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

2. 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

3. 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% of geriatric patients will have at least 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.

4. 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
(16%) 72
(20%) 4 7 12
(8%) 20
(10%)
He W, et al. 65+ in the US: US Census Bureau Web site. Available at: Accessed 11/30/06.

5. 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
Hall KE, et al. Gastroenterology. 2005;129:

6. 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:

7. 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
Hall KE, et al. Gastroenterology. 2005;129:

8. 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 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
Hall KE, et al. Gastroenterology. 2005;129:
Cullen DJE, et al. Gut. 1997;41:

9. 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:

10. GI Disorders Related to Aging

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

12. 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
Hall KE, et al. Gastroenterology. 2005;129:
Image courtesy of David C. Metz, MD.

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

14. 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 (%)
n = 1034
n = 147
n = 63
Age group (years)
Lin OS, et al. JAMA. 2006;295:

15. 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
Hall KE, et al. Gastroenterology. 2005;129:
Petruzziello L, et al. Aliment Pharmacol Ther. 2006;23:

16. 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
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 in North Americans

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

19. Diarrhea
Definition:
Loose stools of more than 200 grams per day in at least 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
I added “Patient’s description usually focuses on loose stools” in the definition
Hoffmann JC, et al. Best Pract Res Clin Gastroenterol. 2002;16:17-36.
Hall KE, et al. Gastroenterology. 2005;129:

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

21. 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 overflow
Decreased rectal or anal sensation
Internal anal sphincter incompetence
Hall KE, et al. Gastroenterology. 2005;129:

22. 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)
Goode PS, et al. J Am Geriatr Soc. 2005;53:

23. 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
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.

24. 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
Changed title to “Hepato-biliary Function with Aging” – I think it should be hypenated.
*Decreases occur between the 3rd and 10th decade of life
Hall KE, et al. Gastroenterology. 2005;129:
Reynaert H, et al. Aliment Pharmacol Ther. 2005;22:

25. 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
Edited title – leave out “hepatobiliary function” – focus on gallstones/gallbladder.
Hall KE, et al. Gastroenterology. 2005;129:

26. 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 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
Changed title to “with Aging” from “in Aging”
Hall KE, et al. Gastroenterology. 2005;129:

27. 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 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: