PRACTICAL GASTROENTEROLOGY • FEBRUARY 200552

INTRODUCTION

Gastroesophageal reflux disease (GERD) is themost common upper gastrointestinal problemseen in clinical practice. It is estimated that

10%–20% of adults have symptoms at least onceweekly and 15%–40% have symptoms at least oncemonthly (1). Although studies report a tendency toreduced heartburn and acid regurgitation symptom fre-quency in older populations, several studies show thatthe frequency of GERD complications, such asesophagitis, esophageal stricture, Barrett’s esophagus,and esophageal cancer is significantly higher in theelderly. Collen, et al (2) found an increase of esophagi-tis and Barrett’s esophagus in patients over 60 years of

age compared to those younger, 81% versus 47%.Also, Huang, et al (3) found in elderly patients, as com-pared with younger patients, more severe gastroe-sophageal reflux and esophageal lesions.

PATHOGENESISA number of abnormalities that appear to play a patho-genic role in GERD are often more serious in the elderly.These include a defective antireflux barrier, abnormalesophageal clearance, reduced salivary production,altered esophageal mucosal resistance, and delayed gas-tric emptying. Injury to the esophagus is due primarily togastric acid and pepsin. In some cases, duodenogastricreflux of bile may cause the injury (4). Also, nocturnalgastroesophageal reflux is associated with more severemanifestations and esophageal and extraesophageal com-

Gastroesophageal Reflux Disease in the Elderly

A SPECIAL ARTICLE

Maxwell Chait M.D., FACP, FACG, Assistant ClinicalProfessor of Medicine, College of Physicians and Sur-geon, Columbia University, New York, NY.

Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinalproblem seen in adults. Although the elderly have fewer complaints of heartburn, theirdisease is usually more severe and has more esophageal and extraesophageal complica-tions. Tests for the evaluation of GERD in the elderly are the same as for the generalpopulation. Treatment of GERD in the elderly is the same as for the adult population.However, a more aggressive approach is warranted, because of the higher incidence ofcomplications in the elderly.

(continued on page 54)

Maxwell Chait

PRACTICAL GASTROENTEROLOGY • FEBRUARY 200554

plications of GERD (5–7). The lower esophageal sphinc-ter (LES) is the antireflux barrier. Abnormalities thatmake it dysfunctional promote acid reflux and the con-stellation of GERD problems. The most common causeof reflux episodes is transient LES relaxations, the dropin LES pressure not accompanied by swallowing. Incom-petence of the LES was shown by Huang, et al to be moreprevalent in the elderly. Multiple medications that aretaken by the elderly are well known to decrease LESpressure, such as those for hypertension, cardiovasculardisease, and pulmonary disease. These include nitrates,calcium channel blockers, benzodiazepines, anticholiner-gics, and antidepressants. The presence of a hiatal herniaimpairs the function of the LES and may impair the clear-ance of refluxed acid from the distal esophagus. The fre-quency of a hiatal hernia appears to increase with age (3).

Esophageal acid clearance can be impaired in theelderly due to disturbances of esophageal motility andsaliva production. In elderly patients, there is a signif-icant decrease in the amplitude of peristaltic contrac-tion and an increase in the frequency of nonpropulsiveand repetitive contractions compared to younger indi-viduals (8). Salivary production is slightly decreasedwith age, with a significantly decreased salivary bicar-bonate response to acid perfusion of the esophagus (9).Many medications taken by elderly patients for comor-bidities can affect esophageal motility as well as theLES. Also, many diseases that affect motility, such asParkinson’s disease, cerebrovascular disease, and dia-betes mellitus, appear with greater frequency withadvancing age.

The role of delayed gastric emptying and duo-denogastric reflux in elderly patients with GERD isuncertain. However, medications used in disease statesmore commonly seen in the elderly may make thesefactors more important in the aging population. Med-ications taken with greater frequency by the elderly,such as nonsteroidal anti-inflammatory drugs(NSAIDs), potassium tablets and biphosphonates alsodirectly injure the esophageal mucosa. Gastric acidsecretion does not decrease with age alone. However,factors that lead to atrophic gastritis, such as Heli-cobacter pylori, reduce gastric acid (10). Such factorsin association with the age-related decrease inesophageal pain perception may explain the phenome-non of reduced heartburn symptom severity as patients

grow older. The feeling of reduced pain may in fact bea factor in the increased rate of GERD complicationsin the elderly, because acid injury can be moreadvanced without the usual warning symptoms (11).

