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Gastroparesis in geriatrics population: A United States population study

Published:December 11, 2022DOI:https://doi.org/10.1016/j.amjms.2022.12.003

      Abstract

      Background

      Older patients with upper gastrointestinal diseases may lack disease-specific symptoms that are required to make the correct diagnosis. This study aimed to compare the gastroparesis demographics, clinical presentation, and surgical management between the older adult and young populations.

      Methods

      The National Inpatient Sample database was used between the years 2012 and 2014 with the primary diagnosis of gastroparesis. Patients were further divided based on their age into two groups: 70 years or older and younger than 70 years.

      Results

      The older adults were more likely to have early satiety and bloating compared to younger population with an odds ratio (OR) = 3.79; 95% Confidence Interval (95%CI) 2.80- 5.11, p < 0.0001 and OR = 2.80, 95%CI 2.07–3.78, p<0.0001 respectively. Older adults had low odds of having nausea with vomiting (OR = 0.86, 95%CI 0.76–0.95, p = 0.003), or abdominal pain (OR = 0.56, 95%CI 0.50–0.63, p<0.0001).

      Conclusions

      Older adults had more early satiety and bloating, whereas younger patients had more nausea with vomiting and abdominal pain.

      Key Indexing Terms

      Introduction

      The average life expectancy has increased from 47 years in 1900 to 79 years in 2014,

      Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. The Merck Company Foundation, Whitehouse Station, NJ 2007. Available at: http://www.cdc.gov/aging/pdf/saha_2007.

      which has led to dramatic increases in the geriatric population over the last century. By 2030, it is expected that the percentage of the population over 65 years of age will exceed 20 percent, or over 70 million people.

      Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. The Merck Company Foundation, Whitehouse Station, NJ 2007. Available at: http://www.cdc.gov/aging/pdf/saha_2007.

      Those 65 years and older are hospitalized three times more than 45 to 65 year old individuals.

      US Centers for Disease Control and Prevention. Number, Percent distribution, rate, Days of Care With Average Length of stay, and Standard Error of Discharges from Short-Stay hospitals, By Sex and Age: United States, 2010.

      In 2015, gastrointestinal (GI) diseases contributed significantly to health care use in the United States, with approximately $135.9 billion dollars more spent annually compared to other common diseases.
      • Peery A.F.
      • Crockett S.D.
      • Murphy C.C.
      • et al.
      Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.
      Gastroparesis is a chronic gastric motility disorder causing considerable distress,
      • Oberbaum M.
      • Schmell M.
      • Schreiber R.
      • et al.
      Do two walk together unless they have agreed to do so?”–Combining conventional and complementary medicine in the treatment of gastroparesis.
      which has cardinal symptoms of nausea, vomiting, early satiety, belching, and/or upper abdominal pain.
      • Camilleri M.
      • Parkman H.P.
      • Shafi M.A.
      • et al.
      Clinical guideline: management of gastroparesis.
      Once a gastroparesis diagnosis is suspected, a mechanical obstruction should be excluded by means of an upper endoscopy. The presence of delayed gastric emptying usually establishes the diagnosis of gastroparesis.
      A prospective study with 146 subjects showed that gastroparesis could present with nausea (93%), vomiting (68–84%), abdominal pain (46–90%), early satiety (60–86%), postprandial fullness and bloating.
      • Soykan I.
      • Sivri B.
      • Sarosiek I.
      • et al.
      Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis.
      There were 81% of females in the study with a mean age of 45 years.
      • Soykan I.
      • Sivri B.
      • Sarosiek I.
      • et al.
      Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis.
      Gastroparesis can also present with weight loss.
      • Hoogerwerf W.A.
      • Pasricha P.J.
      • Kalloo A.N.
      • et al.
      Pain: the overlooked symptom in gastroparesis.
      Several epidemiological and clinical studies suggest that the prevalence of upper gastrointestinal diseases is high in the elderly population.
      • Crane S.J.
      • Talley N.J.
      Chronic gastrointestinal symptoms in the elderly.
      It has been shown that older adults with upper gastrointestinal disorders may not report specific symptoms or could even be asymptomatic, leading to a late diagnosis or severe complications.
      • Maekawa T.
      • Kinoshita Y.
      • Okada A.
      • et al.
      Relationship between severity and symptoms of reflux oesophagitis in elderly patients in Japan.
      ,
      • Seinelä L.
      • Ahvenainen J.
      Peptic ulcer in the very old patients.
      Several clinical and functional disorders may influence the perception and referral of symptoms to the doctor, especially in the older adults.
      • Jones K.L.
      • Doran S.
      • Hveem K.
      • et al.
      Relation between postprandial satiation and antral area in normal subjects.
      Hence, it is troublesome to diagnose gastroparesis in older adults based solely on the typical symptoms. To our knowledge, there has been no study performed solely in the older adults to evaluate gastroparesis symptoms. This study aimed to compare the gastroparesis demographics, clinical presentation, and surgical management between older and younger adults.

