Question

1. Ruthie Long, 84 years of age, presents to the clinic for an annual checkup. The nurse updates the patient’s history by asking her if she has had any gastrointestinal pain associated with meals, at rest, or with activity, or with having a bowel movement. The nurse also asks the patient if she has had any unexplained weight loss or weight gain since her last annual checkup. The nurse asks the patient if she has had any changes in her bowel habits or changes in the usual stool characteristics. The patient stated she has had no such problems. (Learning Objective 3)

What age-related considerations should the nurse utilize when performing the focused physical assessment for the gastrointestinal system?

Answer 1

Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group.

While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years.

Age-related changes of the oral cavity, oesophagus, stomach, small and large bowels, and other factors related with aging like immobility, inactivity, increased use of drugs for various conditions are significant for gastrointestinal manifestation in elderly.

Slowed peristalsis: Slowing down of peristalsis, resulting in food moving slowly through intestine. This means food is staying lionger in intestine resulting in absorption of more water resulting in constipation.

Consipation: Increase in prevalence of constipation in elderly is not related to decrease in colon transition time as much as it is to decreased mobility, cognitive impairment, comorbid medical problems, polypharmacy (especially opioid and anticholinergic medication use), and dietary changes. Elderly patients usually associate constipation with straining rather than decreased frequency of bowel movements

Inactivity. People often become less active as they age. Inactivity can also result in constipated.

Decreased water intake: With age some times people tend to avoid drinking more water for the reason that they need to to bathroom more frequently. Decreased water intake may also result in constipation.

Medications: with age many times people require medications for chronic conditions like hypertension, coronary artery diseases, arthritis etc. Diuretics given for cardiac conditions may lead to increased loss of water in form of urine which can cause constipation. Chronic use of NSAID’s for arthritis may result in gastric ulceration and bleeding.

Physiologic changes with aging:

Oral cavity: elderly has problems with chewing food resulting from loss of teeth and ill- fitting dentures. Inadequately chewed food takes more time to digest. Dryness of mouth or Xerostomia is also common and may occur as a part of systemic disease like Sjogren’s syndrome or as a medication side effect, with tricyclic antidepressants (TCA), atropine, and antiparkinsonian drugs.

Oesophagus: Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinal disorder in older adults. In GERD there is reflux of acid mixed stomach contents in to oesophagus from stomach through cardiac sphincter, causing heart burn and other symptoms. Irregular eating habits, eating late at night and eating the wrong types of foods, such as fast food and fried foods, sleeping immediately after food can all cause reflux. Certain medications, including some antihypertensives, which many older adults take, can also cause heart burn. Obesity increases risk for heartburn and GERD.

Other than GERD oesophageal dysphagia is most commonly manifested as the feeling of food being stuck in the chest. It can be caused by mechanical obstruction inside the oesophagus itself (stricture, tumour) or compression from surrounding tissues (vascular compression or mediastinal masses). Neuromuscular causes include achalasia, scleroderma, or diffuse oesophageal spasm. Finally, inflammatory and infectious causes can lead to oesophageal dysphagia (eosinophilic esophagitis, candidiasis).

Stomach changes: Altered gastric microbiota, reduced mucosal protective mechanisms, decreased gastric blood flow, and consequently compromised repair mechanisms are the hallmarks of age-related gastric changes. These changes make older people more susceptible to the development of several diseases, such as gastric ulcer, atrophic gastritis, and peptic ulcer disease. Additionally, elderly are more likely to experience medication related gastrointestinal side effects which, in turn, can decrease their medication adherence and further contribute to morbidity and mortality. There is significant decrease in postprandial gastric contractile force. This reduction is more pronounced among elderly who led to less active lifestyles. Among the co-morbidities frequently encountered among older people, Parkinson’s disease and diabetes mellitus seem to have the greatest impact on gastric emptying.

