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Aging and GI Disorders Karen E. Hall, MD, PhD Associate Professor Department of Internal Medicine Division of Geriatric Me...
The “Age Wave”  He W, et al. US Census Bureau. Current Population Reports, P23-209. 65+ in the United States: 2005. US Gov...
Population Aged ≥ 65 by Race in 2003, 2030, and 2050 He W, et al. US Census Bureau. Current Population Reports, P23-209. 6...
Epidemiology <ul><li>Over 35 million people aged >65 years in the United States </li></ul><ul><ul><li>12% of the 2003 US p...
Costs <ul><li>$300 million to treat GI disease in older patients today </li></ul><ul><li>Individuals aged 65 years or olde...
The Geriatric Patient Profile <ul><li>Increasing age = increased heterogeneity in  functional status, cognition, and co-mo...
Age-related Changes in the Gastrointestinal Tract Motility Immunity Drug  metabolism Visceral sensitivity <ul><li>Areas id...
Cellular Mechanisms of Aging <ul><li>Most people experience a rapid change in physiologic function between the ages of 60-...
Decreased Autonomic Sensitivity <ul><li>“ Painless GERD” </li></ul><ul><li>“ No Peritonitits ” </li></ul>
CT scan for Acute Abdomen
Effect of Aging on Swallowing <ul><li>Oro-pharyngeal dyskinesia – normal aging </li></ul><ul><ul><li>Slow Transit past pha...
Esophageal Aging <ul><li>Dysphagia, regurgitation, nausea are common </li></ul><ul><li>Heartburn not so common </li></ul><...
Effect of Disease on Swallowing <ul><li>Oro-pharyngeal dyskinesia </li></ul><ul><ul><li>Neurodegenerative disease </li></u...
Peptic Esophageal Stricture Hall KE, et al.  Gastroenterology.  2005;129:1305-1338.
Achalasia <ul><li>Impaired relaxation of the LES </li></ul><ul><ul><li>Loss of inhibitory myenteric neurons </li></ul></ul...
GERD and Barrett’s Esophagus <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Unclear if acid exposure is the cause </li>...
Nutrition  <ul><li>Geriatric patients, especially aged >85 years are at risk for decreased food intake due to several fact...
Weight Loss <ul><li>Assess amount of food eaten </li></ul><ul><li>Screen for depression and dementia </li></ul><ul><li>Get...
Depression Affects the Elderly  <ul><li>Affects 1% of the general population </li></ul><ul><ul><li>Most common psychiatric...
Aging and the Stomach Hall KE, et al.  Gastroenterology.  2005;129:1305-1338. Cullen DJE, et al.  Gut.  1997;41:459-462.  ...
Gastritis  <ul><li>Very common </li></ul><ul><li>NSAIDs </li></ul><ul><li>Other meds (iron, bisphosphonates) </li></ul>Hal...
Gastroparesis  <ul><li>Diabetes </li></ul><ul><li>Medications (anticholinergic) </li></ul><ul><li>Obstructive (benign or m...
Gastrointestinal Bleeding is Common in the Elderly <ul><li>30%  GI bleeding in the lower tract </li></ul><ul><ul><li>Termi...
Gastrointestinal Bleeding in the Elderly <ul><li>Upper tract </li></ul><ul><ul><li>50% bleeding is due to NSAID use </li><...
Gastrointestinal Bleeding in the Elderly <ul><li>Visible vessel – laser or bicap coagulation </li></ul><ul><li>Esophageal ...
Celiac Disease – Malabsorbtion and Anemia <ul><li>IgA and/or IgG antibodies to: </li></ul><ul><ul><li>Anti-tissue transglu...
Colonic Bleeding in the Elderly <ul><li>Angiodysplasia in the colon </li></ul><ul><li>Colitis (medications, ischemic, infl...
Colorectal Cancer in the Elderly <ul><li>An estimated 106,680 cases of colon and 41,930 cases of rectal cancer are expecte...
Colorectal Cancer in the Elderly <ul><li>In a study of 1244 participants divided into three age groups who underwent scree...
Colonic Polyps <ul><li>Most colon cancer (>90%) originates in adenomatous polyp </li></ul><ul><li>>60% are right sided (ce...
Aging-Associated Changes in Colonic Motility <ul><li>Common disorders observed in the elderly that are correlated with col...
Prevalence of Constipation Compared to Other Common Diseases Coronary heart disease Asthma  Diabetes Migraines Hypertensio...
Constipation in the Elderly <ul><li>Constipation is the most common chronic digestive complaint in the United States </li>...
Geriatric Risk Factors for Constipation <ul><li>Immobility (bed-bound) </li></ul><ul><li>Pain </li></ul><ul><ul><li>Muscul...
