The following macromedia presentation has been developed by AANP and

sponsored by an educational grant from Wyeth Pharmaceuticals. This

symposium was presented live at AANP 22nd National Conference in Indianapolis June 21, 2007.

A PDF file of the syllabus is attached and available to print.

This program has been approved for 1.25 contact hours of continuing education from the American Academy of Nurse Practitioners, of those hours .25 is pharmacology content. It is AANP’s goal to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. To meet this goal, both real and/or potential conflicts of interest must be considered during the development of a continuing educational activity. All individuals having control over the development of an activity’s content and all faculty participating in AANP programs are expected to disclose any relationships they may have with commercial companies whose products or services may be mentioned. Potential learners will be informed of all disclosed relationships. Approval date September 1, 2007. Expiring September 1 2009. Target audience is Nurse Practitioners.

Faculty

Julia Pallentino, MSN, JD, ARNP-BC, FNP, Program Chair

Diana “Dee” Swanson, MSN, NP-C, FAANPJudith Shannon Lynch, MS, MA, APRN-BC,

FAANP

FACULTY DISCLOSURES:

Julia Pallentino: Member of Speakers Bureaus for Novartis, Takeda, Astra Zeneca, Roche, and Proctor and Gamble.

Diana “Dee” Swanson: Has nothing to disclose.

Judith Shannon Lynch: Has nothing to disclose.

Julia Pallentino, MSN, JD, ARNP-BC, FNP, Program Chair

Nurse Practitioner, Gastroenterology PracticeMedical Group of North FloridaTallahassee, FL.

Julia Pallentino is a family nurse practitioner providing care for patients in agastroenterology practice in Tallahassee, Florida. Her career began as aregistered nurse in 1971 in Key West, Florida. She has worked in manynursing specialty area with an emphasis on emergency and intensive care.She attended Florida State University where she obtained a Bachelor’sDegree in Nursing. She graduated from the FSU School of Law in 1983.Dr. Pallentino clerked for a Federal District judge before entering privatepractice as a medical malpractice trial attorney. During her legal career shefocused on medical malpractice defense cases, winning every case she tried.Dr. Pallentino also had the privilege of representing the Florida NursesAssociation as a Governmental Relations Consultant during her legal career.She considers the high point of her legal career to be the change in the lawallowing prescriptive privileges for NP’s that resulted from legal actions sheinitiated.In 2001, Dr. Pallentino graduated from Florida State University with aMaster’s Degree in Nursing as a Family Nurse Practitioner. She haspracticed with a Tallahassee physician with a specialty in gastroenterologysince 2002. Dr. Pallentino is a nationally known lecturer in gastroenterologyand medical-legal issues.

Diana “Dee” Swanson, MSN, NP-C, FAANP

Nurse Practitioner, Salt Creek Family PracticeNashville, IN

Diana “Dee” Swanson has worked in primary care for 14 years. She iscertified in Adult and Family primary care, was formerly certified as aGerontological NP and Clinical Nurse Specialist. After starting a clinic for theunderinsured where she practiced for 2 years, she was involved in starting aVolunteer’s in Medicine Clinic in her home county and currently serves as avolunteer provider on a monthly basis. For over 8 years she worked in a multispecialtyinternal medicine clinic providing primary, urgent and nursing homecare. Currently in a rural family practice providing the full range of primarycare services, she also serves as a preceptor for Indiana University, BallState University and Indiana Wesleyan University. She has served as aspeaker on the topic of GERD on several occasions.Dee Swanson has been very active in the Coalition of Advanced PracticeNurses of Indiana serving as the President and currently as the Chair of theLegislative committee. She works extensively with APN legislative issues inIndiana.Dee Swanson has been active in the AANP, serving as Region 5 StateRepresentative and Director, and Treasurer. Currently she is RecordingSecretary, the PAC Treasurer and incoming President -elect of the AANPBoard of Directors. She has done item writing, test construction, and taskanalysis for the AANP certification test. Dee Swanson is a Fellow of theAmerican Academy of Nurse Practitioners

Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Nurse Practitioner, ENT Associates,Waterbury CT.Assistant Clinical Professor,Yale University School of Nursing,New Haven, CT.Judith Shannon Lynch has been a family nurse practitioner for 30 years and has practiced in a wide variety of clinical settings. A graduate of Boston College and Binghamton University, she holds a Master of Science in Family Nursing, a certificate as a Family Nurse Practitioner, and a Master of Arts in Women’s History. Her clinical research centers on issues surrounding care of the elderly in the current healthcare system. Research in history focuses on the early 20th century in New York City and the social reform movements of the Progressive period.Judith Lynch held academic appointments at Binghamton University and Yale University before being named Program Director and Associate Professor of Nursing at Sacred Heart University in Fairfield, Ct. where she devised and implemented a Master’s Degree program in family ursing. She currently remains an Assistant Clinical Professor of Nursing at Yale University and a NP in otolaryngology and allergy, one of the first NPs in the country to practice this surgical subspecialty. Judith Lynch has extensive experience in public speaking and writing. She was Guest Editor for the issue of Lippincott's Primary Care Practice dedicated to ENT clinical and research issues. She is currently an expert on WebMD's. Ask the Expert panel where she authors articles on otolaryngology and allergy for primary care providers. Judith Lynch has appeared on local radio and television shows as a consumer advocate for patients suffering from various health issues including allergies, vertigo, and trauma against women. She is also one of the pioneers in the political movement for NPs. She has appeared before state legislators as a witness for various NP issues and held national office on certification bodies. She continues to speak locally, regionally, and nationally on various health related topics. Judith Lynch is a Fellow of the American Academy of Nurse Practitioners.

Program Objectives• Improve early recognition of GERD symptoms

in elderly patients• Distinguish unique GERD symptoms in the

elderly• Increase awareness of the epidemiology and

quality of life issues surrounding GERD• Develop a comprehensive evidence-based

management plan for elderly patients with GERD including appropriate measures for non-response to therapy

• Discuss health promotion and disease prevention measures for GERD in the elderly

Introductions and Pre-Test Questions

presented by:

Julia Pallentino, MSN, JD, ARNP-BC, FNP, Program Chair

GERD in the ElderlyWhat’s Age Got To Do With It?

Heartburn is the most commoncomplaint of the elderly patient with GERD.

1) True2) False

Question!

Which of these symptoms is present in laryngopharyngeal reflux (LPR) but not in GERD?1)Severe heartburn2)Chest pain3)Chronic hoarseness4)Dyspepsia

Question!

The following measure is mosteffective in the treatment of GERD inelderly patients.1) Elevation of the head of the bed2) Decreased caffeine intake3) Eating frequent large meals4) Exercise immediately following meals

Question!

The initial diagnostic intervention foran elderly patient with suspectedGERD is:1) Trial drug therapy with a PPI2) Endoscopy 3) Upper GI series 4) Barium swallow

Question!

Choose one of the following medications that contributes to pillesophagitis in the elderly.

1) ACE inhibitors2) Glyburides3) Bisphosphonates4) Statins

Question!

Epidemiology GERD

• Most common esophageal disease in the elderly– 33% of all adults– 59% adults over 65

The Symptom/Complication Disconnect

• Elderly patients present with – Decreased complaints of

• Heartburn• Regurgitation• Chest pain

– Increased complaints of• Dysphagia• Respiratory symptoms• Vomiting• Anorexia

Age Related Symptom Severity

Age Related Symptom Prevalence

Age(years)

Figure 2. The prevalence of severe esophagitis by age decade cohort among patients with severe heartburn (P<0.001).

Patie

nts

(%)

45

40

35

30

25

20

15

10

5

0<21 21-30 31-40 41-50 51-60 61-70 >70

Figure 3. Severity of heartburn by age decade cohort among patients with severe esophagitis (P<0.0001).

Age(years)

<21 21-30 31-40 41-50 51-60 61-70 >70

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Patie

nts

(%)

Heartburn Severity by Age Group

Age Related Changes That May Lead to GERD

Decreased salivary secretions

Diminished esophageal Mucosal resistance

Declining esophageal Motility and clearance

Gastric acid Hypersecretion

Delayed gastric emptying

Loss of lower esophageal sphincter tone

GERD Complications in the Elderly

• Increased complications in elderly with greater incidence of– Erosive esophagitis– Barrett’s Esophagus– Peptic ulcer disease– Esophageal strictures– Adenocarcinoma of the esophagus

Contributing Co morbidities Disease States

• CVA• ALS• Parkinson’s• Myasthenia Gravis• Scleroderma• Hypertension

• RA• Obesity• Diabetes• Coronary Artery

Disease

Medications Causing High Risk of Esophagitis

• NSAIDS/ASA• Iron preparations• Potassium chloride tablets• Tetracycline• Quinidine• Bisphosphonates• Narcotics• Vitamin C

Medications That Lower LES Pressure

• Anticholinergics• Beta agonists• Calcium channel blockers• Nitrates• Tricyclic antidepressants• Theophylline

Case Study

• 78 y.o. female presents with a 24 hour history of vomiting, salivation, dysphagia and inability to eat. She admits that she has been having increasing difficulty swallowing breads, meats and rice over the last 6 months. She denies diarrhea, fever, chest pain, abdominal pain, urinary symptoms or shortness of breath.

Past Medical History

• Remote history of heartburn• Alcoholism• Small vessel disease of the brain• 50 pack year history of tobacco use• Surgical Hx-TAH, right inguinal hernia

repair

Social History

• Alcohol use 2-3 ounces weekly• Smokes 1 pack cigarettes daily• Widowed• Lives alone

Medications

• asa ec 81 mg daily• alendronate (Fosamax)* 20mg weekly• warfarin sodium (Coumadin)* 5 mg daily• digoxin (Lanoxin)* 0.25 mg daily• metoprolol (Toprol XL)* 50 mg daily• citalopram (Celexa)* 20 mg daily• ibuprofen otc as needed

Laboratory Findings

• Hemoglobin 11.4• MCV 110• No other abnormal laboratory findings

Manifestations of GERD in the Elderly Patient

Gastroesophageal

Esophageal Symptoms

• Heartburn• Regurgitation• Dysphagia• Dyspepsia

• Chest Pain• Nausea• Vomiting• Belching

Esophageal Symptoms Heartburn

• Retrosternal burning pain• May be epigastric or in neck, throat, or

back• Occurs after large meals, exercise, or in

reclining position• Less frequent in elderly –acidity changes

and decline in esophageal sensitivity

Esophageal Symptoms Dysphagia

• Occurs with long-standing heartburn• Progresses to solids with rare progression to

liquids• Weight loss is infrequent• Increased in elderly – related to peptic stricture,

severe peristaltic dysfunction, and Barrett’s esophagus

Esophageal Symptoms

May mimic other disorders• Cardiac• Infectious• Viral• Peptic• Inflammatory

Alarm Symptoms

• Hematemesis• Anemia• Weight Loss• Dysphagia with solids and liquids• Odynophagia

Manifestations of GERD in the Elderly Patient

Extra-Esophageal

Extraesophageal Symptoms

• Non-cardiac chest pain• Pulmonary• Ears, Nose, and Throat

Non-Cardiac Chest Pain

• May be identical to angina• New onset of concern• High incidence of coronary artery disease

in elderly patients

Pulmonary Symptoms

• Chronic Cough• Asthma• Wheezing• Recurrent

Bronchospasm

• Recurrent Pneumonia• Aspiration Pneumonia• Chronic Bronchitis• Sleep Apnea• Idiopathic Pulmonary

Fibrosis

GERD and Asthma

• Two common diseases• Relationship still under debate• GERD most common trigger in refractory

asthma• Prevalence of GERD in adult asthmatics is

between 34% and 80%• Asthma symptoms are correlated with

esophageal pH events on 24-h esophageal monitoring

ENT Symptoms

• Globus Sensation• Chronic Pharyngitis• Sinusitis• Otitis Media• Dental Erosions

