Acidity and Reflux in Older Adults

What happens in reflux

After swallowing, food passes down the gullet (oesophagus) into the stomach through a muscular valve, the lower oesophageal sphincter. If this valve relaxes or weakens, stomach contents, acid and sometimes bile flow back up, irritating the lining of the gullet. This is gastro-oesophageal reflux, and when it is frequent or troublesome it is called GERD (gastro-oesophageal reflux disease). Acidity in everyday speech may also include indigestion (dyspepsia), gastritis (inflamed stomach lining), ulcers and other upper gut problems, which can feel similar.

Common symptoms

• Heartburn: a burning feeling behind the breastbone, rising towards the throat, often after meals, on bending or lying down.
• Regurgitation: sour or bitter fluid rising into the throat or mouth.
• Belching, bloating, nausea, a feeling of fullness after small meals.
• Hoarseness, sore throat, chronic cough, wheeze or throat clearing, especially at night or in the morning.
• A sensation of a lump in the throat.
• Chest discomfort that may mimic heart pain.

In older adults, symptoms may be milder or atypical, and sometimes the first sign is loss of appetite, weight loss, anaemia or a cough.

Why it is common in older age

• Weaker valve and hiatus hernia, where part of the stomach slides above the diaphragm.
• Slower stomach emptying and reduced saliva that normally neutralises acid.
• Medicines that irritate or relax: aspirin and other anti-inflammatory painkillers (NSAIDs, such as diclofenac, ibuprofen, naproxen), steroids, bisphosphonates for osteoporosis, potassium tablets, iron tablets, some antibiotics, calcium channel blockers (amlodipine and others), nitrates, theophylline, sedatives, anticholinergics and some antidepressants. Do not stop prescribed medicines yourself; ask the doctor whether alternatives or protective measures exist; see medicine side effects families should watch for and painkillers and older adults.
• Large, late, fatty or spicy meals, lying down soon after eating.
• Smoking, tobacco chewing, alcohol, strong tea and coffee.
• ***Helicobacter pylori* infection,** a common cause of gastritis and ulcers, treatable.
• Swallowing disorders and diabetes (slow stomach emptying).
• Lying in bed for long periods, with poor posture, in frail and bedridden people.

Red flags: do not treat these at home

Call 112 or go to hospital immediately for: - Chest pain or pressure, especially with sweating, breathlessness, nausea, pain spreading to the arm, jaw or back, or on exertion: it may be a heart attack. Do not assume "it is only gas"; see after a heart attack: recovery at home. - Vomiting blood or coffee-ground material, or black tarry stools, with dizziness or weakness. - Severe, sudden abdominal pain, a rigid abdomen. - Food stuck in the gullet with inability to swallow saliva.

See a doctor promptly for: - Difficulty or pain when swallowing, food sticking. - Unintentional weight loss, loss of appetite or feeling full quickly. - Persistent vomiting. - Anaemia, pallor, tiredness; see iron and anaemia in older adults. - Symptoms that start for the first time after age fifty to sixty, or change. - Symptoms despite treatment, or that need antacids most days for more than two to three weeks. - A hoarse voice or chronic cough lasting weeks. - Long-term reflux symptoms in a person with risk factors for Barrett's oesophagus.

These "alarm features" may call for endoscopy (a camera test) to look for ulcers, inflammation, Barrett's oesophagus, narrowing or cancer.

Practical steps at home

### Meals and food

• Eat smaller, more frequent meals rather than large ones; avoid overeating.
• Eat dinner early, at least two to three hours before lying down or sleeping.
• Identify and limit personal triggers, which differ: often fried and fatty foods, very spicy dishes, pickles, tomato-based and citrus foods, chocolate, peppermint, onion and garlic in raw form, carbonated drinks, strong tea, coffee and alcohol. Keep a food and symptom diary rather than cutting everything out; in an older person, restricting food too much risks undernutrition; see malnutrition in older adults: signs and prevention.
• Choose gentle protein and cooking methods: steamed, boiled, grilled rather than deep-fried; dal and khichdi are often well tolerated; low-fat curd or buttermilk can soothe some people, though full-fat dairy may worsen symptoms in others.
• Cooling foods and drinks: cold milk, banana, coconut water, watermelon and cucumber are traditionally used; they may help some but do not neutralise acid for long; for people with kidney disease or diabetes, check suitability; see eating with chronic kidney disease: a family guide and eating for diabetes after 60.
• Fasting and long gaps between meals can worsen acidity; see fasting, festivals and older adults: staying safe.
• Do not rely on home remedies such as baking soda in water or large quantities of cold milk regularly: baking soda has a lot of sodium and can cause problems in heart, kidney and blood pressure conditions.

