1. Gastrointestinal Disease 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 DDW New Orleans May 18, 2004

2. 1. Review of common gastrointestinal problems in older patients 2. Address controversies in treatment 3. Use questions from the 5th Edition of the American Geriatric Society Review Syllabus Objectives

3. Handouts Handouts on my website: http://sitemaker.umich.edu/khallinfo

4. 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”

5. Question 1: Effect of aging on GI function Which finding is more likely due to DISEASE rather than normal AGING? 1.Colonic diverticulosis 2.Dysphagia 3.Decreased small bowel motility 4.Decreased splanchnic blood flow 5.Decreased lower esophageal pressure

6. Answer: 3 Which finding is more likely due to DISEASE rather than normal AGING? 1.Colonic diverticulosis 2.Dysphagia 3.Decreased small bowel motility 4.Decreased splanchnic blood flow 5.Decreased lower esophageal pressure

7. 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”

8. Aging-associated changes in GI function Studies in healthy older people have documented significant changes in: Swallowing: slow bolus transit and airway closure Splanchnic blood flow: decreased

9. Decreased blood supply to GI tract Age > 70: Splanchnic Blood flow decreased by 30% Atherosclerosis: IMA occluded in 20% autopsies Esophagus, stomach, and proximal small bowel protected due to rich anastomotic supply ~ 20% decrease in blood flow to liver Impaired metabolism: drugs, bilirubin Impairs recovery from liver damage “Watershed” areas: splenic flexure of colon (ischemic colitis)

10. 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 pressures: Loss of inhibitory nitric oxide signaling

11. Aging and Swallowing 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%

12. 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!

13. Reflux risk increases with age 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 in 30% of elderly

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

15. Question 2: Dysphagia 74 yo man has 1 yr trouble swallowing, nausea, no weight loss, chronic cough. No alcohol, stopped smoking. Meds: ACE, iron, diuretic, K+, vitamin Physical “normal”. Hematocrit 34. Which would you do next? 1.Upper endoscopy (EGD) 2.Esophageal Manometry 3.pH monitoring 4.Discontinue K+ 5.Trial of H2 antagonist

16. Answer: 1- Upper Endoscopy 74yo man has 1 yr trouble swallowing, nausea, no weight loss, chronic cough. No alcohol, stopped smoking. Meds: ACE, iron, diuretic, K+, vitamin Physical “normal”. Hematocrit 34. Which would you do next? 1.Upper endoscopy (EGD) 2.Esophageal Manometry 3.pH monitoring 4.Discontinue K+ 5.Trial of H2 antagonist

17. 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

18. 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

19. Barrett’s Esophagus Earlier studies: 7-10% risk of adenocarcinoma per year Up to 1998-99: Screening EGD for patients with GERD history 2.+Barrett’s: biopsy HGD: surgical referral 3.Low-Moderate Grade Dysplasia: high dose PPI 4.Follow-up EGD every ? 6 months – 1 year?

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

21. 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

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

23. 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

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

25. Back to Question 2: GERD What about the other options? Manometry, pH monitoring: may confirm esophageal spasm or acid but will not diagnose dysplasia or cancer Discontinuing K+: EGD first - If ulceration and/or stricture observed with EGD then discontinue H2 antagonist: Acid reduction sub-optimal for treatment of GERD, side effects (cimetidine)

26. 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”

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

28. 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. Laparoscopic LES myotomy ?similar risk/benefit as balloon Limited availability

29. Question 3: Aspiration pneumonia 69 yo male Nursing Home resident with dementia, GERD, tardive dyskinesia has productive cough, fever, hypoxia. CXR: right LL pneumonia. After treatment of pneumonia, what you do next? 1. Cervical xray to check for cervical spurs 2. Discontinue antipsychotic medication 3. Start metoclopramide 4. Perform swallowing evaluation 5. Place feeding tube

30. Answer: 4. Swallowing evaluation 69yo male NH resident with dementia, GERD, psychosis, tardive dyskinesia has productive cough, fever, hypoxia. CXR: right LL pneumonia. After treatment of pneumonia, what you do next? 1. Cervical xray to check for cervical spurs 2. Discontinue antipsychotic medication 3. Start metoclopramide 4. Perform swallowing evaluation 5. Place feeding tube

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

32. What about the other options? Cervical spurs common, rarely cause dysphagia Discontinuing antipsychotic or adding metoclopramide may worsen dyskinesia Titrate antipsychotic down gradually to lower dose

33. 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

34. 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

35. Why not place a Feeding Tube? Significant complications and ethical issues Swallow study, adjust diet, medication first

