Gastro-oesophageal reflux disease in the elderly

Gastro-oesophageal reflux disease in the elderly

GORD is the reflux of gastric contents into the oesophagus causing troublesome symptoms or mucosal complications.

Pathy's records that GORD is the sixth most common disorder among elderly people in residential care, and that around 20% of the general population experience weekly reflux symptoms.

The prevalence in the elderly is as high as in the young, but the disease behaves differently: it presents atypically and is more likely to be severe.

The dominant mechanism at all ages is transient lower oesophageal sphincter relaxations, particularly after meals — not simply low resting sphincter pressure.

Age-related predisposing changes listed in Pathy's: hiatus hernia in around 60% of those over 60; declining LOS resting pressure and intra-abdominal length; increased acid exposure; reduced salivary flow; and impaired acid clearance.

The number of reflux episodes is similar to the young, but their duration is longer, reflecting impaired clearance from reduced primary and secondary peristalsis and a less compliant oesophagus.

Visceral sensation declines with age — perception of balloon distension and of acid is reduced, and cortical evoked potentials are of lower amplitude. This explains why symptoms are milder despite worse mucosal injury.

The refluxate may be less acidic because of atrophic gastritis, but its bile content may still injure the mucosa and contribute to Barrett's change.

Key examination line: Pathy's states GORD in the elderly presents with more severe mucosal injury — erosive oesophagitis, stricture or Barrett's oesophagus — yet symptoms are characteristically milder or qualitatively different.

Consequently dysphagia, vomiting, respiratory difficulty, weight loss and anaemia are not uncommon presenting features, while heartburn occurs less often than in the young.

In the general population heartburn or regurgitation has a sensitivity of about 70% for GORD but low specificity against 24-hour pH monitoring; comparable data for an ageing population are not available.

Atypical/extra-oesophageal manifestations: chronic cough, asthma, laryngitis and non-cardiac chest pain — mediated either directly by acid-pepsin or by vagal reflexes from oesophageal acid exposure.

Alarm symptoms mandating prompt endoscopy: dysphagia, anorexia, weight loss, haematemesis, anaemia. Pathy's states the threshold for endoscopy in older patients should be lower than in the young.

Endoscopy is the first investigation in older patients — it grades oesophagitis (Los Angeles A–D), detects stricture, Barrett's and malignancy, and permits biopsy and dilatation.

Trial of double-dose PPI for 2–8 weeks (depending on symptom frequency) is a useful and cost-effective initial test in atypical presentations and non-cardiac chest pain, with sensitivity and specificity up to 80%.

Oesophageal manometry and ambulatory pH monitoring are indicated when PPIs fail — manometry is particularly useful to exclude achalasia before considering surgery.

Exclude cardiac disease first in any older patient with chest pain; also consider musculoskeletal, pulmonary, pericardial, gastric and biliary causes.

Lifestyle: weight reduction, head-end elevation, avoidance of late meals, smoking and alcohol; review drugs that lower LOS pressure (calcium channel blockers, nitrates, anticholinergics) and drugs causing pill oesophagitis.

PPIs are the drugs of choice. Pathy's states there is no significant difference in healing capacity between older and younger patients, that PPIs retain superiority over H2 receptor antagonists, and that no dose adjustment is needed for age-related renal or hepatic change.

Important geriatric caveat: downward dose titration is less appropriate than in the young, especially where the initial symptoms were mild or the GORD is complicated — because symptom severity underestimates mucosal disease.

Adverse effects of long-term PPI use (Pathy's grading of causality): Causal relationship likely: acute interstitial nephritis, benign gastric fundic gland polyps, increased enteric infections. Possible: Clostridioides difficile infection, B12 deficiency, hypomagnesaemia/hypocalcaemia. Not supported by strong evidence: osteoporosis and hip fracture, community-acquired pneumonia, dementia, CKD progression. Clopidogrel interaction is of minimal significance except with omeprazole.

Deprescribing principle: PPIs are often over-prescribed and the indication for ongoing therapy should be reviewed periodically. H2RAs are an alternative but are less potent and can cause mental status change in renal or hepatic dysfunction.

Prokinetics have no established role in GORD treatment.

Surgery: laparoscopic fundoplication is an option, with outcomes and complication rates in patients over 70 comparable to those under 60. However, patients with ineffective oesophageal motility risk post-operative dysphagia, and long-term medical therapy is likely more cost-effective in older patients given the fewer remaining years of therapy needed.

Endoscopic anti-reflux procedures have not fulfilled their initial promise and should be restricted to clinical trials.