CLINICAL PRESENTATIONThe most common symptoms of GERD are heartburnand acid regurgitation (4). Other common symptoms arewater brash, belching, and nausea. Generally, thesesymptoms do not change with age, except for heartburn.Heartburn is characterized by epigastric and retrosternalburning pain that may radiate to the neck, throat, andback. It can occur after large meals, exercise, or reclin-ing. Remarkably, the frequency of severe heartburnseems to decline with age, possibly due to a decrease inesophageal pain perception and atrophic gastritis. Dys-phagia, difficulty in swallowing, is an important symp-tom that is increased in the older patient. It may berelated to several disease states more common in theelderly, such as Parkinson’s disease, cerebrovasculardisease, and diabetes. In patients with GERD, it usuallyoccurs in the setting of longstanding GERD and is pro-gressive to solids and, when severe, even to liquids. Itportends a more severe problem, such as severe peri-staltic dysfunction, peptic stricture, or cancer.

Extrasesophageal symptoms are more common inthe elderly. They include atypical chest pain that cansimulate angina; ear, nose, and throat (ENT) manifes-tations such as globus sensation, laryngitis, and dentalproblems; and pulmonary problems such as chroniccough, asthma, and pulmonary aspiration (12).

COMPLICATIONSComplications of GERD are common in the elderly.Up to 20% of patients seeking medical care for GERDin the United States have complications. Severe ill-nesses can result from GERD. These disease statesmay be esophageal or extraesophageal in nature. Noc-turnal gastroesophageal reflux is associated with moresevere manifestations (5–7). They may vary fromminor problems of mild esophagitis to major problemssuch as recurrent pulmonary aspiration, Barrett’sesophagus, and esophageal cancer (Table 1) (13).

A SPECIAL ARTICLE

GERD in the Elderly

(continued from page 52)

(continued on page 56)

PRACTICAL GASTROENTEROLOGY • FEBRUARY 200556

A SPECIAL ARTICLE

GERD in the Elderly

Esophageal ComplicationsThe most common type of complication of GERD isesophagitis. It may progress to severe ulceration andsevere hemorrhage (12). Esophageal stricture occurs inup to 10% of patients who have reflux esophagitis,especially in elderly men. Often, esophageal stricturesare associated with the use of NSAIDs. Treatment usu-ally consists of esophageal dilatation and aggressiveantireflux therapy.

An important and increasingly more commonesophageal complication is Barrett’s esophagus, inwhich columnar epithelium replaces squamous epithe-lium in the distal esophagus. It occurs in approximately10%–15% of patients with GERD symptoms whoundergo endoscopic examinations. It is more commonin elderly white men over the age of 60. Although itspathogenesis is uncertain, GERD appears to injure thesquamous epithelium and promote epithelial repair bycolumnar metaplasia of the esophageal mucosa. Thecurrent treatment is similar to that for routine GERD(14). Barrett’s esophagus is a premalignant conditionhighly associated with the development of adenocarci-

noma of the esophagus and the gastric cardia.Endoscopy should therefore be considered in all elderlypatients with chronic reflux symptoms. Adenocarci-noma of the esophagus is now the most common formof esophageal cancer and is among the fastest growingcarcinomas by incidence in the United States (6). Theincidence of adenocarcinoma in patients with Barrett’sesophagus is approximately 1% per year. These patientstypically present in the seventh or eighth decade of lifewith weight loss and dysphagia. Patients with Barrett’sesophagus must be evaluated with upper gastrointestinal(GI) endoscopy and biopsy for the presence of dyspla-sia, which is a precursor of invasive cancer. Continuedsurveillance and aggressive measures in high-grade dys-plasia are warranted and include endoscopic ablativetechniques such as electrocautery fulguration, laser pho-toablation, and photodynamic therapy, and evenesophagectomy. Although the overall survival rate ofpatients with adenocarcinoma of the esophagus is lessthan 10%, those with cancer identified in surveillanceprograms usually have higher survival rates (15).

