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 are of
C Gastrointestinal
Problems in
the Older Adult

Sue E. Meiner, EdD, APRN, BC, GNP

Editor

SPRINGER PUBLISHING COMPANY

Copyright © 2004 by Springer Publishing Company, Inc.

All rights reserved

No part of this publication may be reproduced, stored in a retrieval system, or transmit-

ted in any form or by any means, electronic, mechanical, photocopying, recording, or
otherwise, without the prior permission of Springer Publishing Company, Inc.

Springer Publishing Company, Inc.

536 Broadway
New York, NY 10012-3955

Acquisitions Editor: Ruth Chasek

Production Editor: Janice Stangel
Cover design by Joanne Honigman

04 05 06 07 08 / 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Care of gastrointestinal problems in the older adult / Sue Meiner, editor.

p. ; cm. — (Springer series on geriatric nursing)
Includes bibliographical references and index.
ISBN 0-8261-1865-8
1. Geriatric gastroenterology. 2. Geriatric nursing. [DNLM: 1. Gastrointestinal
Diseases—nursing—Aged. 2. Geriatric Nursing—methods. WY 156.5 C271 2004]
I. Meiner, Sue. II. Series.
RC802.4.A34C37 2004
618.97'633—dc22 2004004159

Printed in the United States of America by Integrated Book Technology

Contents

Contributors ix
Preface xi

1. Introduction and Demographic Data 1

Sue E. Meiner
2. General Disorders of the Upper Gastrointestinal System 7
Beverly Anderson Reno
3. Gastroesophageal Reflux Disease 23
Catherine Hill
4. Motor Dysfunctions of the Stomach 47
Susan D. Kowalski
5. Helicobacter Pylori and Ulcers 59
Phyllis J. Atkinson
6. Bacterial, Viral, and Parasitic Infections of the Colon 67
Sue E. Meiner
7. Vitamin B12 and Folate Deficiencies 81
Lori Candela
8. Cancers of the Gastrointestinal Tract 95
Ann Schmidt Luggen
9. Nutrition and Gastrointestinal Diseases 129
Barbara Resnick
10. Irritable Bowel Syndrome 157
Sue E. Meiner
11. Diverticular Disease 177
D. Sue Clarren
12. Constipation and Noninfectious Diarrhea 201
Lynn Ferebee and Sue E. Meiner
13. Hemorrhoids and Problems of the Anus and Rectum 215
Catherine Hill

Index 245

vii
I dedicate this book to my family, friends, and caring professionals
in the fields of nursing, nursing education, and advanced practice
nursing. I extend a very special thanks to Ruth Chasek, Nursing
Editor with Springer Publishing Company, for her hours of support
during the high, and sometimes low, road of writing and finishing
a manuscript. And finally, in God I trust.
Contributors

Phyllis Atkinson, MSN, RN, CS, Susan Kowalski, PhD, MSN, RN

GN Associate Professor
St. Elizabeth Medical Center School of Nursing
Family Practice Center University of Nevada, Las Vegas
Edgewood, Kentucky
Ann Schmidt Luggen, PhD, MSN,
Lori Candela, EdD, MSN, RN APRN, GNP
Interim Associate Director Professor of Nursing
School of Nursing Northern Kentucky University
University of Nevada, Las Vegas Highland Heights, Kentucky

Donna Sue Clarren, ND, MSN, Beverly Reno, MSN, RNC

RN Associate Professor of Nursing
Assistant Professor Northern Kentucky University
School of Nursing Highland Heights, Kentucky
University of Nevada, Las Vegas
Barbara Resnick, PhD, CRNP,
Lynn Ferebee, MSN, RN, FNP FAAN, FAANP
Family Nurse Practitioner Associate Professor
Student Health Center University of Maryland School of
University of Nevada, Las Vegas Nursing
Las Vegas, Nevada Baltimore, Maryland

