Effect of age on tests of intestinal and hepatic function in healthy humans

Digestion and Postprandial Metabolism in the Elderly

The elderly are an increasing segment of the population. Despite the rapid gains in medical knowledge and treatments, older adults are more likely to experience chronic illnesses that decrease quality of life and accelerate mortality. Nutrition is a key modifiable lifestyle factor which greatly impacts chronic disease risk. Yet despite the importance of nutrition, relatively little is known of the impact of advancing age on the gastrointestinal function, the digestive responses, and the post-meal metabolic adaptations that occur in response to ingested food. Knowledge of the age-related differences in digestion and metabolism in the elderly is essential to the development of appropriate nutritional recommendations for the maintenance of optimal health and prevention of disease.

Aging and dyslipidemia: a review of potential mechanisms

Elderly adults constitute a rapidly growing part of the global population, thus resulting in an increase in morbidity and mortality related to cardiovascular disease (CVD), which remains the major cause of death in elderly population, including men and women. Dyslipidemia is a well-established risk factor for CVD and is estimated to account for more than half of the worldwide cases of coronary artery disease (CAD). Many studies have shown a strong correlation between serum cholesterol levels and risk of developing CAD. In this paper, we review the changes of plasma lipids that occur in men and women during aging and the potential mechanisms of age-related disorders of lipoprotein metabolism covering humans and/or animals, in which changes of the liver sinusoidal endothelium, postprandial lipemia, insulin resistance induced by free fatty acid (FFA), growth hormone (GH), androgen (only for men) and expression and activity of peroxisome proliferator-activated receptor α (PPARα) are mainly focused.

Small intestinal permeability in older adults

It is not yet clear whether intestinal mucosal permeability changes with advancing age in humans. This question is of high importance for drug and nutrition approaches for older adults. Our main objective was to answer the question if small intestinal barrier integrity deteriorates with healthy aging. We conducted a cross‐sectional study including the pooled data of 215 nonsmoking healthy adults (93 female/122 male), 84 of whom were aged between 60 and 82 years. After a 12‐h fast, all participants ingested 10 g of lactulose and 5 g of mannitol. Urine was collected for 5 h afterwards and analyzed for test sugars. The permeability index (PI = lactulose/mannitol) was used to assess small intestinal permeability. Low‐grade inflammation defined by high‐sensitivity C‐reactive protein ≥1 mL/L and kidney function (estimated glomerular filtration rate) were determined in the older age group. The PI was similar in older compared to younger adults (P =0.887). However, the urinary recovery of lactulose and mannitol was lower in the older adults and this change was neither associated with urinary volume nor glomerular filtration rate. The PI was not significantly correlated with low‐grade inflammation or presence of noninsulin‐dependent type 2 diabetes. However, it significantly deteriorated in the copresence of both conditions compared to low‐grade inflammation alone (P =0.043) or type 2 diabetes alone (P =0.015). Small intestinal mucosal barrier does not deteriorate with age per se. But low‐grade inflammation coupled with minor disease challenges, such as type 2 diabetes, can compromise the small intestinal barrier.

Until now, it has not been clear if the small intestinal mucosal barrier deteriorates with age per se. We investigated the pooled data of 215 nonsmoking healthy adults, 84 of whom were aged between 60 and 82 years and found similar intestinal permeability results in all age classes. However, in participants with low‐grade inflammation coupled with type 2 diabetes the small intestinal integrity was compromised.

