Health Articles

An inability to control defecation. Fecal incontinence is much less common than urinary incontinence, but when it occurs, it is a humiliating regression in bodily function, severely impairing activity and socialization. It may lead lo institulionalization; 16% to 60% of institutionalized older persons have some fecal incontinence.
Etiology
The maintenance of continence is complex, and incontinence can have several causes. Somclimcs, il results from dementia that causes an inability to react normally to the sensation of a full rectum. Incontinence may also be caused by impaired voluntary contraction of the external sphincter resulting from nerve damage that occurred in traumatic vaginal childbirth, rectal prolapse (procidentia), previous anal surgery (hemorrhoidectomy, anal dilation, sphincterotomy), or spinal cord injury. Diabetes and autonomic neuropathy may produce internal sphincter dysfunction.
Diarrhea from any cause may contribute to incontinence, particularly in the elderly, who frequently have decreased sphincteric pressures and continence for liquids compared with younger persons. Fecal impaction commonly causes diarrhea and incontinence, especially in institutionalized elders, because the stool proximal (o the obslrucling fecal mass becomes liquefied and oozes around i(. Because many such patients have long-standing constipation and megacolon, they cannot sense the movement of stool into the rectal vault, and the fecal impaction tonically inhibits Ihe internal anal sphincter, leading to fecal incontinence.
Diagnosis and Treatment
Evaluation should begin wilh a consideration of the underlying causes. Examination of the rectum may show decreased sphincter tone, although the correlation between digital examination of rectal tone and objective measurements is poor. The examination also helps exclude fecal impaction. Appropriate Gl, neurologic, and endocrine studies should be done, and treatment should be individualized.
When constipation and fecal impaction are present, the mass must be removed either digitally or with tap water enemas. (A Fleet enema usually is not useful because the volume is insufficient.) Also, bowel habits should be normalized by administering bulking agents, stool softeners (eg, docusate sodium 50 to 200 mg/day). or mild laxatives (eg, milk of magnesia 1 to 2 tbsp/day or lactulose or sorbitol I tbsp bid) to produce one to two soft bowel movements daily. All these doses can be adjusted to control constipation.
If diarrhea is a contributing factor, underlying causes should be treated. Nonspecific diarrhea can be treated with bulking agents and antidiarrheal drugs (bismuth, loperamide, or diphenoxylate). If sphincter tone is markedly decreased, enemas may be used regularly to cleanse the bowel. Surgical treatment of incontinence has yielded inconsistent results.
Biofeedback therapy is the most exciting advance in the treatment of fecal inconlinence. Successful treatment requires a well-motivated patient who can follow directions and who has an external anal sphincter capable of responding to rectal distention. Using a balloon pressure monitor placed in the rectum, patients watch a physiologic tracing and try to improve Iheir anal contractions. The image of the rectal mano-metric recording provides the biofeedback. Because patients frequently improve after a single session, reinforcement sessions are often unnecessary.
Biofeedback has been successful in treating > 70% of patients with incontinence caused by sensory or motor impairment. In one study of 18 geriatric patients who received biofeedback training, 15 improved by a( least 50%, and 6 became continent. However, some lypes of incontinence, such as incontinence from severe sensory loss (eg, diabeles, spinal cord injury) or incontinence from poor rectal compliance (eg. rectal trauma, radiation injury), do not respond to biofeedback. Also, many elderly patients with fecal inconlinence suffer from dementia and are not suitable candidates for biofeedback training.

Very few palienis with chronic abdominal pain who are referred to diagnostic centers are given a specific medical diagnosis. When such patients are studied psychologically, personality and behavioral abnormalities, which presumably explain their symptoms, are often reported. However, patients with psychogenic abdominal pain may commonly be treated by nonpsychialric physicians.
The problem occurs four times more often in women than in men, and most patients are < 50 yr. Geriatric patients may constitute 10% to 20% of this group. However, the actual prevalence of psychogenic abdominal pain in the elderly is unknown, and differences between the elderly and younger adults have not been well studied.
