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GASTROENTEROLOGY CURRENT HOT TOPICS Aging and GI Disorders Presented by Monica J. Cox, ARNP-BC, GNP, MSN, MPH, DNP(C)

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Presentation on theme: "GASTROENTEROLOGY CURRENT HOT TOPICS Aging and GI Disorders Presented by Monica J. Cox, ARNP-BC, GNP, MSN, MPH, DNP(C)"— Presentation transcript:

1 GASTROENTEROLOGY CURRENT HOT TOPICS Aging and GI Disorders Presented by Monica J. Cox, ARNP-BC, GNP, MSN, MPH, DNP(C)

2 CURRENT HOT TOPICS Objectives Define age-related changes in the gastrointestinal tract Discuss common G.I. problems associated with aging Describe the risk factors for gastro-esophageal reflux disease Describe the risk factors for peptic ulcer development List the causes of diarrhea and fecal incontinence in the elderly Define age-related changes in the gastrointestinal tract Discuss common G.I. problems associated with aging Describe the risk factors for gastro-esophageal reflux disease Describe the risk factors for peptic ulcer development List the causes of diarrhea and fecal incontinence in the elderly

3 CURRENT HOT TOPICS Epidemiology Over 35 million people aged > 65 years in the United States –12% of the 2003 US population were older than million aged million aged million aged ≥ 85 35% to 40% of geriatric patients will have at least 1 GI symptom in any year –Common problems in this age group include constipation, fecal incontinence, diarrhea, irritable bowel syndrome (IBS), reflux disease, and swallowing disorders Over 35 million people aged > 65 years in the United States –12% of the 2003 US population were older than million aged million aged million aged ≥ 85 35% to 40% of geriatric patients will have at least 1 GI symptom in any year –Common problems in this age group include constipation, fecal incontinence, diarrhea, irritable bowel syndrome (IBS), reflux disease, and swallowing disorders Hall 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. Hall 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.

4 CURRENT HOT TOPICS The “Age Wave” Year Population Increase in the Number of Persons Aged 65+ Years in the United States Increase in the Number of Persons Aged 65+ Years in the United States Number (millions) Percent of population Number (millions) Percent of population 3 (4%) 5 (5%) 9 (7%) 17 (9%) 26 (11%) 31 (13%) 35 (12%) 40 (13%) 55 (16%) 72 (20%) 4 (4%) 7 (5%) 12 (8%) 20 (10%) He W, et al. 65+ in the US: US Census Bureau Web site. Available at: Accessed 11/30/06.

5 CURRENT HOT TOPICS Costs $300 million to treat GI disease in older patients in 2005 Individuals aged ≥ 65 years accounted for 60% of all medical expenditures in 2005 $300 million to treat GI disease in older patients in 2005 Individuals aged ≥ 65 years accounted for 60% of all medical expenditures in 2005 Hall KE, et al. Gastroenterology. 2005;129:

6 CURRENT HOT TOPICS Age-Related Changes in the Gastrointestinal Tract Motility Immunity Drug metabolism Drug metabolism Visceral sensitivity Visceral sensitivity 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 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 Hormone responsiveness Hormone responsiveness Lithogenic bile Lithogenic bile Pancreas: Structure and function Pancreas: Structure and function Liver sensitivity to stress Liver sensitivity to stress Colonic function Colonic function Hall KE, et al. Gastroenterology. 2005;129:

7 CURRENT HOT TOPICS Esophageal Aging Dysphagia, regurgitation, chest pain, heartburn- associated nausea are common in the elderly “Presbyesophagus”: (age-related changes in esophageal function) –Decreased contractile amplitude –Polyphasic waves –Incomplete relaxation of the lower esophageal sphincter (LES) –Esophageal dilation GERD –Common in the elderly –Impaired clearance of acid –Longer duration of reflux episodes –Atypical symptom presentation Dysphagia, regurgitation, chest pain, heartburn- associated nausea are common in the elderly “Presbyesophagus”: (age-related changes in esophageal function) –Decreased contractile amplitude –Polyphasic waves –Incomplete relaxation of the lower esophageal sphincter (LES) –Esophageal dilation GERD –Common in the elderly –Impaired clearance of acid –Longer duration of reflux episodes –Atypical symptom presentation Hall KE, et al. Gastroenterology. 2005;129:

8 CURRENT HOT TOPICS Aging and the Stomach Hall KE, et al. Gastroenterology. 2005;129: Cullen DJE, et al. Gut. 1997;41: Hall KE, et al. Gastroenterology. 2005;129: Cullen DJE, et al. Gut. 1997;41: DecreasedIncreased Clearance of liquids from stomach Perception of gastric distention Cytoprotective factors Mucosal blood flow and impaired sensory neuron function in animal models Contact time with NSAIDs or other noxious agents in delayed emptying Tendency for gastric mucosal injury in delayed emptying Prevalence of H. pylori associated with increased risk of bleeding peptic ulcer, pernicious anemia, and lymphoma

9 CURRENT HOT TOPICS 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 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:

10 GASTROENTEROLOGY CURRENT HOT TOPICS GI Disorders Related to Aging

11 CURRENT HOT TOPICS Gastrointestinal Bleeding Is Common in the Elderly 20%-25% GI bleeding in the lower tract –Terminal ileum –Colon –Rectum 75% GI bleeding in the upper tract –Esophagus –Stomach –Small bowel Hall KE, et al. Gastroenterology. 2005;129:

12 CURRENT HOT TOPICS Gastrointestinal Bleeding in the Elderly Of the 75% bleeding in the 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 Continued bleeding and rebleeding are the highest predictors of mortality and morbidity in older patients Of the 75% bleeding in the 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 Continued bleeding and rebleeding are the highest predictors of mortality and morbidity in older patients Hall KE, et al. Gastroenterology. 2005;129: Image courtesy of David C. Metz, MD. Hall KE, et al. Gastroenterology. 2005;129: Image courtesy of David C. Metz, MD.

13 CURRENT HOT TOPICS Colorectal Cancer in the Elderly An estimated 106,680 cases of colon and 41,930 cases of rectal cancer were expected to occur in % of all cases occur in individuals aged > 50 years An estimated 106,680 cases of colon and 41,930 cases of rectal cancer were expected to occur in % of all cases occur in individuals aged > 50 years American Cancer Society. Cancer Facts and Figures Atlanta: American Cancer Society; Burt RW. Gastroenterology. 2000;119: Image courtesy of Subhas Banerjee, MD. American Cancer Society. Cancer Facts and Figures Atlanta: American Cancer Society; Burt RW. Gastroenterology. 2000;119: Image courtesy of Subhas Banerjee, MD.

14 CURRENT HOT TOPICS Colorectal 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 neoplasia Prevalence of neoplasia (%) Age group (years) Lin OS, et al. JAMA. 2006;295: n = 1034 n = 147n = 63

15 CURRENT HOT TOPICS Aging-Associated Changes in Colonic Motility Common disorders observed in the elderly that are correlated with colonic motility are: –Constipation –Diverticular disease –Diarrhea –Fecal incontinence There are age-associated reductions in myenteric neurons, calcium influx, and tensile strength of the collagen and muscle fibers No clear effect of age on colonic transit, as many constipated older patients appear to have normal transit times Common disorders observed in the elderly that are correlated with colonic motility are: –Constipation –Diverticular disease –Diarrhea –Fecal incontinence There are age-associated reductions in myenteric neurons, calcium influx, and tensile strength of the collagen and muscle fibers No clear effect of age on colonic transit, as many constipated older patients appear to have normal transit times Hall KE, et al. Gastroenterology. 2005;129: Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23: Hall KE, et al. Gastroenterology. 2005;129: Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23:

16 CURRENT HOT TOPICS Coronary heart disease Asthma Diabetes Migraines Hypertension Constipation Prevalence in millions Prevalence of Selected Diseases in US Adults *Prevalence in North Americans Pleis 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: Accessed Higgins PDR, et al. Am J Gastroenterol. 2004;99: * Prevalence of Constipation Compared to Other Common Diseases

17 CURRENT HOT TOPICS Diverticular Disease An abnormality in the aging colon involving decreased tensile strength of the muscle wall By age 50 years, one third of Americans will have diverticulosis coli; by age 80 years, two thirds will be affected –Incidence less than 5% among those aged < 40 years –Incidence greater than 60% by age 85 years –Mean age at presentation is 60 years The majority of those affected are asymptomatic An abnormality in the aging colon involving decreased tensile strength of the muscle wall By age 50 years, one third of Americans will have diverticulosis coli; by age 80 years, two thirds will be affected –Incidence less than 5% among those aged < 40 years –Incidence greater than 60% by age 85 years –Mean age at presentation is 60 years The majority of those affected are asymptomatic Hall 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. Hall 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.

18 CURRENT HOT TOPICS Diverticular Disease (Cont.) Other factors in diverticular disease: –Slow colonic transit –Increased frequency of segmenting contractions resulting in increased water reabsorption and hard feces According to data from the National Demographic and Health Survey (NDHS) between 1997 and 2002 –Hospital admissions increased by 14% to 261,180 –Office visits increased by 14% to 1,493,865 –Emergency department visits increased by 84% to 161,364 Other factors in diverticular disease: –Slow colonic transit –Increased frequency of segmenting contractions resulting in increased water reabsorption and hard feces According to data from the National Demographic and Health Survey (NDHS) between 1997 and 2002 –Hospital admissions increased by 14% to 261,180 –Office visits increased by 14% to 1,493,865 –Emergency department visits increased by 84% to 161,364 Hall KE, et al. Gastroenterology. 2005;129:

19 CURRENT HOT TOPICS Diarrhea Definition: –Loose stools of more than 200 grams per day in at least 3 bowel movements per day Approximately 85% of all mortality associated with diarrhea involves the elderly –73 million consultations for acute diarrhea in the United States each year Between 1997 and 2002 –Office visits for chronic diarrhea increased by 115% from 991,886 to 2,132,272 Definition: –Loose stools of more than 200 grams per day in at least 3 bowel movements per day Approximately 85% of all mortality associated with diarrhea involves the elderly –73 million consultations for acute diarrhea in the United States each year Between 1997 and 2002 –Office visits for chronic diarrhea increased by 115% from 991,886 to 2,132,272 Hoffmann JC, et al. Best Pract Res Clin Gastroenterol. 2002;16: Hall KE, et al. Gastroenterology. 2005;129: Hoffmann JC, et al. Best Pract Res Clin Gastroenterol. 2002;16: Hall KE, et al. Gastroenterology. 2005;129:

20 CURRENT HOT TOPICS Causes of Diarrhea in the Elderly Common Causes Infections Drug-induced diarrhea Malabsorption Fecal impaction Colonic carcinoma Small bowel bacterial overgrowth Diabetic diarrhea Hoffmann JC, et al. Best Pract Res Clin Gastroenterol. 2002;16: Hall KE, et al. Gastroenterology. 2005;129: Hoffmann JC, et al. Best Pract Res Clin Gastroenterol. 2002;16: Hall KE, et al. Gastroenterology. 2005;129: Less Common Causes Celiac disease Inflammatory bowel disease Thyrotoxicosis Scleroderma with systemic manifestations Whipple’s disease Amyloidosis with small bowel involvement Pancreatic insufficiency Small bowel tumors

21 CURRENT HOT TOPICS 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: Fecal incontinence can result from: Fecal impaction and subsequent overflow Internal anal sphincter incompetence Decreased rectal or anal sensation Structural impairments in the pelvic floor Anorectal damage from surgery or irradiation