Atypical Presentation of Constipation in the Elderly <ul><li>Anorexia </li></ul><ul><li>Nausea </li></ul><ul><li>Behaviora...
Patient and Physician  Descriptions of Constipation <ul><li>Patient description </li></ul><ul><ul><li>“I haven’t had a bow...
Bristol Stool Chart <ul><li>Types 1-7 </li></ul><ul><li>More than 25% of the time </li></ul><ul><li>Correlates with coloni...
Constipation <ul><li>No evidence that fiber or hydration alone is effective in patients >70 years without dehydration </li...
Enema v.s. Oral agents <ul><li>“ Get patient moving from below before given meds from above” </li></ul><ul><li>If no BM in...
Diverticular Disease <ul><li>An abnormality in the aging colon involving decreased tensile strength of the muscle wall  </...
Diverticular Disease (Cont.) <ul><li>Other factors of diverticular disease: </li></ul><ul><ul><li>Slow colonic transit </l...
Diarrhea  <ul><li>Definition:  </li></ul><ul><ul><li>Loose stools of more than 200g/day in at least three bowel movements ...
Causes of Diarrhea in the Elderly Hoffmann JC, et al.  Best Pract Res Clin Gastroneterol . 2002;16:17-36. Hall KE, et al. ...
Causes of Diarrhea in the Elderly Hoffmann JC, et al.  Best Pract Res Clin Gastroneterol . 2002;16:17-36. Hall KE, et al. ...
Fecal Incontinence <ul><li>Fecal incontinence is uncommon in the general population (2.2%) but has a significantly higher ...
Fecal Incontinence <ul><li>Risk factors identified are:  </li></ul><ul><ul><li>Advancing age </li></ul></ul><ul><ul><li>Di...
Implications for Elderly Suffering from Diarrhea and/or Fecal Incontinence <ul><li>Both can become a chronic problem resul...
Hepato-biliary Function with Aging <ul><li>Dynamic assessments of liver function decrease with aging </li></ul><ul><li>Com...
Hepato-biliary Function <ul><li>Liver “function” tests – actually dysfunction tests </li></ul><ul><ul><li>Enzymes, bilirub...
Gallbladder Function with Aging <ul><li>Bile becomes increasingly lithogenic with aging </li></ul><ul><ul><li>Precipitatio...
Pancreatic Function with Aging <ul><li>Exocrine and endocrine pancreatic function in non-diabetic patients is preserved wi...
Summary <ul><li>The age wave will continue to increase in the next  25 years resulting in a substantial boom of the  65+ g...
Handouts <ul><li>Sitemaker.umich.edu/khallinfo </li></ul><ul><ul><li>AGS 2007 </li></ul></ul>
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GI Disease in the Older Patient

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GI Disease in the Older Patient

  1. 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 AGS 2007
  2. 2. 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. Year Population Increase in the Number of Persons Aged 65+ Years in the United States Number (millions) Percent of population 3 (4%) 5 (5%) 9 (7%) 17 (9%) 26 (11%) 31 (13%) 35 (12%) 40 (13%) 55 (17%) 72 (20%) 4 (4%) 7 (5%) 12 (8%) 20 (10%)
  3. 3. Population Aged ≥ 65 by Race in 2003, 2030, and 2050 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. 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
  4. 4. Epidemiology <ul><li>Over 35 million people aged >65 years in the United States </li></ul><ul><ul><li>12% of the 2003 US population were older than 65 </li></ul></ul><ul><ul><ul><li>18.3 million aged 65-74 </li></ul></ul></ul><ul><ul><ul><li>12.9 million aged 75-84 </li></ul></ul></ul><ul><ul><ul><li>4.7 million aged ≥ 85 </li></ul></ul></ul><ul><li>35% to 40% (45-50 million) of geriatric patients will have at least one GI symptom in any year </li></ul><ul><ul><li>Common problems in this age group include constipation, fecal incontinence, diarrhea, reflux disease, and swallowing disorders </li></ul></ul>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.