### Posture and sleep

• Stay upright for two to three hours after meals; a gentle walk helps; avoid bending, heavy lifting or exercise right after eating.
• Raise the head of the bed by about 15 to 20 centimetres (six to eight inches) using bed risers under the head end legs, a foam wedge pillow or an adjustable bed; extra pillows alone bend the neck and may not help; see positioning a bedridden parent. Sleeping on the left side may reduce reflux for some people.
• Bedridden people: keep the head raised at least 30 degrees during and after feeds and as much as possible; discuss with the nurse.

### Lifestyle

• Lose excess weight gradually, but avoid crash diets, and avoid weight loss in frail older adults.
• Treat constipation; see constipation in older adults: fibre, fluids and movement.
• Review medicines with the doctor: ask whether any can be taken differently (for example with food, with a full glass of water, sitting upright for 30 minutes after bisphosphonates), switched or protected.
• Take tablets with a full glass of water and avoid lying down immediately after.

Antacids and acid reducers

Antacids (liquids and chewable tablets containing aluminium, magnesium, calcium or sodium) neutralise acid and give short-term relief. Occasional use is generally fine, but: - Magnesium products can cause diarrhoea; aluminium ones constipation; calcium ones constipation and, with other calcium supplements, excess calcium; sodium-rich ones raise blood pressure and fluid retention. - Kidney disease: aluminium and magnesium antacids can accumulate; ask the doctor. - Interactions: antacids reduce absorption of thyroid tablets, iron, some antibiotics, osteoporosis tablets and others; separate by two to four hours as the pharmacist advises; see supplements and medicine interactions: a safety guide. - Needing antacids most days is a reason to see a doctor.

Alginate preparations form a foam barrier on the stomach contents and may help reflux.

H2 blockers (such as ranitidine in the past, now famotidine) reduce acid production, are short-acting, and can cause confusion in frail older adults and in kidney impairment; doses may need adjustment.

Proton pump inhibitors (PPIs) (omeprazole, pantoprazole, esomeprazole, rabeprazole, lansoprazole and others) are the most potent and widely used acid reducers, and are very effective for GERD, ulcers and for protecting the stomach in people on certain medicines, as the doctor judges. But they are often continued long after the need has passed. Long-term use has been associated with: - Lower absorption of vitamin B12, magnesium, iron and calcium; see vitamin B12 in older vegetarians. - Higher risk of some infections (including *C. difficile* diarrhoea and pneumonia) and possibly of fractures and kidney problems in some studies. - Rebound acidity when stopped suddenly. - Interactions with some medicines (clopidogrel, methotrexate, others).

Do not start or stop a PPI on your own. Ask the doctor to review whether it is still needed, the lowest effective dose and how to step down safely, often by reducing the dose gradually or using it only as needed. Never abruptly stop a PPI prescribed to protect against bleeding in a person on blood thinners, aspirin or steroids without the doctor's advice.

**Treatment of *H. pylori*** infection, when found, uses a short course of combination medicines prescribed by the doctor; complete the full course.

Surgery or endoscopic procedures are for selected people with severe reflux or complications.

Herbal and "Ayurvedic" digestive products (churna, triphala, amla, liquorice products, aloe vera juice and others) have their own interactions and effects; liquorice raises blood pressure and lowers potassium; ask the doctor and pharmacist before use.

Reflux, cough and swallowing

Reflux can cause chronic cough and hoarseness and worsen asthma and COPD, and it is linked with swallowing problems in frail people; see asthma in older adults: what changes after 60 and swallowing problems (dysphagia) in older adults.

When to ask a professional

Ask the doctor to assess new, frequent or persistent acidity and to decide whether tests such as endoscopy, *H. pylori* testing or blood tests are needed. Ask the doctor and pharmacist to review medicines that cause or worsen reflux, and to review the need for long-term PPIs. Ask a dietician for a plan that avoids unnecessary restriction. Seek urgent help for chest pain, vomiting blood, black stools or severe pain; call 112 if severe.