The Aging Gastrointestinal Tract

An overview of the gastrointestinal tract, changes as a result of aging, and a description of how nutrition may prevent or improve common GI problems in the older adult. Note: this presentation is intended for a health/medical literate audience.

1. The Aging Gastrointestinal Tract Megan Myrdal, RD, LRD Graduate Student North Dakota State University October 14, 2013

2. Objectives Understand the components of the gastrointestinal (GI) tract Understand how aging effects the GI Understand problems associated with the aging GI Understand dietary interventions to maintain adequate GI function throughout the lifespan

3. Gastrointestinal System Oral cavity Throat (oropharynx) Esophagus Stomach Duodenum and small intestine Gallbladder Pancreas Liver Large intestine Rectum Anus

4. Age-Related Changes in the GI Tract Aging affects absorption and metabolism of foods, vitamins and medications Aging results in increased susceptibility to foodborne infections and other infections due to decreased immune function. Table 7-1 pg. 103 – Age-Related Changes in the GI Tract

5. GI Tract Problems in Older Adults The Oral Cavity Gum disease Teeth Dental caries and periodontal disease Oral and Throat Cancers Major cause is tobacco and alcohol

6. Gum Disease vs. Health Teeth

7. Oral health issues in older adults have been associated with comprised dietary quality, likely due to decreased fruit, vegetable, and nut intake . Older adults adapt their diet (through food modification or avoidance) to address these health problems. A report showed that having difficulty fixing meals was associated with a greater risk of mortality, even more than a lack of financial resources. Oral Health Problems & Food Avoidance/Food Modification Savoca , M.R., Arcury , T.A., Leng , X., Chen , H., Bell, R.A., Anderson, M.A., Kohrman , T., Gilbert, G. H., and Quandt , S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232.

8. A population-based, cross sectional survey of the dietary intake with 635 adults aged 60 and older. Food frequency questionnaire (HEI-500, based on the amount of food per 1000kcal of intake) F ood avoidance and food modification were measured. Finally, oral health exams were completed for those with at least one natural tooth Rural Nutrition and Oral Health Study (RUN-OH) Savoca , M.R., Arcury , T.A., Leng , X., Chen , H., Bell, R.A., Anderson, M.A., Kohrman , T., Gilbert, G. H., and Quandt , S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232.

9. Modifying foods in response to oral health problems is associated with improved dietary intake, even for those with severe oral health issues. Strategies to minimize food avoidance and promote food modification may help personals with eating difficulties due to oral health issues. Rural Nutrition and Oral Health Study (RUN-OH) - RESULTS Savoca , M.R., Arcury , T.A., Leng , X., Chen , H., Bell, R.A., Anderson, M.A., Kohrman , T., Gilbert, G. H., and Quandt , S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232.

10. Methods to Prevent Dental Caries & Periodontal Disease Drink fluoridated water Use fluoride toothpaste Brush teeth carefully with a soft brush after meals Professional oral care (even if no teeth are present) Avoid tobacco (all forms) Limit alcohol Watch for changes in taste and smell (notify health professional)

11. Research from the Dental Longitudinal Study found that each serving of good to excellent sources of total fiber was associated with a lower risk of periodontal disease progression and tooth loss. Fruit consumption was also associated with a lower risk of periodontal disease progression. Results: higher intake of high-fiber foods, especially fruits, slow progress on periodontal disease for men aged 65 and older. High Fiber Foods and Periodontal Disease Progression Schwartz, N., Kaye, E.K., Nunn, M.E., Spiro, A., and Garcia, R.I. (2012). High-Fiber Foods Reduce Periodontal Disease Progression in Men Aged 65 and Older: The Veterans Affairs Normative Aging Study/Dental Longitudinal Study. Journal of the American Geriatric Society . 60:676–683.

