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. Increase in the Number of Persons Aged 65+ Years in the United States
The “Age Wave”
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 55
(17%) 72
(20%) 4 7 12
(8%) 20
(10%)
He W, et al. US Census Bureau. Current Population Reports, P in the United States: US Government Printing Office. Washington DC, 2005.

3. Population Aged ≥ 65 by Race in 2003, 2030, and 2050
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
He W, et al. US Census Bureau. Current Population Reports, P in the United States: US Government Printing Office. Washington DC, 2005.

4. Epidemiology
Over 35 million people aged >65 years in the United States
12% of the 2003 US population were older than 65
18.3 million aged 65-74
12.9 million aged 75-84
4.7 million aged ≥ 85
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
He W, et al. US Census Bureau. Current Population Reports, P in the United States: US Government Printing Office. Washington DC, 2005.
Hall KE, et al. Gastroenterology. 2005;129:

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

6. The Geriatric Patient Profile
Increasing age = increased heterogeneity in functional status, cognition, and co-morbidities
Future cohorts likely to be more interested in the maintenance of independent living
Older patients are at high risk of iatrogenic complications
Especially true when the patient is seeing multiple specialists who may be prescribing treatments without coordination of care
Specialists need to be aware of the potential for complications if interventions of other medical providers are not considered
Hall KE, et al. Gastroenterology. 2005;129:

7. Age-related Changes in the Gastrointestinal Tract
Motility
Hormone
responsiveness
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
Visceral
sensitivity
Drug
metabolism
Liver sensitivity
to stress
Pancreas
structure
and function
Immunity
Lithogenic
bile
Colonic
function
Hall KE, et al. Gastroenterology. 2005;129:
Robins J, et al. GI Motility Online. 2006

8. Cellular Mechanisms of Aging
Most people experience a rapid change in physiologic function between the ages of 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
Hall KE, et al. Gastroenterology. 2005;129:

9. Decreased Autonomic Sensitivity
“Painless GERD”
“No Peritonitits”

10. CT scan for Acute Abdomen

11. Effect of Aging on Swallowing
Oro-pharyngeal dyskinesia – normal aging
Slow Transit past pharynx and upper esophageal sphincter (UES)
Aspiration
Zenker’s Diverticulum
Decreased lower esophageal sphincter (LES) pressure
Gastroesophageal reflux (GERD)
Esophagitis
Bleeding
Secondary Esophageal Dysmotility
Poor clearance (“tertiary contractions”)
Spasm
Presbyesophagus (long tortuous esophagus)
Hall KE, et al. Gastroenterology. 2005;129:

12. Esophageal Aging Dysphagia, regurgitation, nausea are common
Heartburn not so common
Atypical chest pain
“Presbyesophagus”: (age-related changes in esophageal function)
Decreased contractile amplitude
Polyphasic waves
Incomplete relaxation of the lower esophageal sphincter (LES)
Esophageal dilation
GERD
Impaired clearance of acid
Longer duration of reflux episodes
Atypical symptom presentation
Hall KE, et al. Gastroenterology. 2005;129:

13. 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
Hall KE, et al. Gastroenterology. 2005;129:

14. Peptic Esophageal Stricture
Hall KE, et al. Gastroenterology. 2005;129:

15. Achalasia Impaired relaxation of the LES
Loss of inhibitory myenteric neurons
Idiopathic
Paraneoplastic
Chagas Disease (parasitic infection)
Tumor can present in same way
Get endoscopy
LES is distensible
Tumor or peptic stricture is fixed
Balloon dilation
Botulinum toxin injection
Myotomy

16. GERD and Barrett’s Esophagus
Unclear if acid exposure is the cause
Intestinal metaplasia
Endoscopic monitoring
How often? 1-3 years
Multiple 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
?DNA testing – experimental
Hall KE, et al. Gastroenterology. 2005;129:

17. 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
Hall KE, et al. Gastroenterology. 2005;129:

18. Weight Loss Assess amount of food eaten
Screen for depression and dementia
Get labs
CBC, basic renal, hepatic, TSH level, folate, B12, iron
Trial of increased calories with prompting by caregivers
If patient will not eat consider further tests
CT or referral
Consider treatment of depression
Abdominal pain may be symptom of depression
Hall KE, et al. Gastroenterology. 2005;129:
Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:
Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11.