      Methods

      This study did not require ethics committee approval or institutional review board approval because the Nationwide Inpatient Sample and Healthcare Cost and Utilization Project (NIS- HCUP) database used for this study does not contain any patient identifiers. The NIS-HCUP database was used between 2012 and 2014. The HCUP contains the most extensive collection of the United States (US) hospital data. The NIS is the part of HCUP and has data regarding patient's demographics, healthcare access, utilization, charges, and outcomes. This database has more than seven million hospital stays each year. When it is weighted to create national estimates, it has 35 million hospital visits nationwide.
      It contains information about patient's demographics (age, sex, race, median household income), principal diagnosis, and up to 29 secondary diagnoses using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding system, severity, and comorbidity measures, expected payment source, hospital characteristics, hospital length of stay and total charges. The primary is the chief reason for the hospitalization of the patient. For this study, older adults are referred to patients with age 70 years or more, meanwhile younger adults are those aged 69 years or less.

      Study population

      Hospital encounters with the primary diagnosis of gastroparesis (ICD-9 code 536.3) were included in this study. Patients were further classified based on their age in two groups: 70 years or older (study group) vs. 69 years or younger (control group). The comorbid conditions were identified in the gastroparesis population using ICD 9 codes: nausea (787.02), vomiting (787.03), nausea with vomiting (787.01), persistent vomiting (536.2), early satiety (780.94), bloating/flatulence (787.3), and upper abdominal pain (789.00, 789.01,789.02, 789.05, 789.06, 789.07 and 789.09).

      Study outcomes and variables

      The study aimed to determine if gastroparesis symptoms in older adults differ from those of younger patients. Symptoms, surgical procedures, and comorbidities were compared between the two groups. The secondary outcome was to assess independent determinants and surgical procedures for gastroparesis in geriatric patients. Multiple confounders were identified and accounted for in the analysis, such as sex, race, median household income and comorbidities.

      Study analysis

      Statistical analysis was conducted through the Statistical Package for the Social Sciences 27 (SPSS). The data were weighted using the discharge-level weight variable (DISCWT) for the analysis. Chi square test was used for categorical factors; p-values less than 0.05 indicate a statistically significant association. Univariate analysis was performed to compare patients' demographics, morbidity, and surgical procedures. Weighted multivariable regression was conducted to identify independent variables associated with gastroparesis in the geriatric's population.

      Results

      A total of 50,170 hospitalizations with a primary diagnosis of gastroparesis were included in this study. Of these, 6265 (12.5%) patients were 70 years or greater, whereas 43,905 (87.5%) were younger than 70 years. Sex, race, median household income and primary payer source were examined in both the groups (Table 1). In the older adults, there were more males in the study group compared to the control group with odds ratio (OR) = 1.22; 95% Confidence Interval (95%CI) 1.16–1.30, p< 0.0001. Older adults had more Caucasians than the control group (76.9% vs. 64.1% respectively) (Table 1). On weighted multivariable analysis, race white and low median household income 0–25th were the great socioeconomic risk factor for gastroparesis in older patients (Table 2).
      TABLE 1Difference between demographic factors of gastroparesis between older and younger adults.
      Geriatrics patientsYounger patients
      Sex
       Male1895 (30.2%)11,465 (26.1%)
       Female4370 (69.8%)32,440 (73.9%)
      Race/ethnicity
       White4635 (76.9%)26,945 (64.1%)
       Black700 (11.6%)9580 (22.8%)
       Hispanic465 (7.7%)3980 (9.5%)
       Asian or Pacific Islander90 (1.5%)320 (0.8%)
       Native American20 (0.3%)230 (0.5%)
       Other115 (1.9%)1000 (2.4%)
      Missing 240Missing 1850
      Median zip code income quartile
       0–25%1880 (30.6%)13,940 (32.3%)
       26–50%1565 (25.5%)11,440 (26.5%)
       51–75%1535 (25%)9860 (22.9%)
       76–100%1160 (18.9%)7865 (18.2%)
      Missing 125Missing 800
      Primary payer
       Medicare5745 (91.8%)13,825 (31.5%)
       Medicaid95 (1.5%)10,250 (23.4%)
       Private insurance380 (6.1%)15,325 (35%)
       Self-pay15 (0.25)2795 (6.4%)
       No charge325 (0.7%)
       Other25 (0.45)1325 (3%)
      Missing 5Missing 60
      TABLE 2Multivariable logistic regression analysis of factors associated with older adults admitted for gastroparesis.
      FactorOdds ratio95%
      Confidence Interval (CI), endoscopic pyloric dilation (EPD), Gastric electrical stimulation (GES), Percutaneous endoscopic gastrostomy (PEG).
      CI
      P-value
      Sex
       Male1.221.14–1.290.0001
      Race
       White2.382.20–2.560.0001
       BlackR
       Hispanic1.321.17–1.490.0001
       Asian or Pacific Islander3.472.70–4.470.0001
       Native American1.190.74–1.900.48
       Other1.411.14–1.730.001
      Median zip code income quartile
       0–25%1.111.03–1.200.01
       26–50%1.0050.93–1.090.91
       51–75%1.091.01–1.190.02
       76–100%R
       Nausea0.990.74–1.320.96
       Vomiting0.380.27–0.530.0001
       Nausea with vomiting0.860.76–0.950.003
       Persistent vomiting0.490.41–0.600.0001
       Early Satiety3.792.80–5.110.0001
       Bloating/flatulence2.802.07–3.780.0001
       Epigastric abdominal pain0.560.50–0.630.0001
       Underweight1.220.68–2.190.50
       Loss of weight1.611.44–1.800.0001
       Obesity1.971.72–2.250.0001
       Smoking0.230.21–0.260.0001
       Alcohol0.500.29–0.850.01
       Cannabis0.000.000.98
       Opiate0.180.13–0.250.0001
       Gastrotomy7.842.23–27.570.001
      Confidence Interval (CI), endoscopic pyloric dilation (EPD), Gastric electrical stimulation (GES), Percutaneous endoscopic gastrostomy (PEG).
      PEG