12. Dysphagia & Odonophagia Dysphagia – difficulty with swallowing Signs: Pocketing of food in cheeks, speech abnormalities with slurring of words, orofacial changes, facial weakness, abnormal tongue movement and foods becoming stuck if swallowed Odonophagia – pain upon swallowing Both may be caused by GERD ( gastroesophageal reflux disease)

13. Swallowing A short video from Nestle Healthcare discussing the swallowing process, complications associated with dysphagia and the importance of proper dysphagia management. http :// www.youtube.com / watch?v =jK1o3LSQmB0

14. Management of Dysphagia Management of dysphagia includes: T argeting the cause (when possible) C onsult with a speech therapist Beginning appropriate food and liquid consistencies H ave someone eat with the older adult M onitor and control progression symptoms. I f esophageal spasm are present, calcium channel blockers may be prescribed.

15. Dysphagia Diet Foods should be pureed, thickened or homogenous No raw foods except bananas Cut tender meat to 1cm or less Avoid nuts; raw, crispy food, stringy foods Liquids – thin, nectarlike (like eggnog, able to drink with a straw), honeylike (like yogurt - eaten rather than straw) or pudding-like.

16. Aspiration Aspiration – a serious risk associated with dyphagia and dysphasia (difficulty speaking) Caused by abnormal entry of food or fluid into the airway. Foreign fluid or substance must be removed by suction from the airway to promote breathing when the airway is obstructed . Can cause airway obstruction but more commonly results in pneumonia Treatment is antibiotics

17. Management of Aspiration Older adult must concentrate at meals and avoid social occasion at mealtime Sit upright in a chair (no eating in bed) Food should be taken and swallowed from the strongest side of the mouth (if paralysis or unilateral weakness is present) Sit upright for 30 minutes following a meal Choose foods which promote salivation Smaller, more frequent meals

18. Gastroesophageal Reflux Disease ( GERD ) GERD is a condition in which the gastric contents move backward (reflux) into the esophagus causing pain and tissue damage. GERD is the most common GI disorder in older adults Symptoms include heartburn, water brash, sour taste in mouth, belching, indigestion, dysphagia and regurgitation 40% of older adults in the US experience these symptoms

19. GERD Management First Line: Nutritional/Positional Avoid symptom-causing foods (fruits, chocolates, caffeine drinks or alcohol, fried/fatty foods, garlic and onions, mints, spicy foods, and tomato-based foods Stop eating large meals Avoid lying down 3 hours after eating Avoid tight-fitting clothes Lose weight if overweight Stop smoking Stop drugs that cause reflux (only with a consultation from a primary caregiver)

20. GERD Management Second & Third Line: Pharmacological Second Steps: Antacids – Maalox, Mylanta or Tums H2 Antagonists – cimetadine (Tagamet), famotidine (Pepcid), or ranitidine hydrochloride (Zantac) Third Steps: Proton Pump Inhibitors (PPIs) – Prilosec/ Nexium , Prevacid , and Protonix

21. Hiatal Hernia Hiatal Hernia – a physical abnormality that allows the stomach to protrude through the diaphragm and up into the chest. Often caused by weakened musculature (specifically esophageal muscles around the opening of the diaphragm) Caused by heavy lifting, coughing, lying flat in bed or performing a Valsalva maneuver

22. Peptic Ulcer Disease Peptic Ulcer Disease (PUD) – a duodenal or stomach ulceration often caused by the bacterium Helicobacter pylori . 80% of duodenal ulcers and 60% of gastric ulcers caused by H. pylori Treatable with antibiotics. Second cause of PUD is NSAIDs ( Nonsteroidal anti-inflammatory drugs) Risk of ulcers 3x greater in NSAID users Signs of PUD include epigastric pain and coffee-ground emesis.

23. Nausea & Vomiting Nausea and Vomiting Main concern is dehydration If seriously ill, hospitalization and IV rehydration may be considered Medication to stop nausea and vomiting may be considered Caution: These drugs may cause confusion, sedation and delirium in the older adult.