Chronic, unrelenting pain, usually lasting > 6 mo and unrelieved by bowel movements, characterizes this syndrome. Patients often describe their symptoms with vague statements, but when they are questioned, the descriptions become more personalized and often bizarre, eg, “like blowing out my side” or “a hoi poker sticking into my belly.” Many patients also have nonspecific symptoms including nausea, bloating, dizziness, fatigue, and musculoskeletal complaints. Up to 30% may have associated symptoms compatible with irritable bowel syndrome.
Diagnosis
Tne diagnosis of psychogenic abdominal pain is difficult because physicians vary in their ability to obtain psychologic data, and many patients resist referrals to psychiatrists and psychologists. When sensitively and sympathetically questioned, most patients report antecedent events involving personal losses, eg, the death of a close family member. Symptoms frequently appear during times of personal stress (eg, the anniversary of a traumatic event, a meaningful birthday, or the Thanksgiving-Christmas holiday season). In other cases, sexual or physical abuse may be the inciting event. Depression, hypochondriasis, histrionic or pain-prone personality, or a combination of these disorders may be identified by psychologic testing.
Treatment
These patients arc difficult lo manage and often frustrate the physician. They see themselves as medical patients and arc reluctant to obtain psychiatric evaluation and treatment. A psychiatric consullant can help the primary care physician confirm the diagnosis and provide treatment guidelines, but general management is best directed by the nonpsychiatnc physician.
For such patients, a reasonably successful outcome is improved psychosocial function (eg, return to work, church, or social aclivitics). rather than complete pain resolulion. For some patients with a relatively short duration of symptoms and without evidence of a personality disorder, greater improvement and even pain resolulion can be anticipated.
When symptoms are related to grieving, a physician’s empalhelic lis-lening can provide considerable relief. If the grief reaction or recurrence manifested by the somatic complaint is severe and prolonged, antidepressant medication may be helpful.

A motility disorder consisting of altered bowel habits, abdominal pain, and no detectable organic pathologic abnormalities.
Irritable bowel syndrome accounts for 20% to 50% of all Gl complaints in private and institutional care facilities. Women outnumber men 2:1, and whites outnumber nonwhites. The preponderance of women wilh this diagnosis may reflect their greater tendency to seek health care rather than the actual incidence. In 50% of palients, symptoms begin before age 35, and 40% of patients are 35 to 50 yr of age. Neither the incidence nor prevalence in the elderly has been well defined. Geriatric patients with this condition usually have a long history of bowel dysfunction, often beginning in childhood.
Pathophysiology
Although irritable bowel syndrome is considered by many to be a disorder of intestinal motility, the motor dysfunctions recorded in the laboratory do not correlate well with the clinical pattern and frequently may be simple exaggerations of normal responses. Abdominal pain, which originates in stretch receptors in the distal colon, is caused by bowel distention from gas and stool or spastic contractions of the bowel. Under baseline conditions, the colonic motility of patients wilh irritable bowel syndrome and that of patients without are indistinguishable. However, palienls with irritable bowel syndrome show greater colonic motility in response lo emotional arousal, pain, balloon dislen-tion, ealing, and stimulation by cholecyslokinin or penlagastrin. These motility changes differ quantitatively rather than qualitatively from ihose in paticnls without the syndrome, suggesting thai irritable bowel syndrome patients arc hyperreactive lo many slimuli.
Psychometric tests show that patients with irritable bowel syndrome are more psychologically disturbed than Ihose withoul, bul Ihey do not show a pattern of psychologic Irails specific to the syndrome. Psychiatric diagnoses are noted in 709? to W/c of inilable bowel syndrome palienls, although the proportion has nol been defined in the elderly. The most common diagnoses are depression, anxiety, and somatization (Ihe conversion of depression or anxiely into bodily complainls). Evidence suggests that psychogenic factors do nol resull from the disorder bul ralher contribute to the onsel and exacerbation of symptoms. In 85% of patients, psychologic factors cither precede or coincide wilh the onsel of symptoms. Moreover, 50% of patients also note an associalion be-Iwecn stress and an exacerbation of symptoms. Most of the stressors mentioned by patients are everyday concerns about family, work relations, or finances. In the elderly, cancer phobias may predominate and need (o be addressed.
