Presentation on theme: "Aging and GI Disorders Presented by Monica J. Cox, ARNP-BC,"— Presentation transcript:
1Aging and GI Disorders Presented by Monica J. Cox, ARNP-BC, GNP, MSN, MPH, DNP(C)
2Objectives Define age-related changes in the gastrointestinal tract Discuss common G.I. problems associated with agingDescribe the risk factors for gastro-esophageal reflux diseaseDescribe the risk factors for peptic ulcer developmentList the causes of diarrhea and fecal incontinence in the elderly
3EpidemiologyOver 35 million people aged > 65 years in the United States12% of the 2003 US population were older than 6518.3 million aged 65-7412.9 million aged 75-844.7 million aged ≥ 8535% to 40% of geriatric patients will have at least GI symptom in any yearCommon problems in this age group include constipation, fecal incontinence, diarrhea, irritable bowel syndrome (IBS), reflux disease, and swallowing disordersHall KE, et al. Gastroenterology. 2005;129:He W, et al. 65+ in the US: US Census Bureau Web site. Available at: Accessed 11/30/06.
4Increase in the Number of Persons Aged 65+ Years in the United States The “Age Wave”YearPopulationIncrease in the Number of PersonsAged 65+ Years in the United StatesNumber (millions)Percent of population3(4%)5(5%)9(7%)17(9%)26(11%)31(13%)35(12%)4055(16%)72(20%)4712(8%)20(10%)He W, et al. 65+ in the US: US Census Bureau Web site. Available at: Accessed 11/30/06.
5Costs $300 million to treat GI disease in older patients in 2005 Individuals aged ≥ 65 years accounted for 60% of all medical expenditures in 2005Hall KE, et al. Gastroenterology. 2005;129:
6Age-Related Changes in the Gastrointestinal Tract MotilityHormoneresponsivenessAreas identified as important to aging are:Pathophysiology of swallowing disordersEsophageal refluxDysmotility symptomsGI immunobiologyCellular mechanisms of neoplasia in the GI tractDecreased visceral sensitivityVisceralsensitivityDrugmetabolismLiver sensitivityto stressPancreas:Structureand functionImmunityLithogenicbileColonicfunctionHall KE, et al. Gastroenterology. 2005;129:
7Esophageal AgingDysphagia, regurgitation, chest pain, heartburn- associated nausea are common in the elderly“Presbyesophagus”: (age-related changes in esophageal function)Decreased contractile amplitudePolyphasic wavesIncomplete relaxation of the lower esophageal sphincter (LES)Esophageal dilationGERDCommon in the elderlyImpaired clearance of acidLonger duration of reflux episodesAtypical symptom presentationHall KE, et al. Gastroenterology. 2005;129:
8Aging and the Stomach Decreased Increased Clearance of liquids from stomachPerception of gastric distentionCytoprotective factorsMucosal blood flow and impaired sensory neuron function in animal modelsContact time with NSAIDs or other noxious agents in delayed emptyingTendency for gastric mucosal injury in delayed emptyingPrevalence of H. pylori associated with increased risk of bleeding peptic ulcer, pernicious anemia, and lymphomaHall KE, et al. Gastroenterology. 2005;129:Cullen DJE, et al. Gut. 1997;41:
9NutritionGeriatric patients, especially aged > 85 years, are at risk for decreased food intake due to several factors:Mobility impairmentAbility to obtain foodLoss of taste, may be due to decreased olfactionPoor dentitionDecreased appetite“Anorexia of Aging,” may be related to neuroendocrine changesDepressionHall KE, et al. Gastroenterology. 2005;129:
11Gastrointestinal Bleeding Is Common in the Elderly 75% GI bleeding in the upper tractEsophagusStomachSmall bowel20%-25% GI bleeding in the lower tractTerminal ileumColonRectumHall KE, et al. Gastroenterology. 2005;129:
12Gastrointestinal Bleeding in the Elderly Of the 75% bleeding in the upper tract50% bleeding is due to NSAID use50% bleeding is due to ulceration or erosions (peptic or esophageal)Females are at higher risk than malesContinued bleeding and rebleeding are the highest predictors of mortality and morbidity in older patientsHall KE, et al. Gastroenterology. 2005;129:Image courtesy of David C. Metz, MD.
