**7. Special populations: Elderly**

Management of GERD in the elderly is generally similar to the adult population. However, there are specific concerns regarding treatments in the geriatric population. Most elderly patients have co-morbid conditions such as cardiovascular disease, hypertension, depression, and osteoporosis that require multiple medications [53]. Many medicines to treat these conditions can lead to decreased LES pressure, esophageal motility, and direct esophageal injury [53]. Examples include calcium channel blockers, benzodiazepines, nitrates, nonsteroidal anti-inflammatory drugs, and anticholinergic agents [53]. Aggressive, individualized treatments may be warranted due to the high risk of complications from GERD and co-morbid illnesses in this patient population [54]. Motility agents may improve LES tone, although success is limited in patients with severe disease [53]. Higher doses, up to four times daily, of H2RA may be required in some elderly patients for adequate acid suppression and symptom relief; however, proper dose adjustment is needed if patients have renal insufficiency [53]. As with most medications, the side effect, and drug interaction profile could be more pronounced in the geriatric population. No evidence-based guidelines support specific treatment options in those over 65. However, PPIs are usually first-line medical therapy in patients with GERD [54]. PPIs provide excellent acid suppression. Capsules may be opened and sprinkled in water, juice, or applesauce. Besides, lansoprazole and omeprazole are available in powder formulation for those that have difficulty or are unable to swallow [53]. Maintenance therapy is usually required in this population as long-term treatment is necessary to prevent relapse. Of note, unless the patient is high-risk (e.g., Barrett esophagitis, erosive esophagitis, chronic NSAID use, etc.), the Beers criteria advises against using PPIs continuously for > 8 weeks for patients ≥65 due to the risk of *Clostridium difficile* infection and bone loss [55]. Beers criteria also suggests avoiding H2RA use in patients who have delirium [55].

Effects of prolonged acid suppression can include: reduced absorption of nutrients, osteoporosis, and drug metabolism interference [53]. Although these effects are controversial, monitoring patients on long-term acid-suppressive therapy is still important. Surgery may be warranted in those with dysplasia, esophageal adenocarcinoma, and Barrett's esophagus [54]. There are important factors to consider regarding the treatment and management of the elderly compared to the younger population. However, with appropriate direction, GERD can be treated in most elderly patients with successful outcomes.
