1. GI Update in the Older Patient Karen E. Hall, M.D., Ph.D. Clinical Assistant Professor Department of Internal Medicine University of Michigan Health System Geriatric Research, Education and Care Center Ann Arbor VA Health System Geriatric Noon Conference June 21, 2005

2. 1. Review of common gastrointestinal problems in older patients 2.Address controversies in treatment Objectives

3. Aging sets the stage for clinical impairment Physiologic effects of aging + Superimposed disease Effects of medications = “Clinical impairment in areas already at risk due to normal aging”

4. Aging-associated changes in GI function Studies in healthy older people have documented significant changes in: Splanchnic blood flow Swallowing Colonic Function

5. Small bowel “resistant” to aging In healthy older people there is minimal change in small bowel: Motility Secretion Absorption “Proximal and distal GI tract at greatest risk for dysfunction in aging”

6. Aging and Swallowing : Dysphagia Shaker and Staff. Gastroenterol Clin North Am 30:335, 2001 Proximal GI tract: Aspiration risk increases with age Swallowing studies: 40% of asymptomatic 80+ year olds have significant abnormalities Asymptomatic aspiration in 10%

7. Dysphagia: Sometimes it’s what you eat Johnny Fox

8. Aging and Swallowing Kern et al. Ann Otol Rhinol Layngol 108: 982, 1999 1. No teeth: Impaired mastication 2. Impaired oropharyngeal co-ordination: Slow transit of food bolus, pooling at larynx 3. Delayed relaxation of upper esophageal sphincter (UES): Food goes where it shouldn’t! = Aspiration

9. GE Reflux: Another risk for aspiration Mean lower esophageal sphincter (LES ) pressure decreases with age: Gastroesophageal reflux disease (GERD) Prevalence: 12-15% age <60 5-10% age >60 **underestimate asymptomatic or atypical symptoms of GERD in 30% of elderly

10. Atypical reflux symptoms in elderly Older patients: esophageal: dyspepsia, nausea, dysphagia aspiration: cough, hoarse voice, laryngitis, asthma, recurrent pneumonia “Unexplained respiratory problems - GERD”

11. GERD: Diagnosis and Treatment Younger patients: “treat then scope” if benign symptoms - acid blockade with antacids, H2 antagonist or PPI** **GERD treatment $10 billion in 2000 70% medication costs Sandler et al. Gastroenterol 122: 1500, 2002

12. GERD: Diagnosis and Treatment Older patients: “scope then treat” Higher risk of neoplasia and complications of GERD

13. Investigation of dysphagia in older patients Endoscopy indicated Older patients: Higher risk of complicated GERD Ulceration Stricture Anemia Barrett’s esophagus Increased incidence of esophageal cancer

14. Barrett’s Esophagus Mucosa: Squamous to intestinal Pre-malignant: Biopsy required to detect dysplastic epithelium High grade dysplasia (HGD) has significant risk of progression to adenocarcinoma

15. Barrett’s Esophagus Earlier studies: 7-10% risk of adenocarcinoma per year Recommendations: Screen all patients with GERD history High Grade Dysplasia: surgical referral Low-Moderate Grade Dysplasia: high dose PPI Follow-up EGD every ? 6 months – 1 year

16. Should we treat Barrett’s Esophagus? Recent RCTs of PPI treatment of Barrett’s: No significant effect on: Rate of progression of low or moderate dysplasia to high grade dysplasia Rate of esophageal adenocarcinoma Screening EDG: esophageal cancer in 0.8% (10x expected population rate)

17. Why didn’t PPI treatment work? ? Not long enough (6 mo – 2 years) ? Genetic mutation already present ? Acid exposure not the only cause ? Biopsy error

18. Treatment of Barrett’s Esophagus Current recommendations: Screening EGD for patients with GERD history +for HGD: surgical referral or laser ablation or endoscopic mucosal resection +for M-LGD: ?PPI + Follow-up EGD ?timing “Future developments” - p53 antigen,cytometry, microscopic endoscopic examination Dong Wang et al. Dis of the Esophagus, 15:80-4, 2002 Conio M et al. Am J Gastroenterol. 98:1931-9, 2003.

19. Achalasia: Is a tight LES a good thing? Subset of patients have pathologic increase in LES pressure termed Achalasia 0.5% prevalence Female: Male 4:1 Often “pretty old”: 75-85 years “Progressive dysphagia to both liquids and solids occurring simultaneously”

20. Achalasia LES: Extreme narrowing - “bird’s beak” Swallow: LES relaxation poor or absent: inhibitory neurons absent or dysfunctional Investigation: Barium swallow and esophagoscopy

21. Achalasia Treatment 1. Forcible balloon distension Rupture, mediastinitis, sepsis 2. Botulinum toxin injection Relief x weeks-months (50% re- treat in 9 months vs 10% balloon) Risks/benefit better in frail pts? 3. Endoscopic or laparoscopic LES myotomy ?similar risk/benefit as balloon Limited availability

