256 CHAPTER 17 | Gastrointestinal Disorders and the Older Adult
effects on gastric acid production, nutritional inade- quacy, and uncomfortable digestive symptoms.2,3
Box
17.7 presents a summary of nutritional implications of age-related changes to the stomach.
Small Intestine
Age-related effects on the small intestine may include diminished motility, reduced absorptive capacity, decreased digestive enzyme production, and changes to gut immune tissue.1,2
These changes may be attrib-
utable to mucosal immunosenescence, and studies have provided extensive evidence of dysregulation and of an overall decline in mucosal immunity of the gastrointestinal tract in older adults.36
These alterations
can lead to new-onset food intolerances, dysbiosis of gut flora, increased risk of infection, and development of gastrointestinal disorders (eg, IBS and SIBO) and autoimmune diseases, including celiac disease.1,2,5 Some evidence suggests that lactase produc-
tion decreases with age, making older adults more likely to experience lactose intolerance. However, the presence of typical symptoms of lactose intol- erance (eg, gas, bloating, abdominal discomfort, or diarrhea) seems to vary.37
Additionally any damage
to the small intestine, including from celiac disease, increases in prevalence among older adults and can affect lactase production.38 Symptoms of celiac disease are often different or absent in older adults compared with younger adults, which can lead to delayed diagnosis and increased nutritional deficiencies (calcium, folate, iron, zinc, and vitamins B6, B12, and D).39,40
Thus, if an older
adult presents with unexplained weight loss, nutri- tional deficiencies, and generalized abdominal symp- toms, screening for celiac disease is recommended. SIBO or intestinal methanogen overgrowth can be caused by small intestinal dysmotility, increased transit time, hypochlorhydria, use of PPIs and other medications, surgical alterations of the gut, reduc- tions in the number of Peyer patches, and age-related increases in populations of certain bacteria that reside in the small intestine.2,9,41-43
These alterations in intes-
tinal function may lead to delayed or diminished sweeping of bacteria from the small intestine distally to the colon, leading to a bacterial colony count of 103
or more colony-forming units per milliliter in a
duodenal or jejunal aspirate and causing excessive fermentation of undigested food in the small intestine and colon.43,44
Box 17.7 Nutritional Implications of Age-Related Changes to the Stomach
Summary of nutritional implications
Reduced gastric acid production may lead to increased risk of nutritional deficiencies, especially calcium, iron, and vitamins B12 and D.
Alterations in motility may lead to gut discomfort and symptoms such as bloating, dyspepsia, and early satiety and can limit food intake or adequacy over time.
Guidance for practitioners working with older adults
Ensure adequate intake of food sources rich in at- risk nutrients. Supplement as appropriate based on laboratory results or comprehensive dietary assessment.
Changes to meal timing and food texture may reduce gut symptoms. Allow at least 3 hours between meals to ensure proper digestion, encourage soſt-textured foods, and limit insoluble fiber intake to address bloating and dyspepsia.
Discuss potential consequences of frequent nonsteroidal anti-inflammatory drug use with older adults and encourage them to discuss alternatives with their physician or primary care practitioner.
Symptoms associated with SIBO or
intestinal methanogen overgrowth include abdominal pain or distention, belching, bloating, constipation, diarrhea, gas, nausea, or vomiting, depending on the type and number of bacteria or methanogens that are most prevalent. In addition, because the presence of excessive bacteria in the small intestine leads to com- petition for nutritional resources, certain nutritional deficiencies may be seen with SIBO, including folate, iron, and vitamin B12.2,44
Fat-soluble vitamins (A, D,
E, and K) may also be deficient in persons with SIBO due to deconjugation of bile acids in the presence of excess bacteria, inhibiting fat absorption.45 The recommended treatment for SIBO is antibiot- ics, with rifaximin being perhaps the most studied and most efficacious.44
Prokinetics, such as prucalopride or
erythromycin, may also be used in cases of reduced motility.44,45
Herbal antibiotics and numerous over-the- counter supplements are also often touted for treatment
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