Introduction
Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder that affects individuals of all ages, but its impact and management differ significantly in the elderly population. Heartburn is the most typical symptom of GERD, which is caused when stomach acid leaks back into the esophagus. Although the incidence of the disorder is still up for debate, older people's difficulties and treatment options deserve special consideration.
What Is the Prevalence of GERD in the Elderly Population?
The prevalence of GERD varies depending on the age group, and it is a common condition. There is ongoing discussion regarding whether GERD is more prevalent in older or younger people, although research points to an estimated lifetime prevalence of 25 % to 30 % in the United States. In a recent study, it was discovered that a sizable proportion of participants over 50 utilized heartburn and dyspepsia drugs more frequently than their younger contemporaries. However, some research suggests that the prevalence of heartburn and acid regurgitation, the two defining symptoms of GERD, does not rise considerably with age. In fact, a different 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.
What Are the Factors Contributing to GERD in the Elderly?
GERD in the elderly is a multidimensional disorder that necessitates careful assessment and management since it is impacted by a complex interaction of several causes. The existence of concurrent esophageal-related medical problems is an important consideration. Older people who have GERD may also have diabetes, Parkinson's disease (a disorder that affects movement, characterized by 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), or amyotrophic lateral sclerosis (a neurodegenerative disease that impacts nerve cells in the brain and spinal cord, leading to progressive muscle weakness and eventual paralysis). These conditions may impair typical esophageal function and make people more vulnerable to reflux.
Additionally, the drugs frequently given to elderly individuals can make GERD symptoms worse. It has been demonstrated that a number of medications, including Theophylline, nitrates, calcium antagonists, benzodiazepines, anticholinergics, antidepressants, Lidocaine, and prostaglandins, reduce the pressure of the lower esophageal sphincter, an essential barrier against reflux.
These drugs may aggravate reflux symptoms and contribute to the onset of GERD because they are more frequently given to elderly patients for a variety of medical issues.
Body weight changes brought on by aging further exacerbate the situation. Over time, the aged population frequently gains weight, and older people are now more likely to be obese. Higher intra-abdominal pressure can result from an increase in body weight, particularly when it is focused on the abdominal region. This increased pressure makes it easier for stomach contents to flow backward into the esophagus as a result of age-related weakening of the lower esophageal sphincter, which raises the possibility of gastroesophageal reflux.
What Is the Prevalence of GERD in Elderly Patients?
Older patients with GERD are at a heightened risk of experiencing complications compared to their younger counterparts. The prevalence of erosive esophagitis, a frequent GERD consequence, is higher in senior GERD patients. According to Collen and colleagues' research, erosive esophagitis affected 81% of GERD patients over the age of 60 compared to 47% of those under 60. Another issue associated with GERD in elderly people is Barrett's esophagus (a condition where the lining of the esophagus changes, increasing the risk of esophageal cancer).
The development of esophageal adenocarcinoma, 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, had a higher frequency of erosions, ulcers, and strictures. Furthermore, esophagitis 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.
For instance, studies have shown that swallow-induced peristalsis, which aids in the movement of food down the esophagus, is less prevalent in older individuals. However, the pressure in the lower esophageal sphincter, a valve that prevents stomach acid from flowing back into the esophagus, remains relatively unchanged between GERD patients who are 65 and older and those who are younger. This means that acid may not be effectively cleared from the esophagus in older individuals, increasing the risk of GERD-related problems.
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.
How to Manage GERD in the Elderly?
Managing gastroesophageal reflux disease (GERD) in older patients presents unique challenges due to age-related physiological changes and the potential for complications. However, various treatment approaches are available to address the needs of older individuals with GERD.
Medical Management:
-
When treating GERD in elderly people, medical intervention is frequently the first line of defense.
-
Proton-pump Inhibitors (PPIs): PPIs (proton-pump inhibitors) have shown promise in treating esophagitis in both elderly and young patients. According to research, elderly people may need a greater amount of acid suppression to receive a successful treatment.
-
H2-receptor Antagonists (H2RAs): H2-receptor antagonists (H2RAs) are a different option, however, PPIs are frequently more efficient, especially in individuals who are older.
-
Recent Studies: Recent research, including a pantoprazole study, revealed that older and younger patients receiving PPIs experienced comparable healing rates.
Use of Promotility Agents:
-
Cautious Approach: The routine use of promotility agents, such as Metoclopramide, is discouraged in older patients due to potential side effects that can include central nervous system disturbances. The elderly, who may be more susceptible to such negative reactions, should be especially concerned about these side effects.
-
Alternatives: Other promotility agents like 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 susceptible to side effects and drug interactions, necessitating careful medication management.
-
Due to potential toxicity, constipation, diarrhea, and interactions with other drugs, antacids should be used with caution.
-
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 the way 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 Approaches:
-
Both older and younger individuals with diagnosed GERD have benefitted from surgical alternatives, such as laparoscopic antireflux surgery.
-
For older individuals who might not be surgical candidates, endoscopic treatments such as suture plication, injection techniques, and electrical energy application are possible options.
-
The possibility of perforation should be taken into account, however, there is little information available on their results and consequences in older people.
Conclusion
In conclusion, managing GERD in older patients presents unique challenges due to age-related physiological changes and the potential for complications. To meet the needs of elderly people with GERD, a variety of therapy modalities are offered. Recent studies indicate that proton pump inhibitors (PPIs) are a viable alternative for treating older patients with esophagitis. PPIs have demonstrated efficacy in treating esophagitis in both older and younger people. For milder cases of GERD, H2-receptor antagonists (H2RAs) can also be taken into consideration. Due to probable side effects and their reduced effectiveness in elderly patients, promoters like Metoclopramide and Tegaserod should be used with caution. Overall, GERD in older people can be effectively treated with the correct strategy and drug management, enhancing their quality of life and lowering the risk of problems.
