Gastroesophageal Reflux Disease in Older Adults: What Is the Difference?
Dr. Shams is a Clinical Fellow, Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences; Dr. Siddiqui is a Resident, Department of Family Medicine, Creighton University, Omaha, NE; and Dr. Heif is a Fellow in the Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock.
Gastroesophageal reflux disease (GERD) is one of the highly prevalent diseases seen in the clinical practice. The prevalence (as defined by at least weekly heartburn and/or acid regurgitation) was 10-20% in the Western world and approximately 5% in Asia.1 The incidence in the Western world was approximately 5 in 1000 person-years.1 One of the population-based surveys in the United States reported the prevalence of heartburn as 22% within the last month and 6% occurring more than twice weekly.2
In the elderly population, few studies have addressed the prevalence of GERD. Some studies reported similar prevalence as in the younger population (ie, weekly heartburn or acid regurgitation of approximately 14-25%).3-5 Another study reported daily reflux to occur in 8% of men and 15% of women age 65 years or older.6 The true prevalence of GERD in older persons may be even higher than reported, because the studies included only heartburn and regurgitation as indicative of symptomatic reflux, and atypical symptoms such as chest pain, cough, and laryngitis were not assessed. Moreover, the complications of GERD, such as esophagitis, esophageal stricture, Barrett’s esophagus, and esophageal cancer, are found to be more frequent in the elderly population.7,8 There is a twofold-to-fivefold increase in the prevalence of GERD in nursing home residents with dementia.9
The main event in the mechanism of GERD, as the name suggests, is the reflux of gastric contents from the stomach into the esophagus. There is an imbalance between the protective forces (mucosal barrier, normal functioning of lower esophageal sphincter [LES]) and the harmful forces (acid reflux, defective acid clearance). The factors that are involved in the pathogenesis of GERD include defective LES function, hiatal hernia, abnormal esophageal clearance, and altered esophageal motility and mucosal resistance.
Huang et al8 found incompetence of LES to be more prevalent in the elderly, which permits acid reflux, especially when intra-abdominal pressure rises. Certain medications commonly prescribed in older adults can also lead to decreased LES tone. Examples of these medications include nitrates, calcium channel blockers, benzodiazepines, antidepressants, and anticholinergics. Elderly patients are more prone to have hiatal hernia as a result of progressive weakening and enlargement of diaphragmatic hiatus with advancing age.8-10 The hiatal hernia is associated with defective LES function and with decreased clearance of refluxed contents from the esophagus. The increased frequency of shorter intra-abdominal segment of the LES in the elderly as compared to a younger population is reported as another factor causing increased reflux.11
There are several changes in the esophageal motility and saliva production that lead to impaired esophageal acid clearance in older persons. Normally, esophageal acid clearance is initiated by the emptying of the refluxed contents from the esophagus by peristalsis and is completed by titration of the residual acid by swallowed saliva.12 Several studies have demonstrated altered esophageal motility in the elderly as the primary factor causing GERD. The esophageal contractile amplitude has been found to be decreased in patients 70-80 years of age by Ferriolli and colleagues.13 They were also found to have longer duration of reflux episodes when compared with those who are younger, suggesting that prolonged contact time between the esophageal mucosa and gastric contents might, in part, explain the increased severity of mucosal disease in these patients. These functional alterations, including an increase in the frequency of ineffective, non-propulsive, and repetitive contractions, are associated with decreased myenteric plexus neurons in the aging esophagus, particularly in the proximal third at the junction with the pharynx.14-17
Numerous medications used by older persons can decrease esophageal motility and promote reflux, such as anticholinergics, calcium channel blockers, theophylline, tricyclic antidepressants, and sedatives. Due to decreased esophageal motility in the elderly, the longer transit time taken by the medications through the esophagus puts the patients at risk for local erosions or ulcers. This is seen frequently with nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, iron sulfate, gelatin capsules, antibiotics, potassium chloride tablets, and bisphosphonates; therefore, these drugs should be prescribed with caution in older patients with GERD, and patients should be encouraged to take them with a full glass of water.18 The esophageal motility is also affected by certain diseases such as cerebrovascular accidents, diabetes, and Parkinson’s disease, which are more prevalent in the elderly population.
Sonnenberg et al19 demonstrated a reduced salivary production and bicarbonate concentration in older patients during esophageal acid perforation, which decreases the buffering capacity of the esophagus against refluxed acid and aggravates mucosal injury.