Ageing and the gut

The goal of this brief review is to address the role of the ageing gut in the genesis of malnutrition in the elderly. We assess the burden of malnutrition in the elderly, exploring the role of comorbid conditions and neurohumoral changes that take place to contribute towards the process of anorexia associated with ageing. Following this, the review assesses physiological changes that occur in each part of the gastrointestinal (GI) tract and what implication they may have in clinical practice. In the oropharynx and the oesophagus, changes in swallowing and oesophageal motility associated with ageing can be demonstrated using physiological testing. However, in the absence of comorbid disease, they often have little, if any, clinical significance. In the stomach, reduced fundal compliance may contribute to early satiety; however, the primary change is hypochlorhydria, which may predispose to malabsorption or bacterial overgrowth further along the GI tract. Almost uniquely, the small bowel, particularly its absorptive function, is unaffected by age and we review the literature demonstrating this. In the colon, there is evidence of a prolonged transit time related to a reduction in both neurotransmitters and receptors. Although this may cause symptoms, this aspect is unlikely to contribute to malnutrition. In addition, we assess the potential changes in the gut microbiome and how this may interact with the immune system in the process of 'inflamm-ageing'. We conclude by summarising the main changes and their impact for the clinician along with recommendations for future areas of research.

Postprandial lipemia in pre- and postmenopausal women

Background and Objective:

The increased risk for coronary artery disease observed in postmenopausal (PoW) women is partly explained by a more atherogenic lipoprotein profile. Moreover, natural menopause has been associated with an altered postprandial lipid profile. This study was designed to test the hypothesis that young premenopausal (PrW) and PoW may be independently associated with postprandial lipemia and indirectly associated with atherosclerosis.

Patients and Methods:

A total of 46 healthy PrW and 44 healthy PoW participated in a 5-h intervention study. Blood samples were taken at the baseline and at 1, 2, 3, and 4 h after eating. Total cholesterol, LDL-cholesterol, HDL-cholesterol, fasting, and postprandial triglycerides (PPTG) were determined sequentially in blood samples.

Results:

PPTG presented significant higher values in PoW compared to PrW (P < 0.05), but other lipids did not significantly differ between groups. PPTG concentrations in PoW were significantly higher than in PrW (P < 0.05). There was a significant time influence (P < 0.05) in TG in PrW and PoW, while time to peak and peak concentration were significantly higher in PoW than PrW. Other lipids were also decreased more in PrW than PoW, but not significantly so. Cholesterol concentrations showed a significant reduction after 2 h, to reach values similar to the baseline after 4 h in PrW but not in PoW. HDL-cholesterol concentration was decreased more in PoW compared to PrW but it was not significant.

Conclusions:

Lipid postprandial response indicates a higher cardiovascular risk pattern in PoW compared to PrW.

Clinical research on liver reserve function by 13C-phenylalanine breath test in aged patients with chronic liver diseases

Background

The objective of this study was to investigate whether the ¹³C-phenylalanine breath test could be useful for the evaluation of hepatic function in elderly volunteers and patients with chronic hepatitis B and liver cirrhosis.

Methods

L-[1-¹³C] phenylalanine was administered orally at a dose of 100 mg to 55 elderly patients with liver cirrhosis, 30 patients with chronic hepatitis B and 38 elderly healthy subjects. The breath test was performed at 8 different time points (0, 10, 20, 30, 45, 60, 90, 120 min) to obtain the values of Delta over baseline, percentage ¹³CO₂ exhalation rate and cumulative excretion (Cum). The relationships of the cumulative excretion with the ¹³C-%dose/h and blood biochemical parameters were investigated.

Results

The ¹³C-%dose/h at 20 min and 30 min combined with the cumulative excretion at 60 min and 120 min correlated with hepatic function tests, serum albumin, hemoglobin, platelet and Child-Pugh score. Prothrombin time, total and direct bilirubin were significantly increased, while serum albumin, hemoglobin and platelet, the cumulative excretion at 60 min and 120 min values decreased by degrees of intensity of the disease in Child-Pugh A, B, and C patients (P < 0.01).

Conclusions

The ¹³C-phenylalanine breath test can be used as a non-invasive assay to evaluate hepatic function in elderly patients with liver cirrhosis. The ¹³C-%dose/h at 20 min, at 30 min and cumulative excretion at 60 min may be the key value for determination at a single time-point. ¹³C-phenylalanine breath test is safe and helpful in distinguishing different stages of hepatic dysfunction for elderly cirrhosis patients.

