From the 5th Edition of the Geriatrics Review Syllabus: Gastrointestinal and Oral Diseases & Disorders

Karen E. Hall, MD, PhD, Assistant Professor at the Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan, Ann Arbor, and Research Scientist, GRECC, at the Ann Arbor VA Medical Center, MI, suggested that esophageal cancer, like colon cancer, may begin with a progression of mutations rather than a single causative event such as acid reflux.  

Current recommendations include that patients with high-grade dysplastic lesions should be referred for endoscopy (to rule out Barrett’s esophagus) and possible surgery.  Dr. Hall feels, however, that patients with moderate-grade dysplastic lesions should also be followed up, possibly annually.  She stated that if patients are cognitively intact, they should decide what kind of diagnostic and therapeutic approach should be taken once they are informed regarding the options.  She pointed out that “the main risk of proton pump inhibitors [PPIs] is wallet risk,” because they are expensive.

In terms of conservative measures, Dr. Hall favors discontinuing potassium and iron supplementation, which has been associated with strictures in both the esophagus and the duodenum, and prescribing PPIs if the patient is willing and financially able to take them. She pointed out that H2 antagonists are not as efficacious in controlling basal acid secretion as PPIs and would have to be taken for a much longer period of time; additionally, agents such as cimetidine can carry an increased risk of side effects in a geriatric patient population. Dr. Hall explained that Barrett’s esophagus often does not manifest any symptoms. Patients’ symptoms will be caused by gastroesophageal reflux disease, and sometimes patients will be asymptomatic except for some hoarseness (“silent reflux”).  “Alarm symptoms,” which should lead a clinician to suspect possible esophageal cancer, include a weight loss of at least 10 pounds or 10% of total weight, anemia, bleeding, and pain.  

She noted that patients with schizophrenia and related disorders may be receiving psychotropic drugs that have anticholinergic and neurological (dyskinetic) side effects that can impair food transit and increase reflux risk.  She cautioned, however, against discontinuing antipsychotic medication abruptly, since that could actually worsen tardive dyskinesia, and suggested switching the patient to a neuroleptic with a lower known rate of side effects.  Dr. Hall advised against using feeding tubes in patients with dementia, because the potential prolongation of life by about one year comes at the expense of quality of life and with the risk of infection and of aspiration pneumonia. When an elderly patient has multiple morbidities, abdominal distention, and intermittent vomiting but no pain, weight loss, or appetite changes, Dr. Hall advised that impacted stool may be implicated and an enema could be the first and best solution, followed by maintenance with a cathartic or osmotic laxative.  She warned the audience that mineral oil and soap-suds enemas can cause problems and stated that plain tap water would probably be the best medium to use.  

The speaker presented the case of an elderly, mildly demented patient with multiple morbidities and symptoms of fever and emesis persisting for 36 hours.  Even though the patient’s white blood cell count appeared within normal limits, Dr. Hall said, it should be compared to his usual count for the possibility of an extreme change.  She suggested a surgical evaluation, pointing out that appendicitis is more common in very old patients and particularly in men.  “In fact,” she added, “about 50% of all deaths from appendicitis are in this small group of individuals.”  She stressed that the physician who knows the patient well may suspect something wrong that others would miss.  “If you’re convinced something is wrong, something is different…I would push to get them evaluated.”   Dr. Hall discussed Clostridium difficile infection, pointing out that elderly nursing home residents are more susceptible, in part because their bodies have lost some ability to rid themselves of implicated organisms and also because C. difficile can be passed between patients.  She suggested that an outbreak of diarrhea in the nursing home should be a signal to look for C. difficile infection, and treatment with an antibiotic is appropriate.

Oral Diseases and Disorders  
Ken Shay, DDS, MS, Extended Care Service Line Director for Division 11 of the Department of Veterans Affairs and a faculty member at the University of Michigan School of Dentistry, Ann Arbor, MI, stressed that even though medicine and dentistry are distinct disciplines, it is important for physicians to recognize oral signs of potential problems; he pointed out that oral dysfunction can contribute to systemic illness by impairing eating and allowing bacteria into the lungs, bloodstream, and digestive tract. It can also contribute to psychological problems by inhibiting social interaction if a patient is embarrassed by appearance or odor.   Dr. Shay described some of the normal differences between old and young teeth.  