Catherine Hill, MSN, RN, CS,

ONC, CEN
Medicine Associates of North Texas
School of Nursing
University of Texas at Arlington

ix
 Sue E. Meiner, EdD, APRN, BC, GNP, is an
Assistant Professor in the School of Nursing
at the University of Nevada, Las Vegas, and
a Gerontological Nurse Practitioner with
HealthEssentials Home Care in Las Vegas.
She received her BSN and MSN degrees at
St. Louis University (Missouri), her EdD at
Southern Illinois University at Edwardsville,
and her GNP from Jewish Hospital College
of Nursing and Allied Health at Washington
University Medical Center in St. Louis, Mis-
souri. She holds two national certifications from the American Nurses
Credentialing Center. Dr. Meiner is certified as a Gerontological Clinical
Nurse Specialist and as a Gerontological Nurse Practitioner. Prior to her
current position, she was Project Director for an NIH and NIA grant at
Washington University School of Medicine (St. Louis). Dr. Meiner has
authored the book, Nursing Documentation: Legal Focus Across Practice
Settings. She is co-author of several other books, including Care of Arthritis
in the Older Adult, NGNA Core Curricula for both gerontological nurses
and gerontological advanced practice nurses, and Handbook for the Care
of Older Adults with Cancer. She is also the author of numerous book
chapters and journal articles. Dr. Meiner held an elected political office in
St. Louis County for five years in the 1980s and remains active in commu-
nity service. For over 15 years, she has served nationally as an expert
witness on nursing standards of care.
Preface

As a gerontological nurse practitioner, I see many older adults with gastro-

intestinal disorders that have been troubling them for decades. Even my
personal experience with family and friends has brought home the preva-
lence of gastrointestinal problems in older adulthood.
This book was developed to provide greater information on a variety
of gastrointestinal disorders and problems than can be found in general
nursing textbooks. While the information in this book ranges from general
to scientific, it is intended for use by a wide variety of nursing professionals
from hospital nurses, to home care nurses, to nurse practitioners. Each
clinician should choose the aspects of the text that are relevant to his or
her practice. However, the overall content will add more specific knowledge
to caring for the most common gastrointestinal problems of older adults.
Most of the chapters follow a pattern that includes discussion of a
specific gastrointestinal problem followed by its cause, noted normal and
abnormal physiology, nursing care with attention to nursing diagnoses,
interventions, medications, and alternative therapies, where appropriate.
Topics such as health promotion and quality of life issues were added as
an essential part of any plan of care for older adults. Home management
and self-care issues are addressed.
I hope that you will learn much from this book and will use the informa-
tion to make the life of the older adults you care for more comfortable
during their remaining life.

Sue E. Meiner, EdD, APRN, BC, GNP

xi
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 1
Introduction and
Demographic Data
Sue E. Meiner

Successful aging can have many different meanings. Freedom from illness
and disease is a wishful thought as the life span progresses over many
decades after the fifth decade of life. The aging process includes maturity
in thinking, planning, acting, and evaluating the outcomes of decisions.
It also means the aging of the human body. Some of the changes that occur
with aging include declining function of some organs and body systems,
which can produce illnesses and disease processes. While aging does not
have to mean experiencing ill health, the changes in physiology associated
with aging are often associated with illness and disease. Given patterns of
decline may be in structure or function, whether from aging or disease or
both, the decline may not be noticed until it reaches a level that is beyond
the individual’s ability to adapt. Successful aging includes successful adapta-
tion to changes. When stress, in many forms, is placed on a body system,
the older adult may not have the prolonged ability to adapt, thus leading
to an inability of that body system to continue its normal function. When
this occurs, illness or a disease process may begin. One system of the body
that is vulnerable to illness and disease throughout the life span is the
gastrointestinal (GI) system. However, the incidence of gastrointestinal
(GI) disease increases with age, making the older adult the most sensitive
to the broadest range of disorders.