13Colorectal Cancer in the Elderly An estimated 106,680 cases of colon and 41,930 cases of rectal cancer were expected to occur in 200690% of all cases occur in individuals aged > 50 yearsAmerican Cancer Society. Cancer Facts and Figures Atlanta: American Cancer Society; 2006.Burt RW. Gastroenterology. 2000;119:Image courtesy of Subhas Banerjee, MD.
14Colorectal Cancer in the Elderly In a study of 1244 participants divided into 3 age groups who underwent screening colonoscopy, increasing age may be associated with an increased prevalence of neoplasiaPrevalence of neoplasia (%)n = 1034n = 147n = 63Age group (years)Lin OS, et al. JAMA. 2006;295:
15Aging-Associated Changes in Colonic Motility Common disorders observed in the elderly that are correlated with colonic motility are:ConstipationDiverticular diseaseDiarrheaFecal incontinenceThere are age-associated reductions in myenteric neurons, calcium influx, and tensile strength of the collagen and muscle fibersNo clear effect of age on colonic transit, as many constipated older patients appear to have normal transit timesHall KE, et al. Gastroenterology. 2005;129:Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23:
16Prevalence of Constipation Compared to Other Common Diseases Prevalence of Selected Diseases in US AdultsCoronary heart disease14Asthma16Diabetes16Migraines33Hypertension49Constipation63*20406080Prevalence in millionsPleis JR and Lethbridge-Cejku M. Summary health statistics for U.S. adults: National health interview survey, National Center for Health Statistics. Vital Health Stat 10(232) Available at: AccessedHiggins PDR, et al. Am J Gastroenterol. 2004;99:*Prevalence in North Americans
17Diverticular DiseaseAn abnormality in the aging colon involving decreased tensile strength of the muscle wallBy age 50 years, one third of Americans will have diverticulosis coli; by age 80 years, two thirds will be affectedIncidence less than 5% among those aged < 40 yearsIncidence greater than 60% by age 85 yearsMean age at presentation is 60 yearsThe majority of those affected are asymptomaticHall KE, et al. Gastroenterology. 2005;129:Cooperman A, et al. Diverticulitis. eMedicine Web Site. Available at: Accessed 11/3/06.Image courtesy of Jennifer Christie, MD.
18Diverticular Disease (Cont.) Other factors in diverticular disease:Slow colonic transitIncreased frequency of segmenting contractions resulting in increased water reabsorption and hard fecesAccording to data from the National Demographic and Health Survey (NDHS) between 1997 and 2002Hospital admissions increased by 14% to 261,180Office visits increased by 14% to 1,493,865Emergency department visits increased by 84% to 161,364Hall KE, et al. Gastroenterology. 2005;129:
19DiarrheaDefinition:Loose stools of more than 200 grams per day in at least bowel movements per dayApproximately 85% of all mortality associated with diarrhea involves the elderly73 million consultations for acute diarrhea in the United States each yearBetween 1997 and 2002Office visits for chronic diarrhea increased by 115% from 991,886 to 2,132,272I added “Patient’s description usually focuses on loose stools” in the definitionHoffmann JC, et al. Best Pract Res Clin Gastroenterol. 2002;16:17-36.Hall KE, et al. Gastroenterology. 2005;129:
20Causes of Diarrhea in the Elderly Common CausesInfectionsDrug-induced diarrheaMalabsorptionFecal impactionColonic carcinomaSmall bowel bacterial overgrowthDiabetic diarrheaLess Common CausesCeliac diseaseInflammatory bowel diseaseThyrotoxicosisScleroderma with systemic manifestationsWhipple’s diseaseAmyloidosis with small bowel involvementPancreatic insufficiencySmall bowel tumorsChanged “small bowel tumors” to small bowel bacterial overgrowth (the overgrowth is by bacteria, not tumor). Small bowel tumors are less common cause – don’t know if there is space to put it back in the lower list.Hoffmann JC, et al. Best Pract Res Clin Gastroenterol. 2002;16:17-36.Hall KE, et al. Gastroenterology. 2005;129:
21Fecal IncontinenceFecal incontinence is uncommon in the general population (2.2%) but has a significantly higher prevalence (10%) in the older populationAnorectal damage from surgery or irradiationStructural impairments in the pelvic floorFecal incontinence can result from:Fecal impaction and subsequent overflowDecreased rectal or anal sensationInternal anal sphincter incompetenceHall KE, et al. Gastroenterology. 2005;129:
22Fecal Incontinence Risk factors identified are: Advancing age Diabetes mellitusUrinary incontinenceStrokePhysical limitationsFemale genderGynecological surgeryPerianal injury or surgeryHypertensionPoor general healthBowel-related factors (incomplete defecation, constipation, straining, fecal urgency)Goode PS, et al. J Am Geriatr Soc. 2005;53:
23Implications 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 homeIt is important to obtain a good history to determine if fecal incontinence is due to diarrhea, urgency, obstruction, or rectal dysfunctionThe Akhtar and Padda reference supports statement #2.Hall KE, et al. Gastroenterology. 2005;129:Akhtar AJ, et al. J Amer Med Dir Assoc. 2005;6:54-60.
24Hepatobiliary Function With Aging Dynamic assessments of liver function decrease with agingCompared to younger adults, in healthy subjects there is a decrease of 30% - 40%* in:Liver sizeBlood flowPerfusionNonalcoholic steatohepatitis (NASH) is a common complication of obesity and diabetes mellitusDiabetes affects 12% of the US population; > 70% of affected individuals are in the geriatric age rangeNASH may progress to cirrhosis in up to ~25% of patientsNASH increases the risk of hepatic side effects of certain drugsChanged title to “Hepato-biliary Function with Aging” – I think it should be hypenated.*Decreases occur between the 3rd and 10th decade of lifeHall KE, et al. Gastroenterology. 2005;129:Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:
25Gallbladder Function with Aging Bile becomes increasingly lithogenic with agingPrecipitation of supersaturated bile and concomitant crystallization of cholesterol or calcium bilirubinateIn subjects aged > 35 years, fasting and postprandial gallbladder volumes increasedIn older individuals, there was less complete gallbladder emptying following a mealAging women may be more susceptible to impaired gallbladder contractilityCompared to young patients, cholecystitis and cholangitis in older patients have increased morbidity and mortalityEdited title – leave out “hepatobiliary function” – focus on gallstones/gallbladder.Hall KE, et al. Gastroenterology. 2005;129:
26Pancreatic Function With Aging Exocrine and endocrine pancreatic function in nondiabetic patients is preserved with agingIncidence of pancreatic cancer is increasing in patients aged > 65 yearsSignificantly worse surgical outcomes in patients > 74 yearsMedian survival is 11 months vs. 25 months in patients aged to 74 yearsApproximately half of acute pancreatitis cases are patients aged > 60 yearsGallstones are most common etiology (60%)40%: surgery, drugs, trauma, infection, alcoholMortality in elderly is 20%; twice that of general populationChanged title to “with Aging” from “in Aging”Hall KE, et al. Gastroenterology. 2005;129:
27SummaryThe age wave will continue to increase in the next years resulting in a substantial boom of the geriatric populationMany physiological and psychological changes occur with ageThere are significant changes in gastrointestinal function that occur in geriatric patientsAging increases the risk of several disorders:GI bleeding, colorectal cancer, constipation, diverticular disease, diarrhea, fecal incontinence, hepatobiliary disorders, and pancreatic cancerHall KE, et al. Gastroenterology. 2005;129: