Ageing and the gut: gastrointestinal diseaseAlmost half of those over 65 years of age complain of chronic abdominalsymptoms. In addition, gastrointestinal diseases such as gastric cancer,colorectal cancer and peptic ulcer disease are more common in older people.Despite this, age related changes in gastrointestinal physiology are poorlyunderstood. In this article, Dr Julia Newton discusses the structural andfunctional changes in the older gut and management of common gastrointestinaldiseases.Over 40 per cent of older people suffer from chronic gastrointestinal symptomsand the incidence and severity of gastrointestinal diseases such as gastriccancer and peptic ulceration increase with age1. The diagnosis and managementof gastrointestinal disease in older people is often more challenging. Olderpeople may present non-specifically; management may be more difficult due tothe presence of co-morbidity and the frequent use of medication such as non-steroidal inflammatory drugs. Older people may also suffer from symptomsrelated to changes in diet and dentition with advancing age. Furthermore, olderpeople might be regarded as unfit for investigations that would be routine inyounger age groups.Older people are also more likely to consult a doctor about their gastrointestinalsymptoms than younger people and those with gastrointestinal symptoms havesignificant health care utilization and poorer quality of life2. Despite this, there isa dearth of information on the underlying changes in the structure and function ofthe gastrointestinal tract during ageing.Age related changes in gastrointestinal physiologyMany changes in gastrointestinal physiology thought to be primary effects ofageing have been re-examined since the discovery of the micro-organismHelicobacter pylori (H. pylori). The prevalence of H. pylori increases with age,with up to 80 per cent of 80 year olds infected. The bacteria itself induceschanges in gastrointestinal physiology and many studies reportedly examiningage related changes in physiology have not controlled for the high prevalence ofH. pylori in older people. These age related changes in gastrointestinalphysiology are summarized in Table 1.As the gastrointestinal tract ages it loses neuronal tissue, this leads to inco-ordination and slower transit time. Clinically this translates into the oesophagealdysmotility and increased incidence of constipation and decreased gastricemptying seen in the elderly3. In addition, atrophy of the gastric mucosa is morecommon in the older stomach4 resulting in smaller volumes of less acidic gastricjuice, which may impact upon the delivery and absorption of medication anddigestion and absorption of nutrients.
In the upper gastrointestinal tract there is a balance between protective andaggressive mechanisms and when this equilibrium is disrupted pathology occurs(see Table 2). There are no age-related increases in the endogenousaggressors, acid or pepsin. However, there are reductions in mucosal protectivemechanisms with age. Levels of prostaglandins in the gastrointestinal mucosa,which stimulate mucus and bicarbonate secretion decline with age5 and thismakes older people more susceptible to potential damage by any furtherreduction in prostaglandin synthesis associated with non-steroidal anti-inflammatory drug use.An adherent mucus gel layer protects the mucosa of the gastrointestinal tract(Figure 1). There are quantitative and qualitative reductions in gastric andduodenal mucus with age6,7. Also there is an age-related decrease in bicarbonatesecretion8 in response to luminal acid. Furthermore, the older stomach has areduced capacity to repair itself9 and in an animal model has a reduced bloodflow. Also in these animal models reductions in the surface area of the smallintestine available for absorption of nutrients have been described with age.Managing gastrointestinal problems in older peopleIn most of the current literature older people are excluded from studies examiningthe diagnosis and management of gastrointestinal problems because of co-morbidity and increased use of medication. Several studies have developedprobability models to guide clinicians in identifying patients at increased risk oforganic disease. In one a 65-year-old male, with non-specific abdominal pain,weight loss and an elevated ESR would have 75 per cent probability ofneoplastic disease10. Older people tolerate upper gastrointestinal endoscopy,colonoscopy and surgery well11,12 and should not be denied the benefits ofdiagnostic investigation and subsequent treatment.Diagnosis and treatment of upper gastrointestinal disease in older peopleGastro-oesophageal reflux disease/ heartburnGastro-oesophageal reflux disease becomes more prevalent with age.Prevalence in older people is up to 20 per cent however, many older subjects donot report heartburn, and self medicate in the community. Older people oftenpresent with complications such as dysphagia secondary to benign oesophagealstricture.The management of reflux disease is established13; however, studies in olderpeople are rare. In one small study those over age 60 years were less likely toreceive lifestyle advice compared to younger patients14.Although there is little evidence in older people, a symptom driven approach isrecommended and this could be either starting with a low dose or treating withhigh doses and stepping down, or the use of empirical treatment without