Symptoms and Signs
Characteristic symptoms of irritable bowel syndrome include abdominal pain, erratic bowel habits, and a variation in stool consistency wilh a passage of mucus. More nonspecific symptoms include bloating, gas dyspepsia, headache, fatigue, lassitude, and flatulence. Patients wilh irritable bowel syndrome are divided inlo two major groups, in the first, the spastic colon group, most patienis have pain over one or more areas of the. colon associated with periodic constipation or diarrhea; in some patients, constipation and diarrhea alternate. Most complain of colicky or dull lower abdominal pain or discomfort over the sigmoid colon, commonly triggered by meals, especially breakfast, and often relieved by a bowel movement. The second group of patienis complain primarily of painless diarrhea. They usually have urgent diarrhea that occurs immediately upon arising or, more typically, during or immediately after a meal. Incontinence may occur, but nocturnal diarrhea is unusual.
On physical examination, patients with either type generally appear to be in good health. However, they are frequently tense and anxious, with autonomic lability evidenced by a rapid, labile pulse; elevaled blood pressure: or sweaty palms. In the elderly, these findings may be masked. Palpation of the abdomen may reveal tenderness, particularly in the left lower quadrant over the sigmoid colon.
Diagnosis
De novo irritable bowel syndrome symptoms are distinctly uncommon in the geriatric patient. Therefore, organic diseases must be excluded before symptomatic therapy is begun. Older patients wilh irri-iablc bowel syndrome usually have a long history of bowel problems, but they need to be recvalualed periodically to rule out any intcrcurreni pathologic process. A diagnosis of irritable bowel syndrome can usually be established within the first few visits.
Evaluation includes a CBC and erythrocyte sedimentation rate to rule out anemia and inflammation. Stools should be cultured and examined for occult blood, ova. and parasites. In a geriatric patient with new complaints, sigmoidoscopy and barium enema examination are essential to rule out more serious underlying disease. Sigmoidoscopy usually reveals normal mucosa except for mild hyperemia and increased mucus. Reproduction of symptoms with air insufflation is a further suggestive finding. Mucosal biopsies may help exclude early ulcerative colitis or collagenous colitis. A double-contrast barium enema may show exaggerated hauslral contractions, particularly in the descending colon, or conversely, an absence of normal hauslral markings, often wilh a narrowed lumen.
The patient may have coexisling diverticulosis, and in the elderly, irritable bowel syndrome may be the precursor of diverticular disease. If weight loss or obstructive symptoms arc present, an abdominal CT scan and small-bowel series should be obtained to exclude malignancy. Crohn”s disease, and adhesions. For patients who complain of distention, bloating, or diarrhea, a 3-wk trial lactose-free diet is recommended. Transient lactase deficiency, often preeipilated by a viral gastroenteritis, may mimic irrilable bowel syndrome in older persons.
Treatment
The palienl should be reassured that the necessary lesls have been performed to exclude organic disease, particularly cancer. The simple act of applying a name to the disorder may provide comfort. The physician should emphasize that the colonic spasm and resulting pain are real and thai they are influenced by several factors that must be managed lo control symptoms. The patient should be assured that irritable bowel syndrome docs not lead to more serious illness or a shortened life span.
In general, a high-liber diet should be followed. Psyllium preparations bind water, thus preventing excessive dehydralion of stool as well as excessive liquidity. Fiber can also be obtained by eating bran cereals or fiber-rich snack bars. Some people respond better to one form than another, and some people find liquid preparations intolerable. Diabetic patients should avoid preparations high in sugar, and obese patients should be advised that bran cereals are often high in calories. Fiber is useful in irrilable bowel syndrome patients who have diarrhea or constipation.
Antispasmodics such as dicyclomine, propantheline bromide, and tincture of belladonna should not be used in the elderly. These drugs have never been shown to provide substantial relief, and their potent anticholinergic properties may cause constipation, confusion, dry mouth, blurred vision, orthostatic hypotension, and urinary retention. When diarrhea is severe, frequent small doses of bismuth subsalicylate may be helpful. Palienis should be warned that it turns siool black. Alternatively, diphenoxylate 2.5 to 5.0 mg q 4 lo 6 h or loperamide 2 mg q 4 to 8 h can be prescribed. Aromatic oils, such as spirit of peppermint, may help relieve cramping.

