1. Digestive Health Karen E. Hall, MD, PhD Clinical Associate Professor Department of Internal Medicine Division of Geriatric Medicine University of Michigan/Ann Arbor VAMC Ann Arbor, MI Karen E. Hall, MD, PhD Clinical Associate Professor Department of Internal Medicine Division of Geriatric Medicine University of Michigan/Ann Arbor VAMC Ann Arbor, MI 2010

2. K. Hall TSRC April 2010 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 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%) 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.

3. K. Hall TSRC April 2010 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 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.

4. K. Hall TSRC April 2010 How does the GI tract work? The GI tract is a tube with two muscular layers and nerves within those layers (intrinsic nerves) External (extrinsic) nerves trigger contractions that move from the mouth towards the anus (aboral direction) Specialized areas for food breakdown, digestion, absorption, elimination The GI tract is a tube with two muscular layers and nerves within those layers (intrinsic nerves) External (extrinsic) nerves trigger contractions that move from the mouth towards the anus (aboral direction) Specialized areas for food breakdown, digestion, absorption, elimination

5. K. Hall TSRC April 2010 Scott and Mertz Clin Perspectives Gastro 2001

6. K. Hall TSRC April 2010 Age-related Changes in the Gastrointestinal Tract Motility Immunity Drug metabolism Drug metabolism Visceral sensitivity Visceral sensitivity –Swallowing disorders –Esophageal reflux –Dysmotility symptoms- constipation, diarrhea –GI immunobiology –Cancer in the GI tract –Decreased visceral sensitivity-serious surgical emergencies less easily detected –Swallowing disorders –Esophageal reflux –Dysmotility symptoms- constipation, diarrhea –GI immunobiology –Cancer in the GI tract –Decreased visceral sensitivity-serious surgical emergencies less easily detected 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;129:1305-1338. Robins J, et al. GI Motility Online. 2006 Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Robins J, et al. GI Motility Online. 2006

7. K. Hall TSRC April 2010 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 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

8. K. Hall TSRC April 2010 What are the common symptoms of GI dysfunction? Swallowing: oropharyngeal - choking, food sticking or difficulty “going down” Reflux (heartburn or nausea) Abdominal pain Gas/bloating Constipation Diarrhea Fecal incontinence Weight loss Bleeding, anemia Swallowing: oropharyngeal - choking, food sticking or difficulty “going down” Reflux (heartburn or nausea) Abdominal pain Gas/bloating Constipation Diarrhea Fecal incontinence Weight loss Bleeding, anemia

9. K. Hall TSRC April 2010 What are the common GI disorders in older people? Oropharyngeal dyskinesia - choking, aspiration Gastroesophageal Reflux Disease (GERD) – heartburn, nausea, inflammation, strictures Dysphagia: food sticking or pain with swallowing Gastritis, ulcers, bleeding Gallstones, cholecystitits Chronic pancreatitis, pancreatic cancer Small bowel overgrowth – gas/bloating Constipation Diarrhea Fecal incontinence Bleeding, anemia Irritable bowel syndrome Oropharyngeal dyskinesia - choking, aspiration Gastroesophageal Reflux Disease (GERD) – heartburn, nausea, inflammation, strictures Dysphagia: food sticking or pain with swallowing Gastritis, ulcers, bleeding Gallstones, cholecystitits Chronic pancreatitis, pancreatic cancer Small bowel overgrowth – gas/bloating Constipation Diarrhea Fecal incontinence Bleeding, anemia Irritable bowel syndrome

10. K. Hall TSRC April 2010 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) 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)

11. K. Hall TSRC April 2010 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 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

12. K. Hall TSRC April 2010 Aging increases chance of stomach injury by acid and drugs Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Cullen DJE, et al. Gut. 1997;41:459-462. Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Cullen DJE, et al. Gut. 1997;41:459-462. 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 NSAID’s or other noxious agents Gastric mucosal injury Prevalence of H. pylori Risk of bleeding Pernicious anemia Gastric cancer Lymphoma