• Chronic Laryngitis• Hoarseness• Vocal Cord

Abnormalities• Laryngeal Cancer

Laryngopharyngeal Reflux

Characterized by:– Sore/burning throat– Throat clearing– Hoarseness/dysphonia– Chronic cough– RARE HEARTBURN/REGURGITATION

LPR Treatment

• More aggressive and prolonged than GERD

• Larynx more susceptible to injury from refluxate than esophagus

• Dose patient upon awakening and in late afternoon to provide 24 hour acid suppression

• Symptoms take several months to resolve

Diagnostic Procedures

Endoscopy is the gold standard forevaluation of patients over 50

–Visual & cytological evidence of erosive esophagitis, Barrett’s esophagus, cancer, h.pylori–Allows grading of GERD severity–Measures disease progress

Diagnostic Testing for GERD: pH Monitoring

• 24 hour ambulatory monitoring quantifies extent of GERD

• May confirm diagnosis when endoscopy normal

• Correlates episodes with symptoms• Use in conjunction with endoscopy

Diagnostic Procedures

• Barium swallow-limited use in elderly• pH monitoring

– To confirm diagnosis– Correlates episodes with symptoms

• Esophageal manometry– Localizes LES before pH testing or reflux

surgery

Diagnostic Testing For LPR

• Traditional GERD testing is often falsely negative

• Laryngeal examination with indirect laryngoscopy

• 24 hour double probe pH monitoring• Endoscopic referral if persistent symptoms

Laryngoscopic Findings

• Laryngeal edema• Vocal cord edema• Soft tissue erythema and edema• Vocal cord ulceration• Vocal cord polyps

GERD Treatment: Lifestyle Modification

• Dietary– Reduce meal size– Avoid eating late in day or prior to exercise– Avoid foods high in fat– Avoid caffeine– Avoid alcohol, highly spiced foods, chocolate– Stop citrus and tomato-based foods until

symptoms reduced

Patients find these difficult to implement and to sustain. Diet modifications are found to be only minimally effective in

reducing symptoms

• High fat foods• Tomato based foods• Citrus products

• Peppermint• Chocolate• Alcohol• Caffeine

Dietary Modifications

GERD Treatment: Lifestyle Modification

• Lose weight• Stop Smoking• Avoid tight clothing• Avoid eating within 2-3 hours before going

to bed• Elevate head of bed• Sleep on left side

GERD Treatment: Lifestyle Modification

• Patient education– Explain mechanisms and causes– Review potential drug interactions– Avoid potentially harmful medications– Take medications that can cause esophageal

injury in upright position with a full glass of water

Treatment Goals for Management of GERD

• Symptom relief• Healing• Prevent/manage complications• Maintain remission

Medication Treatment

• Antacids• H2 Blockers• Proton Pump Inhibitors (PPI)

Antacids

• Ineffective for long term relief• Do not heal erosive esophagitis• Overuse associated with

diarrhea/constipation and electrolyte imbalance

• Interfere with some medications

H2 Blockers

• Less expensive• Generally safe for elderly patients

– Some drug interactions– May cause confusion

• Inferior acid reduction• Use limited to patients with rare or mild

symptoms• Multiple daily dosing• Development of tolerance (tachyphylaxis)

Proton Pump Inhibitors

• Drug of choice in elderly• Most effective in achieving acid reduction• Safe & well tolerated• Few drug-to-drug interactions • Multiple dosing methods to accommodate

elderly needs

Medication Treatment for the Elderly Patient

• Full dose PPI for long term– Induce healing– Prevent reoccurrence– Avoid complications

• Administration Route determined by patient tolerance– Oral tablet or capsule by mouth or by feeding tube– Orally dissolvable table– Liquid preparation– IV

Step Up Treatment

• Typically not effective with elderly patients due to significant symptoms & pathology

• Start with H2 blocker • Increase to low dose PPI if inadequate

relief of symptoms• Increase PPI to full dose if necessary• Reduce dose when symptoms controlled