22. Aspiration pneumonia Major risks for aspiration pneumonia: Tardive dyskinesia (medication) GERD Impaired bolus transit: age, anticholinergic medications Triple phase Swallowing study: fluoroscopy Diagnostic (severity; complications) Guide therapy

23. Are feeding tubes indicated in dementia? “Controversial topic” Demented patients may live longer with a tube Increased calories Cost: Poor quality of life Pain; restraints; ER visits; infection; bleeding Aspiration and pneumonia risk NOT decreased Bacteria in saliva; reflux liquid diet

24. Feeding tubes in Dementia Short-term mortality increased with feeding tubes 50% mortality in 1 month Infection, peritonitis, complications of re-insertion Sanders et al. Am J Gastroenterol 95:1472-5, 2000. Hand-feeding: Mortality and morbidity same as tube feeding Nursing home costs much higher if patients fed by hand – not popular in the US

25. Constipation in the elderly Schiller Gastroent Clin North Am 30: 497, 2001 Multifactorial: Aging-related colonic slowing Superimposed disease (Parkinson’s) Immobile Medications (Ca antagonist, diuretic, levodopa)

26. Aging-associated changes in GI function Colonic motility: Slow transit: loss of myenteric neurons, sarcopenia decreased prokinetic signaling: 5-HT3, 5-HT4, calcium, motilin Increased intraluminal pressure: Impaired relaxation of sphincters: Loss of inhibitory nitric oxide signaling

27. Medications that cause constipation: The “Anti’s” Schiller Gastroent Clin North Am 30: 497, 2001 Antihistamines: diphenhydramine/Benedryl, “Tylenol PM” Antihypertensives: atenolol, diltiazem Antidepressants: tricyclic - amitriptyline Antilipemics: cholestyramine, colestipol Antiparkinsonian: L-dopa/carbidopa Antipsychotics: haloperidol, resperidone Antacids: aluminum-containing, sucralfate Anticonvulsants: phenytoin Analgesics: opiates

28. Constipation Initiate a bowel regimen 1.“Get things moving from below first” Suppository Enema: phospho-soda tap water (not soapsuds –colitis) Milk and molasses Dis-impaction (by your assistant!) 2. Optimize hydration and mobility 3. Maintenance: cathartic/osmotic laxative (Milk of magnesia; Dulcolax; Senna; PEG solution)

29. Constipation Avoid: 1. Initial oral cathartics: potentially dangerous if severely constipated “Use when bowels are moving” 2. Mineral oil by mouth: lipoid pneumonia 3. Fiber alone: unlikely to work and may cause impaction 4. Antispasmodics: anticholinergic and serotonin antagonists associated with fatal ischemic colitis

30. What about Tegaserod maleate (Zelnorm c )? 5-HT4 agonist constipation-predominant IBS Studies showed efficacy only in women Limited data - safe in older patients Contraindications: severe renal failure, hepatic disease, symptomatic gallbladder, previous bowel adhesions 2 mg bid – increase to 6 mg bid if tolerated No adjustment for mild-moderate renal failure

31. Diarrhea Less common than constipation, more socially debilitating Infectious: older patients = higher risk History of travel or problem foods Check hydration status Fecal occult blood, Stool cultures Rectal: impaction with overflow Diverticulitis

32. Diarrhea in Aging population Consider inpatient management if: Bleeding, fever, chills (enteroinvasive) Loss of appetite Live alone, poor hydration/nutrition, disabled Avoid endoscopy until infection and/or acute abdomen ruled out

33. Diarrhea in Aging population Chronic: If stable: recommend colonoscopy Microscopic/lymphocytic colitis Collagenous colitis IBD (inflammatory) Structural: pelvic laxity, fissure Irritable bowel syndrome (yes this does happen!) Treatment: antidiarrheals (Imodium) soluble fiber, cholestyramine, PeptoBismal 5-ASA or steroids for severe colitis REVIEW MEDs – PPIs, antiarrhythmics, Aricept ©

34. What about Alosetron (Lotronex © )? 5-HT3 antagonist Diarrhea-predominant irritable bowel syndrome Only effective in women No Pre-market studies performed > age 45 7/1000 incidence of hospitalization for: Severe constipation, colitis, death – both young and older patients Withdrawn in 2000, re-released in 2002 1 mg/day – 1 mg bid DISCONTINUE IF CONSTIPATION OCCURS

35. “Acute Abdomen” in the Older Patient Morbidity and mortality: higher in geriatric patients Due to delay in diagnosis Symptoms vague/atypical: Rebound and guarding absent in 50-70% WBC: “normal” but may have left shift Confusion, anorexia “High index of suspicion needed”

36. Autonomic sensation impaired in aging Age-associated decrease in visceral sensation Peritonitis: tenderness and guarding often reduced or absent Hall Am J Physiol 283: G827, 2002