  5. 5. Costs <ul><li>$300 million to treat GI disease in older patients today </li></ul><ul><li>Individuals aged 65 years or older account for 60% of all medical expenditures </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  6. 6. The Geriatric Patient Profile <ul><li>Increasing age = increased heterogeneity in functional status, cognition, and co-morbidities </li></ul><ul><li>Future cohorts likely to be more interested in the maintenance of independent living </li></ul><ul><li>Older patients are at high risk of iatrogenic complications </li></ul><ul><ul><li>Especially true when the patient is seeing multiple specialists who may be prescribing treatments without coordination of care </li></ul></ul><ul><li>Specialists need to be aware of the potential for complications if interventions of other medical providers are not considered </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  7. 7. Age-related Changes in the Gastrointestinal Tract Motility Immunity Drug metabolism Visceral sensitivity <ul><li>Areas identified as important to aging are: </li></ul><ul><ul><li>Pathophysiology of swallowing disorders </li></ul></ul><ul><ul><li>Esophageal reflux </li></ul></ul><ul><ul><li>Dysmotility symptoms </li></ul></ul><ul><ul><li>GI immunobiology </li></ul></ul><ul><ul><li>Cellular mechanisms of neoplasia in the GI tract </li></ul></ul><ul><ul><li>Decreased visceral sensitivity </li></ul></ul>Hormone responsiveness Lithogenic bile Pancreas structure and function Liver sensitivity to stress Colonic function Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Robins J, et al. GI Motility Online . 2006
  8. 8. Cellular Mechanisms of Aging <ul><li>Most people experience a rapid change in physiologic function between the ages of 60-75 years that results in impaired function represented by: </li></ul><ul><ul><li>Cellular aging </li></ul></ul><ul><ul><ul><li>Acquisition of genetic errors </li></ul></ul></ul><ul><ul><ul><li>Oxidant damage </li></ul></ul></ul><ul><ul><ul><li>Alterations in pathways in growth and repair </li></ul></ul></ul><ul><ul><li>Immunobiology of aging </li></ul></ul><ul><ul><ul><li>Decreased ability to generate immune response to new stimulus </li></ul></ul></ul><ul><ul><ul><li>Loss of immunocompetent B cells </li></ul></ul></ul><ul><ul><ul><li>Immunosuppressive/cytotoxic T cells increased in animal models </li></ul></ul></ul><ul><ul><li>Neurodegenerative disease </li></ul></ul><ul><ul><ul><li>Dementia rises steeply after age 65 </li></ul></ul></ul><ul><ul><ul><li>Visceral autonomic function impaired </li></ul></ul></ul><ul><ul><ul><li>Pain sensitivity decreased </li></ul></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  9. 9. Decreased Autonomic Sensitivity <ul><li>“ Painless GERD” </li></ul><ul><li>“ No Peritonitits ” </li></ul>
  10. 10. CT scan for Acute Abdomen
  11. 11. Effect of Aging on Swallowing <ul><li>Oro-pharyngeal dyskinesia – normal aging </li></ul><ul><ul><li>Slow Transit past pharynx and upper esophageal sphincter (UES) </li></ul></ul><ul><ul><ul><li>Aspiration </li></ul></ul></ul><ul><ul><ul><li>Zenker’s Diverticulum </li></ul></ul></ul><ul><ul><li>Decreased lower esophageal sphincter (LES) pressure </li></ul></ul><ul><ul><ul><li>Gastroesophageal reflux (GERD) </li></ul></ul></ul><ul><ul><ul><ul><li>Esophagitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bleeding </li></ul></ul></ul></ul><ul><ul><li>Secondary Esophageal Dysmotility </li></ul></ul><ul><ul><ul><li>Poor clearance (“tertiary contractions”) </li></ul></ul></ul><ul><ul><ul><li>Spasm </li></ul></ul></ul><ul><ul><ul><li>Presbyesophagus (long tortuous esophagus) </li></ul></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  12. 12. Esophageal Aging <ul><li>Dysphagia, regurgitation, nausea are common </li></ul><ul><li>Heartburn not so common </li></ul><ul><li>Atypical chest pain </li></ul><ul><li>“ Presbyesophagus”: (age-related changes in esophageal function) </li></ul><ul><ul><li>Decreased contractile amplitude </li></ul></ul><ul><ul><li>Polyphasic waves </li></ul></ul><ul><ul><li>Incomplete relaxation of the lower esophageal sphincter (LES) </li></ul></ul><ul><ul><li>Esophageal dilation </li></ul></ul><ul><li>GERD </li></ul><ul><ul><li>Impaired clearance of acid </li></ul></ul><ul><ul><li>Longer duration of reflux episodes </li></ul></ul><ul><ul><li>Atypical symptom presentation </li></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  13. 