Step Down Treatment

• Begin treatment with full dose PPI• Reduce dose after 8-12 weeks • Introduce H2 blocker after symptoms are

fully controlled• Typically not effective with elderly GERD

patients

Maintenance Therapy

Long term maintenance therapy with adequate doses of proton pump inhibitors is the key to effective care in the elderly

Dosage Formulations of Proton Pump Inhibitors

Product Tablet Capsule ODTPowder Sachet

Oral SuspIV

omeprazole (Prilosec)*

X X X

lansoprazole(Prevacid)*

X X X X

rabeprazole(Aciphex)*

X

pantoprazole(Protonix)*

X

esomeprazole(Nexium)*

X X X

When PPI Treatment Fails

• Add H2 blocker at bedtime• Increase PPI to twice daily dosing

– Before breakfast and dinner• Add sulcrafate (Carafate)* for esophageal

protective effect• Consider motility agent

Promotility Agents

• metroclopramide (Reglan)*– Significant side effects– Legal liability issues

• cisapride (Propulsid)*– Cardiac arrhythmias– Limited access program

Surgical Interventions

• Laparoscopic Fundoplication – Pros

• Safe• Effective

– Cons• Frequent return to medication due to loss of

effective symptom control over time• Not cost effective• Requires access to surgical expertise

Endoscopic Interventions

• Stretta Procedure– Delivery of radiofrequency energy to the

gastroesophageal junction to stimulate collagen formation and tightening of the junction.

• Endoscopic Suturing– Suture placement at the level of the

gastroesophageal junction to tighten the sphincter control and reduce acid reflux

Complications of GERD

• Erosive Esophagitis• Peptic Ulcer• Strictures• Gastrointestinal Bleed • Barrett’s esophagus• Esophageal Adenocarcinoma

Erosive Esophagitis

• Inflammation and wearing away of the esophagus.– Acid reflux– Pill dysphagia

• Defined in severity by Grades from A-D

Peptic Ulcer

• H. Pylori infection• NSAID use

Esophageal Stricture

• Pill dysphagia• Long standing acid reflux

Gastrointestinal Bleed

• Due to severe erosive esophagitis• Secondary to peptic ulcer disease

Barrett’s Esophagus (BE)

• Metaplastic disorder in which specialized columnar epithelium replaces the normal squamous epithelium of the esophagus

• Risk of esophageal adenocarcinoma is 40- 120 times higher than the general population

• Requires regular monitoring by endoscopy

Adenocarcinoma of the Esophagus

• Relatively rare cancer, but increasing incidence

• Significant increased incidence in patients with Barrett’s esophagus

• Poor prognosis

GERD in the Elderly Summary

• Elderly at high risk for GERD• Normal aging changes increase damage

to the esophagus & stomach due to GERD• Atypical presentation-heartburn not the

most significant symptom• Not the usual relationship between

symptom severity and disease severity

GERD in the Elderly Summary

• Endoscopy is the diagnostic tool of choice• PPI treatment is the initial intervention• Lifelong PPI treatment• Prevention of complications is the

treatment goal

Case Study Summary

• Patient was referred for urgent endoscopy due to her inability to swallow. She was found to have a narrowed esophageal ring/esophageal stricture. She underwent esophageal dilatation and was placed on PPI therapy indefinitely.

Although not specific to the elderly, the following link to the AANP website CE

content provides an excellent reference for treatment and patient teaching.

http://www.gerdstoptheburn.com/toolkit/

GERD Toolkit

For your convenience a complete list of references is provided at the back of your syllabus. The syllabus is provided in PDF format attached to this presentation.

*Brand names are used for identification purposes only and do not imply endorsement.

To obtain CE credit please go to www.aanp.org/testingcenter to complete online test, evaluation and to immediately receive certificate of completion.

Post-Test Questions

Heartburn is the most commoncomplaint of the elderly patient with GERD.

1) True2) False

Question!

Which of these symptoms is present in laryngopharyngeal reflux (LPR) but not in GERD?1)Severe heartburn2)Chest pain3)Chronic hoarseness4)Dyspepsia

Question!