A symptom complex, often related to eating, including intermittent epigastric pain, bloating, fullness, gaseousness. nausea, and heartburn. In the elderly, such complaints may indicate peptic ulcer disease but are often misdiagnosed and left untreated until more serious complications develop. The terms nonulcer dyspepsia, functional dyspepsia, flatulent dyspepsia, Moynihan’s symptom complex, and indigestion are all used to indicate a heterogenous group of symptoms.
Pathophysiology
Older studies show that 10% to 40% of patients with normal x-rays and dyspepsia later develop peptic ulcer disease, suggesting that the condition is really an early form of peptic disease. The relalionship lo Helicobacter pylori infection remains uncertain.
Abnormalities in Gl motilily may contribute lo the symptoms of nonujcer dyspepsia. In some patients with flatulent dyspepsia, delayed gastric emptying has been demonstrated by scintigraphy. Nonetheless. most flatulence in Ihe elderly is caused by diet. When flalulence is severe and accompanied by diarrhea, lactose intolerance should be considered. The best way to confirm this diagnosis is a trial lactose-free diet. Sometimes, a hydrogen breath test after a meal of lactose may support the diagnosis.
Eructation is often part of dyspepsia. Frequent belching may be caused by aerophagia Ihal occurs while eating or when anxious, depressed, or under stress. Commonly, air is swallowed as patients sigh. Aerophagia can lead to bloating, early satiety, and abdominal pain. Air swallowing is not easy lo detect, even when watching for it closely.
Intolerance to foods, especially fats and poorly digested carbohydrates in beans, vegetables, and dairy products, may produce gas. A patient should be instructed to avoid such foods for several weeks. If the symptoms disappear, (he patient can start eating these foods one a( a lime unlil (he offending one is identified.
The sensation of bad taste is another common complaint, particularly in older persons. With age. xerostomia becomes more prevalent, no! because less saliva is produced bul because il is not as well retained in the mouth. Dry mouth can alter the taste of food, producing a bitter, sour taste. Poorly fitting and poorly cleaned dentures can also produce bad tastes. Sometimes, drugs cause bad tastes. Diuretics and anticholinergics further dry (he oral mucosa, and some antihypertensives and antibiotics cause a biller lasle. If a drug is suspected, it should be stopped and another substituted. Otherwise, the frequent use of lozenges is usually the best solution. A dental evaluation is usually warranted, and dentists can often recommend medicaments that further al-leviale (he problem.
Dyspepsia may be caused by reflux of alkaline duodenal contents into the stomach. Epigastric discomfort can be produced by distention of the transverse colon by food or gas. Fals and many drugs, including NSAIDs, aspirin, alcohol, and tobacco, may also cause dyspepsia without producing an ulcer or gastritis.
Although scientific data are limited, emotional factors generally play an important role in the genesis of dyspepsia. Several studies confirm a higher prevalence of anxiety, neuroticism. and depression in nonulcer dyspepsia patients than in the general population. Dyspeptic patients are reported lo have more negative life stresses associated with the onset of symptoms and lo view life as more stressful than do control subjects.
Diagnosis
Identified during the patient’s history, dyspepsia has varied presentations, but the pain is usually epigastric and described as burning or gnawing and intermittent. Generally, the pain is not relieved by meals and does no! awaken patients al night, although those with reflux may complain of pain shortly after lying down. If I he pain is associated with heartburn, gastroesophageal reflux should be suspected. Pain associated with defecation or abnormal bowel movements suggests irritable bowel syndrome. The presence or absence of epigastric tenderness is not a reliable indicator of peptic ulcer disease. Routine hematologic and biochemical tesis are usually normal in dyspeptic patients.