13. K. Hall TSRC April 2010 Esophageal Reflux – is it dangerous? Barrett’s Esophagus –Intestinal metaplasia with potential for adenocarcinoma –?Due to acid exposure for years –Endoscopic monitoring Every 1-3 years with biopsies 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 Barrett’s Esophagus –Intestinal metaplasia with potential for adenocarcinoma –?Due to acid exposure for years –Endoscopic monitoring Every 1-3 years with biopsies 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

14. K. Hall TSRC April 2010 Peptic Esophageal Stricture from NSAIDs (ibuprofen)

15. K. Hall TSRC April 2010 Gastritis – Stomach inflammation If you have to take NSAIDs or aspirin use low dose PPI (omeprazole) as well ASA 81 mg increases risk of bleeding from 1% to 6% - use low dose PPI with ASA if you have prior ulcers or bleeding from the GI tract If you have to take NSAIDs or aspirin use low dose PPI (omeprazole) as well ASA 81 mg increases risk of bleeding from 1% to 6% - use low dose PPI with ASA if you have prior ulcers or bleeding from the GI tract

16. K. Hall TSRC April 2010 Gastroparesis – stomach doesn’t empty Causes: Diabetes – 12% of population is diabetic or glucose intolerant! Medications (anticholinergic such as diphenhydramine/Benedryl) Obstruction from strictures or masses (benign or malignant) Constipation! Because the colon inhibits the stomach How to diagnose and treat: Endoscopy UGI series Gastric emptying study (abnormal if >3 hours) Prokinetic drugs –Metoclopramide/Reglan – concern about tardive diskinesia and cardiac side effects –Erythromycin (antibiotic - motilin analog) –(Domperidone in Canada) –(Cisapride – only available with special permission due to cardiac side effects) Causes: Diabetes – 12% of population is diabetic or glucose intolerant! Medications (anticholinergic such as diphenhydramine/Benedryl) Obstruction from strictures or masses (benign or malignant) Constipation! Because the colon inhibits the stomach How to diagnose and treat: Endoscopy UGI series Gastric emptying study (abnormal if >3 hours) Prokinetic drugs –Metoclopramide/Reglan – concern about tardive diskinesia and cardiac side effects –Erythromycin (antibiotic - motilin analog) –(Domperidone in Canada) –(Cisapride – only available with special permission due to cardiac side effects)

17. K. Hall TSRC April 2010 Gastrointestinal Bleeding 30% GI bleeding in the lower tract –Terminal ileum –Colon –Rectum 70% GI bleeding in the upper tract –Esophagus –Stomach –Small bowel

18. K. Hall TSRC April 2010 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) 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) Image courtesy of David C. Metz, MD.

19. K. Hall TSRC April 2010 Gastrointestinal Bleeding Needs urgent medical attention – go to the hospital if you are bleeding Endoscopy is the usual first treatment Visible vessel – treated with endoscopic laser or bicap coagulation Patients with cirrhosis (liver fibrosis) need special treatment because of large veins in the esophagus and stomach –Esophageal varicies usually Grade II-IV –Gastric varicies Rarely small bowel or biliary source of bleeding Needs urgent medical attention – go to the hospital if you are bleeding Endoscopy is the usual first treatment Visible vessel – treated with endoscopic laser or bicap coagulation Patients with cirrhosis (liver fibrosis) need special treatment because of large veins in the esophagus and stomach –Esophageal varicies usually Grade II-IV –Gastric varicies Rarely small bowel or biliary source of bleeding Image courtesy of David C. Metz, MD.

20. K. Hall TSRC April 2010 Colonic Bleeding Angiodysplasia in the colon Colitis (medications, ischemic, inflammatory) Angiodysplasia in the colon Colitis (medications, ischemic, inflammatory)

21. K. Hall TSRC April 2010 Colorectal Cancer An estimated 106,680 cases of colon and 41,930 cases of rectal cancer occurred in 2006 90% of all cases are in individuals older than aged 50 years An estimated 106,680 cases of colon and 41,930 cases of rectal cancer occurred in 2006 90% of all cases are 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. ACS Cancer Facts and Figures 2006. Burt RW. Gastroenterology. 2000;119:837-853. Image courtesy of Subhas Banerjee, MD.

