“Functional” GI Conditions in the Older Adult: DGBIs and Beyond

In discussing disorders of gut-brain interaction (DGBI) previously known as functional GI disorders, we will highlight new literature evaluating prevalence of these conditions and our approach to the evaluation and treatment of these symptoms and conditions in the older adult. We include in this section GI symptoms that may not formally fit into a DGBI condition including secondary symptoms that nevertheless can impact the well-being of the older adult. PubMed was searched for studies related to functional GI disorders in the elderly. Search terms included global terms such “function gastrointestinal” and “disorders of brain gut interaction” as well as specific diagnoses such as “IBS”, “constipation,” “fecal incontinence. Full manuscripts in English were selected for review to determine if the paper addressed DGBI's in those ≥ 65 years old. There is lack of dedicated study of DGBIs in the older adult and many of the studies found in literature review were abstracts which were largely not included in this review and cited inline text if included, highlighting the need for further study in this increasing population. As chronological age is the most straightforward to evaluate, most studies conducted have utilized this metric with age ≥ 65 being utilized in large scales studies. We will utilize age ≥ 65 years when discussing the older adult population in this section unless specified. DISORDERS OF GUT BRAIN INTERACTION Prevalence of DGBI have been shown across multiple studies to decline in adults ≥65 years old with the singular exception of fecal incontinence. Incidence rates of DGBIs in older adults has not been studied. The recent Rome Foundation Global Epidemiology study found an overall global prevalence of having any DGBI to be 40.3% across more than 54,000 participants in 26 countries. Among these, the prevalence of having any DGBIs was significantly higher in the younger ( 1.2 g/kg BW/d of protein tend to have higher muscle and bone mass than women who consume less (14). GI symptoms can also drive poor dietary habits as one study found up to 50% of patients with functional GI conditions have a change in appetite, most often decreased (33%) but also increased in 16% (15). This decrease in appetite can lead to dietary changes that further worsen symptoms from factors including poor nutritional intake or decreased fiber content. The etiology for decreased oral intake extends beyond low appetite. It is important to assess the ability to eat which includes ability to masticate effectively. A thorough review of dentition, adequate fit of dentures, and any symptoms of oropharyngeal and/or esophageal dysphagia should be reviewed. Medications that can cause dysphagia include supplements such as vitamins, bisphosphonates, potassium supplements, and calcium channel blockers which are more commonly prescribed in older adult populations and should be considered during medication review (16). Several studies suggest delay in gastric emptying times of both solids and liquids with age (17,18)with potential clinical consequences including increased post-prandial hypotension after liquid oral glucose load (19,20). However, not all studies concur with this delay (21) and testing was done with heterogenous oral substrate and testing manner, none with scintigraphy utilizing the standard solidegg-meal. Changes in appetite may signal systemic illness (i.e. sepsis, neurodegenerative disorders or malignancy) or depression; thus, alternative causes should be explored in this population prior to attributing these symptoms to a functional GI disorder. Access to healthy food with adequate fiber and protein content and knowledge of healthy eating habits should be holistically considered in a multidisciplinary fashion in collaboration with social workers and dieticians respectively. Sleep Older age has been associated with shorter sleep duration and lower sleep efficiency in multiple studies (22,23). In a prospective study, sleep disturbances including clinical insomnia and poor sleep quality were reported more frequently in adult patients with IBS even compared to other GI conditions including Crohn's disease, GERD, IBD, as well as healthy controls; the mean age of this cohort ranged from 41 to 55 years (24). A study of 2,906 individuals found that excessive daytime sleepiness was associated with higher odds of DGBIs including dyspepsia, IBS-D, and functional constipation. An increasing number of functional GI disorders also increased the risk of excessive daytime sleepiness (25). Patients with GI symptoms and sleep disturbance also had higher morbidity than those without sleep disorders (26). It is difficult to discern the cause and effect of these associations as to whether worsening GI symptoms lead to poor sleep quality or vice versa (4). Regardless of the directionality of the association, sleep disturbances have been shown to be more common with increasing age (22,23) and with GI symptoms and thus sleep habits should be optimized where possible. Control of GI symptoms may also improve sleep quality (26), though the direct impact on older adults with or without DGBIs requires further study. Medications Medication and impact of need to be considered in multiple in the care of older adults. Medications to conditions (i.e. calcium channel blockers for can lead to functional GI symptoms or or GI disorders thus, medication should be considered as secondary causes of GI symptoms including constipation and for DGBIs can with other medications or cause are commonly in the treatment of in older adults are associated with and due to the such as and which can the risk of As an and such as are frequently for the treatment of IBS are utilized for DGBI treatment or for depression, can the of other and increasing the risk of and in this patient population Medications should be considering effect and in patients with constipation, a secondary can be considered to medications are commonly