Extraesophageal ManifestationsExtraesophageal manifestations of GERD are morecommon in the elderly (16). Atypical noncardiac chestpain from GERD may often be indistinguishable fromangina. Atypical chest pain has been related to GERDin up to 60% of cases, with 50% being related directlyto reflux injury and 10% related to esophageal motility.Ear, nose, and throat manifestations of GERD, such asglobus sensation and laryngitis, are more frequent inthe elderly. In up to 10% of patients with hoarseness,acid peptic injury from reflux is the cause. Prolongedantireflux therapy may be necessary and is effective inthese patients. However, prompt relapses do occurwhen therapy is discontinued. Acid injury promotes thedevelopment of laryngeal polyps and cancer, and possi-bly dental problems such as dental erosions, which arenoted with increasing frequency in patients withGERD. Pulmonary problems associated with GERD,such as asthma, chronic bronchitis, pulmonary fibrosis,and aspiration pneumonia, are seen more frequently inthe elderly. Remarkably, chronic cough can be the onlysymptom of GERD is some patient. In up to 21% of

(continued from page 54)

(continued on page 58)

Table 1.Complications of Gastroesophageal Reflux Disease

Esophageal• Esophagitis• Esophageal stricture• Barrett’s esophagus• Esophageal cancer

Extraesophageal • Noncardiac chest pain• ENT complications*

– Globus sensation– Hoarseness/laryngitis– Laryngeal cancer– Dental erosions

• Pulmonary complications– Chronic cough– Asthma– Chronic bronchitis– Pulmonary fibrosis– Aspiration pneumonia

*ENT = ear, nose, and throat.

PRACTICAL GASTROENTEROLOGY • FEBRUARY 200558

A SPECIAL ARTICLE

GERD in the Elderly

patients with chronic cough, GERD is implicated as thecause, and antireflux therapy is often helpful. Themechanisms involved in the development of theseproblems are neurally mediated reflex bronchoconstric-tion due to esophageal irritation by acid and pulmonaryaspiration of refluxed material (15).

EVALUATIONSeveral diagnostic tests are available for the evaluationof GERD. Barium swallow and upper GI endoscopy areused to evaluate dysphagia and mucosal injury. Inpatients with atypical symptoms or when quantitation ofreflux is required, ambulatory pH monitoring is helpful.Esophageal manometry is often used in patients withmarkedly atypical symptoms, for locating the LES forpH testing, and in those for whom surgery is contem-plated. It is not useful for evaluation in the majority ofpatients. Newer tests are now available (17). The protonpump inhibitor (PPI) test has evolved to become one ofthe most useful noninvasive tests in GERD patients.

Patients are given a course of high dose PPI agent, suchas omeprazole 60 mg per day for 7 days, and observedfor improvement in their clinical response (18). Multi-channel intraluminal impedence with pH sensor allowsthe detection of pH episodes irrespective of their pHvalues (acid and nonacid reflux). It is useful in the post-prandial period and in patients with persistent symp-toms while on therapy and those with atypical symp-toms. Diagnostic tests should be performed in patientsin whom the diagnosis remains uncertain; inpatientswith atypical symptoms such as chest pain, ENT prob-lems, or pulmonary complications; and in patients withsymptoms associated with complications such as dys-phagia, odynophagia, unexplained weight loss, GI hem-orrhage, and anemia (16). Tests should also be per-formed in patients prior to consideration of antirefluxsurgery and in patients who have an inadequateresponse to therapy, whether medical or surgical, or whohave recurrent symptoms. In contrast to youngerpatients, endoscopy should be considered earlier as theinitial diagnostic test in elderly patients with heartburnregardless of the severity or duration of complaints. Thisaggressive approach may be warranted because of thehigher incidence of cumulative acid injury over yearsand the higher incidence of complications of Barrett’sesophagus and esophageal cancer in the elderly (2).