It is interesting to note that gastric acid secretion does not change with age alone. Helicobacter pylori is associated with decreased gastric acid production leading to atrophic gastritis.20
There are significant differences in the presentation of GERD between older persons and younger adults. Heartburn and regurgitation are the classic symptoms of GERD in the younger population. In contrast, elderly patients with GERD manifest mainly with atypical symptoms including noncardiac chest pain, chronic cough, asthma, laryngitis, dyspepsia, dysphasia, vomiting, weight loss, anemia, anorexia, and dental problems.21,22
Several studies have reported lower prevalence of heartburn in elderly patients,6,23 which may reflect a decline in esophageal sensitivity with aging. This is evident in one study showing that patients age 65 years or older could tolerate intraesophageal balloon distention to approximately one-third greater volume prior to experiencing chest pain than those younger than age 65 years.24
In comparison to the younger population, elderly patients present with more severe esophageal disease, including upper gastrointestinal bleeding due to erosive esophagitis, esophageal strictures, and Barrett’s esophagus.7,25 Another area of concern in the elderly is the extra-esophageal manifestations of GERD involving pulmonary, cardiac, otolaryngeal, and dental systems.21,22
As mentioned above, the complications of GERD are more prevalent in older adults. It involves a spectrum of diseases, from minor problems such as mild esophagitis and chronic cough, to severe problems such as esophageal hemorrhage, Barrett’s esophagus, pulmonary aspiration, and esophageal cancer.
The most common complication of GERD in older persons is esophagitis. Chait25 showed that the elderly patients (> 70 yr) presented with esophagitis three times more than the younger patients (< 39 yr). Another study reported the prevalence of esophagitis as 81% in the elderly as compared to 47% in the younger adults.7 Esophagitis can lead to severe erosions, ulcerations, and even hemorrhage, which is usually occult but can be massive.6
Esophageal strictures are highly prevalent in patients over 65 years of age, especially in those with a history of NSAID use. Due to many comorbid conditions, elderly patients often take aspirin/NSAIDs; therefore, it is imperative for physicians to use these medications with caution in those with esophagitis.7,26 Esophageal strictures frequently present with progressive dysphagia to solids and liquids. The main course of treatment is aggressive antireflux therapy and esophageal dilatation.27
Chronic acid exposure due to reflux can lead to the metaplasia of squamous epithelium of esophagus to the columnar epithelium, leading to a condition called Barrett’s esophagus. Collen and colleagues7 found the prevalence of Barrett’s esophagus to be as high as 25% in patients older than 60 years of age. Barrett’s esophagus is a premalignant condition highly associated with the adenocarcinoma of the esophagus. Therefore, it should be evaluated by early endoscopy in all elderly patients with reflux disease.28
Atypical chest pain is a common extraesophageal manifestation of GERD in elderly patients, accounting for up to 50-80% of the cases.21,29 It represents an important diagnostic challenge in the geriatric population for a physician, as it mimics anginal pain much of the time.
Pulmonary complications of GERD in older adults include chronic cough, asthma, recurrent pneumonitis, and aspiration pneumonia. These result from reflux-induced activation of the vasovagal arc, causing bronchoconstriction and aspiration of refluxed contents. GERD has been reported as a cause in 21% of patients with chronic cough.30,31 Due to the association of GERD with asthma, antireflux therapy is important in the management of patients with poor response to standard treatment of asthma.
Otolaryngologic manifestations of GERD result from the esophagopharyngeal reflux of gastric contents with subsequent contact injury of the pharyngeal and laryngeal mucosa.32-35 The term “laryngopharyngeal reflux” has been used to describe this process. This can lead to laryngitis, laryngeal polyps, laryngotracheal stenosis, and, in some cases, laryngeal carcinoma.36,37 The acid reflux is also associated with dental erosions in older patients.