22. K. Hall TSRC April 2010 Colorectal Cancer in Older People 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 (%) Age group (years) Lin OS, et al. JAMA. 2006;295:2357-2365. n = 1034 n = 147n = 63

23. K. Hall TSRC April 2010 Colonic Polyps – why do you need Colonoscopy? Most colon cancer (>90%) originates in adenomatous polyp >60% of polyps are right sided (cecal and transverse), more likely flat-type in elderly 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) We are trying to move away from “age cutoff” for colorectal cancer screening – “less than 5 year life expectancy” Virtual colonoscopy (CT colonography) – why not have that? –concerns – sensitivity and specificity? insurance reimbursement? Most colon cancer (>90%) originates in adenomatous polyp >60% of polyps are right sided (cecal and transverse), more likely flat-type in elderly 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) We are trying to move away from “age cutoff” for colorectal cancer screening – “less than 5 year life expectancy” Virtual colonoscopy (CT colonography) – why not have that? –concerns – sensitivity and specificity? insurance reimbursement? ACS Cancer Facts and Figures 2006. Okamoto, Dis Colon Rectum 48;101-107, 2005 Burt RW. Gastroenterology. 2000;119:837-853.MD. ACS Cancer Facts and Figures 2006. Okamoto, Dis Colon Rectum 48;101-107, 2005 Burt RW. Gastroenterology. 2000;119:837-853.MD.

24. K. Hall TSRC April 2010 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;129:1305-1338.

25. K. Hall TSRC April 2010 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 or other concerned family If patient WILL NOT eat consider treatment of depression IF patient CANNOT eat then do further tests –CT of abdomen and pelvis –Endoscopy 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 or other concerned family If patient WILL NOT eat consider treatment of depression IF patient CANNOT eat then do further tests –CT of abdomen and pelvis –Endoscopy Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:288-295. Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11. Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:288-295. Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11.

26. K. Hall TSRC April 2010 Depression Affects more Older People than Younger 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 –We use a two question depression screen –“Often during past month have you been 1) sad or 2) stopped activities?” Somatic symptoms common in elderly depressed patients –Nausea, chronic abdominal pain, and weight loss 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 –We use a two question depression screen –“Often during past month have you been 1) sad or 2) stopped activities?” Somatic symptoms common in elderly depressed patients –Nausea, chronic abdominal pain, and weight loss Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:288-295. Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11. Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:288-295. Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11.

27. K. Hall TSRC April 2010 Coronary heart disease Asthma Diabetes Migraines Hypertension Constipation Prevalence in millions 0 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. Lethbridge-Çejku M, et al. Vital Health Stat 10. 2005;1. Higgins PDR, et al. Am J Gastroenterol. 2004;99:750. 14 16 33 49 63* Constipation is an Extremely Common Symptom

28. K. Hall TSRC April 2010 Why do people get constipated as they get older? Age-associated decrease in: number of myenteric neurons neuronal and myenteric calcium entry into cells connective tissue elasticity However: there is no clear effect of age on colonic transit time - many constipated older patients appear to have normal transit times Age-associated decrease in: number of myenteric neurons neuronal and myenteric calcium entry into cells connective tissue elasticity However: there is no clear effect of age on colonic transit time - 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. Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23:1379-1391.

29. K. Hall TSRC April 2010 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 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. 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.

30. K. Hall TSRC April 2010 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 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.

31. K. Hall TSRC April 2010 Bristol Stool Chart “More than 25% of the time” Types 1-7 Correlates with colonic transit – type 1 slow; type 7 fast “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

32. K. Hall TSRC April 2010 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) 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. 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.

