Treatment of Nausea and Vomiting in the Older Palliative Care Patient

Hannah I. Lipman, MD, Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA.

Diane E. Meier, MD, Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA.

Nausea and vomiting are common problems in the care of the older palliative care patient. Depending on the population studied, incidence is as high as 60%. Distress associated with nausea and vomiting may be relieved in the majority of cases by careful determination of the underlying cause and selection of one or more antiemetic agents. Pathophysiology of nausea and vomiting involves complex interactions among multiple neurotransmitter systems. Antiemetic agents work via modulation of neurotransmitter signalling. Pharmacologic agents are reviewed and geriatric dosing recommendations are made.

Key words: palliative, end of life, geriatric, nausea, vomiting

Irritable Bowel Syndrome in the Older Adult

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Anil Minocha, MD, FACP, FACG, Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
Thomas Abell, MD, FACG, Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.

Irritable bowel syndrome (IBS) in the older adult offers challenges for diagnosis and treatment; however, very little research has been done in this regard. IBS has significant impact on the quality of life, especially in frail individuals. The diagnostic criteria have not been validated in older subjects. Diagnostic strategy needs to be modified to account for the expanded list of differential diagnosis, including high prevalence of colorectal cancer. There is a lack of evidence related to the efficacy of the treatment regimens used. Therapy should focus on specific symptoms and be matched for the potential for side effects and drug interactions. The prognosis for IBS is excellent and in a majority of cases symptoms disappear within five years.

Key words: Irritable bowel syndrome, Functional bowel disorder, Rome II criteria, older adults, spastic colon

Inflammatory Bowel Disease in the Elderly

Alexander I. Aspinall, MD, PhD and Jon B. Meddings, MD, FRCPC, Division of Gastroenterology, Faculty of Medicine, University of Calgary, Calgary, AB.

The inflammatory bowel diseases (IBD)--Crohn's disease (CD) and ulcerative colitis (UC)--have a second peak of onset after the age of 60. Discerning IBD from alternate diagnoses is a great challenge in the geriatric population, as other diseases commonly encountered in the elderly can mimic IBD. The possibilities include ischemic colitis, diverticulitis and infectious colitis. Diagnosing and treating IBD should involve consultation with a gastroenterologist, but the approaches do not vary significantly from the strategies used in younger patients. Therapeutic modalities used in younger age groups are also applicable to the geriatric population, but great attention needs to be given to side effects and drug interactions.
Key words: inflammatory bowel, crohn's disease, ulcerative colitis, differential diagnosis

Epidemiology and Pathophysiology
The inflammatory bowel diseases--Crohn's disease (CD) and ulcerative colitis (UC)--are illnesses of unknown cause.

Management of Premalignant Gastrointestinal Lesions

Clarence K.W. Wong, MD, FRCPC, Gastroenterologist and Clinical Lecturer, Division of Gastroenterology, University of Alberta; Consultant, Cross Cancer Institute, Alberta Cancer Board, Edmonton, AB.

Introduction
Gastrointestinal malignancies collectively account for the greatest number of cancer deaths in Canada.¹ This is particularly evident in the elderly population in which 90% of all new cancers are diagnosed in individuals over the age of 45.² Of these new cancers, one in five are gastrointestinal cancers. As these malignancies are often lethal, improved survival depends on preventive strategies to effectively detect and manage the associated precursor conditions. This paper will review the premalignant conditions associated with three common gastrointestinal cancers. Effective management of conditions leading to esophageal, gastric and colon cancers can greatly reduce the burden of disease among the geriatric population.

Esophageal Cancer
Cancers of the esophagus are lethal, with a death to case ratio of 1.11.¹ Although this estimate is high due to incomplete registration of new cases, it underscores the lack of effective treatment for this disease. Until recently, squamous cell carcinomas were the most common type of esophageal cancer. However, in the last few decades the incidence of esophageal adenocarcinomas has increased exponentially. It is likely that this increase is linked to a rise in incidence of its only known risk factor, Barrett's esophagus.

Gastroesophageal Reflux Disease: Approaching the Burning Issues

Mary Anne Cooper MSc, MD, FRCPC, Department of Medicine, University of Toronto; Lecturer, Sunnybrook and Women’s Health Sciences Centre, Toronto, ON.

Introduction
Gastroesophageal reflux disease (GERD), the abnormal reflux of gastric and duodenal contents into the esophagus, is common. Almost 50% of the North American population experience symptoms once a month and 10% have symptoms daily.¹ Patients most commonly complain of pyrosis and regurgitation, but other symptoms such as dysphagia, chest pain and nausea are not rare.¹ As well, respiratory tract symptoms such as cough, hoarseness and asthma may be attributable to GERD (Table 1).^1,2

Acid reflux into the esophagus is a normal physiologic event. It occurs after meals when the lower esophageal sphincter (LES) tone is reduced. The LES opens, creating a common cavity with the stomach. Because stomach pressures are higher than esophageal pressures, gastric contents reflux into the esophagus. Formal measurement with 24-hour pH monitoring indicates that the pH of the esophagus should be < 4 for < 4% of the time. Factors that increase acid contact time with the esophagus promote GERD.

