Dyspepsia (indigestion) is a common symptom characterised by discomfort or pain in the upper abdomen. It typically occurs after eating or drinking (NHS Inform 2020).
Dyspepsia may be associated with other symptoms such as:
Early satiation (only being able to eat a small amount of food before feeling full)
Dyspepsia is usually mild (NHS Inform 2020), and most people experience occasional episodes (Knott & Willacy 2020), however, about 10% of the Australian population experiences chronic dyspepsia with no obvious cause (a condition known as functional dyspepsia) (Talley, Goodsall & Potter 2017; Mayo Clinic 2019).
Causes of Dyspepsia
In some cases, dyspepsia may be caused by stomach acid coming into contact with and damaging the digestive mucosa (lining), which can lead to painful inflammation and irritation (NHS Inform 2020).
However, many people who experience dyspepsia don’t have inflammation. Instead, the mucosa may be more sensitive to acidity or stretching caused by eating (NHS Inform 2020).
Dyspepsia may be brought on by:
Overeating
Eating too quickly
Constipation
Eating fatty, greasy, spicy or acidic foods
Excessive consumption of caffeine, alcohol, chocolate or carbonated drinks
Smoking
Certain medicines (e.g. nitrates, non-steroidal anti-inflammatory medicines such as ibuprofen, some antibiotics)
Stomach cancer, which damages the protective lining of the stomach and allows acid to come into contact with the stomach wall
Intestinal obstruction
Intestinal ischemia.
(Mayo Clinic 2019; NHS Inform 2020; NIDDK 2016)
Dyspepsia in Older Adults
Dyspepsia is common in older adults for several reasons, including:
Reduced blood flow with age, which causes hypoxia and weakening of the mucosal defences
Reduced effectiveness of digestion due to age-related changes (e.g. reduced saliva, gastric juice, bile and enzyme production)
The ageing stomach being more vulnerable to disease overall
The prevalence of older adults who are prescribed NSAIDs and aspirin
Increased risk of Helicobacter pylori infection in older adults
Inadequate chewing of food due to poorly-fitting dentures, dental decay or tooth loss
Reduced gut movement due to a more sedentary lifestyle.
(Walker & Talley 2019; Elderly Health Service 2020)
Complications of Dyspepsia
Dyspepsia generally has no long-term serious effects. That being said, it can be distressing and significantly impair quality of life, especially if it’s chronic (Talley, Goodsall & Potter 2017).
People who experience dyspepsia may:
Feel uncomfortable
Eat less
Miss work or school
Have other symptoms from an underlying cause of dyspepsia.
(Mayo Clinic 2019)
Investigating and Managing Dyspepsia in Older Adults
History Taking
A detailed history of the patient should be taken in order to determine if there is an underlying cause of the dyspepsia.
This may involve:
Determining whether there is a dominant history of heartburn or regurgitation, which may indicate gastroesophageal reflux disease (GERD)
Undertaking a medicine review to identify any medicines that may be causing symptoms, such as:
NSAIDs
Corticosteroids
Calcium channel antagonists
Nitrates
Theophyllines
Bisphosphonates.
Identifying any symptoms indicative of malignancy such as weight loss, anorexia, vomiting, dysphagia, odynophagia or a family history of gastrointestinal cancers
Determining whether the patient is experiencing severe episodic pain in the epigastric or right upper abdominal regions, which may indicate symptomatic cholelithiasis
Determining whether the patient is experiencing nausea and vomiting (with or without weight loss), which may indicate gastroparesis
Identifying whether the patient has any of the following risk factors:
Family history of oesophagogastric cancer (in over two first-degree relatives)
Family history of familial adenomatous polyposis in any first-degree relative
Barrett's oesophagus
Pernicious anaemia
Undergone gastric surgery over 20 years ago
Known dysplasia, atrophic gastritis or intestinal metaplasia.
(Longstreth & Lacy 2019; NHS Lothian 2017)
Patient Assessment
The only abnormal finding upon physical examination should be epigastric tenderness.
Other findings may suggest a diagnosis other than dyspepsia, for example:
Palpable abdominal mass
Lymphadenopathy
Jaundice
Pallor (secondary to anaemia)
Ascites
Muscle wasting, loss of subcutaneous fat and peripheral edema caused by weight loss (may indicate malignancy).
(Longstreth & Lacy 2019)
Red Flags
Certain symptoms may require an escalation of care involving prompt medical intervention. Adhere to your organisation’s policy and procedures and perform basic life support if necessary. These symptoms include:
In order to identify red flags or underlying metabolic illness, the following routine blood counts and blood chemistry tests should be performed:
Liver function tests
Serum lipase
Amylase.
(Longstreth & Lacy 2019)
Test for Helicobacter pylori
Patients over 60 should undergo an endoscopy and biopsy of the stomach in order to test for Helicobacter pylori infection. If H. pylori are present, the patient can undergo eradication therapy.
(Longstreth & Lacy 2019)
Endoscopy for Diagnostic Testing
Refer the patient for an urgent endoscopy if they have any combination of the following symptoms:
Upper abdominal pain or reflux
Unplanned weight loss
Anaemia
Refer the patient for an endoscopy if they have any of the following symptoms:
Dysphagia
Odynophagia (pain when swallowing)
Upper abdominal pain or discomfort that is new-onset
Upper abdominal pain or discomfort that is new-onset or worsening, along with:
Unplanned weight loss
Unexplained iron deficiency anaemia
Vomiting that lasts for over four weeks.
(NHS Lothian 2017)
Treatment
Depending on the underlying cause of the dyspepsia, if any, the patient may require treatment, including:
Antacids (best taken when expecting symptoms e.g. after eating or before sleeping)
Proton pump inhibitors (PPIs) to reduce stomach acid
H-2-receptor antagonists (H2RAs) to reduce stomach acid
Prokinetics to increase gastrointestinal movement
Antibiotics to treat Helicobacter pylori infection
Antidepressants or anti-anxiety medicine to decrease neuropathic pain
Antisecretory therapy.
(NHS Inform 2020; Mayo Clinic 2019; Longstreth & Lacy 2019)
Note that any medicines should be taken as directed by a prescribing clinician or other appropriately trained professional.
Preventing Dyspepsia in Older Adults
Mild dyspepsia may be prevented or relieved through strategies such as:
New 