Small intestinal disorders in the elderly

The topic of gastroenterology (GI) in the elderly has been extensively reviewed. It takes special skill, patience and insight to interview the elderly, as well as to appreciate their altered physiology and interpretation of their presenting symptoms and signs, often against an extreme background of complex medical problems. The maldigestion and malabsorption coupled with altered motility contributes to the development of malnutrition. There generally a decrease of function of the GI tract, but there may be loss of adaptability in response to changes in diet or nutritional stress. Pathological alterations which might lead to minor overall intestinal functional variations in the young because of a normal process of adaptation, may lead to much more serious events in the elderly.

Assessment of Age-Related Changes in Abdominal Organ Structure and Function With Computed Tomography and Positron Emission Tomography

With the size of the aged population in the United States expected to grow considerably during the next several decades, the number of imaging studies performed on such aged individuals will similarly increase. Thus, it is important to understand normal age-related changes in the structural and functional imaging appearance of the abdominal organs. We therefore present preliminary data and a review of the literature relevant to structural and functional changes in the abdominal organs of children and older adults. In a retrospective study of both adult and pediatric populations, we used computed tomography (CT), positron emission tomography (PET), and PET/CT imaging to investigate age-associated changes in size, attenuation, and metabolic function of the abdominal organs. Organs of interest include the liver, spleen, pancreas, kidneys, adrenal glands, stomach, small bowel, colon, and rectum. Although volumes of adult liver, spleen, pancreas, and kidneys do not change significantly with age, adult left and right adrenal gland volumes do significantly increase with age (r = 0.2823, P = 0.0334, and r = 0.3676, P = 0.0049, respectively). Also, the attenuation of adult liver (r = -0.2122, P = 0.0412), spleen (r = -0.4508, P < 0.0001), pancreas (r = -0.5124, P = 0.0007), and left and right adrenal gland (r = -0.5835, P < 0.0001 and r = -0.6135, P < 0.0001, respectively) decrease significantly with increasing age. Every organ studied in the pediatric population demonstrates a positive association between organ volume and age. Significant age-related changes in organ function are noted in the adult liver and small bowel, with the liver demonstrating a positive association between metabolic activity and age (r = 0.4434, P = 0.0029) and the small bowel showing an inverse association between mean small bowel standardize uptake value and age (r = -0.2435, P = 0.0174). Also, the maximum overall small bowel and colon metabolic activity in children increases with age (r = 0.6478, P = 0.0008). None of the other organs studied (ie, spleen, pancreas, adrenal glands, stomach, colon, rectum) demonstrate significant changes in metabolism with advancing age. The metabolic volumetric product (calculated as the product of organ volume and mean organ SUV) of the liver and spleen does not change significantly with age. In conclusion, various abdominal organs demonstrate differential changes in volume, attenuation, and/or metabolism with increasing age in pediatric and adult populations.

Intestinal malabsorption in the elderly

BACKGROUND

Intestinal malabsorption in the elderly is infrequent, and clinical features are muted so that the diagnosis is often missed. Physiologic changes with aging are restricted to altered absorption of calcium and perhaps zinc and magnesium; however, achlorhydria can lead to impaired absorption of vitamin B(12), folic acid, and calcium.

METHODS AND RESULTS

Small bowel bacterial overgrowth occurs more commonly in elderly than in younger patients, accompanying gastric hypochlorhydria, altered intestinal motor activity, or diseases such as Parkinson's disease. Changes in pancreatic anatomy and secretion occur but are insufficient to produce macronutrient malabsorption. In addition to pancreatic cancer and pancreatic stones, older patients may present with severe pancreatic insufficiency of unknown etiology. Celiac disease is recognized as very common at all ages and may not become evident until late in life. Manifestations of celiac disease in the elderly are occult and the diagnosis often is not considered until serologic tests are performed and confirmed by upper small intestinal biopsy. Associated intestinal lymphoma, esophageal carcinoma, intestinal pseudo-obstruction, and splenic atrophy may be more common in the elderly. Treatment of older patients with celiac disease with a gluten-free diet may be difficult, and intensive vitamin and micronutrient replacement is mandatory. A pragmatic approach to the evaluation of malabsorption in elderly patients is discussed.

