Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 448

GORD is the sixth most common disorder amongst the elderly in residential care, which is not surprising; even in the general population, around 20% experience weekly reflux symptoms.⁴³ GORD presents in the elderly with more severe mucosal injury (erosive esophagitis, stricture, or Barrett’s oesophagus) than in the young, yet symptoms are characteristically milder or may be qualitatively different. Thus dysphagia, vomiting, respiratory difficulty, weight loss, and anaemia are not uncommon presenting features, while ‘typical’ reflux symptoms like heartburn occur less often than in the young, reflecting diminished oesophageal sensitivity. In the general population, symptoms of heartburn or regurgitation have a high sensitivity (about 70%) for a diagnosis of GORD but low specificity when using 24‐hour pH monitoring as the gold standard; corresponding data for an ageing population are not available. The alarm symptoms mentioned for NCCP are indications for prompt endoscopic investigation.

Atypical or extra‐oesophageal manifestations of GORD include chronic cough and asthma and may be mediated either directly by acid‐pepsin reflux or by oesophageal acid exposure triggering vagal reflexes. The prevalence of excessive acid reflux in patients complaining of these symptoms is controversial; and as for NCCP, the most useful diagnostic test may be a therapeutic trial of intense acid suppression with double‐dose PPI for two to eight weeks, depending on symptom frequency.

There appear to be no significant differences in the capacity to heal esophagitis in older patients compared to the young, and PPIs maintain their superiority over histamine receptor antagonists in this age group. No dosage adjustment is needed in the elderly to compensate for age‐related changes in renal or hepatic function, but downward titration of the dose according to symptoms may be less appropriate than in the young, especially when the initial symptoms were mild or in the setting of complicated GORD. While long‐term use of PPIs has generally been regarded as safe, a number of observational studies have identified associations between PPI use and various adverse conditions, especially in older individuals.⁴⁴ Causality is often difficult to establish since there is substantial potential for confounding by comorbidities, and pathophysiological mechanisms are frequently unclear, but it is unlikely that definitive randomised controlled trials will be undertaken, and the evidence should not be dismissed lightly. A causal relationship appears likely for the rare cases of acute interstitial nephritis, as well as increased prevalence of benign gastric fundic gland polyps and a greater propensity for enteric infections, and appears possible for Clostridium difficile infection, B12 deficiency, and hypomagnesemia/hypocalcemia. Causal relationships for osteoporosis and hip fracture, community‐acquired pneumonia, dementia, and exacerbation of chronic kidney disease are currently not supported by strong evidence, while the interaction with clopidogrel to reduce the efficacy of the latter appears of minimal significance other than for omeprazole.⁴⁵ While there are frequently good indications for prescribing PPI therapy, and while some patients benefit from long‐term use, this class is often over‐prescribed, and the indication for ongoing therapy should be reviewed periodically. Histamine type 2 receptor antagonists represent an alternative class for acid suppression but are less potent than PPIs and carry their own risks of adverse events, including changes in mental status, especially in patients with renal or hepatic dysfunction. Prokinetic drugs do not have an established role in the treatment of GORD.

Laparoscopic fundoplication is a treatment option for troublesome GORD in the elderly; the outcomes and complication rates in patients over 70 are comparable to those <60.⁴³ However, it should be noted that patients with ineffective oesophageal motility are at increased risk of postoperative dysphagia. Moreover, long‐term medical therapy is likely to be more cost‐effective than anti‐reflux surgery in older patients based on the number of years of medical therapy likely to be needed. Endoscopic anti‐reflux procedures to date have not fulfilled their initial promise, and their use should be restricted to clinical trials.