Cardiovascular disease and cancer are the most important causes of death in the elderly. Large surveys reveal that arthritis is the most common medical condition compromising the quality of life for elderly people in the community. The elderly themselves have an understandable fear of stroke and dementia, and the possible loss of mental faculties that results from these conditions. Despite these geriatric giants, gastrointestinal complaints--even if not the chief complaint--seem almost universal in the average geriatric practice.
The most ubiquitous gastrointestinal complaints concern constipation and dyspepsia (usually symptoms of gastroesophageal reflux disease, or GERD). When prescribing any medications for the elderly, it is my personal habit to consider the impact they might have on the symptoms of reflux and constipation. We are all aware of the havoc narcotics can wreak on the aging gastrointestinal system, but numerous other medications can also have profound effects. Constipation is not a minor issue for the frail elderly, and fecal impaction can result in significant morbidity and even death. Over the last few years, the Geriatric and Long Term Care Review Committee of the Chief Coroner of Ontario has published several cases of patients who died secondary to poorly managed constipation. It is more difficult to quantify the contribution of GERD to mortality (e.g., aspiration pneumonia), but it is easy to appreciate how much it can affect quality of life.
Much of my personal practice is hospital based, and sometimes it seems that nausea also is universal among elderly patients. In my experience, I have found that prescribing an anti-nausea medication (typically dimenhydrinate) is not helpful. The first step in managing a patient with nausea should be a medication review and treatment of constipation if present. If these simple steps do not help, the problem is usually impaired gastrointestinal motility, and prescribing a drug such as dimenhydrinate, which further impairs motility, would be counterproductive. For the occasional case where it is unreasonable to stop agents that impair motility or to start treatment of constipation, nausea is better treated with a prokinetic agent than with the usual anti-nausea medications (which are usually strongly anticholinergic and can thus impair cognition as well).
Even in areas where the literature might appear cut and dried, such as colonoscopy for colon cancer screening, there remain numerous questions. Among the most pressing are, what is the most cost-effective age to perform the screening, and how will we get the resources to make this a realistic population-based initiative?
These concerns and many more are covered in this issue of Geriatrics & Aging, which focuses on gastrointestinal disease in the elderly. Drs. Shabbir Alibhai and Marisa Battistella discuss the management of constipation, and Dr. Clarence Wong reviews how to manage gastrointestinal lesions with malignant potential. We have not forgotten about those patients who present with an upset stomach to their doctor. Dr. C.A. Fallone presents an approach to the management of dyspepsia in older adults, while Drs. Peter Rossos and Naveen Arya tackle the more specific topic of preventing peptic ulcer disease in patients on chronic, non-steroidal anti-inflammatory drug therapy. We also present an article on the pharmacological management of gastroesophogeal reflux disease, by Dr. Mary Anne Cooper. Rounding off the focus articles, are a review of diverticular disease by Drs. Eldon Shaffer and Christopher Andrews, and a patient information page from the Canadian Digestive Health Foundation.
Enjoy this month's edition.