GERD is a diagnostic challenge in the geriatric population due to the presence of minor and atypical symptoms as the manifestation of severe disease. A thorough history is therefore imperative in the evaluation of extra-esophageal manifestations of GERD in older persons. Various diagnostic modalities are available to evaluate GERD, including endoscopy, barium studies, ambulatory pH monitoring, and manometry. These are indicated in the elderly patients with atypical or recurrent symptoms, refractory or complicated disease, and prior to antireflux surgery.38
Upper gastrointestinal endoscopy is the most specific tool to detect esophagitis, ulcers, esophageal strictures, Barrett’s esophagus, and malignancy. It provides histopathological diagnosis and grading of esophageal lesions. Early endoscopy is warranted in the elderly as compared to younger patients due to the increased incidence of severe and complicated disease, including Barrett’s esophagus and esophageal cancer.7 Special consideration should be given to those who present with anemia, weight loss, and dysphagia. Patients with Barrett’s esophagus should have surveillance endoscopy done regularly. Endoscopy can also be used to evaluate the response to medical therapy.
Ambulatory esophageal pH monitoring is useful to confirm GERD in symptomatic patients with negative endoscopy, to evaluate refractory cases,39,40 and to monitor the adequacy of treatment in those with continued symptoms.
Esophageal manometry is occasionally used to evaluate for motility disorders, to locate the LES for pH testing, and to assess peristaltic function before antireflux surgery.
Barium studies are usually nonspecific in the diagnosis of GERD, though they are helpful in detecting hiatal hernia and structural abnormalities in patients with dysphagia.27
A therapeutic trial of medications is considered diagnostically useful in younger patients with reflux disease, but in the elderly population it is not preferable for the diagnosis of GERD, as it can delay the detection of severe disease.
The management goals for GERD comprise relief of symptoms, healing of esophagitis, managing complications, and maintaining remission. Geriatric patients need more aggressive management of GERD as compared to younger patients, due to high incidence of complications and severe disease.10 There are three main treatment options: lifestyle modifications, medications, and surgery.
Traditionally, lifestyle modification measures include elevation of the head of the bed, dietary changes, and avoidance of alcohol and tobacco. Some of these measures might be beneficial in healthy adult patients, but they may not be sufficient to control symptoms in elderly patients with severe disease. Moreover, their therapeutic effectiveness in elderly patients has not been extensively evaluated in the clinical trials.41 Head-of-the-bed elevation might be helpful for patients with laryngeal or nocturnal symptoms. Certain foods such as chocolate, citrus juices, peppermint, and those containing fat and caffeine can precipitate GERD symptoms in a subset of patients; however, it is not advisable to restrict them in other patients, as it may impair their quality of life. Promotion of salivation by either chewing gum or use of oral lozenges may be helpful in mild heartburn. Salivation neutralizes refluxed acid, thereby increasing the rate of esophageal acid clearance.
The most common and effective treatment of GERD is to reduce gastric acid secretion with either an H2 blocker or a proton pump inhibitor (PPI).40 These medications do not prevent reflux, but they remove the caustic elements of the refluxate. The greater the degree of pathologic esophageal acid exposure, the greater the degree of acid suppression required.
Antacids temporarily raise the pH of refluxed gastric contents and are found to be effective in mild reflux disease, but they have no effect on healing esophagitis.42,43
Prokinetic drugs (bethanechol, metoclopramide, domperidone, erythromycin, cisapride) can potentially be used as adjuncts in the treatment of GERD, as they increase LES pressure, enhance gastric emptying, and improve peristalsis. However, their effectiveness is limited when used as a single agent or in severe disease.40 Also, their side-effect profiles and drug interactions restrict their use in elderly patients.44 In fact, cisapride was taken off the U.S. market in 2000 due to its association with fatal cardiac arrhythmias.45 Metoclopramide is associated with central nervous system side effects including drowsiness, extrapyramidal effects, tremors, and agitation that make its use limited in the elderly.46
H2 receptor blockers are a safe and effective treatment option for GERD in older patients. They are found to relieve symptoms in 50-60% of patients after 6-12 weeks of therapy. The healing rate of esophagitis is also found to be increased by two- to threefold in patients taking H2 receptor blockers as compared to placebo.47 The four currently available H2 blockers (cimetidine, ranitidine, famotidine, nizatidine) are equally effective at equivalent doses; however, their efficacy is reported to decline over time due to the development of tolerance.48 Side effects and drug interactions are rare and are usually dose-related. Care should be taken especially when using cimetidine in elderly patients, as it inhibits the cytochrome P-450 system, resulting in serious drug interactions with warfarin, phenytoin, benzodiazepines, and theophylline.49 Hallucinations, agitation, restlessness, and mental status changes have been described in patients taking cimetidine and, to a lesser extent, in patients taking ranitidine. These side effects are more common in elderly patients in the intensive care unit.50 Concomitant renal or hepatic dysfunction might increase the risk of these central nervous system symptoms, so caution should be exercised when prescribing these medications to elderly patients with renal or hepatic dysfunction.50
PPIs are the most effective therapy currently available for patients with GERD. They offer excellent acid suppression by inhibiting the H+/K+ ATPase enzyme that in turn inhibits the release of acid from the parietal cells. PPIs are superior to H2 receptor blockers in providing complete relief of reflux symptoms and promoting esophageal healing.51,52 Moreover, PPIs are not associated with tolerance. This is particularly important in elderly patients who need aggressive acid suppression due to the presence of severe disease or complications.7 A meta-analysis of 43 randomized controlled trials (RCTs) showed that PPIs produce higher healing rates (83.6 ± 11.4%) than H2 antagonists (51.9 ± 17.1%).53 Another RCT involving elderly patients demonstrated that once-daily therapy with a PPI was more effective at healing reflux esophagitis than an H2 antagonist twice daily.54 There is no clinically significant difference among the efficacies of various PPIs (omeprazole, lansoprazole, pantoprazole, esomeprazole, and rabeprazole).55 One of the advantages of PPIs is that their capsules can be opened and the granules can be taken with drinks. This is of particular importance in older patients with swallowing difficulty.
