THE AMERICAN JOURNAL OF GASTROENTEROLOGY
1, 2000
© 2000 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
CLINICAL REVIEWS
An Overview of Special Considerations in the
Evaluation and Management of the Geriatric Patient
Patricia P. Barry, M.D., M.P.H.
Geriatrics Section, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
ABSTRACT
As the population ages, physicians will care for increasing
numbers of older patients. Promoting independence is a
major goal of care. Gastrointestinal dysfunction is often
caused by chronic disease, medications, and lifestyle expo-
sures, rather than to age alone. A useful approach to the
older patient focuses on maintaining function and avoiding
complications. (Am J Gastroenterol 2000;95:8 –10. © 2000
by Am. Coll. of Gastroenterology)
EPIDEMIOLOGY
Between 1980 and 1991, the numbers of persons in the US
aged ⱖ65 yr increased more than any other age group.
Although the overall US population increased only by 11%,
those very old persons ⱖ85 increased by 41% (to 3.2 mil-
lion), and those 75– 84 increased 33% (to 10.3 million.) It
has been estimated that older persons account for approxi-
mately 60% of health care expenditures, 35% of hospital
discharges, and 47% of hospital days. In this group, 8%
have at least one chronic disease, such as arthritis, hyper-
tension, heart disease, or sensory impairment; and the ma-
jority have two (1).
In the elderly, the need for health care and services
correlates well with functional limitations. Functional capa-
bility includes the ability to perform basic activities of daily
living (ADLs) and the more complex tasks that are referred
to as intermediate activities of daily living. Basic ADLs
include toileting, bathing, dressing, transferring, feeding,
and grooming; and intermediate ADLs include meal plan-
ning and preparation, keeping house, managing finances,
taking medication, arranging transportation, and using a
telephone. Functional impairment rises with advancing age,
adversely affecting the ability to remain independent and
increasing the need for assistance.
INFLUENCE OF AGING ON DIGESTIVE FUNCTION
The anatomy and physiology of the digestive system are
influenced by aging. As the reserve capacity is ample, func-
tion of secretory and absorptive cells is usually maintained
in normal aging. Changes in connective tissue are respon-
sible for many digestive disorders, including diverticulosis,
and alterations in the immune system, especially T-cell
Vol. 95, No.
ISSN 0002-9270/00/$20.00
PII S0002-9270(99)00756-X
function, may also play a role. The effects of comorbid
conditions and multiple exposures to the environment, nu-
trition, alcohol, and tobacco increase as the years pass (2).
Consumption of medications increases with age, largely due
to increasing numbers of medical conditions. Polypharmacy
is common and may not only complicate diagnosis and
treatment of digestive diseases, but can actually cause or
exacerbate digestive symptoms and disorders such as an-
orexia, diarrhea, constipation, gastritis, pancreatitis, cho-
lestasis, and gallstones (3, 4). Many diseases prevalent in the
elderly have effects on the digestive system, such as isch-
emia due to atherosclerosis and motility disorders due to
diabetes mellitus. In addition, digestive diseases are impor-
tant causes of morbidity and mortality in the elderly, notably
epithelial cancers (especially colorectal), peptic ulcer dis-
ease, swallowing disorders, and fecal incontinence and/or
constipation (2). These topics will be addressed in future
articles in this series.
In a recent review of scientifically supported physiolog-
ical changes associated with aging in the GI system (5), the
authors noted that, in general, many essential aspects of GI
function are preserved well into old age, and much dysfunc-
tion is actually due to chronic disease, medications, and
lifestyle exposures. Assessment of age-related changes in
any organ system is confounded by the effects of both local
and remote conditions that may not be easily identified. In
the GI system, modest declines in function have been noted
in gastric mucosal cytoprotection and esophageal acid clear-
ance. Significant decreases have been found in lower GI
motor function (motility and transit), GI immunity, bile
lithogenesis, and hepatic drug metabolism, especially the
cytochrome P450 system. Evidence is conflicting for some
age-related changes once thought to be important, such as
esophageal dysmotility, and evidence is lacking for age-
related alterations in gastric acid secretion, intrinsic factor
secretion, gastric emptying, and small bowel transit time.
COMMON COMORBID CONDITIONS
As noted, numbers of diseases increase in aging persons.
Important conditions that may interact with the diagnosis
and treatment of digestive diseases in older persons include
ischemic heart disease, diabetes, chronic pulmonary disease,
and several neurological conditions. One common and dif-
AJG – January, 2000 Special Considerations for the Geriatric Patient 9

Table 1. Mini-Mental State Examination

Orientation
What is the (year) (season) (date) (day) (month)? 5
Where are (state) (county) (town) (hospital) (floor)? 5
Registration
Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for 3
each correct answer. Repeat them until he/she learns all 3. Count trials and record number:
Attention and calculation
Serial 7’s: 1 point for each correct answer. Stop after 5 answers. Alternatively, spell “world” backwards. 5
Recall
Ask for the three objects repeated above. 1 point for each correct. 3
Language
Name: pencil and watch 2
Repeat: “no ifs, and or buts.” 1
Follow a three-stage command: “Take a paper in your right hand, fold it in half, and put it on the floor.” 3
Read and obey: “Close your eyes.” 1
Write a sentence. 1
Copy a design (intersecting pentagons) 1
Total points 30
Source: Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:196 – 8.

