Gastroesophageal reflux disease is a common disorder in all patients but a particular problem in the elderly, for whom the disease often presents with advanced mucosal damage and other complications. Symptoms are also not as reliable an indication of disease severity in older patients. Likewise, therapy is more difficult because of potential side effects and drug interactions.
Key points
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Gastroesophageal reflux disease (GERD) is a prevalent disorder in the elderly, and seems to be associated with more severe and advanced disease in a population that is growing in size in the United States.
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Changes in esophageal physiology predispose to more esophageal damage in older patients, as well as to a frequent disconnect between the type and severity of symptoms and severity of mucosal damage.
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Comorbidities make the diagnosis and treatment of GERD more challenging in aged patients, yet the treatment goals and approach are similar in older and younger patients.
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Older patients may be at increased risk of complications from reflux therapy, whether medical or surgical.
Introduction
Gastroesophageal reflux disease (GERD) is a common disorder affecting 20% of the United States population and 6% to 17% of the elderly. GERD is not only common in the elderly, but when compared with younger counterparts, older patients have more intense patterns of abnormal acid contact time and advanced erosive disease. The United States older population is growing and is at its highest level since 1900 according to the US Census Bureau. In 1900, there were fewer than 5 million Americans aged 65 and older. This rate increased to 35 million in 2000 and rose to more than 40 million by 2011, representing 13.8% of the total population. By the year 2050, more than 20% of the United States population will be older than 65 years, and approximately 20 million individuals will be older than 85.
There were about 1.5 million nursing home residents in 16,100 facilities according to the 2004 National Nursing Home Survey. The number of Americans needing long-term care is projected to double between 2000 and 2050. A recent, retrospective cross-sectional study of almost 20,000 long-term care residents of nursing homes aged 65 years and older identified the 20 most common chronic conditions. GERD was the sixth most common disorder in the confined elderly, with 23% prevalence in men and women. In summary, GERD is a prevalent disorder in the elderly, and seems to be associated with more severe and advanced disease in a population that is growing in size in the United States.
Introduction
Gastroesophageal reflux disease (GERD) is a common disorder affecting 20% of the United States population and 6% to 17% of the elderly. GERD is not only common in the elderly, but when compared with younger counterparts, older patients have more intense patterns of abnormal acid contact time and advanced erosive disease. The United States older population is growing and is at its highest level since 1900 according to the US Census Bureau. In 1900, there were fewer than 5 million Americans aged 65 and older. This rate increased to 35 million in 2000 and rose to more than 40 million by 2011, representing 13.8% of the total population. By the year 2050, more than 20% of the United States population will be older than 65 years, and approximately 20 million individuals will be older than 85.
There were about 1.5 million nursing home residents in 16,100 facilities according to the 2004 National Nursing Home Survey. The number of Americans needing long-term care is projected to double between 2000 and 2050. A recent, retrospective cross-sectional study of almost 20,000 long-term care residents of nursing homes aged 65 years and older identified the 20 most common chronic conditions. GERD was the sixth most common disorder in the confined elderly, with 23% prevalence in men and women. In summary, GERD is a prevalent disorder in the elderly, and seems to be associated with more severe and advanced disease in a population that is growing in size in the United States.
Esophageal physiology and aging
Aging of the esophagus has been associated with several important changes in esophageal physiology that predispose to both the prevalence and severity of GERD. These factors are summarized in Box 1 and Table 1 .
Decreased salivary flow and bicarbonate secretion
Weakened and/or disordered esophageal motility
Weakened lower esophageal sphincter pressure
Hiatal hernia
Declining prevalence of Helicobacter pylori allows continued acid secretion into old age
Increased rates of obesity
| Factor | Mechanism/Notes |
|---|---|
| Weak UES pressure | Increased risk of aspiration |
| Decreased sensation | Increased risk of complications and delayed identification of disease |
| Poor primary and secondary peristalsis | Longer duration of acid exposure |
| Comorbidities (diabetes, medications, etc) | Increase acid exposure and/or increase severity of damage |
Structural Studies
In a rodent model, aging impairs the cholinergic nerve cell population in the stomach and intestines. Studies of the animal or human esophagus appear scarce. In a study that evaluated the histology of the Auerbach plexus and esophageal smooth muscle in autopsy material from young and old subjects, the investigators found a significant decrease in ganglion cells per square centimeter ( P <.05) and a heavier lymphocytic infiltration in comparison with younger counterparts. This situation could potentially produce disorders similar to idiopathic achalasia and diffuse spasm. Pathologic changes seen in the esophagus with aging are similar to changes seen in patients with the more specific spastic esophageal motility disorders.