Upper Gl endoscopy is the most sensitive and specific method of excluding organic lesions of the esophagus, stomach, and duodenum. Although barium studies may miss 10% to 20% of peptic ulcers and most mucosal lesions, they are still commonly used. Whether the frail elderly more easily lolcrate an upper GI barium study or endoscopy is not known; choosing the appropriate test requires a consideration of sensitivity, specificity, and the condition of the patient. If symptoms persist or are associated with weight loss, endoscopy is usually besl. Older persons with severe, persistent pain should also be evaluated by CT scan to rule out pancreatic cancer and by barium enema or colonoscopy to rule out a colonic lesion in the transverse colon.
Treatment
The most important component in treating dyspepsia is reassurance. Many patients have an inordinate fear of cancer or ulcers thai reinforces and magnifies symptoms.
Four controlled studies have been done on I he efficacy of antacids in chronic nonulcer dyspepsia; all report negative results. The studies on histamine H;-reeeptor blockers are eonlradietory: about half show no benefit, but the studies wilh the largest numbers of patients show that cimetidine and ranitidine have a statistically significant benefit over the placebo. Data specific to the elderly are lacking, and because these drugs more often cause side effects in the elderly, they cannot be recommended without evidence of gastritis or ulcer. Olher drugs, such as metoclopramide (10 mg tid before meals) and cisapride (10 mg lid before meals) may be useful in flalulenl patients wilh delayed gastric emptying, bul side effects (eg, parkinsonism and tardive dyskinesia with metoclopramide) are particularly common in the elderly and may be severe. In patients with flalulence caused by dietary intolerance, these drugs are not helpful. Thus, in general, they should not be used. The role of sucralfate in nonulcer dyspepsia remains to be tested.

The subjective sensation of a lump in the throat. No specific cause or physiologic mechanism has been identified for this condition, and little information about globus hystericus in the elderly exists. Some studies suggest that elevated pressure in the upper esophageal sphincter or abnormal hypopharyngeal motilily is present when symptoms occur. Other reports suggest an increased incidence of gastroesophageal reflux. Aerophagia and drying of the throat associated with emotional states may also contribute to globus hystericus.
Medical disorders Ihat can be confused with globus hystericus include esophageal webs, esophageal motility disorders (especially achalasia), gastroesophageal reflux, musculoskeletal disorders (eg. myasthenia gravis, myotonic dystrophy, and polymyositis), and mass lesions in Ihe neck or mediastinum causing esophageal compression. Most oflen. history and physical examination can exclude these disorders. Globus hystericus occurs during certain emotional stales and does not worsen during swallowing. Food does not stick in the throat, a determination that can be made by carefully observing the palient cat. and the symptom is occasionally relieved with eating. No pain or weight loss occurs. True dysphagia from a structural or motor disorder of the pharynx or esophagus must be ruled out. The best approach is to obtain cineesophagography.
Treatment primarily involves reassurance. No drug has proved beneficial, and commonly prescribed anticholinergics can aggravate the situation. Underlying depression or anxiety should be managed. Providing support and pointing out the association between the symptom and the patient’s mood or life situation can be very beneficial. When the problem disrupts the patient’s lifestyle or functional level, psychiatric referral is indicated.

Typical angina-like pain is not always cardiac in origin, especially in the elderly. Noncardiac causes are mosl common in older women whose chest pain is unrelated to exertion. Long-term follow-up studies in > 2500 patients showed that myocardial infarctions (1.6%) and cardiac death (0.5%) were rare in this group. Nevertheless, these patients suffer real disability and often undergo repeated, unnecessary testing and treatments if their conditions are not properly diagnosed.
Etiology
The most common identifiable causes of noncardiac chesl pain are musculoskeletal and esophageal problems. Other, less common causes include pulmonary embolism, pneumonia, peptic ulcer, biliary tract disease, thoracic conditions, and colon problems (usually irritable bowel syndrome). A large proportion of elderly palienls with noncardiac chest pain have an esophageal problem, although new studies suggest that esophageal causes of noncardiac chest pain may not be as common as once thought. Among esophageal causes, gastroesophageal reflux is more common than esophageal motility disorders.
