No Heartburn (or Heart Attacks)
for the Holidays

Your elderly patients are just like the rest of us: We all want to enjoy ourselves at the holidays. Parties and family gatherings often bring with them an abundance of food and drink that is a bit richer and sweeter than the usual fare. Though festive, these foods increase the chance of gastroesophageal reflux disease (GERD). The resulting heartburn can really dampen the party spirit. This is especially true for older adults since the aging process itself, along with other illnesses and medications, create increased risk for GERD. Here are some strategies you can use to help your patients understand their risk and how they can decrease it, as well as dealing with symptoms if they should develop heartburn.

Aging contributes to increased heartburn in several ways. First, the aging process itself includes changes to the key apparatus keeping stomach fluids in place. Next, older adults are more likely to have chronic illnesses including diabetes, COPD, congestive heart failure, and depression, which can create increased risk by virtue of their pathophysiology. Finally, older adults may be at increased risk from the medications they need to take for management of other conditions.

Anatomically, GERD or heartburn occur due to a weakening and excessive relaxation of the lower esophageal sphincter, as well as the surrounding diaphragmatic wall muscles that collectively contribute to lower esophageal sphincter competence. This creates more opportunity for stomach fluids, which are often acidic, to flow into the esophagus and create the symptom of heartburn. Certain foods and substances such as tobacco, caffeine, and alcohol can lead to sphincter relaxation and heartburn as well.

Older adults are also likely to suffer other medical illnesses that increase the risk for GERD of heartburn. Common associated illnesses include obesity, hiatal hernia, diabetes, and COPD.

Certain disease states require mediations that are known contributors to GERD (via lowering sphincter pressure). These include anticholinergics, antihistamines, tricyclic antidepressants, calcium channel blockers, and nitrates.

Here’s a good strategy to follow. Have your patients take nonpharmacologic steps first. Some initial strategies include the following:

• Suggest elevating the head of the bed about six inches (wedge pillows are available at Walmart or Target).
• Recommend avoiding eating within two to three hours of sleeping.
• Remind patients to avoid coffee, alcohol, fats, chocolate, and smoking.
• Review medication for such offenders as anticholinergics.
• Recommend weight loss for overweight patients and those who have recently gained weight.

If these strategies don’t adequately relieve the symptoms, suggest medication options such as proton pump inhibitors or H2 blockers.

Here’s the No Heart Attacks Part:
Special Alert When It’s Not Really Heartburn

As you counsel patients about this common minor ailment, please remember to “think like a geriatrician.” We want to be sure we educate our elderly patients about risks and educate them regarding obtaining care quickly in the event of a serious problem such as a heart attack. Heartburn symptoms can mimic cardiac pain.

From a favorite online information site, MayoClinic.org, comes the following list of typical signs and symptoms. For most patients experiencing GERD, these are not common and can help distinguish between the two.

Typical heart attack signs and symptoms include the following:

• pressure, tightness, pain, or a squeezing or aching sensation in the chest or arms that may spread to the neck, jaw, or back;
• nausea, indigestion, heartburn, or abdominal pain;
• shortness of breath;
• cold sweat;
• fatigue; and
• lightheadedness or sudden dizziness.

The most common symptom of heart attack for both men and women is chest pain or discomfort. But women are more likely than men to experience some of the other symptoms, such as jaw or back pain, shortness of breath, and nausea or vomiting.

For Patient Handout

The last thing on anyone’s holiday wish list is heartburn. But as we age, our risk for GERD increases and makes suffering heartburn more common. While we can’t change the aging trajectory, the following are some steps you can take to make sure your holiday fun isn’t derailed by heartburn:

• Choose wisely at the buffet table. Avoid chocolate, peppermint, and citrus. Choose baked foods rather than fried. Lower-sugar options are best.
• Nibble, don’t gorge. It’s tempting to overeat when your seasonal favorite is making its annual appearance, but smaller quantities will keep the stomach more settled.
• Time your dining well. Eat early, not late. Take a walk after eating; don’t head for a nap.
• Toast in moderation. A glass of wine or champagne to welcome the New Year is fine, but larger quantities may bring on the burn.

Keep in mind that sometimes heartburn isn’t from the food you ate but can be a symptom of a more serious problem. A heart attack can include indigestion or heartburn symptoms. Often if heartburn is being caused by a heart attack, there are other symptoms as well, including the following:

• pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back;
• nausea, indigestion, heartburn, or abdominal pain;
• shortness of breath;
• cold sweat;
• fatigue; and
• lightheadedness or sudden dizziness.

The most common symptom of heart attack for both men and women is chest pain or discomfort. But women are more likely than men to experience some of the other symptoms, such as jaw or back pain, shortness of breath, and nausea or vomiting.

If you are having any of these symptoms or if you are unsure, call 911 or proceed to the nearest emergency department for evaluation.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.