First Report®

Digestive Disease Week 2011

May 7-10, 2011; Chicago, IL

Study Finds Anticholinergic Medications Well Tolerated by Community-Dwelling Geriatric Patients With Irritable Bowel Syndrome

Chicago, IL—Treatment with anticholinergic medication improved gastrointestinal symptoms and was well tolerated among a cohort of geriatric patients with irritable bowel syndrome (IBS), according to a poster that was presented during DDW 2011. Anticholinergic drugs are antispasmotic agents used to treat a variety of conditions, including several gastrointestinal ailments that cause stomach and intestinal cramping and/or spasms. Douglas J. Sprung, MD, The Gastroenterology Group, Altamonte Springs, FL, conducted the prospective outcomes study in response to growing concern that anticholinergic drugs might evoke worse adverse effects in elderly patients with IBS.

Sprung reviewed medical charts for 192 elderly patients (age range, 65-93 years) with IBS who had been treated with an anticholinergic at his community-based gastroenterology practice in 2009. In addition to IBS symptoms, 84% of patients showed evidence of stress, depression, and anxiety at baseline; 38% were taking selective serotonin reuptake inhibitors; and 5% had been using sedatives. Nearly three-quarters (71%) of patients first observed symptoms of IBS after 56 years of age, and 43% of these patients said that they did not experience symptoms until after 65 years of age. IBS was least likely to develop prior to 35 years of age, with only 12% of patients describing symptom onset before age 35. For the remaining 17% of patients, symptoms first appeared when they were between 36 and 55 years of age.

Oral anticholinergic medications used to treat IBS in the study participants included hyoscyamine; the combination drug chlordiazepoxide/clidinium; dicyclomine; and belladonna/phenobarbital, another combination drug. All medications had been prescribed at the usual recommended adult dose, and patients continued on anticholinergic therapy for an average of 6 months.

Records showed that IBS symptoms improved by >75% for 83% (159/192) of patients. Another 12% (23/192) were somewhat better, but the degree of improvement from baseline did not exceed 50%. Only 5% of patients failed to experience any improvement in IBS symptoms with anticholinergic medication.

The most common adverse effects included dry mouth, which was reported by 36% of patients. Fatigue was the next most frequent adverse effect, experienced by 9% of patients. A cumulative 3% of patients developed headaches, dizziness, diarrhea, constipation, and abdominal pain. The author said that adverse effects “did not increase in incidence with advancing age nor limit usage.”

Sprung concluded that, contradicting popular belief, anticholinergic medications are safe and effective to treat elderly patients with IBS. Because agents from this class are also inexpensive, he recommended that additional studies investigate the use of anticholinergics in this patient population.


Geriatric Syndromes May Shorten Life Expectancy for Patients With Colorectal Cancer

Chicago, IL—A recent study indicates that elderly patients with colorectal cancer (CRC) have worse outcomes if they have comorbid conditions such as dementia, depression, incontinence, and pressure ulcers or a history of falls. The increased risk of death in patients with concomitant CRC and a concomitant geriatric condition persisted even after adjusting for age, anticancer treatment, and comorbidity. Data from the retrospective study were presented at a poster session during DDW 2011.

In conducting the study, researchers searched inpatient, outpatient, and mortality data contained in the Veterans Health Administration National Patient Care Database to identify US veterans age ≥60 years with a diagnosis of CRC that had not spread beyond regional lymph nodes. The original sample included 60,265 veterans, who were predominantly male (98.4%) and white (66.4%), with a median age of 74.5 years. Records indicated that 29,254 of the veterans had died from October 2003 to October 2008, the 5-year period for which mortality risk was analyzed. Patient and disease characteristics and treatment administered were similar between the cohort of veterans who died and the cohort of veterans who survived.

The overall prevalence of geriatric syndromes was 15%, and the proportion of patients with multiple syndromes was similar between the deceased group and the living group. The most frequent geriatric syndrome was falls, observed in 61% of patients. This was followed by dementia (12.8%), depression (11.7%), and incontinence (10.6%).

Although pressure ulcers were not among the most common geriatric syndromes observed, they proved to be the greatest predictor of mortality (hazard ratio, 2.5; 95% confidence interval, 2.0-3.2). Investigators also found that age and coexistent geriatric syndrome(s) correlated strongly with survival outcomes. As an example, they calculated life expectancy at 12.8 years for patients age 60 to 69 years with a history of falls and no psychiatric illness. If the patient also had a psychiatric illness, expected length of survival declined to 6.9 years (a decrease of 5.9 years). In the subset of patients with falls, life expectancy correlated with age, assessed at 7.1 years for individuals age 70 to 79 years and 4.8 years for patients age ≥80 years. In both age groups, coexistent psychiatric illness was associated with shorter life expectancy, falling to 4.9 years for patients age 70 to 79 years and 2.88 years for patients age ≥80 years (a 40% reduction). The shortest median lifespan (1.4 years) was seen among patients in the oldest demographic who had falls, psychiatric illness, and pressure ulcers. The authors also found chronic illness to be an independent predictor of a 16% to 50% reduction in life expectancy among patients with geriatric syndromes and CRC.

The authors concluded that “geriatric syndromes are an important risk factor predicting mortality, independent of age, treatment, and comorbidity, following CRC diagnosis.” They recommended that gastroenterologists factor in the preexistence of geriatric syndromes when discussing treatment options for geriatric patients.


Study Identifies Long-Term Risk Factors for Onset of Constipation in Elderly Women

Chicago, IL—Although several factors are thought to predispose an individual to constipation—a problem that affects up to 20% of the general population—researchers have yet to discover precisely why the condition so commonly arises in older women. New data from a team of Australian investigators suggest that giving birth at some point, smoking, and having generally poor health increase the likelihood that a woman will struggle with constipation later in her life. The researchers shared the results of their large, prospective study in a poster presentation during DDW 2011.

The findings constitute a subanalysis of data from the Australian Longitudinal Study on Women's Health, which was initiated in 1996 and surveyed 12,762 community-dwelling women age 70 to 75 years on various health issues. The women were randomly selected from the Australian Health Insurance Database. The survey also solicited information on demographics (eg, nationality, education, marital status, socioeconomic status) and lifestyle issues, such as history of smoking and alcohol consumption, body mass index, number of live births, history of uterine prolapse repair, and cumulative incidence of stressful life events in the previous 3 years. In 2005, approximately 9 years after completing the 1996 survey, 3716 of the women (age range, 79-84 years) agreed to complete a follow-up questionnaire.

In both surveys, respondents were asked, "Have you had constipation in the past 12 months?" The authors defined constipation as “persistent difficulty, infrequent, or seemingly incomplete defecation.” According to the investigators, 40.3% (1501/3716) of the women surveyed in 2005 affirmed that they had developed constipation in the intervening 9 years between surveys.

A univariate analysis found significant correlations between new-onset constipation and higher number of live births, higher number of stressful events, lower socioeconomic status, and poorer quality of life across multiple domains, which had been assessed in 1996 using the SF-36, a 36-question short-form health survey. The final multivariate analysis determined that independent risk factors for new-onset constipation consisted of positive marital status (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.01-1.39; P = .04); a history of childbirth (OR, 1.07; 95% CI, 1.0-1.14; P = .04), a history of smoking (OR, 1.24; 95% CI, 1.04-1.48; P = .02), a higher score on the pain subscale of the SF-36 (OR, 0.95; 95% CI, 0.92-0.99; P = .01), and a lower score on the general health subscale of the SF-36 (OR, 0.91; 95% CI, 0.87-0.95; P <.000).

The authors noted that constipation commonly occurs among older women living independently in the community setting and degrades health-related quality of life. Previous studies have implicated concurrent disease, certain medications, immobility, and lifestyle factors such as alcohol consumption and lack of fluid and fiber in the diet in the genesis of constipation. This study looked specifically at new-onset constipation and concluded that childbirth issues and poor quality of life are probable long-term risk factors that predispose a woman to constipation late in life.