33. K. Hall TSRC April 2010 Constipating Medications (Over the Counter) Ca supplements Iron supplements Antidiarrheals: loperamide; bismuth NSAIDS Antacids: aluminum, calcium Ca supplements Iron supplements Antidiarrheals: loperamide; bismuth NSAIDS Antacids: aluminum, calcium

34. K. Hall TSRC April 2010 Constipating Prescription Medications Narcotics - codeine,morphine Anticholinergics - benztropine, trihexyphenedyl Antipsychotics - chlorpromazine Antidepressants - tricyclics Antiparkinson - levodopa Antispasmodics - dicyclomine Antihistamines - diphenhydramine Ca blockers - verapamil Diuretics - furosemide Narcotics - codeine,morphine Anticholinergics - benztropine, trihexyphenedyl Antipsychotics - chlorpromazine Antidepressants - tricyclics Antiparkinson - levodopa Antispasmodics - dicyclomine Antihistamines - diphenhydramine Ca blockers - verapamil Diuretics - furosemide

35. K. Hall TSRC April 2010 Less obvious symptoms of constipation in older patients Anorexia Nausea Behavioral changes (demented patients) Abdominal distension (“gas”) Fecal impaction Overflow incontinence - “diarrhea” Get an abdominal xray – lots of stool proximal to descending colon Anorexia Nausea Behavioral changes (demented patients) Abdominal distension (“gas”) Fecal impaction Overflow incontinence - “diarrhea” Get an abdominal xray – lots of stool proximal to descending colon 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. 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. K. Hall TSRC April 2010 Constipation: Myths and Facts No evidence that fiber or hydration alone is effective in patients >70 years without dehydration Increasing physical activity does decrease constipation Drugs? Only agents studied in randomized trials are psyllium (Metamucil), osmotic agents (Miralax) and newer drugs (tegaserod, lubiprostone) –Tegaserod was withdrawn April 2007 due to cardiac events (0.11% vs 0.03% placebo) Stimulant laxative (senna, bisacodyl, milk of magnesia, lubiprostone) are safe and effective Osmotic agents (lactulose, sorbital, PEG) also effective but may cause bloating or vomiting if severe constipation is present No evidence that fiber or hydration alone is effective in patients >70 years without dehydration Increasing physical activity does decrease constipation Drugs? Only agents studied in randomized trials are psyllium (Metamucil), osmotic agents (Miralax) and newer drugs (tegaserod, lubiprostone) –Tegaserod was withdrawn April 2007 due to cardiac events (0.11% vs 0.03% placebo) Stimulant laxative (senna, bisacodyl, milk of magnesia, lubiprostone) are safe and effective Osmotic agents (lactulose, sorbital, PEG) also effective but may cause bloating or vomiting if severe constipation is present Muller-Lissner S. Best Practice Res Clin Gastroenterol. 2002;16:115-33.

37. K. Hall TSRC April 2010 What if I’m really “bunged up”? “Get things moving from below before giving medications from above” If no BM in over 2 days - use bisacodyl suppository then enema if no result Enemas: tap water or milk and molasses (1 liter: 0.5 cups) enemas for severely constipated people Mineral oil enema may work but some cases of oil absorption and pneumonia have been described May need multiple enemas –> 3 may increase risk of colitis Avoid soapsuds enemas (ischemic colitis) “Get things moving from below before giving medications from above” If no BM in over 2 days - use bisacodyl suppository then enema if no result Enemas: tap water or milk and molasses (1 liter: 0.5 cups) enemas for severely constipated people Mineral oil enema may work but some cases of oil absorption and pneumonia have been described May need multiple enemas –> 3 may increase risk of colitis Avoid soapsuds enemas (ischemic colitis)

38. K. Hall TSRC April 2010 Do Probiotics promote Digestive Health? What are probiotics? Why is everyone interested in them? Probiotics are live bacteria that are normally present in the colon Antibiotics can decrease the percentage of these bacteria It is hypothesized that this may predispose patients to develop serious superinfections such as C. difficile colitis What are probiotics? Why is everyone interested in them? Probiotics are live bacteria that are normally present in the colon Antibiotics can decrease the percentage of these bacteria It is hypothesized that this may predispose patients to develop serious superinfections such as C. difficile colitis