19. Depression Affects the Elderly
Affects 1% of the general population
Most common psychiatric disorder
Affects 3%-12% of community-dwelling elderly patients
More common (>26%) in nursing home residents
May be associated with GI symptoms
Social withdrawal, and somatic symptoms such as nausea, abdominal pain, and weight loss add to the burden of GI disease
Hall KE, et al. Gastroenterology. 2005;129:
Boyle VL, et al. Am J Geriatr Psychiatry. 2004;12:
Fountoulakis KN, et al. Ann Gen Hosp Psychiatry. 2003;2:11.

20. Aging and the Stomach Decreased Increased
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 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, gastric cancer and lymphoma
Hall KE, et al. Gastroenterology. 2005;129:
Cullen DJE, et al. Gut. 1997;41:

21. Gastritis Very common NSAIDs Other meds (iron, bisphosphonates)
Hall KE, et al. Gastroenterology. 2005;129:

22. Gastroparesis Diabetes Medications (anticholinergic)
Obstructive (benign or malignant)
Endoscopy
UGI series
Gastric emptying study (abnormal if >3 hours)
Prokinetics
Metoclopramide
Erythromycin (motilin analog)
(Domperidone in Canada)
(Cisapride)

23. Gastrointestinal Bleeding is Common in the Elderly
70% GI bleeding in the upper tract
Esophagus
Stomach
Small bowel
30% GI bleeding in the lower tract
Terminal ileum
Colon
Rectum
Hall KE, et al. Gastroenterology. 2005;129:

24. 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
Continued bleeding or 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.

25. Gastrointestinal Bleeding in the Elderly
Visible vessel – laser or bicap coagulation
Esophageal varicies
usually Grade II-IV
Gastric varicies
Rarely small bowel or biliary
Hall KE, et al. Gastroenterology. 2005;129:
Image courtesy of David C. Metz, MD.

26. Celiac Disease – Malabsorbtion and Anemia
IgA and/or IgG antibodies to:
Anti-tissue transglutamidase
Anti-endomysial
Anti-gliadin
Small bowel mucosal atrophy
Weight loss and malabsorbtion – diarrhea
Anemia
Vitamin deficiencies (fat soluble and B vitamins)
May present for first time in geriatric patients
Get serology, imaging (UGI + SBFT), duodenal biopsy
If diet-resistant: oral steroid and workup for small bowel lymphoma

27. Colonic Bleeding in the Elderly
Angiodysplasia in the colon
Colitis (medications, ischemic, inflammatory)

28. Colorectal Cancer in the Elderly
An estimated 106,680 cases of colon and 41,930 cases of rectal cancer are expected to occur in 2006
90% of all cases occur in individuals older than aged 50 years
ACS Cancer Facts and Figures 2006.
Burt RW. Gastroenterology. 2000;119:
Image courtesy of Subhas Banerjee, MD.

29. Colorectal Cancer in the Elderly
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 (%)
n = 1034
n = 147
n = 63
Age group (years)
Lin OS, et al. JAMA. 2006;295:

30. Colonic Polyps
Most colon cancer (>90%) originates in adenomatous polyp
>60% are right sided (cecal and transverse) polyps - colonoscopy
1-5% of low risk patients undergoing colonoscopy have a carcinoma-in-situ (CIS)
8% of patients over 85 have CIS
60% of 85+ patients have Dukes A tumors (no extension out of the polyp)
Virtual colonoscopy not sensitive or specific enough (no insurance reimbursement !)
No “age cutoff” – “less than 5 year life expectancy”
ACS Cancer Facts and Figures 2006.
Burt RW. Gastroenterology. 2000;119: MD.

