Understanding and Managing GERD in the Elderly

What Is GERD in the Elderly?

GERD is a condition in which there is a backflow of stomach contents into the esophagus. GERD symptoms are less reported by the elderly as they have a high tolerance. GERD is found to be severe among them. Elderly people exhibit fewer GERD symptoms, but their difficulties and treatment options need special considerations.

What Are the Factors Contributing to GERD in the Elderly?

GERD in the elderly is linked to many factors. Hence, it should be given importance for its assessment and treatment. It may be caused by various factors that occur within the body. The repeated problems with the esophagus (food pipe) need to be taken into consideration.

Older people who have GERD may also have other diseases, such as:

• Diabetes.

• Parkinson's disease (a disorder that affects movement and exhibits tremors, stiffness, and difficulty with balance and coordination).

• Alzheimer's disease (a disorder that causes memory loss, cognitive decline, and behavioral changes, primarily affecting older individuals).

• Amyotrophic lateral sclerosis (a neurodegenerative disease that impacts cells of the brain and the spinal cord). This may result in muscle weakness and paralysis.

These conditions may impair esophageal function, making people more susceptible to reflux.

When many medications are given to older individuals, it can make GERD symptoms worse. Moreover, some medications can weaken the lower esophageal sphincter (LES), which is responsible for preventing the backflow of stomach acid.

These include:

• Theophylline (a bronchodilator that relaxes the muscles around the airways).

• Nitrates.

• Calcium antagonists.

• Benzodiazepines (central nervous system depressants used to treat anxiety, insomnia, seizures).

• Anticholinergics.

• Antidepressants.

• Lidocaine.

• Prostaglandins (these are hormone-like lipid compounds present in all tissues that help control inflammation, pain, and uterine contractions).

These medicines can worsen reflux symptoms and can become responsible for the development of GERD. Older individuals are given these medicines as they suffer from various health issues.

As individuals age, they tend to gain weight. This may worsen their GERD symptoms. Many older people become overweight as they age. This extra weight may put pressure on the abdomen. This increased pressure can push stomach acid back into the esophagus. Another thing is that LES gets weaker with age. This also contributes to the worsening of GERD symptoms.

What Is the Prevalence of GERD in Elderly Patients?

The prevalence of GERD varies by age group, and it is a relatively common condition. There is ongoing discussion regarding whether GERD is more prevalent in older or younger people.

A recent study has shown that people aged over 50 take medicines for heartburn and dyspepsia more often than the younger age group. However, some other studies have shown that heartburn and acid reflux do not increase or become common with increasing age.

A different United States (US) study found that among people between the ages of 25 and 74, the prevalence of these symptoms remained largely unchanged, and heartburn even decreased.

Older individuals have a higher chance of developing GERD complications than the younger age group. A common problem, like erosive esophagitis, is more common among older individuals.

According to research, erosive esophagitis affected 81 percent of GERD patients over the age of 60 compared to 47 percent of those under 60. Barrett's esophagus (a condition in which the lining of the esophagus alters, increasing the risk of esophageal cancer) is also linked with GERD in elderly individuals.

The development of esophageal adenocarcinoma (esophageal adenocarcinoma forms in the glandular cells. It is a cancer of the esophagus), which is more common in older people, is perhaps the most worrisome side effect of GERD.

Studies have indicated that older GERD patients, especially older white males, have a higher frequency of erosions (small areas where the surface of the food pipe is worn away), ulcers (deeper sores in the lining of the food pipe), and strictures (narrowing of the food pipe due to scarring). Furthermore, esophagitis (inflammation of the lining of the esophagus) appears to be the cause of gastrointestinal bleeding in a higher-than-expected percentage of those over the age of 80.

What Are the Physiological Changes in Older Patients That Can Increase the Chances of GERD?

It is fascinating that older people with GERD may experience more serious reflux problems but fewer obvious symptoms. Age-related alterations to their upper digestive systems can be used to explain this mystery.

Studies have shown that as people age, the movement of the food pipe, which helps move food downwards, becomes slower and weaker. However, the pressure in the LES remains unchanged among aged individuals. As a result, acid cannot be cleared effectively from the esophagus. Hence, older individuals are at increased risk of acid reflux or GERD-related issues.

Additionally, older patients may experience a reduced ability to sense discomfort in the esophagus. Studies have shown that older people need significantly more balloon distention in their esophagus to feel pain compared to younger individuals. This decreased sensitivity to acid and irritants in the esophagus can lead to delayed diagnosis and potentially more severe complications in older GERD patients.

According to the study, acid production does not decrease with age, but instead increases. However, the production of saliva decreases with age. Saliva plays a crucial role in protecting the food pipe. When the salivary production is decreased among older individuals, the protection becomes weaker. Apart from this, the long-term use of certain medications, such as painkillers, may reduce the food pipe’s natural defenses. This may cause the lining of the food pipe to be damaged easily.

Some medications commonly used by older individuals may contribute to weakening the LES. This leads to GERD. This is the reason for increased age-related exposure to gastric acid.

The complications of GERD include:

• Esophageal ulceration (infection with Helicobacter pylori).