1
2 Care of the Older Adult With Gastrointestinal Problems

Many GI tract disorders begin with a loss of appetite and nausea, with
or without vomiting. Nausea is an ill-defined, unpleasant sensation that
is often accompanied by pallor, sweating, and tachycardia. It can be fol-
lowed by vomiting. This expulsive discharge of the contents of the stomach
might or might not relieve the feeling of nausea. Continued nausea usually
results in loss of appetite and potential weight loss. These examples are
presented to demonstrate the human suffering that often accompanies GI
disorders. More complicated GI conditions of older adults account for
great personal expenditure for treatment, and a drain on the nation’s
economy (National Digestive Diseases Information Clearinghouse, 2002).
Every year approximately 62 million Americans are diagnosed with
GI tract diseases (National Digestive Diseases Information Clearinghouse,
2002). Other than gastroenteritis and appendicitis, which are predomi-
nantly pediatric illnesses, and hemorrhoids, inflammatory bowel disease,
and chronic liver disease, which are found predominantly among young
and middle-aged people, the incidence and prevalence of GI disorders from
the oral cavity to the anus are seen more frequently with advancing age.
Digestive diseases may be acute and self-limiting, chronic and debilitating,
or sudden and devastating.
The cause and progression of many GI tract diseases are unknown, but
a family history of similar symptoms or even a diagnosis of the same disease
in another family member is a frequent finding. Additional factors that are
associated with patterns of gastrointestinal tract symptoms may include
prolonged stress, fatigue, food choices, smoking, and alcohol abuse. Alco-
hol abuse is the highest risk factor for GI diseases, particularly for esopha-
geal, colorectal, and liver cancers (National Digestive Diseases Information
Clearinghouse, 2002).
Women are more likely than men to report a GI problem to their primary
care providers. The reason for this is assumed to be the frequency of
women’s visits to health care professionals compared with the number of
visits made by men (National Digestive Diseases Information Clearing-
house, 2002).
Some general disorders of the upper GI tract pose difficulties for older
adults. These include odynophagia, dyspepsia, dysphagia, hiatal hernia,
regurgitation, pyrosis, and/or esophagitis. Most hiatal hernias are caused
by a physical abnormality that may be present at birth. These disorders
will be discussed in Chapter 2. Another major problem for older adults is
gastroesophageal reflux disease, more commonly referred to as GERD.
Nearly one-third of the American population is affected with symptoms
of GERD. This disease will be discussed in Chapter 3.
Introduction and Demographic Data 3

Problems with the stomach can span motor dysfunctions, ulcers, bacte-
rial or viral infections, and vitamin deficiencies. Motor dysfunctions relate
to rapid emptying disorders to delayed emptying conditions. These will
be presented in Chapter 4. Peptic ulcer disease is estimated to affect 4.5
million people in the United States. This disease is responsible for substan-
tial human suffering and a large economic burden. The various illnesses
caused by ulcers, especially those resulting from infection with Helicobacter
pylori will be discussed in Chapter 5. Food-borne illness results from
eating food contaminated with bacteria, viruses, parasites, and other patho-
gens. These illnesses can range from an upset stomach to more severe
symptoms that can lead to dehydration and even death in more vulnerable
people. Other bacterial diseases, and infections caused by viruses and
parasites will be presented in Chapter 6. The role of deficiencies from
vitamin B12 and folic acid (folate) are important to add to any discussion
of GI illnesses. Chapter 7 will present information on vitamin B12 and
folate deficiencies.
Predominant cancers of the GI tract are oropharyngeal, esophageal,
stomach, gallbladder, pancreatic, liver, small intestine, colon, and rectal.
Chapter 8 will provide information on these cancers, statistics on their
incidence and prevalence, and care issues.
Nutrition is essential to life and the GI tract is the organ system that
accepts, processes, and provides benefit to the body from the foods that
are eaten. While basic nutrition needs to be understood, specialty diets
and food preparation issues are an integral part of treating GI disorders,
illnesses, and diseases. Chapter 9 will provide information on general
nutrition and the special nutritional needs of older adults.
Diseases, disorders, and illnesses of the lower GI tract will cover specific
concerns related to irritable bowel syndrome (IBS), diverticular disease,
constipation, noninfectious diarrhea, hemorrhoids, and problems of the
rectum and anus. Irritable bowel is a common functional disorder of the
intestines with an unknown cause. The term “functional” refers to a disor-
der with symptoms of disease but without findings on diagnostic testing.
This will be explained in Chapter 10.
Diverticula are pouchings, approximately the size of large peas, formed
in the intestinal walls. The more common location is in the large intestine
or colon. Diverticulosis is very common, especially in older adults. It is
estimated that nearly half of all persons over the age of 60 have diverticulo-
sis. Diverticulitis is characterized by inflammation and subsequent infection
of one or more diverticuli. However, when diverticulitis becomes compli-
cated, abscesses, bowel obstruction, or fistulae can occur.
4 Care of the Older Adult With Gastrointestinal Problems

