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General Principles in Older Adults
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According to data from the U.S. Census Bureau in 2005, 45–50 million people older than age 65 years had at least 1 gastrointestinal (GI) complaint that impacted their daily life and that could result in a medical visit. GI symptoms are common in older adults and range from mild self-limited episodes of constipation or acid reflux to life-threatening episodes of infectious colitis or bowel ischemia. In addition to the increased prevalence of diseases such as diverticulitis and colon cancer in older patients, other common comorbidities, such as pain requiring nonsteroidal antiinflammatory drug use or atrial fibrillation requiring use of anticoagulants, increase the risk of GI complications such as ulceration or bleeding. Patients may present with unusual or subtle symptoms of serious GI disease caused by alterations in physiology with aging. An example of this is seen in older patients presenting with a GI perforation or colitis who do not have guarding or significant abdominal tenderness as a result of the decrease in visceral sensitivity that accompanies aging. Changes in the neuromuscular control of the colon with aging appear to predispose to constipation, thus explaining the increased prevalence of constipation and impaction developing with bed rest or use of constipating medications.
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Disorders of the Esophagus
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Essentials of Diagnosis
Gastroesophageal reflux is experienced monthly by at least 40% of older persons and usually requires ongoing therapy.
To maximize quality of life and minimize office visits, treatment of reflux can be started with a proton pump inhibitor along with initiation of lifestyle changes.
Dysphagia may be oropharyngeal (mostly caused by neurologic disorders) or esophageal; the causes of esophageal dysphagia can generally be determined by history.
Esophageal cancer usually presents in an advanced stage in older adults, with symptoms of progressive dysphagia and weight loss.
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Gastroesophageal Reflux Disease
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General Principles in Older Adults
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Gastroesophageal reflux disease (GERD) is one of the more common GI disorders affecting older adults. Population studies indicate that more than 20% of adults older than age 65 years have heartburn at least weekly. This may actually underestimate the true prevalence of GERD because of the finding that, although symptoms appear to decrease in intensity with age, the severity of reflux and the risk of complications increases. Once symptoms develop, more than 50% of patients will have persistent symptoms and may require ongoing medical therapy.
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GERD can be readily diagnosed if the patient complains of typical symptoms of pyrosis (substernal burning with radiation to the mouth and throat) and sour regurgitation, and if these symptoms improve with treatment. Pathophysiologic changes with aging outlined above may decrease symptoms of GERD, such that patients may present with atypical symptoms, such as a chronic cough, difficult-to-control asthma, laryngitis, or recurrent chest pain rather than heartburn.