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with distal oesophageal spasm, demonstrating segmentation of the barium column by contractions, producing a corkscrew appearance.

      Non‐cardiac chest pain

      Chest pain is a prevalent symptom in the community and not infrequently presents diagnostic difficulty, especially in older patients who are at greater risk of ischaemic heart disease than the young. The oesophagus is often implicated when cardiac causes have been excluded, but musculoskeletal, pulmonary, pericardial, gastric, and biliary pathology should also be considered, and an association with panic disorder has been reported.⁴⁰

      GORD may be responsible for a proportion of non‐cardiac chest pain (NCCP), and about 50% of NCCP patients have excessive oesophageal acid exposure on pH studies. Many patients with excessive acid exposure do not have reflux esophagitis, limiting the value of endoscopic examination. Rather, a trial of a double‐dose proton pump inhibitor (PPI) for between two and eight weeks (depending on symptom frequency) is a useful and cost‐effective initial test in NCCP, with a sensitivity and specificity as high as 80% for a diagnosis of GORD. If symptoms are relieved, the medication dose can subsequently be titrated down to the minimum effective dose. If PPIs prove ineffective, oesophageal manometry and ambulatory pH measurement (while remaining on the PPI) are indicated; the former is particularly helpful for excluding achalasia. Endoscopy should be performed whenever there are ‘alarm symptoms’ such as dysphagia, anorexia, weight loss, hematemesis, or anaemia. The threshold for endoscopy in older patients should be lower than that in the young (age less than 40).

      The association between NCCP and oesophageal motility disorders, including distal oesophageal spasm and jackhammer oesophagus, is less strong than previously assumed, and even when these disorders are demonstrated, a causal relationship can be difficult to establish. Furthermore, medical therapy for oesophageal motility disorders with smooth muscle relaxants such as nitrates, calcium channel antagonists, or sildenafil has limited efficacy. Botulinum toxin injection, surgical myotomy, and POEM have been advocated but currently do not have strong evidence to support their use.⁴¹

      Visceral hypersensitivity is now considered to play a major role in non‐GORD related NCCP, and pain‐modifying agents, including tricyclic antidepressants and selective serotonin reuptake inhibitors, have been shown to be superior to placebo in the management of this disorder. Limited data also suggest that theophylline, an adenosine receptor antagonist, may be beneficial. Caution should be exercised in the elderly due to potential adverse effects of all these agents, particularly tricyclics. Psychological techniques, such as cognitive behavioural therapy, are reported to have good outcomes in NCCP, as is the case with other functional gastrointestinal disorders.

      It is generally assumed that NCCP, although often persistent over a number of years, has an excellent prognosis in terms of mortality, although this remains controversial⁴² and may depend on the specific population being considered.

      Gastro‐oesophageal reflux disease

GORD is the sixth most common disorder amongst the elderly in residential care, which is not surprising; even in the general population, around 20% experience weekly reflux symptoms.⁴³ GORD presents in the elderly with more severe mucosal injury (erosive esophagitis, stricture, or Barrett’s oesophagus) than in the young, yet symptoms are characteristically milder or may be qualitatively different. Thus dysphagia, vomiting, respiratory difficulty, weight loss, and anaemia are not uncommon presenting features, while ‘typical’ reflux symptoms like heartburn occur less often than in the young, reflecting diminished oesophageal sensitivity. In the general population, symptoms of heartburn or regurgitation have a high sensitivity (about 70%) for a diagnosis of GORD but low specificity when using 24‐hour pH monitoring as the gold standard; corresponding data for an ageing population are not available. The alarm symptoms mentioned for NCCP are indications for prompt endoscopic investigation.

      Atypical or extra‐oesophageal manifestations of GORD include chronic cough and asthma and may be mediated either directly by acid‐pepsin reflux or by oesophageal acid exposure triggering vagal reflexes. The prevalence of excessive acid reflux in patients complaining of these symptoms is controversial; and as for NCCP, the most useful diagnostic test may be a therapeutic trial of intense acid suppression with double‐dose PPI for two to eight weeks, depending on symptom frequency.

      There appear to be no significant differences in the capacity to heal esophagitis in older patients compared to the young, and PPIs maintain their superiority over histamine receptor antagonists in this age group. No dosage adjustment is needed in the elderly to compensate for age‐related changes in renal or hepatic function, but downward titration of the dose according to symptoms may be less appropriate than in the young, especially when the initial symptoms were mild or in the setting of complicated GORD. While long‐term use of PPIs has generally been regarded as safe, a number of observational studies have identified associations between PPI use and various adverse conditions, especially in older individuals.⁴⁴ Causality is often difficult to establish since there is substantial potential for confounding by comorbidities, and pathophysiological mechanisms are frequently unclear, but it is unlikely that definitive randomised controlled trials will be undertaken, and the evidence should not be dismissed lightly. A causal relationship appears likely for the rare cases of acute interstitial nephritis, as well as increased prevalence of benign gastric fundic gland polyps and a greater propensity for enteric infections, and appears possible for Clostridium difficile infection, B12 deficiency, and hypomagnesemia/hypocalcemia. Causal relationships for osteoporosis and hip fracture, community‐acquired pneumonia, dementia, and exacerbation of chronic kidney disease are currently not supported by strong evidence, while the interaction with clopidogrel to reduce the efficacy of the latter appears of minimal significance other than for omeprazole.⁴⁵ While there are frequently good indications for prescribing PPI therapy, and while some patients benefit from long‐term use, this class is often over‐prescribed, and the indication for ongoing therapy should be reviewed periodically. Histamine type 2 receptor antagonists represent an alternative class for acid suppression but are less potent than PPIs and carry their own risks of adverse events, including changes in mental status, especially in patients with renal or hepatic dysfunction. Prokinetic drugs do not have an established role in the treatment of GORD.

      Laparoscopic fundoplication is a treatment option for troublesome GORD in the elderly; the outcomes and complication rates in patients over 70 are comparable to those <60.⁴³ However, it should be noted that patients with ineffective oesophageal motility are at increased risk of postoperative dysphagia. Moreover, long‐term medical therapy is likely to be more cost‐effective than anti‐reflux surgery in older patients based on the number of years of medical therapy likely to be needed. Endoscopic anti‐reflux procedures to date have not fulfilled their initial promise, and their use should be restricted to clinical trials.

      Stomach and duodenum

While only a modest slowing in gastric emptying is observed with healthy ageing, as recently demonstrated in a longitudinal study,⁴⁶ both the perception of gastric distension and humoral responses to duodenal nutrient exposure differ markedly from the young and could contribute to the anorexia of ageing, which is discussed in detail in Chapter 13. Moreover, postprandial hypotension, a common cause of falls and syncope in the elderly, can be regarded as a gastrointestinal disorder related to both the rate of gastric emptying and the small intestinal response to ingested nutrient. Slow gastric emptying, as well as alterations in gastric pH (for example, higher pH postprandially than in the young), could also influence the absorption of orally administered medications,⁴⁷ and a slight reduction in the rate of paracetamol absorption has been reported in the healthy elderly when compared to the young. However, absorption of benzodiazepines, tetracycline, or L‐dopa is not significantly altered with age per se. Several systemic disorders that frequently occur in the elderly are associated with markedly delayed gastric emptying or gastroparesis (Table 17.2) – acute gastroparesis may also result from the administration

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