Most patients with gastroesophageal reflux complain of heartburn, but 5% to 20% present with only atypical chest pain. Although acid reflux may cause esophageal motility dysfunction, the pain probably results from stimulation of acid-sensitive c he mo receptors. Theoretically, esophageal motility disorders could stimulate chesl pain by high-amplitude, nonperistallic contractions producing esophageal myoisch-emia or retarding bolus movement. The most common esophageal motility disorder associated with chest pain is nutcracker esophagus, a syndrome characterized by high-amplitude peristaltic contractions confined to the distal esophagus.
Psychologic factors and stress may contribute to or cause chest pain. Studies suggesl that persons with noncardiac chest pain have more physical complaints than age-matched controls and score higher on psychologic measures of neuroticism and depression. Two studies in patients with noncardiac chesl pain and esophageal motility disorders also confirm a high frequency of psychiatric diagnoses, primarily depression, anxiety, and somatization. These psychologic profiles are similar to those reported in patients with irritable bowel syndrome.
Diagnosis
The differential diagnosis of noncardiac chest pain first demands that cardiac disease be excluded. In older patients, evaluation is not always easy. Baseline ECGs may not correlate with active symptomatic disease; stress testing or coronary angiography is required. Occasionally, pericarditis and mitral valve prolapse may cause recurrent chest pain. A normal erythrocyte sedimentation rate (ESR) helps exclude pericarditis, and Ihe presence of a click and murmur or use of echocardiography may help diagnose mitral valve prolapse.
After cardiac disease is excluded, emphasis should be placed on the musculoskeletal and upper GI systems. Clinical history alone is usually not helpful in separating diseases of these systems from cardiac problems. A thorough musculoskeletal examination should be performed with particular attention to locating trigger points that replicate the patient’s pain syndrome. Trigger points painful to palpation suggest the fibromyositis syndrome. An elevated ESR also supports an inflammatory cause for pain.
Structural lesions of the upper GI tract should be excluded by barium studies or endoscopy. Radiographic studies should include the esophagus to exclude webs, constrictions, or achalasia. Rarely, gallstones cause chest pain. When they are suspected, cholecystography or abdominal ultrasonography is useful: however, many gallstones are silent, and their discovery does not prove that they are the cause of chesl pain. If esophagitis or an ulcer is found, further testing is nol needed.
Occasionally. Ihe failure to make a diagnosis requires further evaluation for an esophageal cause, which may be done with a provocative test, such as the esophageal acid perfusion lest (Bernstein test) or Ihe edrophonium lest (Tensilon 80 mg/kg IV). Generally, these tests are performed in Ihe office without esophageal manometry. However. Ihe validity, safety, and reliability of these tests in the elderly have nol been determined, if the tests reproduce the patient’s typical chest pain, a diagnosis of an esophageal cause is likely. If the tests arc negative, additional studies wilh manometry and prolonged ambulatory pH monitoring may be warranted.
Treatment
When a favorable patient-doctor relationship is established, most palienls respond lo confident reassurance based on thorough diagnostic studies. This supportive approach results in belter patient acceptance of symptoms, fewer limitations on lifestyle, and frequently a decrease in or even a resolution of Ihe chest pain.
More specific therapy should be directed at identifiable causes of noncardiac chest pain. Patients with musculoskeletal problems can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and monitored closely for both Gl and renal side effects. If gastroesophageal reflux is a possibilily. it should be vigorously treated. Elevating the head of the bed at nighl and eating smaller, more frequent meals are often helpful. Antacids, histamine Hh-receptor blockers, or omeprazole can also be used with appropriate dose reductions for the elderly. Esophageal motility disorders may respond to sublingual nitroglycerin, anticholinergics (eg, dicyclomine 20 mgtid), or calcium channel blocking agents (nifedipine 10 to 20 mg tid or diltiazem 60 to 90 mg tid); however, the anticholinergics usually should be avoided because of their potent side effects in (he elderly. Although not extensively studied, especially in the elderly, behavior-modification programs and biofeedback may also help in long-term management of noncardiac chest pain.

Disturbances of gut physiology arising us par! of an army of adaptive reactions, often to stress, nongastrointestina! illness, or thugs. Patients wilh such disturbances account for about 60% of all consultations forGI symptoms and about 2.4% of all hospital admissions. Functional GI disorders arc common in patients of all ages, but often the presenla-tion is different in elderly patients. Instead of intermiltent cramping and diarrhea, older patients more commonly develop conslipalion, bloating, eructation, swallowing disorders, fecal incontinence, and sensations of bad taste.