13. Effect of Disease on Swallowing <ul><li>Oro-pharyngeal dyskinesia </li></ul><ul><ul><li>Neurodegenerative disease </li></ul></ul><ul><ul><ul><li>Stroke </li></ul></ul></ul><ul><ul><ul><li>Dementia </li></ul></ul></ul><ul><ul><ul><li>Parkinson’s Disease </li></ul></ul></ul><ul><ul><ul><li>Others </li></ul></ul></ul><ul><ul><li>Tumor </li></ul></ul><ul><ul><ul><li>Head and neck (extrinsic to gut) </li></ul></ul></ul><ul><ul><ul><li>Esophageal </li></ul></ul></ul><ul><ul><ul><li>Paraneoplastic (lung) </li></ul></ul></ul><ul><ul><ul><li>Brain and spinal cord </li></ul></ul></ul><ul><ul><li>Benign “Stricture” </li></ul></ul><ul><ul><ul><li>Peptic </li></ul></ul></ul><ul><ul><ul><li>Achalasia </li></ul></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  14. 14. Peptic Esophageal Stricture Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  15. 15. Achalasia <ul><li>Impaired relaxation of the LES </li></ul><ul><ul><li>Loss of inhibitory myenteric neurons </li></ul></ul><ul><ul><ul><li>Idiopathic </li></ul></ul></ul><ul><ul><ul><li>Paraneoplastic </li></ul></ul></ul><ul><ul><ul><li>Chagas Disease (parasitic infection) </li></ul></ul></ul><ul><ul><li>Tumor can present in same way </li></ul></ul><ul><ul><ul><li>Get endoscopy </li></ul></ul></ul><ul><ul><ul><li>LES is distensible </li></ul></ul></ul><ul><ul><ul><li>Tumor or peptic stricture is fixed </li></ul></ul></ul><ul><ul><li>Balloon dilation </li></ul></ul><ul><ul><ul><li>Botulinum toxin injection </li></ul></ul></ul><ul><ul><ul><li>Myotomy </li></ul></ul></ul>
  16. 16. GERD and Barrett’s Esophagus <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Unclear if acid exposure is the cause </li></ul></ul><ul><ul><li>Intestinal metaplasia </li></ul></ul><ul><ul><li>Endoscopic monitoring </li></ul></ul><ul><ul><ul><li>How often? 1-3 years </li></ul></ul></ul><ul><ul><ul><li>Multiple biopsies </li></ul></ul></ul><ul><ul><ul><li>Dysplasia can regress or progress </li></ul></ul></ul><ul><ul><ul><li>Proton pump inhibitor (PPI) treatment </li></ul></ul></ul><ul><ul><ul><li>Not clear if beneficial </li></ul></ul></ul><ul><ul><li>High grade dysplasia or cancer </li></ul></ul><ul><ul><ul><li>Esophagectomy </li></ul></ul></ul><ul><ul><ul><li>Endoscopic mucosal stripping or laser ablation </li></ul></ul></ul><ul><ul><ul><li>?DNA testing – experimental </li></ul></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  17. 17. Nutrition <ul><li>Geriatric patients, especially aged >85 years are at risk for decreased food intake due to several factors: </li></ul><ul><ul><li>Mobility impairment </li></ul></ul><ul><ul><li>Ability to obtain food </li></ul></ul><ul><ul><li>Loss of taste, may be due to decreased olfaction </li></ul></ul><ul><ul><li>Poor dentition </li></ul></ul><ul><ul><li>Decreased appetite </li></ul></ul><ul><ul><li>“ Anorexia of aging”, may be related to neuroendocrine changes </li></ul></ul><ul><ul><li>Depression </li></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  18. 18. Weight Loss <ul><li>Assess amount of food eaten </li></ul><ul><li>Screen for depression and dementia </li></ul><ul><li>Get labs </li></ul><ul><ul><li>CBC, basic renal, hepatic, TSH level, folate, B12, iron </li></ul></ul><ul><li>Trial of increased calories with prompting by caregivers </li></ul><ul><li>If patient will not eat consider further tests </li></ul><ul><ul><li>CT or referral </li></ul></ul><ul><li>Consider treatment of depression </li></ul><ul><li>Abdominal pain may be symptom of depression </li></ul>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. 19. Depression Affects the Elderly <ul><li>Affects 1% of the general population </li></ul><ul><ul><li>Most common psychiatric disorder </li></ul></ul><ul><li>Affects 3%-12% of community-dwelling elderly patients </li></ul><ul><ul><li>More common (>26%) in nursing home residents </li></ul></ul><ul><li>May be associated with GI symptoms </li></ul><ul><li>Social withdrawal, and somatic symptoms such as nausea, abdominal pain, and weight loss add to the burden of GI disease </li></ul>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.