Chronic atrophic gastritis (CAG) is also more prevalent in the elderly and is associated with H. pylori infection. The hallmark of disease is the partial loss of glands in the gastric mucosa leading to hypochlorhydria or achlorhydria. The prevalence of CAG is higher in elderly and there are significant geographical variations showing elderly from China and Japan are particularly affected with a prevalence of up to 50% in those above age 60 years. Decrease in acid secretion as a consequence of chronic atrophic gastritis leads to two problems that are particularly prominent in the elderly population one is small intestinal bacterial overgrowth (SIBO) and other is malabsorption. H. pylori infection prevalence in developing countries is the highest among the children, while in developed countries is higher with increasing age. This marked difference is most likely due to a cohort effect of the earlier generation exposed to poor sanitation in developing countries which is a known risk factor for contracting the infection.

Severity of upper gastrointestinal symptoms secondary to H. pylori infection seems to be higher in the elderly.

Peptic ulcer disease encompasses both gastric and duodenal peptic injury that leads to a break in gastric or duodenal mucosa. The majority of ulcers in elderly is caused by H. pylori infection or is associated with the use of NSAIDs/aspirin, anticoagulants, selective serotonin reuptake inhibitors (SSRIs), and oral steroids. Gastric ulcers in elderly are usually larger and tend to occur higher in the stomach on the lesser curve. Clinical manifestation of peptic ulcer in elderly is often atypical, only 30% of elderly patients with endoscopy proven peptic ulcer disease had typical epigastric pain. Additionally, elderly patients with acute gastric or duodenal ulcer perforation might not exhibit classic signs of chemical peritonitis.

Small intestine: small intestinal bacterial overgrowth is excessive presence of bacteria, above 105-106 organism/mL in small bowel aspirate. Common in elderly, and is associated with chronic diarrhoea, malabsorption, weight loss, and secondary nutritional deficiencies. Vitamin B12 deficiency is commonly seen in small intestinal bacterial overgrowth. Motility of the small intestine is not affected by age itself. Rather than age itself, slower motility in elderly is associated with medications, polypharmacy, and presence of concomitant diseases more frequently seen in this population such as autonomic neuropathy from long standing diabetes. Celiac disease is also common with age.

Large intestine: Aging negatively impacts gastrointestinal motility and increases colon transit time. Another important change that occurs along the process of aging is the change in human intestinal microbiota. Age-related changes in human microbiota have been associated with inflammatory bowel diseases (Crohn’s disease and ulcerative colitis), irritable bowel syndrome, and metabolic disorders (diabetes mellitus types 1 and 2 and obesity). Two major phyla of human microbiota are Firmicutes (gram positive bacteria) and Bacteroidetes (gram negative bacteria). Immune homeostasis by intestinal microbiota is maintained by the equilibrium between these two major phyla. Age-related alteration in this balance may lead to activation of dendritic cells within the lamina propria of the intestine which, in turn, starts the cascade of events leading to release of pro-inflammatory cytokines, and altered defense, which then allows entry of pathogens into mucosal layers, finally resulting in generation of low - grade inflammation.

Diverticulosis and diverticulitis. Combined, they are the most common disease affecting the large bowel in the Western world, with the highest rates in the Unites States and Europe showing no gender predilection.

Irritable bowel syndrome (IBS) is common functional gastrointestinal disorder. It manifests with abdominal pain and alteration in bowel movements in the absence of any organic pathology. Depending on bowel patterns, IBS can be diarrhoea predominant, constipation predominant or IBS with mixed bowel habits.

Disease conditions: there are many age-related conditions like dementia, parkinsonism, cerebrovascular accidents or stroke which result in difficulty in swallowing.

Polyps. After age 50, the risk for developing polyps in the colon increases. Polyps may benign, or malignant or a benign one may later become malignant. Exact cause of polyps is not known but here's been speculation that it is probably cumulative effect of some dietary factors and genetics. Most of times polyps are asymptomatic. Therefore screening colonoscopies are recommended after age of 50 years.

So elderly patients represent a specific population with unique needs in regards to diagnostic and therapeutic approaches in regard to gastro intestinal symptoms.