Diagnosis and Management of Gastroesophageal Reflux Disease and Dyspepsia among Older Adults

Sander Veldhuyzen van Zanten, MD, PhD, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB.

Dyspepsia is defined as an epigastric pain or discomfort thought to originate in the upper gastrointestinal (GI) tract. There is discussion, especially in uninvestigated patients, about whether gastroesophageal reflux disease (GERD) can be separated from dyspepsia. If heartburn and regurgitation are the dominant symptoms, GERD is the likely diagnosis. Among older adults, more severe esophagitis is often seen, while at the same time patients report less severe symptoms. The use of nonsteroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), and cyclo-oxygenase 2 selected inhibitors is associated with an increased frequency of dyspepsia and, more importantly, ulcers and upper GI bleeding. In new-onset dyspepsia among older adults, endoscopy should be considered given the increased risk of an upper GI malignancy. Among individuals taking NSAIDs, the medication should ideally be discontinued if it is thought to be the cause of dyspepsia. For NSAID prophylaxis, there is evidence that use of a once-daily proton pump inhibitor or misoprostol 200 µg two to four times per day decreases the risk of upper GI ulcers. NSAID prophylaxis is underused among older adults taking non-ASA NSAIDs, and the reasons for this and its consequences require further study.
Key words: dyspepsia, gastroesophageal reflux disease, NSAIDs, ASA,
H. pylori.