  20. 20. Aging and the Stomach Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Cullen DJE, et al. Gut. 1997;41:459-462. <ul><ul><li>Contact time with NSAID’s or other noxious agents in delayed emptying </li></ul></ul><ul><ul><li>Tendency for gastric mucosal injury in delayed emptying </li></ul></ul><ul><ul><li>Prevalence of H. pylori associated with increased risk of bleeding peptic ulcer, pernicious anemia, gastric cancer and lymphoma </li></ul></ul><ul><ul><li>Clearance of liquids from stomach </li></ul></ul><ul><ul><li>Perception of gastric distention </li></ul></ul><ul><ul><li>Cytoprotective factors </li></ul></ul><ul><ul><li>Mucosal blood flow and impaired sensory neuron function in animal models </li></ul></ul>Increased Decreased
  21. 21. Gastritis <ul><li>Very common </li></ul><ul><li>NSAIDs </li></ul><ul><li>Other meds (iron, bisphosphonates) </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  22. 22. Gastroparesis <ul><li>Diabetes </li></ul><ul><li>Medications (anticholinergic) </li></ul><ul><li>Obstructive (benign or malignant) </li></ul><ul><li>Endoscopy </li></ul><ul><li>UGI series </li></ul><ul><li>Gastric emptying study (abnormal if >3 hours) </li></ul><ul><li>Prokinetics </li></ul><ul><ul><li>Metoclopramide </li></ul></ul><ul><ul><li>Erythromycin (motilin analog) </li></ul></ul><ul><ul><li>(Domperidone in Canada) </li></ul></ul><ul><ul><li>(Cisapride) </li></ul></ul>
  23. 23. Gastrointestinal Bleeding is Common in the Elderly <ul><li>30% GI bleeding in the lower tract </li></ul><ul><ul><li>Terminal ileum </li></ul></ul><ul><ul><li>Colon </li></ul></ul><ul><ul><li>Rectum </li></ul></ul><ul><li>70% GI bleeding in the upper tract </li></ul><ul><ul><li>Esophagus </li></ul></ul><ul><ul><li>Stomach </li></ul></ul><ul><ul><li>Small bowel </li></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  24. 24. Gastrointestinal Bleeding in the Elderly <ul><li>Upper tract </li></ul><ul><ul><li>50% bleeding is due to NSAID use </li></ul></ul><ul><ul><li>50% bleeding is due to ulceration or erosions (peptic or esophageal) </li></ul></ul><ul><li>Females are at higher risk than males </li></ul><ul><li>Continued bleeding or rebleeding are the highest predictors of mortality and morbidity in older patients </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Image courtesy of David C. Metz, MD.
  25. 25. Gastrointestinal Bleeding in the Elderly <ul><li>Visible vessel – laser or bicap coagulation </li></ul><ul><li>Esophageal varicies </li></ul><ul><ul><li>usually Grade II-IV </li></ul></ul><ul><li>Gastric varicies </li></ul><ul><li>Rarely small bowel or biliary </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Image courtesy of David C. Metz, MD.
  26. 26. Celiac Disease – Malabsorbtion and Anemia <ul><li>IgA and/or IgG antibodies to: </li></ul><ul><ul><li>Anti-tissue transglutamidase </li></ul></ul><ul><ul><li>Anti-endomysial </li></ul></ul><ul><ul><li>Anti-gliadin </li></ul></ul><ul><li>Small bowel mucosal atrophy </li></ul><ul><li>Weight loss and malabsorbtion – diarrhea </li></ul><ul><li>Anemia </li></ul><ul><li>Vitamin deficiencies (fat soluble and B vitamins) </li></ul><ul><li>May present for first time in geriatric patients </li></ul><ul><li>Get serology, imaging (UGI + SBFT), duodenal biopsy </li></ul><ul><li>If diet-resistant: oral steroid and workup for small bowel lymphoma </li></ul>
  27. 27. Colonic Bleeding in the Elderly <ul><li>Angiodysplasia in the colon </li></ul><ul><li>Colitis (medications, ischemic, inflammatory) </li></ul>
  28. 28. Colorectal Cancer in the Elderly <ul><li>An estimated 106,680 cases of colon and 41,930 cases of rectal cancer are expected to occur in 2006 </li></ul><ul><li>90% of all cases occur in individuals older than aged 50 years </li></ul>ACS Cancer Facts and Figures 2006. Burt RW. Gastroenterology. 2000;119:837-853. Image courtesy of Subhas Banerjee, MD.
  29. 29. Colorectal Cancer in the Elderly <ul><li>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 </li></ul>Prevalence of neoplasia (%) Age group (years) Lin OS, et al. JAMA . 2006;295:2357-2365. n = 1034 n = 147 n = 63
  30. 30. Colonic Polyps <ul><li>Most colon cancer (>90%) originates in adenomatous polyp </li></ul><ul><li>>60% are right sided (cecal and transverse) polyps - colonoscopy </li></ul><ul><li>1-5% of low risk patients undergoing colonoscopy have a carcinoma-in-situ (CIS) </li></ul><ul><li>8% of patients over 85 have CIS </li></ul><ul><li>60% of 85+ patients have Dukes A tumors (no extension out of the polyp) </li></ul><ul><li>Virtual colonoscopy not sensitive or specific enough (no insurance reimbursement !) </li></ul><ul><li>No “age cutoff” – “less than 5 year life expectancy” </li></ul>ACS Cancer Facts and Figures 2006. Burt RW. Gastroenterology. 2000;119:837-853.MD.