Ageing and the gut

The current concepts on diagnosis, clinical features, and management of common gastrointestinal conditions in the elderly population, taking into account physiological aspects of ageing, are evaluated. Gastrointestinal (GI) disorders are discussed with an emphasis on oesophageal problems, Helicobacter pylori infection, malabsorption, diverticular disease, and cancer. GI problems are acquiring greater importance in hospitals and in the community and their incidence is increasing. Newer treatments have less impact on patients' wellbeing and meticulously planned investigation and treatment is needed. Careful selection of patients and application of modern techniques has improved survival and outcomes, with comparable results to those in younger age groups.

Aging and the intestine

Over the lifetime of the animal, there are many changes in the function of the body’s organ systems. In the gastrointestinal tract there is a general modest decline in the function of the esophagus, stomach, colon, pancreas and liver. In the small intestine, there may be subtle alterations in the intestinal morphology, as well as a decline in the uptake of fatty acids and sugars. The malabsorption may be partially reversed by aging glucagon-like peptide 2 (GLP2) or dexamethasone. Modifications in the type of lipids in the diet will influence the intestinal absorption of nutrients: for example, in mature rats a diet enriched with saturated as compared with polysaturated fatty acids will enhance lipid and sugar uptake, whereas in older animals the opposite effect is observed. Thus, the results of studies of the intestinal adaptation performed in mature rats does not necessarily apply in older animals. The age-associated malabsorption of nutrients that occurs with aging may be one of the several factors which contribute to the malnutrition that occurs with aging.

Study of liver function in healthy elderly subjects using the 13C-methacetin breath test

BACKGROUND

The issue of whether or not liver function is compromised in the healthy elderly population remains unsolved.

AIM

To investigate the putative age-related modifications of hepatic function using the 13C-methacetin breath test. Because endogenous CO2 production changes with age, motor activity and nutrition, a different form of processing the results was investigated.

PATIENTS AND METHODS

Twenty-nine elderly subjects (mean age, 79.8 +/- 7.9 years; female/male ratio, 17/12) and 28 adult subjects (mean age, 40.6 +/- 12.3 years; female/male ratio, 13/15) underwent 13C-methacetin breath test and trans-abdominal echosonography with Doppler pulsed wave analysis of the coeliac axis and portal vein.

RESULTS

Although the 13CO2 peak occurred within 15-30 min in both elderly and adult subjects, it was significantly decreased in the former (30.66% +/- 9.2% vs. 38.33% +/- 6.05%; P < 0.001), as was the cumulative excretion (33.07% +/- 7.06% vs. 39.81% +/- 5.68%; P < 0.001). When correcting for the effects of CO2 excretion by age, the age-related modification of the cumulative dose became more evident (elderly group 30.15% +/- 6.46% vs. adult group 37.97% +/- 5.92%; P < 0.0001). The elderly group also showed an increase in the intra-hepatic resistance index using Doppler pulsed wave analysis, which inversely correlated with the results of the breath test.

CONCLUSIONS

Hepatic function is not well preserved in healthy humans throughout life and may be due to an increase in vascular resistance.

Physiologic determinants of the anorexia of aging: insights from animal studies

The anorexia of aging is a syndrome characterized by unexplained losses in food intake and body weight that occur near the end of life. Proposed etiologies cover a wide range of biological and psychological conditions. The observation of this phenomenon in older laboratory animals suggests that physiological changes play a significant causal role. Research on the neurochemical control of energy balance has received much attention in recent years, and age-related alterations in the neuropeptidergic effectors of food intake have been implicated in the anorexia of aging. This review provides an update on putative mechanisms underlying this dysregulation of feeding during advanced age.