endoscopy based on what is most appropriate. In view of the tendency foratypical presentation in older people, caution suggests referral for endoscopy toexclude malignancy. Treatment in all age groups is with the most effectivetherapy and this is currently regarded as proton pump inhibitors13.Dyspepsia/heartburnIn those over age 30 years consulting with upper abdominal pain, organicdiseases such as peptic ulceration and gastric cancer will be found in a third15.The prevalence of all these diseases increases with age and therefore thelikelihood of pathology is higher in older people. Dyspepsia in the elderly oftenpresents atypically, and prompt investigation is more appropriate than empiricaltreatment16.Consensus guidelines state that older people (in this case those over 45 years ofage) presenting with new dyspeptic symptoms16, should be referred for uppergastrointestinal endoscopy, because risk of cancer increases with age. Urgentreferral is recommended when patients present with ‘alarming’ or ‘sinister’features such as onset of symptoms after 40 to 45 years of age, anaemia, bloodloss, weight loss, anorexia, recurrent vomiting and progressive dysphagia17.Helicobacter pyloriH. pylori infects the human stomach (Figure 2) causing inflammation (Figure 3)and has been implicated in the pathogenesis of gastric cancer and peptic ulcerdisease (Figure 4). Eradication of H. pylori is mandatory in those with a recent orprevious diagnosis of peptic ulcer disease18 and personal or family history ofgastric cancer. Eradication improves clinical outcome, reduces ulcer recurrencesand symptoms. In all age groups, the role of H. pylori in the aetiology of non-ulcerdyspepsia is controversial. In general, evidence suggests that treatment of on-going dyspeptic symptoms despite a normal endoscopy should be with acidsuppressive medication such as proton pump inhibitor18.Management algorithms for H. pylori, have been developed from studies inyounger age groups. A ‘test and treat’ H. pylori management strategy has beensuggested, however, this approach has no place in older people considering thehigh prevalence of sinister pathology. The choice of optimum eradication regime,proton pump inhibitor and two antibiotics such as amoxycillin and clarithromycin,does not differ with age. However, the efficacy of specific eradication regimens inolder people needs evaluation in randomized controlled trials. Previoussuggestions that older people remain on H2 antagonists are no longeraccepted19.Diagnosis and treatment of lower gastrointestinal disease in older peopleColorectal cancerMortality rates from colorectal cancer are particularly high in those over the ageof 65 years – the group in whom two thirds of the cases arise. Older people with
colorectal cancer present non-specifically compared to younger age groups20.Treatment is generally surgical, but despite this older people are more oftenreferred to medical or geriatric units20.The prognosis of colorectal cancer is good if diagnosed early. Screening of olderpeople by faecal occult blood (FOB) and particularly sigmoidoscopy reducesmortality and is cost effective. Opportunistic testing for occult gastrointestinalblood loss is generally felt by patients to be acceptable, however compliance islower in those over 70 years.As in subjects with upper gastrointestinal tract symptoms the incidence,prevalence, and mortality of colonic cancer increase with age and a change inbowel habit in those over 45 years is an immediate cause for concern, requiringprompt referral for secondary investigations. Irritable bowel rarely presents forthe first time in the elderly and should be a diagnosis of exclusion10,17.Functional constipationConstipation hugely impacts upon the quality of life of older people and is acommon cause of consultations in older people. Laxative use is common in olderpatients but despite improved bowel movement frequency, stool consistency andsymptoms there is little evidence for marked differences in effectiveness betweenlaxatives. Further good quality trial evidence is required in the management ofconstipation in older people.ConclusionThe natural ageing of the upper gastrointestinal tract is an important but poorlyunderstood area of gerontology. Research exploring this area could be translateddirectly into the clinical setting and potentially make a real impact upon thequality of life of older people. In general, there are few prospective studies toguide clinicians and in particular, few studies that examine the management ofgastrointestinal problems in older people.Julia Newton is a Senior Lecturer in Geriatric Medicine at the Institute for Ageingand Health, University of Newcastle upon TyneReturn to GastroenterologyReturn to Archive Main PageReferences 1. Kay L. Prevalence, Incidence and prognosis of gastrointestinal symptoms in a random sample of an elderly population. Age and Ageing 1994; 23: 146–9 2. Frank L, Kleinman L, Ganoczy D et al. Upper gastrointestinal symptoms in North America: prevalence and relationship to healthcare utilization and quality of life. Dig Diseases and Sciences 2000; 45: 809–18
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