31. 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 compliance in connective tissue
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:

32. Prevalence of Constipation Compared to Other Common Diseases
Prevalence of Selected Diseases in US Adults
Coronary heart disease 14
Asthma 16
Diabetes 16
Migraines 33
Hypertension 49
Constipation
63* 20 40 60 80
Prevalence in millions
*Prevalence in North Americans
Lethbridge-Çejku M, et al. Vital Health Stat ;1.
Higgins PDR, et al. Am J Gastroenterol. 2004;99:750.

33. Constipation in the Elderly
Constipation is the most common chronic digestive complaint in the United States
Age
The incidence increases after the age of 65
Prevalence 30% - 40% among people aged > 65 years
Gender
2-3x more common in females
Impaired evacuation a significant factor in elderly women
Of 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:

34. Geriatric Risk Factors for Constipation
Immobility (bed-bound)
Pain
Musculoskeletal in spine, pelvis, hips
Abdominal
Severe generalized pain
Opiate use
Deconditioning
Muscle weakness
Neurodegenerative disease
Thyroid disease
Added “for constipation” to title (to remind audience what is the subtopic)
Higgins PDR, et al. Am J Gastroenterol. 2004;99:750.
Muller-Lissner S. Best Practice Res Clin Gastroenterol. 2002;16:
Hall KE, et al. Gastroenterology. 2005;129:
De Lillo AR, et al. Am J Gastroenterol. 2000;95:901.

35. Atypical Presentation of Constipation in the Elderly
Anorexia
Nausea
Behavioral changes
Abdominal discomfort/distension
Fecal impaction
Overflow incontinence - “diarrhea”
Get an abdominal xray
if stool proximal to descending colon – not “normal”
Same – added “of constipation” to title
De Lillo AR, et al. Am J Gastroenterol.2000;95:901.
Leonard R, et al. Arch Intern Med Jun 26;166(12):

36. 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
Herz MJ, et al. Fam Pract. 1996;13:156.

37. Bristol Stool Chart Types 1-7 More than 25% of the time
Correlates with colonic transit – type 1 slow; type 7 fast
Lewis SJ, Heaton KW. Scan J Gastroenterol 2007; 32:920

38. Constipation
No evidence that fiber or hydration alone is effective in patients >70 years without dehydration
Only RTC evidence for psyllium, osmotic agents (PEG solution) and newer drugs (tegaserod, lubiprostone)
Tegaserod recently withdrawn (April 2007) due to cardiac events (0.11% vs 0.03% placebo)
Consider stimulant laxative (senna, bisacodyl, milk of magnesia, lubiprostone)
No evidence of myenteric damage with above agents
Osmotic agents (lactulose, sorbital, PEG) also effective but may cause bloating or vomiting

39. Enema v.s. Oral agents
“Get patient moving from below before given meds from above”
If no BM in 1-2 days use suppository
Use tap water or milk and molasses (1 liter: 0.5 cups) enemas for severely constipated
Mineral oil enema may work but some cases of oil absorption and pneumonia
Avoid soapsuds enemas (ischemic colitis)

40. Diverticular Disease
An abnormality in the aging colon involving decreased tensile strength of the muscle wall
By aged 50 years one third of Americans will have diverticulosis coli; by aged 80 years, two-thirds will be affected
Incidence less than 5% <40 years
Incidence greater than 60% by aged 85 years
Mean age at presentation is aged 60 years
The majority of those affected are asymptomatic
Hall KE, et al. Gastroenterology. 2005;129:
Cooperman A. Diverticulitis. eMedicine Web Site. Available at: Accessed 11/3/2006.
Image courtesy of Jennifer Christie, MD.