PPIs are generally a safe class of drugs. They usually do not require dosage adjustments in renal or hepatic dysfunction56; however, drug interactions are possible, especially with warfarin, phenytoin, digoxin, and diazepam. There are no proven data that long-term use of PPIs or its resultant hypergastrinemia can cause carcinoid or other gastric tumors in humans.57 Another concern is the association of PPIs with chronic atrophic gastritis in patients infected with H. pylori, but the risk is very small.58 Long-term treatment with PPIs can result in vitamin B12 malabsorption. This is particularly important in elderly patients with dementia; therefore, vitamin B12 level should be checked regularly in patients taking long-term PPI treatment.59 Possible associations with hip fractures60 and community-acquired pneumonia61 have also been suggested, but not proven.
Maintenance therapy with a PPI or H2 receptor blocker is often needed in patients with GERD due to the increased risk of recurrence. A study by Pilotto et al62 reported that 68% of elderly patients with reflux esophagitis who received acute treatment and who were healed still required maintenance therapy after 6 months, and that 46% needed therapy after 3 years. The need for maintenance medical therapy can be determined by the rapidity of recurrence. Recurrent symptoms after discontinuation of antireflux therapy in less than 3 months suggests that GERD is best managed with continuous therapy, while remissions in excess of 3 months can be adequately managed by repeated courses of acute therapy as necessary. Intermittent (on-demand) therapy may be successful in some patients with mild-to-moderate heartburn without moderate-severe esophagitis. Depending upon the initial therapy rendered, the medical regimen is adjusted in a step up or step down to the most cost-effective regimen.
Antireflux surgery has an important role in patients with inability to tolerate medications, severe aspiration or pulmonary symptoms, esophageal strictures, nonhealing ulcers, persistent “reflux symptoms” despite acid suppression, Barrett’s esophagus, or hiatal hernia. It is also an option for patients who do not wish to take life-long medications, are noncompliant, or cannot afford the cost of medications. Laparoscopic antireflux surgery is shown to have a satisfactory clinical outcome in elderly patients.63 Mortality, morbidity, and hospital stay are not increased in the elderly patients undergoing laparoscopic fundoplication as compared to the younger patients.63 Therefore, older patients should not be denied laparoscopic antireflux surgery on the basis of their age alone. Various novel endoscopic and minimally invasive procedures are also available as an alternative to medical or surgical treatments; however, their role needs to be defined.64,65
GERD is a highly prevalent disease in older persons. It needs special consideration in this age group due to the presence of more severe disease and complications. Older patients with GERD tend to present with minimal or atypical symptoms, and are more likely to be poorly diagnosed or underdiagnosed. Therefore, the clinician needs to be more aggressive in the evaluation and management of GERD in these patients. Among the various treatment options, PPIs are the most potent and effective therapy available for acid suppression. Due to their safety and effectiveness, they are the most suitable agent for the maintenance therapy in older adults. Antireflux surgery is available for complicated and refractory cases. Further studies are needed to define the role of upcoming innovative endoscopic or minimally invasive surgical techniques.
The authors report no relevant financial relationships.