      1.571.27–1.930.0001
       Pyloromyotomy0.0000.000.99
       Pyloroplasty0.630.47–0.840.001
      Confidence Interval (CI), endoscopic pyloric dilation (EPD), Gastric electrical stimulation (GES), Percutaneous endoscopic gastrostomy (PEG).
      EPD
      0.750.47–1.210.24
      Confidence Interval (CI), endoscopic pyloric dilation (EPD), Gastric electrical stimulation (GES), Percutaneous endoscopic gastrostomy (PEG).
      GES
      0.170.12–0.260.0001
      low asterisk Confidence Interval (CI), endoscopic pyloric dilation (EPD), Gastric electrical stimulation (GES), Percutaneous endoscopic gastrostomy (PEG).
      Older adults had low odds of having vomiting, nausea with vomiting, persistent vomiting, or abdominal pain; however, they were more likely to have early satiety and bloating/flatulence. Also, they had lower odds of smoking, alcohol or opiate use compared to the younger cohort. Moreover, older adults were more likely to have weight loss compared to the younger population (Table 3). A 61% increased likelihood of weight loss among older adults was found (Table 2).
      TABLE 3Comparison of morbidity between gastroparesis patients based on age.
      FactorGeriatrics patientsYounger patientsOdds ratioP-value
      Nausea60 (1%)350 (0.8%)1.20 (0.91–1.58)0.19
      Vomiting35 (0.6%)505 (1.2%)0.48 (0.34–0.68)0.0001
      Persistent vomiting145 (2.3%)2235 (5.1%)0.44 (0.37–0.52)0.0001
      Nausea with vomiting510 (8.1%)4250 (9.7%)0.83 (0.75–0.91)0.0001
      Early Satiety75 (1.2%)140 (0.3%)3.79 (2.86–5.02)0.0001
      Bloating/Flatulence65 (1%)160 (0.4%)2.87 (2.15–3.83)0.0001
      abdominal pain340 (5.4%)4270 (9.7%)0.53 (0.48–0.60)0.0001
      Diabetes Mellitus1620 (25.9%)8080 (18.4%)1.55 (1.45–1.64)0.0001
      Smoking285 (4.5%)7920 (18%)0.22 (0.20–0.24)0.0001
      Alcohol15 (0.2%)260 (0.6%)0.40 (0.24–0.68)0.0001
      Opioid type dependence35 (0.6%)1595 (3.6%)0.15 (0.11–0.21)0.0001
      Obesity250 (4%)3195 (7.3%)0.53 (0.46–0.60)0.0001
      Loss of weight485 (7.7%)2210 (5%)1.58 (1.43–1.75)0.0001
      Underweight15 (0.2%)75 (0.2%)1.40 (0.81–2.44)0.23
      Constipation1170 (18.7%)6420 (14.6%)1.34 (1.25–1.44)0.0001
      Parkinson disease270 (4.3%)125 (0.3%)15.77 (12.74–19.53)0.00001
      Older adults were more likely to receive gastrotomy and percutaneous endoscopic gastrostomy (PEG) with OR=7.01, 95%CI 2.03–24.23, p < 0.0001 and OR=1.89, 95%CI 1.54–2.31, p<0.0001 respectively. On the other hand, they were less likely to receive gastric electrical stimulator (GES) with OR=0.22, 95%CI 0.15–0.32, p< 0.0001 (Table 4). Similarly, on weighted multivariate analysis, older adults were more likely to receive gastrotomy and PEG, whereas the younger group was more likely to receive pyloroplasty, endoscopic pyloric dilation and GES.
      TABLE 4Comparison of surgical procedures between the gastroparesis patients based on age.
      Geriatrics patientsYounger patientsP-value
      Gastrotomy5 (0.1%)5 (0.0%)0.0001
      Pyloroplasty55 (0.9%)465 (1.1%)0.185
      Pyloromyotomy050 (0.15%)0.008
      PEG*120 (1.9%)450 (1%)0.0001
      Endoscopic pyloric dilation20 (0.3%)170 (0.4%)0.413
      GES*25 (0.4%)800 (1.8%)0.0001
      Percutaneous endoscopic gastrostomy (PEG), gastric electrical stimulation (GES).