ficult problem is cognitive dysfunction, which is not part of
normal aging and always requires careful evaluation. Sig-
nificant cognitive dysfunction is often due to dementia,
which affects 10 –15% of those aged ⬎65 yr and up to 50%
of those ⬎85 yr. Although dementia negatively influences
both life expectancy and quality of life, treatment of other
disease conditions may actually improve cognitive function,
and health promotion and disease prevention continue to be
essential. (6) When caring for persons with dementia, health
care providers must recognize and respect the primary car-
egiver’s role in the care and management of the patient. In
addition, it is important to note that the patient’s ability to
participate in decision-making is determined not by the
diagnosis but by the ability to understand the context of the
question and participate in the process.
Sensory loss is also common, most often because of
cataracts, macular degeneration, and presbycusis. Hearing
impairment, in particular, impairs communication and can
lead to social isolation; clear enunciation (facing the older
person and speaking in a low-pitched voice) and writing
questions on paper may be helpful. Visual impairment ham-
pers functional capacity, especially the ability to maintain
independence.
APPROACH TO THE ELDERLY PATIENT
Evaluation and management of the elderly patient requires
attention to more subtle, atypical, or nonspecific symptoms,
recognition of the importance of maintaining function, and
patience in both the interaction itself and the pace of progress.
Geriatric assessment is usually performed by the primary care
provider and includes evaluation of basic and intermediate
activities of daily living (ADLs), cognitive function, and symp-
toms of depression (7). The purpose is to obtain additional
information to develop a comprehensive plan of care. Depres-
sion and subtle changes in cognitive function are common in
older patients, and structured assessment (Tables 1 and 2)
increases early detection of these as well (8).

Table 2. Geriatric Depression Scale (Short Form)

Choose the best answer for how you felt over the past week.
1. Are you basically satisfied with your life? N
2. Have you dropped many of your activities and interests? Y
3. Do you feel that your life is empty? Y
4. Do you often get bored? Y
5. Are you in good spirits most of the time? N
6. Are you afraid that something bad is going to happen to you? Y
7. Do you feel happy most of the time? N
8. Do you often feel helpless? Y
9. Do you prefer to stay home, rather than going out and doing things? Y
10. Do you feel you have more problems with memory than most? Y
11. Do you think it is wonderful to be alive now? N
12. Do you feel pretty worthless the way you are now? Y
13. Do you feel full of energy? N
14. Do you feel that your situation is hopeless? Y
15. Do you think that most people are better off than you are? Y
One point for each of the above answers. Normal: 0–5; above 5 suggests depression.
Source: Sheikh JI, Yesavage JA. Geriatric Depression Scale: Recent evidence and development of a shorter version. Clin Gerontol 1986;5:165–72.
10 Barry
Physiological changes in hepatic and renal blood flow and
function, as well as body composition, affect the pharma-
cokinetics of many drugs used in the elderly. In general, the
overall effect of such changes is to amplify the effect of
most drugs and, therefore, to increase the likelihood of an
adverse drug event (4). In addition, because of diminished
physiological reserves, older persons are more vulnerable to
disturbances in the environment and have reduced capacity
to maintain homeostasis compared to younger persons. The
term “homeostenosis” has been used to characterize this
phenomenon, which may result in difficulties regulating
volume, perfusion, and temperature, among other functions
(1). Physicians must, therefore, be attentive to the need to
prevent complications, especially during diagnostic and
therapeutic procedures and in the prescribing of medica-
tions. For example, ensuring that “preps” are well tolerated
and avoiding excessive conscious sedation during proce-
dures are crucial in the management of older patients. The
value of interventions should be determined by their effect
on the patient’s independence and quality of life, and the
endpoint is often improvement rather than cure (9). Life
expectancy may be longer than anticipated and is often
dependent upon the significance of comorbid conditions.
Planning for care beyond an acute episode is critical and
involves an understanding of the importance of rehabilita-
tion and community-based services (including home care),
as well as involvement of a caregiver, if possible. Close
contact with primary care providers and attention to transi-
tions from hospital or outpatient procedure site to interme-
diate or long term care facility, or home, are critical in
maintaining continuity, ensuring that the level of care is
appropriate for the patient’s needs, and helping to maintain
independence and quality of life.
AJG – Vol. 95, No. 1, 2000
Reprint requests and correspondence: Patricia P. Barry, M.D.,
M.P.H., Geriatrics Section, F4, 88 East Newton Street, Boston,
MA 02118.
Received May 10, 1999; accepted Aug. 26, 1999.
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