TREATMENTAlthough treatment of GERD in the elderly is essen-tially the same as in all adults, a more aggressiveapproach to treatment may often be necessary in thisgroup because of the higher incidence of complica-tions. The treatment goals for GERD include elimina-tion of symptoms, healing of esophagitis, managing orpreventing complications, and maintaining remission(19). The vast majority of patients can be treated suc-cessfully with the noninvasive methods of lifestylemodification and medication (Table II).

Although lifestyle modification remains a corner-stone of therapy in GERD, it may not be sufficient tocontrol symptoms in the majority of patients, espe-cially in those with complications.

Patients should try to elevate the head of their bedsbefore going to sleep, avoid eating within three hours ofbedtime, stop smoking tobacco, and change their diet to

(continued from page 56)

Table 2.Noninvasive Treatment of Gastroesophageal Reflux Disease*

Lifestyle Modification• Elevation of head of bed• Avoid eating within 3 hours of bedtime• Avoid tobacco, alcohol, caffeine, fatty food, peppermint• Avoid harmful medications if possible, such as

NSAIDs, beta blockers, calcium-channel blockers,theophylline, potassium tablets, bisphosphonate

Medications• Antacids• Motility agents: metoclopramide, erythromycin,

bethanechol, cisapride• H2-receptor antagonists: cimetidine, famotidine,

nizatidine, ranitidine• PPI agents: esomeprazole, lansoprazole, omeprazole,

pantoprazole, rabeprazole

NSAIDS= nonsteroidal anti-inflammatory drugs: H2 = histamine2; PPI-proton pump inhibitor.*Most often successful.

decrease fat and volume of meals and to avoid dietaryirritants such as alcohol, peppermint, onion, citrus juice,coffee, and tomatoes. Potentially harmful medications,such as NSAIDs, potassium tablets, bisphosphonates,beta blockers, Theophylline and calcium-channel block-ers should be avoided, if possible. If these agents must becontinued, the regimen should be modified on an indi-vidual basis. Often, it may not be possible to avoid thesemedications due to comorbid conditions in the elderly.

Over-the-counter antacids and histamine2- (H2)blockers on an as-needed basis may be helpful forthose individuals who have mild disease. However, forthe majority of patients, and certainly for thosepatients with complications, one must use prescriptionagents for more effective therapy, at least until symp-toms are initially controlled.

Motility agents, such as cisapride, metoclopramide,erythromycin, and bethanechol, have helped some inimproving LES tone and esophagogastric motility inselect patients. In patients with severe disease, their suc-cess is limited. For patients with diabetes, cisapride andmetoclopramide have been used with moderate success inimproving gastric emptying and reducing GERD symp-toms. However, cisapride is only available on a compas-sionate-use basis due to potentially fatal cardiac arrhyth-mias. Metoclopramide must be used with caution in theelderly because it can cause side effects, such as muscletremors, spasms, agitation, insomnia, drowsiness, and tar-dive dyskinesia, in up to one-third of patients.

Histamine2-receptor antagonists, including cimeti-dine, ranitidine, famotidine, and nizatidine, are veryhelpful in patients with GERD, by providing good acidsuppression and symptom relief. They are remarkablysimilar in their action and equally effective at equivalentdoses. However, high doses of up to four times dailymay be necessary in some patients. Although they aresafe agents in the elderly, reduced doses in renal insuf-ficiency, which is more common in the elderly, are nec-essary. Also, all may contribute to the development ofdelirium in this age group. Drug-drug interactions, espe-cially with cimetidine, may be potentially harmful inelderly patients who often use medications (eg, war-farin, phenytoin, benzodiazepines, and Theophylline)that can be affected by metabolism of the hepaticcytochrome P-450 system. Side effects of these agents,especially cimetidine, are more common in the elderly.

Central nervous system side effects, such as mental con-fusion, delirium, headache, and dizziness are more com-mon in the elderly. Antiandrogen side effects of gyneco-mastia and impotency, cardiac side effects of sinusbradycardia, atrioventricular block, and prolongation ofthe QT interval, and hematologic side effects of anemia,neutropenia, and thrombocytopenia have increased fre-quency in the elderly, especially with comorbid condi-tions. However, most side effects are reversible withdosage reduction or withdrawal of the drug.