Older teeth are more pigmented and more translucent than younger teeth.  They are also more brittle, breaking more easily, and have less reparative capacity.  Because there is a loss of neurons that accompanies diminished blood supply, older patients are more likely than younger patients to have asymptomatic disease, since they may not feel pain at the site.   Dr. Shay emphasized that Streptococcus mutans, the primary cause of tooth decay, is present in almost everyone’s mouth. By ingesting refined sugars or the sugars resulting from the degradation of starches, it causes acids to form that attack the teeth. It causes decalcification by firmly adhering to tooth surface.  In older individuals, the acid attacks the roots of teeth more than the crown, as it does in younger people.  If the decay is left untreated, the integrity of the tooth can be undermined, abscesses can form that eat away the bone around the tooth, and infection can invade the bloodstream.  Brushing the teeth regularly and thoroughly and avoiding sugars can help prevent decay; however, older individuals have other problems that can render them susceptible:  Salivary hypofunction, often induced by medications or radiation, is a danger in that saliva has antimicrobial properties, can help remineralize decalcified teeth, lubricates the structures of the mouth, and aids in chewing and swallowing.  

Other risk factors include less frequent professional dental attention, inadequate exposure to fluoride, and an inability to brush the teeth adequately.  Dr. Shay believes that helping patients brush their teeth is a nursing function that is often neglected.  In terms of fluoride supplements, he recommended sodium fluoride, rather than stannous fluoride, for elderly patients, because sodium fluoride has been shown to be more effective against root caries, which is a bigger problem for older patients. Dr. Shay described gingivitis as an inflammation of the gingiva, the tissue closest to the tooth.  Gingivitis can cause pain, unsightliness, and spontaneous bleeding.  It can be resolved via the removal of bacterial deposits.  Without attention, however, it can progress to a more serious form, periodontitis, in which the inflammation affects the bone and tissue supporting the teeth.  Periodontal disease is usually worse in people with diabetes and has also been seen to exacerbate blood sugar levels.  It is also more actively destructive in certain immunopathic states.  In addition, the presence of osteoporosis can indicate a propensity for more severe bone loss in periodontal disease.

Although dentures can enhance a person’s appearance and ability to chew, they are not always fitted accurately, they may need to be refitted fairly frequently, and they can be prohibitively expensive, especially considering the fact that Medicare has no dental coverage, which makes this last factor particularly hard on seniors. Dr. Shay continued his presentation with discussion of the American Heart Association’s recommendations regarding antibiotic prophylaxis for individuals about to undergo dental procedures that may cause bleeding.  He pointed out that patients who have had cardiac bypass are not at risk for bacterial endocarditis except during the first few days after surgery, whereas those who have had previous bacterial endocarditis and those who have received or are candidates for prosthetic cardiac valves are at heightened risk.  Having a pacemaker or defibrillator, having had rheumatic fever, and having a functional murmur do not render a patient susceptible. Individuals who are immunocompromised in any way, those taking corticosteroids, people with recent prosthetic joint infection, and those with rheumatoid arthritis are all more vulnerable to bacterial infection during dental procedures.  

Finally, Dr. Shay addressed oral cancer, stating that annually there are about 30,000 new cases and about 8000 deaths related to oral cancer.  It is more prevalent in men than in women, with a 2:1 male-to-female ratio except in lip cancer, which has an 8:1 ratio. Besides the lips, common sites of oral cancer are the tongue, oral pharynx, and floor of the mouth.   More than 95% of cases of oral cancer appear in individuals 40 years of age or older, and more than 96% are oral squamous cell carcinomas.  In addition to age, tobacco and alcohol use are common risk factors.   A red sore (erythroplakia) in a patient’s mouth that cannot be attributed to an obvious cause, such as loose dentures rubbing, should raise an alert, and the patient should be sent for a biopsy.  A white patch (leukoplakia) can be caused by several factors, not just cancer, and only 10% of leukoplakias are malignant, whereas 93% of erythro?plakias are.  White patches in the mouth are often caused by infections such as candidiasis. Dr. Shay stressed that overall, diligent brushing of the teeth and regular dental care are the best ways to avoid oral disorders.