Constipation and noninfectious diarrhea are problems that are common

among older adults. Constipation is the passage of small amounts of hard,
dry stools, usually fewer than three times a week. The feeling of being
bloated, accompanied by sluggish behavior and general discomfort are
usual when constipation is present. Noninfectious diarrhea, which is the
passing of loose, watery stools occurring more than three times in one day
is less common than constipation in the older adult, but can lead to
dehydration or electrolyte disturbances, and needs immediate treatment.
Constipation and noninfectious diarrhea will be presented in Chapter 12.
Hemorrhoids are redundant mucosa, venous and arterial plexuses,
smooth muscle, and connective tissue in the submucosa of the anal canal.
Hemorrhoids are not varicose veins of the rectum. After age 50, hemor-
rhoids are common in approximately 75% of older adults. Hemorrhoids,
rectal prolapse, proctitis, and anal disorders are presented in Chapter 13.
The symptoms of many GI diseases are subtle, yet complex, and can be
difficult to diagnose early in an illness. Many disorders have similar symp-
toms and differentiating the specific symptoms of a single disease often
takes time and several visits to the health care professional. Diagnostic
tests can include blood tests, an upper, lower, or combined GI series of
radiographs, an abdominal ultrasound, and an endoscopic examination of
the esophagus, stomach, small intestine, colon, or rectum. If answers are
still pending, a CT scan or an MRI can reveal physiologic information that
can assist in making a diagnosis.
Treatment options include dietary changes, physical activity, watchful
waiting, and prescription or over-the-counter medications as recommended
by a primary care provider.
According to the National Institutes of Health, digestive diseases cost
nearly $107 billion in direct health care expenditures. These illnesses result
in approximately 200 million sick days, 50 million visits to physicians,
16.9 million days lost from school, and 10 million hospitalizations. Nearly
200,000 deaths per year are attributable to GI diseases (National Digestive
Diseases Information Clearinghouse, 2002).
When the yearly costs of each of the major GI diseases are calculated,
the five most expensive are diarrheal infections ($4.7 billion); gallbladder
disease and colorectal cancer ($4.5 billion); liver disease ($3.2 billion);
and peptic ulcer disease ($2.5 billion). Of the acute, noncancerous GI
medical conditions reported (440 million) in the United States annually,
over 22 million are for acute GI conditions, with 11 million from gastroen-
teritis. Another six million cases are related to indigestion, nausea, and
vomiting (National Digestive Disease Information Clearinghouse, 2002).
Introduction and Demographic Data 5

Deaths due to cancers of the GI tract total 117,000 deaths annually. Of

the noncancerous GI disease deaths each year, the single largest killer is
chronic liver disease which accounts for 36% (National Digestive Diseases
Information Clearinghouse, 2002).
Diseases of the GI tract have a massive influence on health and the
health care system in the United States. New technologies and new drugs
have revolutionized the comprehension and treatment of peptic ulcer dis-
ease and GERD. The success of future research will, optimistically, continue
to reduce the economic and health care costs related to diagnosing and
treating digestive diseases.

REFERENCES

National Digestive Disease Information Clearinghouse (2002). Overview of digestive

diseases, retrieved from www.niddk.nih.gov/health/digest/pubs/overview.htm