Several age-related changes in the GI tract predispose the elderly to such complaints. Although transit time does not change much with aging, illness, depression, and medication slow transit time more profoundly in the old than in the young. Also, the myenteric reflexes that help prevent conslipalion become less effective with age. The capacity of the rectum to store feces increases, making impaction more likely. Acid secretion in the stomach decreases, and gastrin levels increase. Substantial changes occur in esophageal motility, with intrinsic slow waves slowing and decreasing in amplilude, a condition sometimes called presbyesophagus. Also, some evidence indicates that sphincter pressure at Ihe esophagogastric junction decreases, more readily allowing reflux.
Disease and medical interventions arc more common with age. and many of them affect GI function. Diabetes may impair the autonomic nervous system and voluntary innervalion of the anus. Heart failure can cause fluid shifts, producing edema of the GI tract. Many medications affect GI function. Anticholinergics substantially slow transit time and commonly cause constipation; diuretics may dehydrate the feces; and other drugs may cause GI upset.
The relationship between functional GI problems and psychologic imbalance is strong at all ages, and psychosocial stress commonly causes or exacerbates functional GI disturbances in the elderly. Loss of a spouse, emotional adjustment to retirement, admission to a hospital or nursing home, and fruslration resulting from disease and the aging process all contribute to psychophysiologic stresses in elderly patients. Depression often goes undiagnosed and untreated. Also, poor dietary habils and lack of physical activity may cause or compound problems.
Approach to the Patient
An evaluation of GI disturbances requires a thorough review of traditional medical issues as well as a review of prescription and over-the-counter drugs, diet, physical activities, and psychologic issues. The history should be obtained in an open-ended interview, which encourages the patient to respond spontaneously and helps prevent physician bias. I .ending questions or those that elicit yes or no answers should be avoided at first. At all times, the questions should communicate the physician’s willingness to consider all aspects of the illness, whether biologic or psychogenic.
Rather than asking, “Arc you under stress?” at the end of the history, the physician should make an open-ended request early in the interview, eg, “Tell me what happened and how you felt during your last attack.” ‘I,his type of requcsl is less threatening and allows the patienl to offer medical and psychologic data concurrently.
The history should explore the patient’s eating habits, especially the timing of meals, the amount of fiber consumed, the amount of liquid consumed daily, the relationships of particular foods with symptoms, and stressful factors that might be related to eating.
Medication use must be fully explored. Questions should cover both prescription and over-the-counter drugs. Special attention should be paid to the correlation between symptoms and medicalions taken on an as needed basis.
Physicians should resist the tendency to order unneeded studies or treatments just to do something for an insistent patienl. When the initial examination and studies are unrevealing and the palienl is clinically stable, the wise course is to tolerate the diagnostic uncertainly and monitor the patient. However, a nonthreatening behavioral disorder causing GI symptoms docs nol preclude the presence or development of a medical disease lhal presents as a GI or other complaint. Complete objectivity musl guide the approach to even the most vague, dramatic, or bizarre symptom complex.
In persons of all ages. GI symptoms may have adaplive value to the palienl. In younger patients, secondary gain may include obtaining disability pay. avoiding family chores, and receiving attention. In the elderly, the gain is more likely to be receiving attention from family,friends, and the physician. Giving up the benefits of the illness may be a greater loss than the presumed benefits of symptom relief. Suspicion should be high when the paiienl overtly or covertly resists management Management can he fruslrating for the physician, and therapeutic interventions can cause more harm than good.
Frequently, older persons with GI complaints are given psychoactive drugs. Such therapy is often warranted, especially when depression or chronic anxiety is at the root of the problem. However, these medications are also overused. Medication cannol replace counseling or psychotherapy and can cause serious side effects. In fact, many psychoactive drugs, especially the tricyclic antidepressants and antipsychotics, are strongly anticholinergic and can worsen GI disturbances. Thus. they must be used judiciously and only after thorough evaluation.