22 CURRENT HOT TOPICS Fecal Incontinence Risk factors identified are: –Advancing age –Diabetes mellitus –Urinary incontinence –Stroke –Physical limitations –Female gender –Gynecological surgery –Perianal injury or surgery –Hypertension –Poor general health –Bowel-related factors (incomplete defecation, constipation, straining, fecal urgency) Risk factors identified are: –Advancing age –Diabetes mellitus –Urinary incontinence –Stroke –Physical limitations –Female gender –Gynecological surgery –Perianal 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:

23 CURRENT HOT TOPICS 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 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 Hall KE, et al. Gastroenterology. 2005;129: Akhtar AJ, et al. J Amer Med Dir Assoc. 2005;6: Hall KE, et al. Gastroenterology. 2005;129: Akhtar AJ, et al. J Amer Med Dir Assoc. 2005;6:54-60.

24 CURRENT HOT TOPICS Hepatobiliary Function With Aging Dynamic assessments of liver function decrease with aging Compared to younger adults, in healthy subjects there is a decrease of 30% - 40%* 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 certain drugs Dynamic assessments of liver function decrease with aging Compared to younger adults, in healthy subjects there is a decrease of 30% - 40%* 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 certain drugs Hall KE, et al. Gastroenterology. 2005;129: Reynaert H, et al. Aliment Pharmacol Ther. 2005;22: Hall KE, et al. Gastroenterology. 2005;129: Reynaert H, et al. Aliment Pharmacol Ther. 2005;22: *Decreases occur between the 3 rd and 10 th decade of life

25 CURRENT HOT TOPICS Gallbladder Function with Aging Bile becomes increasingly lithogenic with aging –Precipitation of supersaturated bile and concomitant crystallization of cholesterol or calcium bilirubinate In subjects aged > 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 have increased morbidity and mortality Bile becomes increasingly lithogenic with aging –Precipitation of supersaturated bile and concomitant crystallization of cholesterol or calcium bilirubinate In subjects aged > 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 have increased morbidity and mortality Hall KE, et al. Gastroenterology. 2005;129:

26 CURRENT HOT TOPICS Pancreatic Function With Aging Exocrine and endocrine pancreatic function in nondiabetic patients is preserved with aging Incidence of pancreatic cancer is increasing in patients aged > 65 years –Significantly worse surgical outcomes in patients > 74 years –Median survival is 11 months vs. 25 months in patients aged 64 to 74 years Approximately half of acute pancreatitis cases are patients aged > 60 years –Gallstones are most common etiology (60%) –40%: surgery, drugs, trauma, infection, alcohol –Mortality in elderly is 20%; twice that of general population Exocrine and endocrine pancreatic function in nondiabetic patients is preserved with aging Incidence of pancreatic cancer is increasing in patients aged > 65 years –Significantly worse surgical outcomes in patients > 74 years –Median survival is 11 months vs. 25 months in patients aged 64 to 74 years Approximately half of acute pancreatitis cases are patients aged > 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:

27 CURRENT HOT TOPICS Summary The age wave will continue to increase in the next 20 years resulting in a substantial boom of the 65+ geriatric population Many physiological and psychological changes occur with age There are significant changes in gastrointestinal function that occur in geriatric patients Aging increases the risk of several disorders: –GI bleeding, colorectal cancer, constipation, diverticular disease, diarrhea, fecal incontinence, hepatobiliary disorders, and pancreatic cancer The age wave will continue to increase in the next 20 years resulting in a substantial boom of the 65+ geriatric population Many physiological and psychological changes occur with age There are significant changes in gastrointestinal function that occur in geriatric patients Aging increases the risk of several disorders: –GI bleeding, colorectal cancer, constipation, diverticular disease, diarrhea, fecal incontinence, hepatobiliary disorders, and pancreatic cancer Hall KE, et al. Gastroenterology. 2005;129:


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