  31. 31. Aging-Associated Changes in Colonic Motility <ul><li>Common disorders observed in the elderly that are correlated with colonic motility are: </li></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Diverticular disease </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Fecal incontinence </li></ul></ul><ul><li>There are age-associated reductions in myenteric neurons, calcium influx, and compliance in connective tissue </li></ul><ul><li>No clear effect of age on colonic transit, as many constipated older patients appear to have normal transit times </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Petruzziello L, et al. Aliment Pharmacol Ther . 2006;23:1379-1391.
  32. 32. Prevalence of Constipation Compared to Other Common Diseases Coronary heart disease Asthma Diabetes Migraines Hypertension Constipation Prevalence in millions 0 20 40 60 80 Prevalence of Selected Diseases in US Adults *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. 14 16 16 33 49 63*
  33. 33. Constipation in the Elderly <ul><li>Constipation is the most common chronic digestive complaint in the United States </li></ul><ul><li>Age </li></ul><ul><ul><li>The incidence increases after the age of 65 </li></ul></ul><ul><ul><li>Prevalence 30% - 40% among people aged > 65 years </li></ul></ul><ul><li>Gender </li></ul><ul><ul><li>2-3x more common in females </li></ul></ul><ul><ul><li>Impaired evacuation a significant factor in elderly women </li></ul></ul><ul><li>Of community-residing elderly patients, 30% report that they suffer from constipation at least monthly </li></ul>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.
  34. 34. Geriatric Risk Factors for Constipation <ul><li>Immobility (bed-bound) </li></ul><ul><li>Pain </li></ul><ul><ul><li>Musculoskeletal in spine, pelvis, hips </li></ul></ul><ul><ul><li>Abdominal </li></ul></ul><ul><ul><li>Severe generalized pain </li></ul></ul><ul><ul><li>Opiate use </li></ul></ul><ul><li>Deconditioning </li></ul><ul><li>Muscle weakness </li></ul><ul><li>Neurodegenerative disease </li></ul><ul><li>Thyroid disease </li></ul><ul><li>Higgins PDR, et al. Am J Gastroenterol . 2004;99:750. </li></ul><ul><ul><li>Muller-Lissner S. Best Practice Res Clin Gastroenterol . 2002;16:115-33. </li></ul></ul><ul><ul><li>Hall KE, et al. Gastroenterology . 2005;129:1305-1338. </li></ul></ul><ul><ul><li>De Lillo AR, et al. Am J Gastroenterol . 2000;95:901. </li></ul></ul>
  35. 35. Atypical Presentation of Constipation in the Elderly <ul><li>Anorexia </li></ul><ul><li>Nausea </li></ul><ul><li>Behavioral changes </li></ul><ul><li>Abdominal discomfort/distension </li></ul><ul><li>Fecal impaction </li></ul><ul><li>Overflow incontinence - “diarrhea” </li></ul><ul><li>Get an abdominal xray </li></ul><ul><ul><li>if stool proximal to descending colon – not “normal” </li></ul></ul>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.
  36. 36. Patient and Physician Descriptions of Constipation <ul><li>Patient description </li></ul><ul><ul><li>“I haven’t had a bowel movement today” </li></ul></ul><ul><ul><li>“My stools are hard and lumpy” </li></ul></ul><ul><ul><li>“It’s hard to have a bowel movement” </li></ul></ul><ul><li>Physician description </li></ul><ul><ul><li>Infrequent bowel movements </li></ul></ul><ul><ul><li>Difficulty during defecation (straining) </li></ul></ul><ul><ul><li>Sensation of incomplete bowel evacuation </li></ul></ul><ul><ul><li>Abnormal stool form </li></ul></ul><ul><ul><li>Smaller bowel movements </li></ul></ul>Herz MJ, et al. Fam Pract. 1996;13:156.