41. Diverticular Disease (Cont.)
Other factors 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) 1996 to 2002 for diverticulitis
Hospital admissions increased by 14% to 261,180
Office visits increased by 14% to 1,493,865
Emergency department visits increased by 47% from 87,512  161,364
Significant morbidity and mortality from abcess and perforation (delay in diagnosis)
Hall KE, et al. Gastroenterology. 2005;129:

42. Diarrhea
Definition:
Loose stools of more than 200g/day in at least three bowel movements per day
Patient’s description usually focuses on loose stools
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 2000
Office visits for chronic diarrhea increased by 115% from 991,886  2,132,272
?Medications vs Exposure – food, institutions
I added “Patient’s description usually focuses on loose stools” in the definition
Hoffmann JC, et al. Best Pract Res Clin Gastroneterol. 2002;16:17-36.
Hall KE, et al. Gastroenterology. 2005;129:

43. Causes of Diarrhea in the Elderly
Common Causes
Infections
Drug-induced diarrhea
Malabsorption
Fecal impaction
Colonic carcinoma
Small bowel bacterial overgrowth
Diabetic diarrhea
Changed “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 Gastroneterol. 2002;16:17-36.
Hall KE, et al. Gastroenterology. 2005;129:

44. 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
Changed “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 Gastroneterol. 2002;16:17-36.
Hall KE, et al. Gastroenterology. 2005;129:

45. Fecal Incontinence
Fecal incontinence is uncommon in the general population (2.2%) but has a significantly higher prevalence (10%) in the older population
Anorectal damage from surgery or irradiation
Structural impairments in the pelvic floor
Fecal incontinence can result from:
Fecal impaction and subsequent flow
Decreased rectal or anal sensation
Internal anal sphincter incompetence
Hall KE, et al. Gastroenterology. 2005;129:

46. 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)
Goode PS, et al. J Am Geriatr Soc. 2005;53:

47. 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
Refer to specialist center for multifactorial assessment and treatment (biofeedback, surgery)
The 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.

48. Hepato-biliary Function 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) 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
Changed title to “Hepato-biliary Function with Aging” – I think it should be hypenated.
Hall KE, et al. Gastroenterology. 2005;129:
Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:

49. Hepato-biliary Function
Liver “function” tests – actually dysfunction tests
Enzymes, bilirubin level
Liver Function tests
Albumin
PT/INR
Bilirubin conjugation
Hepatic Ultrasound with Portal vein Doppler
Check for cirrhosis, portal hypertension
May add CT if undiagnostic
Refer to specialist if enzymes >100, hepatic alkaline phosphatase persistently elevated, or liver function impaired
Mild AST or ALT elevation without dysfunction is NOT a contraindication to use of statins
Changed title to “Hepato-biliary Function with Aging” – I think it should be hypenated.
Hall KE, et al. Gastroenterology. 2005;129:
Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:

50. Gallbladder Function with Aging
Bile becomes increasingly lithogenic with aging
Precipitation of supersaturated bile and concomitant crystallization of cholesterol or calcium bilirubinate
In subjects older than 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 has increased morbidity and mortality
Hepatic ultrasound and HIDA scan, consider referral for ERCP
Edited title – leave out “hepatobiliary function” – focus on gallstones/gallbladder.
Hall KE, et al. Gastroenterology. 2005;129:

51. Pancreatic Function with Aging
Exocrine and endocrine pancreatic function in non-diabetic patients is preserved with aging
Incidence of pancreatic cancer is increasing 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
Changed title to “with Aging” from “in Aging”
Hall KE, et al. Gastroenterology. 2005;129:

52. Summary
The age wave will continue to increase in the next years resulting in a substantial boom of the geriatric population
Many physiological and psychological changes occur with age
There are significant changes in gastrointestinal function that occur in geriatric-aged patients
Aging increases the risk of several disorders:
Dysphagia, GI bleeding, colorectal cancer, constipation, diverticular disease, diarrhea, fecal incontinence , pancreatic cancer, and hepatobiliary disorders
He W, et al. US Census Bureau. Current Population Reports, P in the United States: US Government Printing Office. Washington DC, 2005.
Hall KE, et al. Gastroenterology. 2005;129:

53. Handouts
Sitemaker.umich.edu/khallinfo
AGS 2007