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Arizona Geriatric Education Center Arizona Reynolds Program of Applied Geriatrics Aging Pearls: Gastroenterology Answer Guide Carol L. Howe, MD, MLS, College of Medicine, University of Arizona 1. Although tube feeding does not necessarily improve the risk of aspiration, there is little choice for patients with end stage dementia, whose proxy decision makers should be encouraged to request this life-preserving procedure. True or False? Please discuss your choice. False Finucane, Christmas and Travis conducted an extensive literature review whose results were reported in a 1999 JAMA article.1 All ethical considerations aside, they found no evidence of clinical improvement in the incidence or severity of aspiration pneumonia, pressure ulcers, infection, discomfort, or prolonged survival. In fact, they found some data suggesting the opposite which, together with the considerable risks of PEG placement itself caused them to conclude: “The widespread practice of tube feeding should be carefully reconsidered, and we believe that for severely demented patients the practice should be discouraged on clinical grounds.”1 2. It is currently recommended that proton pump inhibitors (PPIs) be prescribed not only to treat, but also to prevent gastrointestinal injury secondary to aspirin and nonsteroidal anti-inflammatory agents in patients 60 and older. True or False? True Figure 1. See endnote 2 PPI therapy is believed to reduce the risk in all patients; the more risk factors present, the more cost-effective the additional therapy likely becomes.2 3. The median age at which individuals are diagnosed with colorectal cancer is: a. 41 b. 51 c. 61 d. 71 Answer: d. 71 “From 2002-2006, the median age at diagnosis for cancer of the colon and rectum was 71 years of age. Approximately 0.1% were diagnosed under age 20; 1.1% between 20 and 34; 3.8% between 35 and 44; 12.0% between 45 and 54; 18.7% between 55 and 64; 24.7% between 65 and 74; 27.7% between 75 and 84; and 12.1% 85+ years of age.” 3 Colon cancer can have a very long latency period—(10-15 years4 ). For this reason it is important to screen most adults in their 50’s, 60’s and early 70’s. By the time patients reach their mid to late 70’s, their individual health status becomes a more important determinant of screening recommendations-- to insure that the potential benefits of screening will outweigh potential complications such as bleeding or perforation. Similarly the benefits of finding colorectal carcinoma in very old (greater than age 85), and/or frail patients who may have multiple comorbidities, probably do not outweigh the risks of treatment or the effects of that treatment on their quality of life—making screening an unnecessary burden. 1 Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999;282(14):1365-70. 2 ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2008 Oct 28;52(18):1502-17. 3 SEER Stat Fact Sheets - Cancer of the Colon and Rectum. . http://seer.cancer.gov/statfacts/html/colorect.html. Accessed 10/28/2009. 4 Winawer SJ. Natural history of colorectal cancer. Am J Med. 1999;25;106(1A):3S-6S; discussion 50S-51S.