• Esophageal stricture (abnormal narrowing of the esophagus).

• Gastrointestinal bleeding (a sign of a disorder in the digestive tract).

• Barrett’s esophagus (the lining of the esophagus damaged by acid reflux).

• Adenocarcinoma (cancer of the glands that line the organs).

The complications of GERD may occur among all age groups, but are more frequent and severe among older individuals. The reason is cumulative injury from years of acid reflux.

With increasing age, the stomach muscles and tissue fibers weaken. The upper portion of the stomach may protrude into the chest cavity, resulting in a hiatal hernia. This causes GERD.

What Are the Symptoms of GERD in Older Adults?

GERD is found to be common among the elderly population. The symptoms of this condition differ in the elderly compared to those in the younger group.

The symptoms of GERD in the elderly may resemble those of other diseases, such as cardiac, infectious, viral, peptic, and inflammatory diseases. Older individuals generally have other conditions, and hence, they may not be able to recognize GERD symptoms. These individuals may not experience or sense some of the symptoms due to changes in the central nervous system that occur with age. This causes atypical symptoms.

Atypical symptoms are different from heartburn or regurgitation. Hence, the diagnosis of this condition is either missed or overlooked among the elderly.

The symptoms of GERD among the elderly include:

Esophageal symptoms:

• Heartburn (not a primary symptom).

• Regurgitation.

• Chest pain.

• Epigastric pain.

• Dyspepsia.

• Difficulty in swallowing.

• Nausea and vomiting.

• Belching.

Other symptoms:

• Anorexia.

• Anemia,

• Fatigue.

• Weight loss.

• Chronic cough.

• Chronic hiccups.

• Dental erosion.

• Hoarseness.

• Recurrent pneumonia.

• Recurrent bronchospasm.

• Sore throat.

• Wheezing.

How to Diagnose GERD in the Elderly?

The diagnosis of GERD in the elderly is the same as that of the younger age group. In elderly patients, there are more complications; hence, a more prompt diagnosis is needed.

• Barium swallow, upper gastrointestinal (GI) series, and upper gastrointestinal endoscopy are used.

• Capsule endoscopy is considered superior for use in the elderly. It is less invasive than an upper GI endoscopy.

How to Manage GERD in the Elderly?

Managing gastroesophageal reflux disease effectively in older patients exhibits unique challenges. These challenges are due to age-related physiological changes and complications.

Medical management includes:

When treating GERD in elderly people, medical treatment is considered the first line of defense.

• Proton-pump inhibitors (PPIs):

PPIs have shown promising results in treating esophagitis in elderly and young patients.

• H2-receptor antagonists (H2RAs):

H2-receptor antagonists (H2RAs) are a different option. However, PPIs are frequently more efficient, especially in older individuals.

• Current studies:

Studies have observed that individuals on PPIs have excellent healing rates.

• Promotility agents:

These medicines help the food pipe (esophagus) move food downwards more easily and increase the muscle tone of the valve called the lower esophageal sphincter. These help empty the stomach contents efficiently.

• Cautious approach:

The use of promotility agents, such as Metoclopramide, is not recommended in older individuals. This may be due to side effects, such as disturbances in the central nervous system. The elderly, who may be more susceptible to such negative reactions, should be especially concerned about these side effects.

• Alternatives:

Other promotility agents, such as Domperidone, Cisapride, and Bethanechol, are available but are generally considered less effective in treating GERD. Additionally, they may pose risks, especially in older patients who are more likely to experience medication-related complications.

• Tegaserod:

It is a more recent promoter of motility, has demonstrated very modest efficacy in treating GERD symptoms, and its application in the elderly population has not been thoroughly investigated. Therefore, it may not be a preferred choice for older individuals with GERD.

Side effects and drug interactions:

• Older patients are more prone to side effects. Hence, medications should be given carefully.

• Antacids should be used carefully as they may cause toxicity, constipation, diarrhea, and interactions with other drugs.

• Higher doses of H2RAs may cause mental status changes in older patients, particularly those with renal or liver dysfunction. When coupled with specific medications, the H2RA Cimetidine can alter how hepatically metabolized pharmaceuticals are processed, necessitating dose modifications.

• PPIs, despite reduced plasma clearance with age, generally do not require dose reduction in older patients.

Surgical and endoscopic procedures:

• Laparoscopic antireflux surgery can be done for both older and younger individuals with GERD symptoms.

• Older individuals who cannot undergo surgery can be treated with endoscopic treatments like suture plication, injection techniques, and electrical energy application.

Conclusion

Treating GERD in older individuals can be challenging. This may be due to the body changes that occur with age, and they also suffer from various health issues. Many treatments are available to manage GERD among older people. Hence, it is essential to understand GERD in the elderly in detail to identify and treat it effectively without any complications. Using the right medications for older individuals can help manage their GERD effectively.

Key Takeaway From iCliniq

• GERD in the elderly may exhibit less severe heartburn, but they will have other serious complications like esophagitis, Barrett’s esophagus, and strictures.

• During treatment, older individuals should be given special consideration, as they may have underlying health conditions.

• For more information, you can consult a gastroenterologist at iCliniq.