      Discussion

      This study elucidates the clinical presentation of hospitalized gastroparesis patients and highlights the differences between the older and younger populations. The heterogeneity of symptoms among geriatric and young patients may be due to the difference in disease pathogenesis. The higher odds of early satiety and bloating/flatulence among older adults, might be due to impaired gastric motility. Some studies have shown that the rate of gastric emptying is slower in older individuals compared to younger persons.
      • Horowitz M.
      • Maddem G.J.
      • Chatterton B.E.
      • et al.
      Changes in gastric emptying rates with age.
      • Moore J.G.
      • Tweedy C.
      • Christian P.E.
      • et al.
      Effect of age on gastric emptying of liquid- solid meals in man.
      • Wegener M.
      • Borsch G.
      • Schaffstein J.
      • et al.
      Effect of ageing on the gastrointestinal transit of a lactulose-supple- mented mixed solid-liquid meal in humans.
      Shimamoto et al.
      • Shimamoto C.
      • Hirata I.
      • Y Hiraike
      • et al.
      Evaluation of gastric motor activity in the elderly by electrogastrography and the 13C- acetate breath test.
      demonstrated a significant decrease in postprandial peristalsis and gastric contractile force in the older population with delayed gastric emptying. The most plausible explanation could be the loss of enteral cholinergic neurons, causing decrease motility in the geriatric population, which could be due to enteric neurodegeneration that occurs with aging secondary to reactive oxygen species.
      • Dumic I.
      • Nordin T.
      • Jecmenica M.
      • et al.
      Gastrointestinal tract disorders in older age.
      The increase in early satiety felt in older adults could be secondary to different reasons: Firstly, the degree of antral distention is directly proportional to the development of satiation after a meal, as observed with functional dyspepsia.
      • Jones K.L.
      • Doran S.M.
      • Hreen K.
      • et al.
      Relation between postprandial satiation and antral area in normal subjects.
      Secondly, reduced antral compliance also enhances gastric emptying of liquids leading to postprandial anorexia.
      • Morley J.E.
      Anorexia of ageing: physiological and pathological.
      Thirdly, delayed emptying of solids may also cause prolonged postprandial satiety.
      • Di Francesco V.
      • Fantin F.
      • Omizzolo F.
      • et al.
      The anorexia of ageing.
      ,
      • Serra-Prat M.
      • Mans E.
      • Palomera E.
      • et al.
      Gastrointestinal peptides, gastrointestinal motility, and anorexia of aging in frail elderly persons [published correction appears in Neurogastroenterol Motil. 2016;28(1):158].
      The purpose of nitric oxide (NO) production is to cause dilatation of the fundus of the stomach to allow it to act as a reservoir for food before passing to the antrum.
      • Morley J.E.
      Anorexia of ageing: physiological and pathological.
      Impaired fundic NO synthesis, cause reduced receptive and adaptive relaxation of the stomach's fundus, resulting in an earlier satiation feeling in older individuals.
      • Morley J.E.
      Anorexia of ageing: physiological and pathological.
      Early satiety results in reduced food intake hence associated with significant weight loss.
      • Matsuo H.
      • Van Cutsem E.
      • Wilmer A.
      • et al.
      Impaired gastric compliance is related to weight loss in severe motility-like dyspeptic patients.
      Abdominal pain is associated with hypersensitivity to gastric distention,
      • Tack J.
      • Caenepeel P.
      • Fischler B.
      • et al.
      Symptoms associated with hypersensitivity to gastric distention in functional dyspepsia.
      which is impaired in older adults. This could be the one of possible reasons behind the results of our study, where we showed that abdominal pain was less common in the older population.
      A Parkman et al. study that had 416 gastroparesis patients showed that diabetic gastroparesis (DG) patients had more severe vomiting and retching than idiopathic gastroparesis (IG) patients, whereas IG had more severe early satiety and excessive fullness.
      • Parkman H.P.
      • Yates K.
      • Hasler W.L.
      • et al.
      Similarities and differences between diabetic and idiopathic gastroparesis.
      This study postulated that IG might be due to sensory or accommodative dysfunction with abdominal pain and fullness. In contrast, DG may be more motor dysfunction-induced symptoms with vomiting and delayed gastric emptying.
      • Parkman H.P.
      • Yates K.
      • Hasler W.L.
      • et al.
      Similarities and differences between diabetic and idiopathic gastroparesis.
      Like Parkman et al.,
      • Soenen S.
      • Rayner C.K.
      • Horowitz M.
      • et al.
      Gastric emptying in the elderly.
      in this study, it is hypothesized that early satiety was more common in the older adults due to the stomach's accommodative dysfunction. In agreement with the current literature, older patients had more diabetes mellitus and Parkinson's disease than younger patients. These diseases seem to significantly impact the gastric emptying study in the older adults.
      Clinical studies have only shown beneficial effects of GES on nausea and vomiting severity score.
      • Abell T.
      • McCallum R.
      • Hocking M.
      • et al.
      Gastric electrical stimulation for medically refractory gastroparesis.
      • Forster J.
      • Sarosiek I.
      • Delcore R.
      • et al.
      Gastric pacing is a new surgical treatment for gastroparesis.
      • Lin Z.
      • Forster J.
      • Sarosiek I.
      • et al.
      Treatment of diabetic gastroparesis by high- frequency gastric electrical stimulation.
      • McCallum R.
      • Lin Z.
      • Wetzel P.
      • et al.
      Clinical response to gastric electrical stimulation in patients with postsurgical gastroparesis.
      Similarly, in an open-label trial, transpyloric stent procedures led to a clinical response of 75% with greater efficacy in those with predominant nausea and vomiting than in those with predominant pain.
      • Khashab M.A.
      • Besharati S.
      • Ngamruengphong S.
      • et al.
      Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video).
      The possible explanation for lower odds of older adults receiving GES or pyloric intervention, could be the improvement in nausea and vomiting associated with these two surgical procedures. On the contrary, the most common symptoms of older individuals were early satiety and bloating.
      This study had shown that older adults commonly received PEG or gastrostomy tube. Gastrostomy tubes can relieve the symptoms of motility disorders by venting gastric contents and reducing the need for hospitalization for acute exacerbation of dysmotility.
      • Pitt H.A.
      • Mann L.L.
      • Berquist W.E.
      • et al.
      Chronic intestinal pseudo-obstruction. Management with total parenteral nutrition and a venting enterostomy.
      ,
      • Murr M.M.
      • Sarr M.G.
      • Camilleri M.
      The surgeon's role in the treatment of chronic intestinal pseudoobstruction.
      The comorbid conditions increase with age, with 8% having at least one chronic illness, and 50% having at least two chronic conditions.

      Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. The Merck Company Foundation, Whitehouse Station, NJ 2007. Available at: http://www.cdc.gov/aging/pdf/saha_2007.

      We hypothesize that the high burden of comorbid disease that accompanies the older population may be a limiting factor for receiving disease-specific procedures like GES or pyloric intervention.
      This study has several limitations. We used the national inpatient database that included data from all over the US, which provided an adequate sample size for the study. This database uses an ICD coding system, which carries the risk of bias due to the reporting system. We could not estimate the difference of delayed gastric emptying between the older and younger population as there are no specific ICD-9 codes for it. Since NIS contains hospitalized patients only, community-level studies could not be performed using this database.

      Conclusions

      This study involving gastroparesis patients highlights the symptomatology differences between older and younger adults. Geriatric patients had more early satiety and bloating, whereas younger patients had more nausea with vomiting and abdominal pain. We recommend for older adults that endoscopy should be considered first, due to the possible increased likelihood of structural abnormalities.
      We found the difference between the surgical intervention performed in the two groups; older patients mainly received PEG and gastrotomy tubes, whereas younger patients received mostly GES and pyloric intervention. More community-level prospective randomized clinical trials are needed to determine if these differences in symptoms and surgical interventions influence the natural history and response to these patients' treatment.

      Key points

      • 1.
        Gastroparesis symptomatology might differ among geriatric patients compared to younger adults.
      • 2.
        Older adults had more early satiety and bloating, whereas younger patients had more nausea with vomiting and abdominal pain.
      • 3.
        There was difference between the surgical intervention performed in the two groups; older patients mainly received PEG and gastrotomy tubes, whereas younger patients received mostly gastric electrical stimulation and/or pyloric intervention.

      Acknowledgements

      The authors would like to thank Catherine McBride for help with manuscript preparation.

      Conflicts of Interest

      Dr Abell: Main funding: NIH GpCRC and Gastric Dysrhythmias
      Investigator: Censa, Cindome, Vanda, Allergan, Neurogastrx
      Consultant: Censa, Nuvaira, Takeda, Medtronic
      Speaker: Takeda, Medtronic
      Reviewer: UpToDate
      GES editor: Neuromodulation, Wikistim
      ADEPT-GI: IP for autonomic/enteric and bioelectric diagnosis and therapies
      None of the other authors have any disclosures to report.

      Funding

      No funding was received for this study.

      Author contributions

      SS, MJW, and PR conceived and designed the analysis; SS, MA, and ZT collected the data; SS, MA, and ZT contributed data or analysis tools; SS, MA, and ZT performed the analysis; SS, MA, ZA RI, PR, and TLA wrote the paper.

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