Proton pump inhibitors (PPIs), such as esomepra-zole, lansoprazole, omeprazole, pantoprazole, andrabeprazole, constitute the most effective therapy forGERD. Proton pump inhibitors provide excellent acidsuppression and effective symptom relief. Theseagents are particularly useful in elderly persons whooften require more acid suppression due to moresevere disease or complications. In older patients whoare unable to swallow pills, capsules may be openedand the granules mixed in water or juice or sprinkledon applesauce or yogurt.

Lansoprazole is also available as an orally dissolv-ing tablet and an oral suspension, which may be usefulfor those with swallowing disorders or those who areon tube feedings. Relapses are common in patients withGERD, especially in the elderly. Maintenance therapyis important. Long-term treatment with adequate dosesof medication is the key to effective care in the elderly.For the majority of patients with peptic esophagealstrictures, the use of acid suppression and esophagealdilatation are effective therapy. Aggressive acid sup-pression is effective in the majority of patients withGERD-related chest pain. Ear, nose, and throat prob-lems, such as hoarseness, have dramatic responses touse of these agents when used for prolonged periods. Inpatients with GERD-mediated asthma, significantimprovement with acid suppression by H2 blockers andPPIs will occur. Maintenance therapy is required in allof these patients because relapses occur very soon aftercessation of therapy. In patients with Barrett’s esopha-gus, chronic medical therapy is warranted, although itssuccess remains controversial (11). Although profoundacid suppression by PPIs may potentially affect suchfactors as B12 absorption and bacterial proliferation,clinical relevance remains uncertain. Therefore, longterm maintenance with PPIs is safe (20).

PRACTICAL GASTROENTEROLOGY • FEBRUARY 2005 59

A SPECIAL ARTICLE

GERD in the Elderly

PRACTICAL GASTROENTEROLOGY • FEBRUARY 200560

Although the vast majority of patients can be suc-cessfully managed with medical therapy, invasive meth-ods of surgery and endoscopic treatment of GERD maybe warranted. Surgery is an option for some patientswith GERD (21). Surgery is contemplated now withmore frequency because of the ability to perform antire-flux surgery laparoscopically. It is indicated in patientswith intractable GERD, difficult-to-manage strictures,severe bleeding, nonhealing ulcers, recurrent aspiration,and GERD requiring large maintenance doses of PPIs orH2-receptor antagonists. Barrett’s esophagus alone isnot an indication for surgery. Given that there appears tobe no more increase in postoperative morbidity or mor-tality in the elderly with this type of surgery, healthyelderly patients should not be denied surgery on thebasis of age alone (22). Careful patient selection withcomplete preoperative evaluation, including upper GIendoscopy, esophageal manometry, pH testing, and gas-tric emptying studies, should be done prior to surgery.

Endoscopic therapy of GERD is evolving. Implan-tation of Enteryx, a biocompatible, non-biodegradablepolymer into the gastric cardia, appears to be effectivefor treatment of GERD (23). Radiofrequency energydelivery to the gastroesophageal junction, the StrettaProcedure, has been effective in reducing symptoms ofGERD (24). In addition, endoscopically suturing belowthe gastroesophageal junction is possible and has beenused successfully to treat GERD (25). Further investi-gation and perfection of these techniques is warranted.

CONCLUSIONGastroesophageal reflux disease is a very commoncondition in the elderly. Although elderly patients havefewer complaints of heartburn, their disease is usuallymore severe and has more complications. With appro-priate management, GERD can be treated successfullyin most elderly patients. n

References 1. Howard PJ, Heading RC. Epidemiology of gastroesophageal reflux

disease. World J Surg, 1992; 16:288-293.2. Collen MJ, Abdulian JD, Chen YK. Gastroesophageal reflux dis-

ease in the elderly: More severe disease that requires aggressivetherapy. Am J Gastroenterol, 1995;90:1053-1057.

3. Huang X, Zhu HM, Deng CZ, et al. Gastroesophageal reflux: Thefeatures in elderly patients. World J Gastroenterol, 1995;5(5):421-423.

4. Traube M. The spectrum of the symptoms and presentations of gas-troesophageal reflux disease. Gastroenterol Clin North Am,1990;19:609-616.

5. Robertson D, Aldersley M, Shepherd H, et al. Patterns of acid refluxin complicated oesophagitis. Gut, 1987;28:1484-1488.

