2012-02-07 20:57:37 UTC

Geriatric GI: Are Older Patients Just Like Any Adult? No ... and Yes

Sept. 14, 2010

Karen E. Hall, MD, PhD

Karen E. Hall, MD, PhD

Associate Professor, Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan Healthcare System, Ann Arbor; Research Scientist, Geriatric Research Education and Clinical Center, Ann Arbor Veterans Affairs Healthcare System, MI  


Odd words coming from a geriatrician-gastroenterologist who has spent the last decade advocating for consideration of the unique features of patients aged 65 years and older. In 2005, Deborah Proctor, Laurel Fisher, Suzanne Rose and I wrote a summary paper on the subject of the effect of aging of the population on gastroenterology practice, research and education.1 In addition to the usual reviews of GI physiology and disease prevalence, we included many “out-of-the-box” sections, such as one advocating inclusion of assessment of physical function and cognition into routine GI assessments of geriatric patients, based on the high prevalence of impaired cognition and mobility in this population. Impairment in cognition, or a patient’s ability to perform activities of daily living, is more predictive of health outcome and subsequent mortality than any single disease entity.2 

Geriatric patients are not just like any younger adult patient in many important aspects. As patients enter the “middle-to-old” age range of 75 to 85 years, the functional reserve of physiologic systems decreases. Patients are more vulnerable to perturbations of normal function by disease and iatrogenic causes. Witness the frustrating experience of resuscitating an 85-year-old patient with IV fluids, only to have him or her develop pulmonary edema and require diuresis, which then causes renal impairment that requires IV fluids, etc. Decrease in physiologic reserve (homeostenosis) requires modification of the usual approach to treatment.3 Many GI disorders are much more prevalent in older patients (constipation, colon cancer and achalasia, for example). Treatment paradigms often are tested in younger patients without the common co-morbidities and age-related decline in organ function of geriatric patients, resulting in unexpected complications and increased post-market drug-related adverse events in this population.

Another difference is the dramatically increased prevalence of dementia over age 65, which is a risk factor for delirium. Because the impact of dementia on adverse outcomes, institutionalization and caregiver workload has been estimated to be $100 billion annually, cognitive impairment is the 800 lb gorilla in the room of health care.4 Gastroenterologists, like any other health-care workers who treat older patients, will need the training and tools to deal with the impact of dementia on care decisions. Defining cognitition with assessment tools and having the ability to determine decision-making capacity of older adults are essential skills for the practicing gastroenterologist to provide appropriate care, manage resources and minimize risk of litigation.

However, there are some important similarities between older and younger patients, as the likelihood of response to standard treatment of many conditions (depression, constipation, peptic ulcer disease) appears to be very comparable in the two groups if no serious comorbidities limit treatment. Therefore, age alone should not automatically exclude treatment. In fact, attempts to set strict age limits on GI care based on population statistics are likely to be doomed to failure, due to the difficulty of predicting lifespan in a particular patient of advanced age. A much more useful approach is to remember that, just as location is key for real estate, optimizing “function, function, function” is what is most important to patients of any age.

And just like younger people, old people don’t think they are old — they feel young inside, but can’t understand why their body is failing them.  Telling patients that they are “too old” for a treatment or procedure is not likely to be viewed favorably, and having a perceived “younger” age may actually improve patients’ ability to cope with illness.5 Older patients deserve the same risk/benefit thought process as younger patients, based on a discussion in which both patient and health-care provider define what is important to THIS patient. Delineation of strict limits of care by nameless, faceless panels of experts is unlikely to achieve this, and is one of the most feared outcomes of current health-care reform efforts.

The looming increase in health-care needs by the baby boomer cohort is likely to increase economic pressure on health-care systems to increase use of physician extenders such as physician assistants and nurse practitioners in primary care.6 I do not think that gastroenterology will be immune to this trend, although the specialized nature of endoscopy requires substantial additional training. I believe that a proactive approach that highlights our ability to provide appropriate and thoughtful care of the elderly will be essential to cope with future needs of our geriatric patients.


  1. Hall KE, Proctor DD, Fisher L, Rose S. American gastroenter-ological association future trends committee report: effects of aging of the population on gastroenterology practice, education, and research. Gastroenterology 2005; 129: 1305-1338.
  2. Inouye SK, Peduzzi PN, Robison JT, Hughes JS, Horwitz RI, Concato J. Importance of Functional Measures in Predicting Mortality Among Older Hospitalized Patients. JAMA. 1998;279:1187-1193.
  3. Resnick NM. Harrison’s Principles of Internal Medicine, 15th Edition, McGraw-Hill, 2001; Volume 1: pp 36-39.
  4. National Institute on Aging, and National Institute on Health (1999). Progress Report on Alzheimer's Disease, 1999. Silver Spring, MD: Alzheimer's Disease Education and Referral Center.
  5. Boehmer S. Relationships between Felt Age and Perceived Disability, Satisfaction with Recovery, Self-efficacy Beliefs and Coping Strategies. J Health Psychol (2007) 12(6): 895-906.
  6. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324:819-823.

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