24. Gastroparesis Gastroparesis – delayed stomach empting Normal stomach emptying – the stomach contracts (controlled by the V agus nerve) and food moves down into the small intestine for digestion Symptoms include nausea, early satiety, vomiting, pain and possibly heartburn from reflux Common causes: diabetes, idiopathic, and postsurgical Occurs in 30% of those with type 2 diabetes Occurs in 27% to 58% of those with type 1

25. Management of Gastroparesis Dietary Recommendations: First Diet: Liquids to prevent dehydration, salt and mineral losses; avoid milk products, vegetables, fruits, and meat; eat saltine crackers and drink Gatorade Second Diet: Small amount of dietary fat, skim milk and yogurt; low-fat cheeses; fat-free bouillon and soups made with skim milk and with pasta; cream of wheat; white rice,; eggs; peanut butter; vegetable juice; well-cooked vegetables w/o skins; apple, cranberry, grape, pineapple and prune juices; canned fruits without skins Avoid citrus fruits

26. Management of Gastroparesis Third Diet All items in Diet 2 with the addition of poultry, fish, and lean ground beef; breads and cereals; coffee, tea and water <50 grams of fat/day Restrict non-calorie fluids if calorie intake cannot be maintained Enteral and parenteral nutrition if symptoms flare, weight loss (10% over 6 months), nutrient deficiencies, or electrolyte imbalances

27. Malabsorption Some defect that occurs during digestion and absorption of food nutrients Can occur at any of the three phases of digestion: (1) Luminal Phases – dietary fats, proteins and carbohydrates are hydrolyzed and solubilized (2) Mucosal Phase – brush-border membrane of intestinal epithelial cells transport digested nutrients from the lumen into cells (3) Postabsorptive Phase – lipids and other nutrients are transported from epithelial cells via the lympatic system and portal circulation to other parts of the body

28. Malabsorption Causes Pancreatic insufficiency (20-30% of older adult malabsorption cases) Anatomic abnormalities (30%) – stasis and predispose to bacterial overgrowth Bacterial Overgrowth Syndrome w/o anatomic abnormalities (20%)– inadequate gastric acid secretion Pernicious anemia and vitamin B12 deficiency are common Treatment will be dependent on the cause.

29. Steatorrhea Steatorrhea – production of stools containing an abnormally high amount of fat Hallmark of malabsorption Stool smells foul, bulky and difficult to flush down the toilet >6% of dietary fat is excreted in feces Clinical signs: anemia, deficiencies in iron, folate , B12, Vit K or a combination, easy bruising

30. Steatorrhea Diagnosis: 72-Hour Stool Collection If fecal fat is >40 g, pancreatic insufficiency or small intestine mucosal disease indicated D-xylose test to differentiate Treatment: Correct nutrient deficiencies and treat underlying causes Iron supplement via ferrous sulfate or gluconate tablets Monthly B12 injections Supplement fat-soluble vitamins and calcium High protein/calorie, low-fat diet prescribed MCT supplement

31. Behavior Assessment Used with permission from the “Nourish Your Digestive System” program by Julie Garden-Robinson, NDSU Extension Service

32. Basic age-related gastrointestinal changes may impact absorption and metabolism of food, vitamins and medication Special attention needs to be paid to oral health issues, including chewing and swallowing, which may impact nutritional status Prevention is key to many age-related gastrointestinal issues In Summary

33. Bernstein , M. and Schmidt Luggen , A. (2010).  Nutrition for the older adult . Sudbury, MA: Jones and Barlett Publishers. DOI: www.jbpub.com National Institute of Dental and Craniofacial Research. Periodontal (Gum) Disease: Causes, Symptoms & Treatment Retrieved 17 September 2013. http://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/ PeriodontalGumDisease.htm Nestle HealthCare - http://www.youtube.com/watch?v= jK1o3LSQmB0 “ Nourish Your Digestive System.” Packaged program by Julie Garden-Robinson, NDSU Extension Service. Savoca , M.R., Arcury , T.A., Leng , X., Chen, H., Bell, R.A., Anderson, M.A., Kohrman , T., Gilbert, G. H., and Quandt , S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232 . Schwartz , N., Kaye, E.K., Nunn, M.E., Spiro, A., and Garcia, R.I. (2012). High-Fiber Foods Reduce Periodontal Disease Progression in Men Aged 65 and Older: The Veterans Affairs Normative Aging Study/Dental Longitudinal Study. Journal of the American Geriatric Society . 60:676–683. References