6. Lagergren J, Bergstrom R, Lindgren A, et al. Symptomatic gastroe-sophageal reflux as a risk factor for esophageal carcinoma.N Engl J Med, 1999;340:825-831.

7. Shaker R, Castell DO, Schoenfeld PS, et al. Nighttime heartburn isan under-appreciated clinical problem that impacts sleep and day-time function: the results of a Gallup survey conducted on behalf ofthe American Gastroenterological Association. Am J Gatroenterol,2003;98:1487-1493.

8. Ferriolli E, Oliveira RB, Matsuda NM, et al. Aging, esophagealmotility, and gastroesophageal reflux. J Am Geriatr Soc, 1998;46:1534-1537.

9. Sonnenberg A, Steinkamp U, Weise A, et al. Salivary secretion inreflux esophagitis. Gastroenterology, 1982;83:889-895.

10. Hurwitz A, Brady DA, Schaal SE, et al. Gastric acidity in olderadults. JAMA, 1997; 278:659-662.

11. Fass R, Pulliam G, Johnson C, et al. Symptom severity andoesophageal chemosensitivity to acid in older and young patientswith gastro-oesophageal reflux. Age Ageing, 2000; 29:125-130.

12. Raiha IJ, Impivaara O, Seppala M, et al. Prevalence and character-istics of symptomatic gastroesophageal reflux disease in the elderly.J Am Geriatric Soc, 1992;40:1209-1211.

13. Chait MM. The many complications of gastroesophageal reflux dis-ease. Home Health Care Consultant, 2000; 7:25-27.

14. Spechler SJ. Barrett’s esophagus. Semin Oncol, 1994;21:431-437.15. Van der Burgh A, Dees J, Hop WC, et al. Oesophageal cancer is an

uncommon cause of death in patients with Barrett’s oesophagus.Gut, 1996;39:5-8.

16. DeVault KR, Castell DO. Current diagnosis and treatment of gas-troesophageal reflux disease. Mayo Clin Proc, 1994:69:867-876.

17. Wong WM, Wong BC. Definition and diagnosis of gastroe-sophageal reflux disease. J Gastroenterol Hepatol, 2004;19(S3):S26-S32.

18. Fennerty MB. Use of a therapeutic trial as a diagnostic test forGERD. Practical Gastroenterology, 2004;28:45-50.

19. Richter JE. Gastroesophageal reflux disease in the older patient:Presentation, treatment, and complications. Am J Gastroenterol,2000;95:368-373.

20. Laine L, Ahnen D, McClain C, et al. Review article: potential gas-trointestinal effects of long-term acid suppression with proton pumpinhibitors. Aliment Pharmacol Ther, 2000; 14:651-668.

21. Spechler SJ, and the Department of Veterans Affairs Gastroe-sophageal Reflux Disease Study Group. Comparison of medical andsurgical therapy for complicated gastroesophageal reflux disease inveterans. N Engl J Med, 1992;326:786-792.

22. Trus TL, Laycock WS, Wo JM, et al. Laparoscopic antirefluxsurgery in the elderly. Am J Gastroenterol, 1998;93:351-353.

23. Johnson DA, Ganz R, Aisenberg J, et al. Endoscopic, deep muralimplantation of Enteryx for the treatment of GERD: 6-month fol-low-up of a multicenter trial. Am J Gastroenterol, 2003;98:250-258.

24. Triadafilopoulos G, DiBaise JK, Nostrant TT, et al. The Stretta pro-cedure for treatment of GERD: 6 and 12 month follow-up of theU.S. open label trial. Gastrointes Endosc, 2002; 55:149-156.

25. Mahmood Z, McMahon BP, Arfin Q, et al. Endocinch therapy for gastro-oesophageal reflux disease: A one year prospective follow-up. Gut, 2003;52:34-39.

A SPECIAL ARTICLE

GERD in the Elderly

OO RR DD EEOO RR DD EE RRRR PP RR AA CC TT II CC AA LL GG AA SS TT RR OO EE NN TT EE RR OO LL OO GG YY RR EE PP RR II NN TT SSRR EE PP RR II NN TT SS