Prevention of NSAID-related Gastrointestinal Complications in the Geriatric Patient

Naveen Arya, MD, FRCP(C), Resident, Gastroenterology sub-specialty training program, Univerity of Toronto, Toronto, ON.
Peter G. Rossos, MD, FRCP(C), Staff Gastroenterologist, University Health Network; Program Director, Division of Gastroenterology, University of Toronto, Toronto, ON.

Introduction
With advancing age, the use of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of arthritis, pain and headache increases. Although there are many benefits of NSAIDs for their analgesic and anti-inflammatory properties, there are also potential serious side effects. The side-effect profile includes dyspepsia, gastrointestinal mucosal ulceration and bleeding, cardiac dysfunction, renal toxicity and platelet dysfunction (Table 1). Chronic use of NSAIDs is associated with serious gastrointestinal (GI) toxicity, which severely restricts the use of these medications. In the United States, adverse events associated with NSAIDs result in 103,000 hospitalizations and 16,500 deaths per year.¹ In the United Kingdom, it is estimated that 1/2000 NSAID prescriptions lasting for two months will result in death.²

The average cost of both over-the-counter and prescription NSAID use in the United States is approximately $5-10 billion dollars (U.S.) per year.³ Despite significantly increased costs of therapy, newer COX-2 inhibitors are frequently prescribed in an effort to reduce complications.

Evaluation and Treatment of Constipation

Marisa Battistella, BScPhm, Pharm D, Education Coordinator & Hemodialysis Pharmacist, Pharmacy Department, University Health Network, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, University Health Network, Toronto, ON.

Constipation is a common symptom in patients of all ages, but its occurrence is highest among persons 65 years of age or older.^1,2 Constipation has been shown to diminish both quality of life and feeling of well-being.^3-5 Although constipation can have many causes, it is most often functional or idiopathic.^5,6 Furthermore, constipation can lead to serious complications such as malnutrition, fecal impaction, fecal incontinence, colonic dilation and even perforation of the colon.⁷

Definition
Constipation has different meanings to patients and physicians. A patient's perception of constipation may include not only the objective observation of infrequent bowel movements but also subjective complaints of straining with defecation, incomplete evacuation, abdominal bloating or pain, hard or small stools or a need for digital manipulation to enable defecation. Because the definition of constipation can be subjective, an international committee has recommended an operational definition of chronic functional constipation in adults.

Management of Dyspepsia in the Elderly

C.A. Fallone, MD, FRCP(C), Division of Gastroenterology, McGill University Health Centre, Montreal, QC.

Definition of Dyspepsia
Defining dyspepsia is a somewhat confusing endeavour mainly because the definition itself has varied somewhat over the last few decades. Moreover, the distinction between uninvestigated and investigated dyspepsia is not always clear. Clinically, dyspepsia symptoms must be distinguished from the lower gastrointestinal symptoms of irritable bowel syndrome. Furthermore, the term dyspepsia is often used synonymously for upper gastrointestinal symptoms, but because most experts feel that dyspepsia must be distinguished from gastroesophageal reflux disease (GERD), it does not represent all upper gastrointestinal symptoms.

The Rome II definition of dyspepsia is the most recent and widely accepted.¹ Dyspepsia is defined as a pain or discomfort centred in the upper abdomen. This epigastric discomfort can be associated with other gastrointestinal symptoms such as bloating, feeling full, nausea, early satiety and heartburn. It is important to note that burning sensation in the epigastrium is not heartburn. Rather, heartburn refers to a burning sensation that originates from the epigastric region and radiates up towards the neck. Heartburn alone is not considered dyspepsia according to this definition.

Diverticular Disease of the Colon: Review and Update

Christopher N. Andrews, MD, Gastroenterology Fellow, Faculty of Medicine, University of Calgary, Calgary, AB.
Eldon A. Shaffer, MD, FRCPC, Professor of Medicine, Division of Gastroenterology, Faculty of Medicine, University of Calgary, Calgary, AB.

Introduction
Diverticular disease of the colon (or diverticulosis) is an anatomical description of saccular outpouchings of mucosa through the wall of the colon. It is very common in the Western world, and its prevalence is rising. This paper will briefly review the epidemiology and pathophysiology of diverticular disease, followed by a focus on the diagnosis and management of the two most common complications of the disease: diverticulitis and diverticular bleeding.

Epidemiology
The true prevalence of diverticulosis is unknown, but autopsy reports suggest that up to half of patients over 60 years are affected.¹ The frequency increases with age and is much higher in developed societies in which fibre intake is lower. In the Western world, the most commonly affected site in the colon is the sigmoid colon, sometimes with more proximal involvement.² However, in Asian countries diverticulae tend to be right-sided (in the ascending colon) and fewer in number. The reason for this difference is unknown.

Pathophysiology
The colon is made up of circumferential and longitudinal (taenia coli) muscle layers, which act in unison to propel stool towards the rectum.

Gastrointestinal Complaints Stand Among the Giants

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.