1 / 52

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

tieve
Download Presentation

Aging and GI Disorders

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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.

More Related