39. K. Hall TSRC April 2010 Do Probiotics promote Digestive Health? There is “soft” evidence they may treat constipation Studies were all done by, or funded by the manufacturers Patients who used probiotic capsules or yogurt containing probiotics had more bowel movements per week compared to placebo Has not been compared with standard laxatives Claims on TV never include treatment of any specific disease (FDA prohibits claims by “non- pharmaceuticals) There is “soft” evidence they may treat constipation Studies were all done by, or funded by the manufacturers Patients who used probiotic capsules or yogurt containing probiotics had more bowel movements per week compared to placebo Has not been compared with standard laxatives Claims on TV never include treatment of any specific disease (FDA prohibits claims by “non- pharmaceuticals)

40. K. Hall TSRC April 2010 Is there evidence that probiotics are beneficial? Best evidence for efficacy is using: Lactobacillus, Bifidobacterium, Sacromyces (yeast) Studies in the UK indicate giving probiotics on admission to hospital may prevent C. difficile diarrhea C. difficile colonizes 13% of patients admitted to hospital within 4 days C. difficile colitis has a mortality of 7% in younger patients, 12% in patients over 65 years Best evidence for efficacy is using: Lactobacillus, Bifidobacterium, Sacromyces (yeast) Studies in the UK indicate giving probiotics on admission to hospital may prevent C. difficile diarrhea C. difficile colonizes 13% of patients admitted to hospital within 4 days C. difficile colitis has a mortality of 7% in younger patients, 12% in patients over 65 years

41. K. Hall TSRC April 2010 Are Probiotics Safe? Probably yes in people with normal immunity There have been reports of serious or fatal blood infection with probiotic bacteria when administered to immunosuppressed patients: Avoid if you are Immunosuppressed Who is immunosuppressed? Patients using prednisone, other immune suppression for rheumatoid arthritis, inflamatory bowel disease, cancer Inherited deficiencies of antibodies or immune cells Patients with cancer Old people (over 75)?- decreased resistance to infection Probably yes in people with normal immunity There have been reports of serious or fatal blood infection with probiotic bacteria when administered to immunosuppressed patients: Avoid if you are Immunosuppressed Who is immunosuppressed? Patients using prednisone, other immune suppression for rheumatoid arthritis, inflamatory bowel disease, cancer Inherited deficiencies of antibodies or immune cells Patients with cancer Old people (over 75)?- decreased resistance to infection

42. K. Hall TSRC April 2010 Diverticular Disease – a byproduct of constipation? Or aging? An abnormality in the aging colon involving decreased tensile strength of the muscle wall By aged 50 years one third of Americans have diverticulosis coli; by aged 80 years, two-thirds are affected The majority of those affected are asymptomatic An abnormality in the aging colon involving decreased tensile strength of the muscle wall By aged 50 years one third of Americans have diverticulosis coli; by aged 80 years, two-thirds are affected 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. 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.

43. K. Hall TSRC April 2010 Diverticular Disease 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) Significant morbidity and mortality from abcess and perforation (delay in diagnosis) Treatment: promote frequent bowel movements with fiber and laxatives, avoid straining Inflamation (Diverticulitis) requires antibiotics, fluids and sometimes bowel rest to avoid surgery 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) Significant morbidity and mortality from abcess and perforation (delay in diagnosis) Treatment: promote frequent bowel movements with fiber and laxatives, avoid straining Inflamation (Diverticulitis) requires antibiotics, fluids and sometimes bowel rest to avoid surgery Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

44. K. Hall TSRC April 2010 Diarrhea Definition: –Physician’s: Loose stools of more than 200g/day in at least three bowel movements per day –Patient’s: “I have 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 Definition: –Physician’s: Loose stools of more than 200g/day in at least three bowel movements per day –Patient’s: “I have 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. Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

45. K. Hall TSRC April 2010 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 Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

46. K. Hall TSRC April 2010 Causes of Diarrhea in the Elderly Less Common Causes Celiac disease Inflammatory bowel disease Thryotoxicosis Scleroderma with systemic manifestations Whipple’s disease Amyloidosis with small bowel involvement Pancreatic insufficiency (screen for ETOH) Small bowel tumors Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36. Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