prescribed in older adults which can cause constipation, the risk of or leading to or risk disorders causes of constipation to data from the Rome Epidemiology study, patients with a DGBI who have a symptom older in age, and have are more to Patients with a DGBI often have a higher prevalence of pain medication including as well as can lead to dyspepsia, with or without and potential bowel which may lead to work and pain medications can delay symptoms with subsequent treatment medications to have also been shown to esophageal with abnormalities including and esophageal This may contribute to dysphagia and decreased oral intake with subsequent health consequences A study that older with had higher rates with as well as other GI medications The GI specific medications that with recommendations for in the older adult. include the and for high quality for symptoms for risk of and bone for > to high quality the treatment medication access can be limited in the population. status should be considered when medications or options for functional GI conditions, many of which are lack of treatment such as brain gut including therapy and and and alternative as have and on a of options after medication review should be undertaken to the most and options for with a on medication The impact of GI conditions, including DGBIs on the older adult population to be considered to care to this population. A prevalence of symptoms of with an of compared to healthy rates of were higher with an of symptoms, particularly fecal incontinence and pain that can can have a impact on quality of in of bowel symptoms can lead to limited social which can lead to isolation, and which are in the older adult population incontinence and incontinence can the of with of for and for As it is that up to 50% of in the from the and that those older than years of age, those with GI disorders reported more compared to those without with higher rates of and social In those with GI symptoms, and were associated with odds of poor or health those with mobility issues or need with of bowel movements can lead to of not being to access facilities when who are on for or are not to can and increased risk if fecal is not to be factors can contribute significantly to worsening Summary: protein and fiber intake should be in all older adults. sleep is common and can impact GI symptoms. A thorough medication review should be undertaken as of the evaluation of patients with DGBI and prior to of new A review of impact of bowel symptoms should be of the clinical to care and secondary While constipation in the of irritable bowel syndrome with constipation and functional constipation is less common in the older adult population compared to their younger overall rates of constipation are ranging from in a general population to up to in those residing in a facilities compared to in the overall general population. This is due to higher rates of secondary constipation as systemic disorders, and medication more as comorbid conditions While it is often difficult in large studies to from functional constipation with a of related abdominal the overall approach to these constipation conditions will be the In clinical the presence of as to associated with change in bowel or frequency will a patient with where a more global approach to symptoms may be from one with functional constipation. The impact of pelvic floor dysfunction in the older adult is and the rates of disorders pelvic floor is not well is known disorders in to and have shown that aging the of pelvic of with up to a of risk of syndrome associated with and can impact both and women and lead to and constipation. Patients with related constipation tend to be older than those with related constipation years vs. While symptoms not and of rectal for pelvic floor etiology should be in patients who need for a of and to including and of the or Patients may also impact in the pelvic including symptoms of emptying and increased frequency of as well as of constipation should with review of the lifestyle factors that can frequently drive constipation, including of dietary fiber and mobility in of overall degree of independence and control of their of living have shown that fiber intake in older adults residing in care facilities where the of fiber was significantly lower than the which on was levels (13). with new constipation should for if not up to Other secondary causes of constipation should be particularly in those with systemic such as in in patients with or glucose in those with Medication should be conducted to for potential and should be conducted in to the pelvic floor as this will both constipation and the commonly of fecal incontinence in the aging population. testing to the should include symptoms are of rectal evacuation disorder with and rectal with or can be considered to further the of the pelvic and potential In those with pelvic floor evaluation for constipation can be considered if is to of constipation and fiber are that are not or in the There are of fiber which are based on to in to a and degree of for the general adult population is at and fiber in the of has shown the most evidence for the treatment of IBS and constipation Other of dietary fiber include and of fiber include and fiber adequate is to remain and to It is important to patients and assess for any in intake which may be driven from mobility incontinence, or and intake should be increased over the of in those in dietary fiber to possible of and especially that are in the individuals should for of fiber that are and the high prevalence of secondary constipation, of systemic review of medication with of as can be of pelvic floor dysfunction and physical therapy can be safe and data on of pelvic floor for rectal evacuation disorders in the older adult population is not studies of pelvic floor with for incontinence and in a cohort of women > years old of including and are safe and should be therapy options if fiber is not or can be considered for further therapy