The following measure is mosteffective in the treatment of GERD inelderly patients.1) Elevation of the head of the bed2) Decreased caffeine intake3) Eating frequent large meals4) Exercise immediately following meals

Question!

The initial diagnostic intervention foran elderly patient with suspectedGERD is:1) Trial drug therapy with a PPI2) Endoscopy 3) Upper GI series 4) Barium swallow

Question!

Choose one of the following medications that contributes to pillesophagitis in the elderly.

1) ACE inhibitors2) Glyburides3) Bisphosphonates4) Statins

Question!

Which of the following contribute to the lowering of the lower esophageal sphincter pressure?

1) Medication2) Obesity3) Smoking4) All of the above

Question!

7. Which of the following statements is TRUE about the patient with laryngopharyngeal reflux (LPR)?

1) LPR patients have no day time reflux symptoms 2) LPR patients have prolonged periods of acid exposure3) LPR patients have a high incidence of dysmotility problems4) LPR patients primary defect is upper esophageal sphincter dysfunction

Question!

8. Although difficult to implement and maintain, dietary modifications alone are extremely effective in reducing both GERD and LPR symptoms.

1) True2) False

Question!

9. Which of the following medications used for treatment of GERD is associated with development of tachyphylaxis (tolerance)?

1) Proton pump inhibitors (PPI)2) H2 blocker3) Antacids4) None of the above

Question!

10. Which of the following medication management techniques is not typically effective for treatment of GERD in the elderly?

a. All of the below are effective b. Step up treatmentc. Maintenance therapyd. Step down treatment

Question!

References• Chait M. Gastroesophageal reflux disease in the Elderly. Pharmacy Times. 2006, 3.

http://secure.pharmacytimes.com/lessons/200601-01.asp. Slide: 29.• Davis, RH; Miller, SK. GERD: stop the burn: a case-based approach to the diagnosis, treatment & long-term

management of patients with gerd. Developed from the 2006 AANP National Conference. Retrieved June 15, 2007 from AANP.org. Slide: 75.

• Friedel D. Gastrointestinal motility in the elderly. Clinical Geriatrics. 2006; 6.• htpp://www.clinicalgeriatrics.com/article/1065. Slide: 13.• Johnson, DA ; Fennerty, MB.. Hearburn Severity Underestimates Erosive Esophagitis Severity in Elderly Patients

With Gastroesophageal Reflux Disease. Gastroenterology. 2004;126:660-664. Slides 8, 9 and 10.• Koufman J. Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease. ENT Journal. Sept

2002(Supp). Slides: 33,34,39 and 41. • Lynch J. Can chronic hoarseness be a symptom of GERD? Ask the Experts. Medscape. 2003.

http://www.medscape.com/viewarticle/446026. Slides: 31 and 44.• Postma G. Laryngopharyngeal reflux testing. ENT Journal. Supp 2: 81(S2): 2002; 14. Slide 43.• Qadeer M. Proton Pump Inhibitor Therapy for Suspected GERD-Related Chronic Laryngitis: A Meta-Analysis of

Randomized Controlled Trials. Am J Gastroenterol. 2006.• Ramirez FC. Diagnosis and treatment of gastroesophageal reflux disease in the elderly. Cleve Clin J Med 2000;

67(10):755-66. Reprinted with permission. Copyright © 2000 Cleveland Clinic Foundation. All rights reserved. Slide 5.

• Ramirez F. Diagnosis and treatment of gastroesophageal reflux disease in the elderly. Cleveland Clinic Journal of Medicine. 67(10): 2000: 755-66.. Slides 21and 29.

• Richter J. Gastroesophageal reflux disease in the older patient: presentation, treatment, and complications. Am J Gastroenterol. 95(2)2000; 369-70. Slides: 22, 23, and 32.

• Sharma B. Effect of omeprazole and domperidone on adult asthmatics with gastroesophageal reflux. World J Gastroenter 13(11); 2007. http://www.wignet.com/1007-9327/13/1706.asp. Slide 30.