36. Question 4: A constipated patient? 86 yr man Nursing Home resident - has fever, emesis x 36 hours. History of HTN, CAD, diabetes, moderate dementia, acute MI 1 mo ago. Temp 99.5; HR 112; BP 105/66; abdomen not tender; no guarding/rigidity; WBC 8; rest of lab tests normal; EKG: nonspecific ST changes. Advance directives on file: wants hospital management of “reversible conditions”, no CPR

37. Question 4 What would you do next? 1. Serial abdominal exams and xrays in NH 2. Serial EKGs and cardiac enzymes in NH 3. Bowel regimen for constipation 4. Fluids and antibiotics in NH 5. To ER for urgent surgical evaluation

38. Answer: 5. Surgical Evaluation What would you do next? 1. Serial abdominal exams and xrays in NH 2. Serial EKGs and cardiac enzymes in NH 3. Bowel regimen for constipation 4. Fluids and antibiotics in NH 5. To ER for urgent surgical evaluation

39. 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”

40. 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

41. Acute Abdomen in the Older Patient Acute abdomen: potentially treatable appendicitis; diverticular abcess; ischemic colitis; cholecystitis Patient’s Advance Directives: indicated desire for treatment of potentially reversible conditions

42. Question 4: the other options? Patient already too ill for serial abdominal exams or cardiac enzymes in nursing home Bowel regimen contraindicated if acute abdomen suspected – may cause perforation Fluids and antibiotics in nursing home: Unlikely to prevent deterioration if surgical disease If patient/family want “trial of therapy” rather than comfort care: NH treatment may not be feasible

43. Appendicitis in the Older Patient Diagnosis at surgery: Appendicitis 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

44. 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

45. Diverticular disease 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)

46. Diverticular disease Presentation: usually some pelvic localization of symptoms, diarrhea or constipation, chills, (bleeding) Rectal exam: localized tenderness or mass CT scan may be helpful Avoid flexible sigmoidoscopy! Patient stable: trial of antibiotics, see again within a week “Needs close observation”

47. Question 5: “The Bottom End” 89 yr woman NH resident with abdominal distension, mild confusion; Parkinson’s disease; hypertension; CHF; hypothyroidism; immobility. No pain, weight loss, appetite change. Meds: Ca antagonist, digoxin, diuretic, levothyroxine, carbidopa/levodopa Px: afebrile, abdomen distended, not tender, hard stool in rectum, no occult blood, CBC normal, abdominal films + CXR: no free air

48. Question 5 What should you do next? 1. Abdominal ultrasound 2. Colonoscopy 3. Discontinue Ca antagonist 4. Administer enema 5. Start prokinetic medication

49. Answer: 4 - Enema What should you do next? 1. Abdominal ultrasound 2. Colonoscopy 3. Discontinue Ca antagonist 4. Administer enema 5. Start prokinetic medication

50. Constipation Camilleri et al. JAGS 48:1142, 2000 *

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

52. Medications that cause constipation: The “Anti’s” Schiller Gastroent Clin North Am 30: 497, 2001 Antihistamines: diphenhydramine, “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

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

54. 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

55. What about Tegaserod maleate (Zelnorm c )? 5-HT4 agonist constipation-predominant IBS Only effective 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

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

57. Diarrhea in Aging population Acute: Outpatient vs Inpatient management: Bleeding, fever, chills (enteroinvasive) Live alone, poor hydration/nutrition, disabled Avoid endoscopy until infection and/or acute abdomen ruled out

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

59. 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 – older patients Withdrawn in 2000, re-released in 2002 1 mg/day – 1 mg bid DISCONTINUE IF CONSTIPATION OCCURS

60. Colon Cancer: a disease of Aging 1.7 million office visits, 45,000 deaths in 2000

61. 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 Increased prevalence of right-sided tumors Polypectomy decreases cancer incidence Medicare - once every 10 years

62. Colon Cancer Recommendations for screening: Colonoscopy age 55-60 then q 10 years to age 85 Continue yearly FOB Barium enema if colonoscopy fails

63. Colon Cancer: What if patient is over 85? Use your best judgement: Functional status/cognition Expected life span > 5 years Patient’s wishes Gastroenterologist’s wishes

64. Colon Cancer – new tests Virtual colonoscopy Sensitivity/specificity 85-90% for polyps >1cm Cannot remove or biopsy tissue 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

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

66. Colon Cancer What about primary prevention? NSAIDs, calcium, Vitamin D may decrease risk of polyps Fiber: controversial + and – studies May be 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.

67. Handouts 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 Handouts on my website: http://sitemaker.umich.edu/khallinfo