority of those affected are asymptomatic Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Cooperman A. Diverticulitis. eMedicine Web Site. Available at: www.emedicine.com/MED/topic578.htm. Accessed 11/3/2006. Image courtesy of Jennifer Christie, MD.

  40. Diverticular Disease (Cont.) • Pathophysiology of diverticular disease: • Slow colonic transit • Increased frequency of segmenting contractions resulting in increased water resorption and hard feces • National Demographic and Health Survey (NDHS) 1996 to 2002 for diverticulitis • Hospital admissions increased by 14% to 261,180 • Office visits increased by 14% to 1,493,865 • Emergency department visits increased by 47% from 87,512  161,364 • Significant morbidity and mortality from abcess and perforation (delay in diagnosis) Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  41. Diarrhea • Definition: • Loose stools of more than 200g/day in at least three bowel movements per day • Patient’s description usually focuses on loose stools • Elderly account for 85% of all mortality associated with diarrhea in U.S. • 73 million consultations for acute diarrhea in the United States each year • Between 1997 and 2000 • Office visits for chronic diarrhea increased by 115% from 991,886  2,132,272 • ?Medications vs Exposure – food, institutions Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  42. Causes of Diarrhea in the Elderly Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  43. Causes of Diarrhea in the Elderly Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  44. Structural impairments in the pelvic floor Anorectal damage from surgery or irradiation Fecal incontinence can result from: Fecal impaction and subsequent flow Decreased rectal or anal sensation Internal anal sphincter incompetence Fecal Incontinence • Fecal incontinence is uncommon in the general population (2.2%) but has a significantly higher prevalence (10%) in the older population Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  45. Fecal Incontinence • Risk factors identified are: • Advancing age • Diabetes mellitus • Urinary incontinence • Stroke • Physical limitations • Female gender • Peri-anal injury or surgery • Hypertension • Poor general health • Bowel –related factors (incomplete defecation, constipation, straining, fecal urgency) Goode PS, et al. J Am Geriatr Soc. 2005;53:629-635.

  46. Implications for Elderly Suffering from Diarrhea and/or Fecal Incontinence • Both can become a chronic problem resulting in social isolation and decreased activity out of the home • It is important to obtain a good history to determine if fecal incontinence is due to diarrhea, urgency, obstruction, or rectal dysfunction • Refer to specialist center for multifactorial assessment and treatment (biofeedback, surgery) Hall KE, et al. Gastroenterology. 2005;129:1305-1338 Akhtar AJ, et al. J Amer Med Dir. Assoc. 2005;6:54-60.

  47. Hepato-biliary Function with Aging • Dynamic assessments of liver function decrease with aging • Compared to younger adults, in healthy subjects there is a decrease by 30% - 40% decrease in • Liver size • Blood flow • Perfusion • Nonalcoholic steatohepatitis (NASH) is a common complication of obesity and diabetes mellitus • Diabetes affects 12% of the US population; >70% of affected individuals are in the geriatric age range • NASH may progress to cirrhosis in up to ~25% of patients • NASH increases the risk of hepatic side effects of drugs Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905.

  48. Hepato-biliary Function • Liver “function” tests – actually dysfunction tests • Enzymes, bilirubin level • Liver Function tests • Albumin • PT/INR • Bilirubin conjugation • Hepatic Ultrasound with Portal vein Doppler • Check for cirrhosis, portal hypertension • May add CT if undiagnostic • Refer to specialist if enzymes >100, hepatic alkaline phosphatase persistently elevated, or liver function impaired • Mild AST or ALT elevation without dysfunction is NOT a contraindication to use of statins Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905.

  49. Gallbladder Function with Aging • Bile becomes increasingly lithogenic with aging • Precipitation of supersaturated bile and concomitant crystallization of cholesterol or calcium bilirubinate • In subjects older than 35 years, fasting and postprandial gallbladder volumes increased • In older individuals there was less complete gallbladder emptying following a meal • Aging women may be more susceptible to impaired gallbladder contractility • Compared to young patients, cholecystitis and cholangitis in older patients has increased morbidity and mortality • Hepatic ultrasound and HIDA scan, consider referral for ERCP Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

  50. Pancreatic Function with Aging • Exocrine and endocrine pancreatic function in non-diabetic patients is preserved with aging • Incidence of pancreatic cancer is increasing in patients aged > 65 years • Older patients have significantly worse surgical outcomes • Median survival is 11 months vs. 25 months in patients < 65 yrs • Approximately half of acute pancreatitis cases are patients >60 years • Gallstones are most common etiology (60%) • 40%: surgery, drugs, trauma, infection, alcohol • Mortality in elderly is 20%; twice that of general population Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

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