DIARRHEA AND MALABSORPTION IN THE ELDERLY

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Diarrhea and malabsorption usually are not thought to be major clinical gastrointestinal problems in the elderly. Data show clearly, however, that diarrhea occurs commonly in older people and that malabsorption is present more often than has been realized previously. Such disorders occur more covertly in the elderly than in the young and often are overlooked. It is particularly important for clinicians to recognize that in the elderly diarrhea may be significant and that weight loss or nonspecific gastrointestinal symptoms may be the presenting features of malabsorption. Although the elderly often complain of constipation, they are less likely to volunteer complaints of diarrhea, perhaps because diarrhea frequently results in intermittent incontinence in this age group. Fecal incontinence is embarrassing to the patient, and reports of such symptoms frequently are not volunteered (see the article on “Constipation and Fecal Incontinence in the Elderly”). Symptoms resulting from malabsorption tend to be muted in older patients, and the condition may not present with weight loss, but rather with failure to maintain body weight after an intercurrent illness.

Most gastrointestinal disorders resulting in diarrhea or malabsorption present in similar ways in elderly and young patients. Some diseases may present first commonly later in life, such as multiple jejunal diverticulosis. The manifestation and course of some diseases, and in some cases, may differ in the old and the young; however, treatment may need to be altered because of a greater frequency or severity of side effects of certain medications in the elderly. A classic example is treatment with glucocorticoids, which in the elderly can cause devastating disability if used chronically. In considering the elderly patient with either diarrhea or malabsorption, it is important to recognize the limits of physiologic changes that occur as a function of age to avoid the clinical trap of misinterpreting symptoms presumed to be a normal consequence of aging but actually caused by a disease.

Section snippets

DIARRHEA

Diarrhea is an abnormal frequency or liquidity of fecal evacuation. In most patients, diarrhea is defined as the passage of loose stools, that is, stools with a greater water content than normal.27 A frequency of greater than 3 bowel movements per day, without excess water, can be considered to be part of the definition of diarrhea, although patients may not equate an increased frequency of defecation alone with diarrhea.95 Some older patients use the term diarrhea when they have rectal urgency.

INTESTINAL MALABSORPTION

It is a common belief, although essentially incorrect, that intestinal absorption and digestive enzyme secretion decrease with age. Earlier reviews and textbooks often suggested that there is a reduction in the number of mucosal absorptive epithelial cells in advanced age. As described subsequently, however, the evidence for structural and functional changes in the small intestine is insubstantial. Although age-dependent changes in the intestinal absorption of individual nutrients may occur and

SUMMARY

Physicians who care for elderly patients should be alert to the possible presence of diarrhea and malabsorption. Older patients may not admit to having chronic diarrhea, particularly if they also are incontinent. If diarrhea is of short duration, an infectious cause is at least as common as in the young. Institutionalized elderly are particularly prone to gastrointestinal infections, but the manifestations may not be overt. When an intestinal infection and potential medication-induced

ACKNOWLEDGMENT

The author acknowledges the excellent secretarial assistance of Ms. Karol Winslow in the preparation of this article.

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    Address reprint requests to Peter R. Holt, MD Division of Gastroenterology St. Luke's/Roosevelt Hospital Center S & R 12, 1111 Amsterdam Avenue New York, NY 10025 e-mail: [email protected]

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    Division of Gastroenterology, St. Luke's/Roosevelt Hospital Center; and the College of Physicians and Surgeons, Columbia University, New York, New York

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    Copyright © 2001 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.