GASTROESOPHAGEAL REFLUX DISEASE
(GERD) IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • Classic symptoms: heartburn (pyrosis), regurgitation, and sometimes dysphagia
  • Other symptoms: atypical chest pain, hoarseness, nausea, cough, odynophagia, asthma, chronic cough, pulmonary aspiration
  • Weight loss

 

CONTEXT / / COMMUNICATION

Unless the resident is moribund or has a limited life expectancy, the signs and symptoms noted above  merit evaluation. Symptom relief is always appropriate.
If endoscopy is considered the resident or health care agent should be contacted
by the MD or NP or facility nurse.

 

ASSOCIATED RISKS

  • Acidic foods: citric juices, soda, coffee
  • Food/drugs that lower esophageal sphincter tone: peppermint, alcohol, chocolate, caffeine, anticholinergics, b -adrenergic agonists, calcium channel blockers, nicotine, Theophylline, Morphine, Nitrates, Meperidine, Iron Salts, antiparkinson drugs, Valium, Estrogen, NSAIDs, Potassium, Tetracycline, tricyclic antidepressants
  • Esophageal motility disorders (gastroparesis)
  • Obesity or ascites
  • Tight fitting clothing
  • Hiatal hernia
  • Supine position after eating
  • Decreased neutralization of refluxed material from decreased secretion of bicarbonate from esophageal submucosal glands

 

PHYSICAL EXAMINATION

  • Rule out other causes for cough or chest pain or weight loss
  • Evaluation of teeth for erosion caused by acid (compare findings with initial dental consult)

 

DIAGNOSTIC WORK-UP

  • Relief of symptoms after 14-day trial of proton pump inhibitor (Prevacid, Protonix or Prilosec) is considered diagnostic
  • Endoscopy is initial test of choice useful for diagnosing complications (Barrett's esophagus, esophagitis, strictures)

 

TREATMENT OPTIONS

Goal of treatment is to reduce episodes of reflux, promote healing, eliminate symptoms, prevent complications and relapse.

  • Lifestyle changes: Elevate head of bed six inches, decrease fat, coffee, chocolate, caffeine, alcohol, peppermint intake, stop smoking, reduce weight/control ascites, avoid recumbency for three hours postprandially, small portions, abstain from eating 3 hours before bedtime, avoid risky drugs if possible (NSAIDs, beta blockers, calcium-channel blockers, theophylline, potassium, biphosphonates)
  • Medications : Start H2 receptor agonist such as Zantac 150 mg BID (decrease dose to QD in renal failure) + antacid prn/pc meals X 6 weeks. If no improvement or if complicated GERD (erosive esophagitis, Barrett's esophagus, strictures) add PPI such as Prilosec 10-20 mg QD X 60 days
  • Maintenance: For symptomatic relapse use lowest effective H2-receptor agonist or proton pump inhibitor for complicated disease
  • Prokinetic drugs : Short course indicated to increase both gastric emptying and lower esophageal sphincter pressure in refractory GERD- Reglan  5-10 mg AC & HS (avoid if patient has Parkinson's Disease).
  • Referral: If previously or currently under care of gastroenterologist, periodic communication or consultation should be maintained

 

References for GERD

  1. Castell, DO, Richter, JE, et al: Achieving better outcomes for patients with GERD in Patient Care, April 30, 1996, 21-43.
  2. Chait, M: Gastroesophageal Reflux Disease in the Elderly in Clincial geriatrics, Vol. 12, No. 4, April 2004, 39-45.
  3. Elliott, D., Small, S.: Gastroesophageal Reflux Disease (GERD) in Supplement 5 to the Journal of the American Society of Consultant Pharmacists 1997, Vol.13. 5-1 . 5-8.
  4. Fackler, WK, Richter, JE: Refractory GERD: What Next? in Consultant, May, 2001, 973-983.
  5. Flynn, CA: The Evaluation and Treatment of Adults with Gastroesophageal Reflux Disease in  The Journal of Family Practice, Vol. 50, No. 1, January 2001, 57-64.
  6. Higbee, M: Medical Treatment of GERD in Elderly Nursing Home Residents in Annals of Long-Term Care, Vol.5, No. 12, November, 1997, 413-422.
  7. Hsu, R, Wolfgang, R: Which drug class is best for GERD? in Patient Care, September 15, 2001, 26-44.
  8. Isselbacher, KJ, Braunwald, E. et al: Gastroesphageal Reflux in Harrison. s Principles of Internal Medicine, 13th Edition, 1995, 485-486.
  9. Omnicare Formulary, Gastroesophageal Reflux Disease, (GERD) in Geriatric Pharmaceutical Care Guidelines, 1999 Edition, 173-185.
  10. Scott, M., Gelhot, AR: Gastroesophageal Reflux Disease: Diagnosis and Management in American Family Physician, March 1, 1999, 1161-1169.

 

MS/9.99
ŠEMS
Revised 12.04

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