37. Decreased blood supply to GI tract Age > 70: Increased risk of gastrointestinal ischemia Superior mesenteric artery flow decreased by 30% Inferior mesenteric artery occluded in 20% autopsies Esophagus, stomach, and proximal small bowel protected due to anastomotic blood supply “Watershed” areas at risk for ischemia: splenic flexure of colon ~ 20% decrease in blood flow to liver Impaired metabolism of drugs, bilirubin; impairs recovery from liver damage

38. Ischemic Colitis Age > 70: incidence 5% in age > 70 90%: mild tenderness, hematochezia change in bowel habit 85-90% will recover without surgery Mortality: low (2-6%) if not transmural >50% if transmural Requires close observation with serial imaging to detect colonic dilatation or free air

39. Acute Abdomen in the Older Patient Acute abdomen: potentially treatable appendicitis; diverticular abcess; ischemic colitis; cholecystitis Patient’s Advance Directives: If desire for treatment of potentially reversible conditions – investigation should not be delayed

40. Appendicitis in the Older Patient Increased incidence: men aged 80+ 70-90% have rupture at time of surgery delay in diagnosis a major factor 6-10% mortality vs 0.5% in young 50% of deaths from appendicitis occur in aged

41. Diverticular Disease > 70 % geriatric patients have diverticuli Circular muscle: fewer fibers; larger spaces between fibers Increased collagen between muscle bundles Prolongation of muscle contraction Increased intraluminal pressure Mucosa/submucosa protrudes through wall = Diverticulum

42. Diverticulitis Caused 5000 deaths in 1998 (1/10 colon cancer rate) Most deaths occurred in patients aged >75 years Delay of diagnosis with perforation and abcess Mortality rate: women 2.4 x higher than men (more older women) “Diverticular bleeding” often diagnosis of exclusion

43. Diverticulitis Presentation: usually some pelvic localization of symptoms, diarrhea or constipation, chills, (bleeding) Rectal exam: localized tenderness or mass – check for occult blood CT scan, avoid flexible sigmoidoscopy! Patient stable: trial of antibiotics, see again within a week “Needs close observation”

44. Diverticular bleeding

45. Colon Cancer: a disease of Aging 1.9 million office visits, 55,000 deaths in 2003

46. Colon Cancer: a disease of Aging 80-90% of tumors arise from colon polyps 70% of age >65 have polyps, those who don’t by age 75 are probably never going to Colonoscopy is screening method of choice (AGA, ACG, ACS): Medicare covers once every 10 years > 50% of polyps and cancers are in the ascending/transverse colon

47. Colon Cancer Screening Recommendations for screening: Colonoscopy age 55-60 then q 10 years to age 85 … don’t have guidelines > 85 Continue yearly FOB Barium enema if colonoscopy fails

48. What if patient is over 85? Use your best judgement: Functional status/cognition Expected life span > 5 years Patient’s wishes Gastroenterologist’s wishes “Never screened” – 1-3% have cancer

49. Colon Cancer Screening Recommended follow-up of polyps: Yearly FOB Colonoscopy: at 1 year for high grade lesions (villous, polyps >2 cm, High Grade Dysplasia), then q 3-5 years at 3-5 years for low grade lesions

50. Colon Cancer What about primary prevention? NSAIDs, calcium, Vitamin D may decrease risk of polyps Fiber: controversial + and – studies May work better with Vitamin D Pignone M, Levin B. Am Fam Physician. 2002 Jul 15;66(2):297-302. Lieberman et al. JAMA 290:2959-2967, 2003.

51. Colon Cancer – new tests Stool DNA testing “Not ready for prime time” Lot of candidate genes: p53, Apc, K-ras, BAT- 26 Variable expression (40-80% of Dukes A-D) Longer DNA fragments may indicate neoplasm

52. Colon Cancer – new tests Virtual colonoscopy “Almost ready for prime time?” ?Sensitivity/specificity 85-90% for polyps >1cm Cannot remove or biopsy tissue Still need prep, air insufflation, dilute oral contrast dye to opacify stool Benefit: Avoid conscious sedation in older patients Pickhardt et al. NEJM 349: 2003; Cotton et al. JAMA 1713, 2004

53. Virtual Colonoscopy Pickhardt et al., Annals Int Med 141: 352-59, 2004

54. Virtual Colonoscopy

57. “Flyback” transverse colon: view looking back towards rectum Pink areas: posterior folds Polyps on posterior more often missed during optical colonoscopy

58. Virtual Colonoscopy Who will read: radiology or GI? Indications not yet clear: primary screening vs adjunct to optical colonoscopy Possible primary screening tool: low risk patients, no contraindication to colonoscopy if test +

59. References Reviews: Physiology: Am J Physiol 283:G827-832, 2002 Gastro Clinics North America 30, 2001 Geriatric Review Syllabus 5 th Edition http://www.americangeriatrics.org/products/grs5.shtml Volume 2 to follow: bleeding, dyspepsia, malabsorbtion, pancreatic, hepatobiliary Handouts on my website: http://sitemaker.umich.edu/khallinfo