Hiatal hernias are an important factor in the genesis of GERD, and their presence and size has been noted to partially correlate with the severity of mucosal damage from GERD. For example, hernias of 3 cm or larger may predispose to lower pressures in the lower esophageal sphincter (LES), greater acid exposure, and higher prevalence of erosive esophagitis. Hernias are more common with increasing age, and were noted in 60% of patients older than 60 years.
Esophageal Motility Studies
Lower esophageal sphincter
There is no clear relationship between basal LES pressure and aging. When acid exposure and LES pressures were compared, LES pressure was lower with more severe acid exposure, but did not correlate with advancing age. An additional study showed increased esophageal acid exposure with advancing age, and that these changes in acid exposure were associated with a decrease in both abdominal LES length and a weakening in esophageal motility. Most studies seem to suggest that LES pressure relates more to acid exposure and hiatal hernia than specifically to age. Transient LES relaxations (tLESR) are an important mechanism in GERD, and the authors are not aware of any studies looking at tLESR in older subjects in comparison with younger counterparts or controls.
Esophageal body
Much still remains to be learned about the effects of aging on esophageal physiology. In 1964, with the use of combined radiographic and esophageal manometric techniques, investigators coined the term presbyesophagus to suggest that elderly patients have a unique array of findings. In 15 patients between 90 and 97 years old, they found evidence of nonpropulsive, often repetitive contractions and tertiary contractions in a pattern resembling esophageal spasm. Unfortunately, this study may have overestimated age-related deterioration because most of the patients were infirm with comorbidities that, by themselves, may explain the esophageal changes. Four were hospitalized patients, 4 had senile dementia, and 10 had evidence of diabetes and stroke or neuropathy.
Hollis and Castell recruited 21 nonhospitalized elderly men (age 70–87 years) without evidence of diabetes, neuropathy, or dementia, and compared their basal and edrophonium-stimulated esophageal motility results with those of 11 men with no history of heartburn or dysphagia (age 19–27, mean 23 years). Their main finding was a decrease in basal esophageal pressures and a marked blunted cholinergic response ( P <.05) in older patients (especially those >80 years) when compared with younger controls. The investigators concluded that disrupted muscle activity (rather than a neurologic process) was the explanation for the age-related differences. In another study, 10 normal subjects had repeated longitudinal studies over 8 years without evidence of deterioration in esophageal motility, but they were fairly young at the onset of the study (mean age 36, range 30–53 years).
In a database of 562 patients undergoing manometry, 126 were noted to have aperistalsis. Detailed investigations were performed, which explained the aperistalsis in all patients except for a group of 26 elderly (>65 years) subjects. It was concluded that aging might be associated with deterioration of esophageal motility in these patients. In 1979 a group in Barcelona, Spain published a study of 79 volunteers without obvious history of esophageal disease. Esophageal motility testing was done with a water-perfused system. To assess esophageal motility as a function of age, the 79 subjects were divided into 6 age groups (≤25 [n = 26], 26–35 [n = 10], 36–45 [n = 10], 46–55 [n = 10], 56–65 [n = 10], >65 years [n = 13]). The results showed that LES pressure, upper esophageal sphincter (UES) pressure, and peristaltic wave amplitude and progression speed decrease with advancing age, whereas contractile wave duration and the proportion of nonperistaltic contractions increase. A Brazilian study recruited 40 subjects from the community distributed by age (20 aged 20–30, 10 aged 50–60, and 10 aged 70–80 years), and performed esophageal manometry and scintigraphy. The investigators found abnormal peristalsis and impaired esophageal clearance to be more common in older volunteers. In a population of 470 consecutive symptomatic esophageal patients (some with GERD and some with dysphagia and other symptoms referred for esophageal motility at a tertiary center), older patients (>75 years) tended to have more common abnormal motility (68.7%) when compared with their younger (<50 years) counterparts (45.7%).
There are some motility data available from older patients who specifically have GERD. The effects of age on esophageal motility were recently reported in a study of 326 patients with symptoms and objective confirmation of GERD (erosions on esophagogastroduodenoscopy or abnormal pH). Subjects were grouped by decades. Whereas normal motility was observed in 87% of subjects aged 17 to 39 years, only 56% of those older than 70 had a normal study. Older age, but not GERD status, was also associated with lower esophageal amplitude of contraction. No age differences were noted in LES length or resting pressures, although, as expected for GERD subjects, LES resting pressures were lower on comparison with those without GERD ( Fig. 1 ). In an additional study of 349 consecutive patients undergoing motility and pH studies, the authors’ group found that when compared with younger subjects (age <40 years), older patients (>65 years) had a significantly lower percentage of normal swallow-induced peristalsis, and that peristaltic failure was associated with increased levels of esophageal acid exposure. These changes in esophageal motility were confirmed in a large (n = 1307) retrospective study. Older GERD subjects had decreased abdominal LES length and esophageal motility. Age was associated with an increase in esophageal acid exposure, but the severity of reflux symptoms decreased with age.