if with for a and in older patients with both constipation and a channel can be in older compared to younger adults. a has a but should be with in older adults to due to a that and in the is safe and in the treatment of in patients on has not been in the older population, clinical patients a receptor with should be with in older adults due to of in clinical were to at for with to to in adults ≥65 years old with of these medications have risk of including abdominal pain and patients and should be prior to to symptoms. is important to consider when a The can be for if on the if may be lower in than an have been for treatment of constipation with A review of studies of for treatment of of constipation but included studies and a of adult patients A prospective study of or constipation with not in this of patients The of for constipation treatment is not well in GI symptoms in incontinence where evidence for is more general approach in this population particularly if is or is to dietary and lifestyle assess and pelvic floor and if this is not with patient driven of such as have medication and thus can be by the to for a but bowel including or can be on of this and to bowel are effect and whether a is can be considered in with and of the low and of any therapy for constipation can be and which can be for older patients with more limited the and of functional GI symptoms in an older adult of constipation in the older adult should with a thorough evaluation of lifestyle factors including fiber and activity as well as possible secondary including thorough medication review and age floor dysfunction should be considered in and the and can be considered as if dietary and lifestyle are rates are higher in of care facilities with increased rates of and living in ability to and increased risk for in the of those with illness this on the of the evaluating is to both of individuals and on the of to to can with or fecal incontinence factors for fecal include older age, lack of and A rectal and/or abdominal can fecal with in patients with A thorough can be to whether a patient with is having multiple with evacuation which would suggest constipation or a lower number of or which would be more in with or survey based studies are limited by and patient the of constipation with bowel movements and be The prevalence of irritable bowel syndrome with associated with increased frequency of of is lower in the older adult the prevalence of and/or without is higher The prevalence of was in individuals years or older compared to in those in their risk factors for included high and high the higher prevalence of alternative diagnoses should be considered in older patients of causes of into and can lead to symptoms without evidence of on or This condition and impact in older adults is addressed in in the section of this of and lifestyle are the for patients with IBS patients with related symptoms, dietary such as the low diet can be to of dietary patients should be for especially in older patients who are at higher risk of and In older adults, the can be and safe when by a medication of of individual IBS symptoms of and abdominal in should include effect potential interaction and of medications are thus, should be at the and to the at the of was associated with higher rates of compared to the lower of older patients were more to to the lower of than younger patients with is safe in older adults and not However, other should be with and in patients Medications with such as and should be with our general therapy for and in the older The approach to in older individuals should be to the general approach to and include a with of supplements and However, older individuals are more to illness and causes of due to or prior a to from fecal incontinence. testing should include fecal and and can be as an for to functional and bowel disorders leading to with high in the older compared to younger adult population Patients who are not to therapy should further evaluation IBS Summary: diagnoses for in the older adult should include secondary and with risk by comorbid conditions, of and fecal including are as as in younger adults for in older adults. for should be symptom control with evaluation of effect and when The prevalence of fecal incontinence reported in the literature Among older the prevalence can be as high as in the and in In a large in individuals reported of those individuals reported of the age, and other disorders were risk factors for such that of individuals ≥ 65 years of age have in their Despite the prevalence of only of individuals have reported 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The overall rates of disorders of gut brain interaction with age, but symptoms of constipation, and fecal incontinence remain with potential for impact on and overall quality of particularly when is lack of control can contribute to and social leading to related be particularly in those with limited mobility living with symptoms of fecal and incontinence to and safe access and when to secondary Medications can have impact on GI and can cause secondary constipation, or GI symptoms including and abdominal which can of leading to A thorough medication review and as possible should be of the The of in aging is an not have evidence to their as a in this population. most of the functional GI disorders not an in can cause morbidity and impact quality of symptom and control should be considered as of of care to patient and are in to their bowel The overall prevalence of DGBIs is lower in older compared to younger adults with the exception of fecal incontinence. When evaluating functional GI symptoms in older adults, a thorough work up for secondary causes of symptoms should include a structural work of systemic and medication DGBIs to have high impact and can contribute to worsening morbidity by and increasing symptoms as well as overall and should with dietary and lifestyle as possible the of other comorbid options need to be reviewed for potential and to