  37. 37. Bristol Stool Chart <ul><li>Types 1-7 </li></ul><ul><li>More than 25% of the time </li></ul><ul><li>Correlates with colonic transit – type 1 slow; type 7 fast </li></ul>Lewis SJ, Heaton KW. Scan J Gastroenterol 2007; 32:920
  38. 38. Constipation <ul><li>No evidence that fiber or hydration alone is effective in patients >70 years without dehydration </li></ul><ul><li>Only RTC evidence for psyllium, osmotic agents (PEG solution) and newer drugs (tegaserod, lubiprostone) </li></ul><ul><li>Tegaserod recently withdrawn (April 2007) due to cardiac events (0.11% vs 0.03% placebo) </li></ul><ul><li>Consider stimulant laxative (senna, bisacodyl, milk of magnesia, lubiprostone) </li></ul><ul><li>No evidence of myenteric damage with above agents </li></ul><ul><li>Osmotic agents (lactulose, sorbital, PEG) also effective but may cause bloating or vomiting </li></ul>
  39. 39. Enema v.s. Oral agents <ul><li>“ Get patient moving from below before given meds from above” </li></ul><ul><li>If no BM in 1-2 days use suppository </li></ul><ul><li>Use tap water or milk and molasses (1 liter: 0.5 cups) enemas for severely constipated </li></ul><ul><li>Mineral oil enema may work but some cases of oil absorption and pneumonia </li></ul><ul><li>Avoid soapsuds enemas (ischemic colitis) </li></ul>
  40. 40. Diverticular Disease <ul><li>An abnormality in the aging colon involving decreased tensile strength of the muscle wall </li></ul><ul><li>By aged 50 years one third of Americans will have diverticulosis coli; by aged 80 years, two-thirds will be affected </li></ul><ul><ul><li>Incidence less than 5% <40 years </li></ul></ul><ul><ul><li>Incidence greater than 60% by aged 85 years </li></ul></ul><ul><ul><li>Mean age at presentation is aged 60 years </li></ul></ul><ul><li>The majority of those affected are asymptomatic </li></ul>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.
  41. 41. Diverticular Disease (Cont.) <ul><li>Other factors of diverticular disease: </li></ul><ul><ul><li>Slow colonic transit </li></ul></ul><ul><ul><li>Increased frequency of segmenting contractions resulting in increased water resorption and hard feces </li></ul></ul><ul><li>National Demographic and Health Survey (NDHS) 1996 to 2002 for diverticulitis </li></ul><ul><ul><li>Hospital admissions increased by 14% to 261,180 </li></ul></ul><ul><ul><li>Office visits increased by 14% to 1,493,865 </li></ul></ul><ul><ul><li>Emergency department visits increased by 47% from 87,512  161,364 </li></ul></ul><ul><li>Significant morbidity and mortality from abcess and perforation (delay in diagnosis) </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  42. 42. Diarrhea <ul><li>Definition: </li></ul><ul><ul><li>Loose stools of more than 200g/day in at least three bowel movements per day </li></ul></ul><ul><ul><li>Patient’s description usually focuses on loose stools </li></ul></ul><ul><li>Approximately 85% of all mortality associated with diarrhea involves the elderly </li></ul><ul><ul><li>73 million consultations for acute diarrhea in the United States each year </li></ul></ul><ul><li>Between 1997 and 2000 </li></ul><ul><ul><li>Office visits for chronic diarrhea increased by 115% from 991,886  2,132,272 </li></ul></ul><ul><ul><li>?Medications vs Exposure – food, institutions </li></ul></ul>Hoffmann JC, et al. Best Pract Res Clin Gastroneterol . 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  43. 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. Small bowel bacterial overgrowth Diabetic diarrhea Colonic carcinoma Fecal impaction Malabsorption Drug-induced diarrhea Infections Common Causes
  44. 44. 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. Small bowel tumors Pancreatic insufficiency (screen for ETOH) Amyloidosis with small bowel involvement Whipple’s disease Scleroderma with systemic manifestations Thryotoxicosis Inflammatory bowel disease Celiac disease Less Common Causes
  45. 45. Fecal Incontinence <ul><li>Fecal incontinence is uncommon in the general population (2.2%) but has a significantly higher prevalence (10%) in the older population </li></ul>Hall KE, et al. Gastroenterology . 2005;129:1305-1338. Fecal incontinence can result from: Fecal impaction and subsequent flow Internal anal sphincter incompetence Decreased rectal or anal sensation Structural impairments in the pelvic floor Anorectal damage from surgery or irradiation
  46. 46. Fecal Incontinence <ul><li>Risk factors identified are: </li></ul><ul><ul><li>Advancing age </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Urinary incontinence </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Physical limitations </li></ul></ul><ul><ul><li>Female gender </li></ul></ul><ul><ul><li>Peri-anal injury or surgery </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Poor general health </li></ul></ul><ul><ul><li>Bowel –related factors (incomplete defecation, constipation, straining, fecal urgency) </li></ul></ul>Goode PS, et al. J Am Geriatr Soc . 2005;53:629-635.