Upper esophageal sphincter dysfunction
Although not directly related to the pathophysiology of GERD, GERD-related aspiration into the airways is a potential cause of morbidity and mortality in the older patient. Several studies have also identified several findings in this region of the esophagus. In 1990, a study of 10 elderly volunteers (age >60, range 62–79 years) and 10 younger adults (age <60, range 24–59 years) was completed with solid-state microtransducers. The investigators focused on UES physiology, and found that aging was associated with lower resting UES pressure and delayed UES relaxation, relative to the pharyngeal contraction peak.
In a study of 67 healthy subjects aged 17 to 67 years, older subjects were found to have only marginally lower UES resting pressures but markedly elevated pharyngeal contraction pressures. Increasing age was associated with a reduction in duration of upper esophageal contractions and, for bread swallows, an increase in pharyngoesophageal wave velocity. An additional, protective mechanism may also be affected with aging. Comparing 9 healthy young (26 ± 2 years) with 9 older subjects (77 ± 1 years), Ren and colleagues noted significant differences in UES contractile reflex, showing this reflex to be impaired with age. This mechanism may be important in protecting the airway from aspiration of a refluxed bolus located in the proximal esophagus. Ongoing studies using high-resolution manometry may help to clarify the importance of the UES and proximal, striated muscle esophagus in reflux and other diseases.
Sensory Changes
Sensory changes in esophageal perception have also been noted, and may explain the concept that older patients often present with more advanced disease, but with symptoms similar to or milder than younger patients. When compared with younger control individuals (mean age 27, range 18–57 years), older subjects 65 years or greater (mean age 72.5, range 65–87 years) showed a decreased sensory perception to esophageal distension. An acid perfusion study found that older patients with GERD were noted to have less severe symptoms and a longer lag time until the appearance of symptoms when compared with younger patients.
Other Changes
Salivary bicarbonate is important in the neutralization of refluxed acid, and may tend to decrease with aging. The relationship of aging and gastric acid secretion is somewhat complex. Historically it was suggested that older patients experience an age-related decrease in acid secretion, but this was likely related to Helicobacter pylori status. Curing H pylori infection may actually increase reflux in some patients. Because the prevalence of H pylori seems to be decreasing, more patients may retain their ability to secrete acid into old age. This continued acid secretion, when combined with some degree of peristaltic dysfunction, may lead to a greater risk for GERD and its complications. Other factors that have not been well studied in older patients include esophageal mucosa resistance, gastric emptying, and duodenogastric reflux.
Diabetes, Parkinson disease, Alzheimer disease, amyotrophic lateral sclerosis, and many other disorders increase in prevalence with aging, and thus may likely contribute to or are associated with GERD. Medication use is more common in older patients, and medications that may increase the risk of GERD include theophylline, nitrates, calcium antagonists, benzodiazepines, anticholinergics, antidepressants, lidocaine, and prostaglandins. An increase in body weight with age may also predispose to GERD, which is important because our older population is now more likely to be obese than in the past.
Age and GERD prevalence
The physiologic changes noted earlier likely predispose elderly patients to GERD, and an increased prevalence of GERD symptoms in elderly patients has been reported in some, but not all studies. The proportion of patients using antacids who are older than 50 years is greater than in patients younger than 50 (22% vs 9%). On the other hand, in a random sample of 2200 residents of Olmsted County, Minnesota, aged 25 to 74 years, the overall prevalence of heartburn or acid regurgitation at least weekly was 20%, and no significant increase in prevalence occurred with age. The prevalence of heartburn declined with age although regurgitation did not. This finding supports the concept of impaired sensory function with aging. A recent systematic review found 9 population-based studies and 7 clinical studies on age-related prevalence and incidence. No increase in GERD symptom prevalence with age was noted, but aging was associated with more severe patterns of acid reflux and reflux esophagitis; symptoms associated with GERD become less severe and more nonspecific with aging ( Fig. 2 ). The investigators concluded that “the real prevalence of GERD may well increase with age.”