47. K. Hall TSRC April 2010 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 people over age 65 Get blood tests, imaging (UGI + SBFT), duodenal biopsy If diet-resistant: oral steroid and workup for small bowel lymphoma 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 people over age 65 Get blood tests, imaging (UGI + SBFT), duodenal biopsy If diet-resistant: oral steroid and workup for small bowel lymphoma

48. K. Hall TSRC April 2010 Fecal Incontinence Fecal incontinence is uncommon in the general population (2.2%) but has a significantly higher prevalence (10%) in the older population 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

49. K. Hall TSRC April 2010 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) 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.

50. K. Hall TSRC April 2010 What can be done about Fecal Incontinence? Your medical provider should ask questions and may do tests to determine if it is due to diarrhea, inflammation in the rectum, obstruction, or rectal dysfunction If no obvious cause, or if rectal dymotility is the cause, referral to specialist center for multifactorial assessment and treatment (biofeedback, surgery) Michigan Bowel Disorders program at UM – multidisciplinary team of gastroenterologists, urologists, surgeons, physical therapists Your medical provider should ask questions and may do tests to determine if it is due to diarrhea, inflammation in the rectum, obstruction, or rectal dysfunction If no obvious cause, or if rectal dymotility is the cause, referral to specialist center for multifactorial assessment and treatment (biofeedback, surgery) Michigan Bowel Disorders program at UM – multidisciplinary team of gastroenterologists, urologists, surgeons, physical therapists Hall KE, et al. Gastroenterology. 2005;129:1305-1338 Akhtar AJ, et al. J Amer Med Dir. Assoc. 2005;6:54-60. Hall KE, et al. Gastroenterology. 2005;129:1305-1338 Akhtar AJ, et al. J Amer Med Dir. Assoc. 2005;6:54-60.

51. K. Hall TSRC April 2010 Changes in the Liver and gallbladder 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-”fatty liver”) 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 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-”fatty liver”) 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 Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905.

52. K. Hall TSRC April 2010 Hepato-biliary Function We order “liver function” blood tests to check levels of liver enzymes – actually these are “dysfunction tests” as enzymes are released by damaged cells Real liver function tests –Albumin –PT/INR –Bilirubin conjugation Hepatic Ultrasound with Portal vein Doppler is helpful –Check for cirrhosis, portal hypertension –May add CT if undiagnostic Refer to hepatologist or gastroenterologist if very abnormal enzyme levels or other evidence of impaired liver function Mild elevation in enzymes without dysfunction is NOT a contraindication to use of statins for high cholesterol We order “liver function” blood tests to check levels of liver enzymes – actually these are “dysfunction tests” as enzymes are released by damaged cells Real liver function tests –Albumin –PT/INR –Bilirubin conjugation Hepatic Ultrasound with Portal vein Doppler is helpful –Check for cirrhosis, portal hypertension –May add CT if undiagnostic Refer to hepatologist or gastroenterologist if very abnormal enzyme levels or other evidence of impaired liver function Mild elevation in enzymes without dysfunction is NOT a contraindication to use of statins for high cholesterol Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905. Hall KE, et al. Gastroenterology. 2005;129:1305-1338. Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:897-905.

53. K. Hall TSRC April 2010 Gallbladder Function with Aging Bile becomes increasingly lithogenic (stone-forming) with aging In older individuals there is less complete gallbladder emptying following a meal Aging women may be more susceptible to impaired gallbladder contractility Compared to young patients, inflammation (cholecystitis and cholangitis) in older patients has increased morbidity and mortality We do hepatic ultrasound and HIDA scan (Gallbladder emptying scan), consider referral for ERCP – special endoscopic procedure Bile becomes increasingly lithogenic (stone-forming) with aging In older individuals there is less complete gallbladder emptying following a meal Aging women may be more susceptible to impaired gallbladder contractility Compared to young patients, inflammation (cholecystitis and cholangitis) in older patients has increased morbidity and mortality We do hepatic ultrasound and HIDA scan (Gallbladder emptying scan), consider referral for ERCP – special endoscopic procedure Hall KE, et al. Gastroenterology. 2005;129:1305-1338.

