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.

Constantine A. Soulellis, MD, FRCP(C), GI Fellow, McGill University; Division of Gastroenterology, McGill University Health Centre, Montreal, QC.
Carlo A. Fallone, MD, FRCP(C), AGA(F), Associate Professor, McGill University; Director, GI Services, Royal Victoria Site of the McGill University Health Centre, Montreal, QC.

Peptic ulcer disease (PUD) is a prevalent medical problem among older adults. Several issues unique to older adults impart variability and complexity to PUD, making this entity difficult to diagnose and treat. Age-related gastrointestinal physiological changes, increasing prevalence of Helicobacter pylori, comorbidities, and polypharmacy (especially nonsteroidal anti-inflammatory drug [NSAID] use) are factors that potentiate ulcer formation. Older adults may present with few or none of the usual features of PUD, often delaying diagnosis and therapy. The cornerstones of therapy include cessation of NSAIDs, proton pump inhibition, and eradication of H. pylori if present.
Key words: peptic ulcer, older adults, NSAIDs, Helicobacter pylori.

Naveen Arya, MD, FRCP(C), Resident, Gastroenterology sub-specialty training program, Univerity of Toronto, Toronto, ON.
Peter G. Rossos, MD, FRCP(C), Staff Gastroenterologist, University Health Network; Program Director, Division of Gastroenterology, University of Toronto, Toronto, ON.

Introduction
With advancing age, the use of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of arthritis, pain and headache increases. Although there are many benefits of NSAIDs for their analgesic and anti-inflammatory properties, there are also potential serious side effects. The side-effect profile includes dyspepsia, gastrointestinal mucosal ulceration and bleeding, cardiac dysfunction, renal toxicity and platelet dysfunction (Table 1). Chronic use of NSAIDs is associated with serious gastrointestinal (GI) toxicity, which severely restricts the use of these medications. In the United States, adverse events associated with NSAIDs result in 103,000 hospitalizations and 16,500 deaths per year.¹ In the United Kingdom, it is estimated that 1/2000 NSAID prescriptions lasting for two months will result in death.²

The average cost of both over-the-counter and prescription NSAID use in the United States is approximately $5-10 billion dollars (U.S.) per year.³ Despite significantly increased costs of therapy, newer COX-2 inhibitors are frequently prescribed in an effort to reduce complications.

Neil P. Fam, BSc

Arthritis has been called the sleeping giant of Canadian health care. According to Statistics Canada, over 3 million Canadians suffer from osteo-arthritis (OA), with another 300,000 affected by rheumatoid arthritis (RA).¹ Together, these diseases represent one of the leading causes of chronic disability, lost productivity and worker absenteeism in Canada.² As our population ages, more patients are presenting to physicians with musculoskeletal complaints, most of which center around chronic joint pain.

Treatment of the pain of arthritis involves both pharmacologic and non-pharmacologic approaches. Traditionally, treatment of OA and RA has revolved around the use of non-steroidal anti-inflammatory drugs (NSAIDs). Although these medications are often effective in relieving pain, they are associated with significant gastrointestinal and renal complications. Elderly patients are particularly prone to life-threatening complications such as GI bleeding and perforation. For these reasons, other treatment modalities are often utilized. This article presents an overview of pain management strategies, with a focus on OA, the single most common cause of arthritis in seniors.

OA pain

In the management of osteoarthritic pain in the elderly, the best approach is to begin with therapies that are inexpensive and have a low risk of side effects. The following is a stepwise approach, summarized in Table 1.