  47. 47. Implications for Elderly Suffering from Diarrhea and/or Fecal Incontinence <ul><li>Both can become a chronic problem resulting in social isolation and decreased activity out of the home </li></ul><ul><li>It is important to obtain a good history to determine if fecal incontinence is due to diarrhea, urgency, obstruction, or rectal dysfunction </li></ul><ul><li>Refer to specialist center for multifactorial assessment and treatment (biofeedback, surgery) </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338 Akhtar AJ, et al. J Amer Med Dir. Assoc . 2005;6:54-60.
  48. 48. Hepato-biliary Function with Aging <ul><li>Dynamic assessments of liver function decrease with aging </li></ul><ul><li>Compared to younger adults, in healthy subjects there is a decrease by 30% - 40% decrease in </li></ul><ul><ul><li>Liver size </li></ul></ul><ul><ul><li>Blood flow </li></ul></ul><ul><ul><li>Perfusion </li></ul></ul><ul><li>Nonalcoholic steatohepatitis (NASH) is a common complication of obesity and diabetes mellitus </li></ul><ul><ul><li>Diabetes affects 12% of the US population; >70% of affected individuals are in the geriatric age range </li></ul></ul><ul><ul><li>NASH may progress to cirrhosis in up to ~25% of patients </li></ul></ul><ul><ul><li>NASH increases the risk of hepatic side effects of drugs </li></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905.
  49. 49. Hepato-biliary Function <ul><li>Liver “function” tests – actually dysfunction tests </li></ul><ul><ul><li>Enzymes, bilirubin level </li></ul></ul><ul><li>Liver Function tests </li></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><li>PT/INR </li></ul></ul><ul><ul><li>Bilirubin conjugation </li></ul></ul><ul><li>Hepatic Ultrasound with Portal vein Doppler </li></ul><ul><ul><li>Check for cirrhosis, portal hypertension </li></ul></ul><ul><ul><li>May add CT if undiagnostic </li></ul></ul><ul><li>Refer to specialist if enzymes >100, hepatic alkaline phosphatase persistently elevated, or liver function impaired </li></ul><ul><li>Mild AST or ALT elevation without dysfunction is NOT a contraindication to use of statins </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905.
  50. 50. Gallbladder Function with Aging <ul><li>Bile becomes increasingly lithogenic with aging </li></ul><ul><ul><li>Precipitation of supersaturated bile and concomitant crystallization of cholesterol or calcium bilirubinate </li></ul></ul><ul><li>In subjects older than 35 years, fasting and postprandial gallbladder volumes increased </li></ul><ul><ul><li>In older individuals there was less complete gallbladder emptying following a meal </li></ul></ul><ul><li>Aging women may be more susceptible to impaired gallbladder contractility </li></ul><ul><li>Compared to young patients, cholecystitis and cholangitis in older patients has increased morbidity and mortality </li></ul><ul><li>Hepatic ultrasound and HIDA scan, consider referral for ERCP </li></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  51. 51. Pancreatic Function with Aging <ul><li>Exocrine and endocrine pancreatic function in non-diabetic patients is preserved with aging </li></ul><ul><li>Incidence of pancreatic cancer is increasing in patients aged > 65 years </li></ul><ul><ul><li>Older patients have significantly worse surgical outcomes </li></ul></ul><ul><ul><li>Median survival is 11 months vs. 25 months in patients < 65 yrs </li></ul></ul><ul><li>Approximately half of acute pancreatitis cases are patients >60 years </li></ul><ul><ul><li>Gallstones are most common etiology (60%) </li></ul></ul><ul><ul><li>40%: surgery, drugs, trauma, infection, alcohol </li></ul></ul><ul><ul><li>Mortality in elderly is 20%; twice that of general population </li></ul></ul>Hall KE, et al. Gastroenterology. 2005;129:1305-1338.
  52. 52. Summary <ul><li>The age wave will continue to increase in the next 25 years resulting in a substantial boom of the 65+ geriatric population </li></ul><ul><li>Many physiological and psychological changes occur with age </li></ul><ul><li>There are significant changes in gastrointestinal function that occur in geriatric-aged patients </li></ul><ul><li>Aging increases the risk of several disorders: </li></ul><ul><ul><li>Dysphagia, GI bleeding, colorectal cancer, constipation, diverticular disease, diarrhea, fecal incontinence , pancreatic cancer, and hepatobiliary disorders </li></ul></ul>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.
  53. 53. Handouts <ul><li>Sitemaker.umich.edu/khallinfo </li></ul><ul><ul><li>AGS 2007 </li></ul></ul>

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