54. K. Hall TSRC April 2010 Pancreatic Function with Aging Exocrine and endocrine pancreatic function in non- diabetic patients is preserved with aging Older people may have insulin resistance so they secreate more insulin Incidence of pancreatic cancer is increased 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 Exocrine and endocrine pancreatic function in non- diabetic patients is preserved with aging Older people may have insulin resistance so they secreate more insulin Incidence of pancreatic cancer is increased 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.

55. K. Hall TSRC April 2010 1.Tips to keep your GI tract Healthy Karen Hall, MD www.sitemaker.umich.edu/kehall If you do notice that you are choking on food more often (or have had pneumonia frequently) Tell your doctor – he/she may order tests of swallowing function Chew food well (meat is a common culprit for impaction in the esophagus) If you have oropharyngeal motility problems, you may need to thicken liquids to stop them going “the wrong way” Tucking the chin down when swallowing can decrease the risk of aspiration If you do notice that you are choking on food more often (or have had pneumonia frequently) Tell your doctor – he/she may order tests of swallowing function Chew food well (meat is a common culprit for impaction in the esophagus) If you have oropharyngeal motility problems, you may need to thicken liquids to stop them going “the wrong way” Tucking the chin down when swallowing can decrease the risk of aspiration

56. K. Hall TSRC April 2010 2. Tips to keep your GI tract Healthy Try to avoid injury to the lining of the esophagus and stomach Don’t smoke or use alcohol in excess (1 drink per day not more) less alcohol also helps the liver Be careful about medications – acetaminophen is safer than aspirin or NSAIDs (ibuprofen or naproxyn) If you must take NSAIDs – use a protective drug (omeprazole or other PPI) Bisphosphonates used for osteoporosis can cause inflammation – tell your doctor if you develop swallowing problems or pain Try to avoid injury to the lining of the esophagus and stomach Don’t smoke or use alcohol in excess (1 drink per day not more) less alcohol also helps the liver Be careful about medications – acetaminophen is safer than aspirin or NSAIDs (ibuprofen or naproxyn) If you must take NSAIDs – use a protective drug (omeprazole or other PPI) Bisphosphonates used for osteoporosis can cause inflammation – tell your doctor if you develop swallowing problems or pain

57. K. Hall TSRC April 2010 3. Tips to keep your GI tract Healthy Treat constipation with increased physical activity, fluids (6 glasses water per day), fiber, laxatives If very constipated use fiber LAST - start with stimulant laxative or osmotic laxative to avoid impaction Try promoting a bowel movement by toileting after breakfast (use the normal gastro-colonic reflex) Treat constipation with increased physical activity, fluids (6 glasses water per day), fiber, laxatives If very constipated use fiber LAST - start with stimulant laxative or osmotic laxative to avoid impaction Try promoting a bowel movement by toileting after breakfast (use the normal gastro-colonic reflex)

58. K. Hall TSRC April 2010 4. Tips to keep your GI tract Healthy Watch for infections – older people can get food poisoning more easily so avoid uncooked eggs, raw seafood Have rehydration solution at home (Pedialyte or other product) C. difficile can be transmitted outside the hospital by recently-admitted patients so be careful when visiting those who have been in hospital – wash your hands! Watch for infections – older people can get food poisoning more easily so avoid uncooked eggs, raw seafood Have rehydration solution at home (Pedialyte or other product) C. difficile can be transmitted outside the hospital by recently-admitted patients so be careful when visiting those who have been in hospital – wash your hands!

59. K. Hall TSRC April 2010 Questions? This talk will be posted on my website as: “Digestive Health, Turner Senior Resource Center, 2010” www.sitemaker.umich.edu/kehall This talk will be posted on my website as: “Digestive Health, Turner Senior Resource Center, 2010” www.sitemaker.umich.edu/kehall