Annals of Long Term Care

Karen E. Hall, MD, PhD, Assistant Professor at the Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan, Ann Arbor, and Research Scientist, GRECC, at the Ann Arbor VA Medical Center, MI, suggested that esophageal cancer, like colon cancer, may begin with a progression of mutations rather than a single causative event such as acid reflux.  

Current recommendations include that patients with high-grade dysplastic lesions should be referred for endoscopy (to rule out Barrett’s esophagus) and possible surgery.  Dr. Hall feels, however, that patients with moderate-grade dysplastic lesions should also be followed up, possibly annually.  She stated that if patients are cognitively intact, they should decide what kind of diagnostic and therapeutic approach should be taken once they are informed regarding the options.  She pointed out that “the main risk of proton pump inhibitors [PPIs] is wallet risk,” because they are expensive.

In terms of conservative measures, Dr. Hall favors discontinuing potassium and iron supplementation, which has been associated with strictures in both the esophagus and the duodenum, and prescribing PPIs if the patient is willing and financially able to take them. She pointed out that H2 antagonists are not as efficacious in controlling basal acid secretion as PPIs and would have to be taken for a much longer period of time; additionally, agents such as cimetidine can carry an increased risk of side effects in a geriatric patient population.

Dr. Hall explained that Barrett’s esophagus often does not manifest any symptoms. Patients’ symptoms will be caused by gastroesophageal reflux disease, and sometimes patients will be asy?mp?tomatic except for some hoarseness (“silent reflux”).  “Alarm symptoms,” which should lead a clinician to suspect possible esophageal cancer, include a weight loss of at least 10 pounds or 10% of total weight, anemia, bleeding, and pain.  She noted that patients with schizophrenia and related disorders may be receiving psychotropic drugs that have anticholinergic and neurological (dyskinetic) side effects that can impair food transit and increase reflux risk.  She cautioned, however, against discontinuing antipsychotic medication abruptly, since that could actually worsen tardive dyskinesia, and suggested switching the patient to a neuroleptic with a lower known rate of side effects.  Dr. Hall advised against using feeding tubes in patients with dementia, because the potential prolongation of life by about one year comes at the expense of quality of life and with the risk of infection and of aspiration pneumonia.

When an elderly patient has multiple morbidities, abdominal distention, and intermittent vomiting but no pain, weight loss, or appetite changes, Dr. Hall advised that impacted stool may be implicated and an enema could be the first and best solution, followed by maintenance with a cathartic or osmotic laxative.  She warned the audience that mineral oil and soap-suds enemas can cause problems and stated that plain tap water would probably be the best medium to use.  

The speaker presented the case of an elderly, mildly demented patient with multiple morbidities and symptoms of fever and emesis persisting for 36 hours.  Even though the patient’s white blood cell count appeared within normal limits, Dr. Hall said, it should be compared to his usual count for the possibility of an extreme change.  She suggested a surgical evaluation, pointing out that appendicitis is more common in very old patients and particularly in men.  “In fact,” she added, “about 50% of all deaths from appendicitis are in this small group of individuals.”  She stressed that the physician who knows the patient well may suspect something wrong that others would miss.  “If you’re convinced something is wrong, something is different…I would push to get them evaluated.”  

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