Plasma vitamin D and 25OHD responses of young and old men to supplementation with vitamin D3

OBJECTIVES

This study was conducted to determine whether there are age differences in the plasma parent vitamin D and 25-hydroxyvitamin D (25OHD) responses to eight weeks of supplementation with 20 microg/day of vitamin D3.

METHODS

Twenty-five healthy young men (age 18-35) and 25 healthy older men (62-79) were randomly assigned to supplementation with 20 microg/day of vitamin D3 or to no intervention and followed for eight weeks. Plasma vitamin D3 was measured by high performance liquid chromatography and 25OHD was measured by competitive protein binding.

RESULTS

Both young and old men in the supplemented group had pronounced, rapid and similar increases in plasma vitamin D3, whereas vitamin D3 concentrations were stable in the control group. By the end of the eight-week adaptation period, plasma vitamin D3 of young and old men had increased by 4.3 and 6.2 nmol/L respectively. In the supplemented group, mean 25OHD concentrations of both the young and old men increased during the study, and the magnitude of the change after eight weeks was nearly identical in the two age groups (22.5 and 22.1 nmol/L in the young and the old men, respectively). In the control group there was a modest decrease in 25OHD of both the young and old men.

CONCLUSIONS

There appears to be no age-related impairment among men in the absorption or metabolism of 20 microg/day of vitamin D3 taken orally for at least eight weeks.

Liver function and phase I drug metabolism in the elderly: a paradox

Aging is accompanied by marked changes in the physiology of many organs, as well as in their constituent cells. These nonpathological alterations in structure and/or function may affect normal physiological processes in the elderly (individuals > 65 years), for example drug disposition. The liver plays a major role in drug clearance and aging has been reported to diminish this hepatic capacity, particularly the clearance of drugs that undergo mandatory oxidation by the microsomal cytochrome P450-dependent mono-oxygenase systems. Liver volume and blood flow decline with age in humans and, no doubt, this contributes to the diminished clearance of drugs that exhibit first-pass kinetic profiles. Changes in liver morphology with aging that have been described in rodents are limited to the hepatocytes, for example accumulation of dense bodies and loss of smooth surfaced endoplasmic reticulum. There is no evidence that the increase in intracellular lipofuscin adversely affects hepatocyte functions. A number of studies have documented significant age-related declines in the amounts, specific activities and rates of induction of liver microsomal mono-oxygenases in inbred male rats. On the basis of a variety of clinical tests, most liver functions in humans appear to be well preserved. The most remarkable characteristic of liver function in the elderly is the increase in interindividual variability, a feature that may obscure age-related differences. Most in vitro studies using nonhuman primate or human liver tissue did not detect age-related deficiencies in cytochrome P450-dependent microsomal mono-oxygenases. On the other hand, there have been recent reports of age-related, but not gender-related, declines in the in vitro activities of several human liver mono-oxygenases, for example the cytochrome P450 isoform CYP3A. Nevertheless, reduced liver volume and blood flow in the elderly permit the reconciliation of: the in vivo clinical pharmacokinetic data indicative of reduced hepatic drug clearance; and the absence of significant age-related declines in the amounts or in vitro activities of liver microsomal mono-oxygenases.

Nutrient absorption and intestinal adaptation with ageing

Malabsorption of carbohydrates, lipids, amino acids, minerals and vitamins has been described in the elderly. The ability of the intestine to adapt may be impaired in the elderly and this may lead to further malnutrition. Dietary manipulation may prove to be useful to enhance the needed intestinal absorption with ageing. There is an age-associated increase in the prevalence of dyslipidaemia as well as diabetes. These conditions may benefit from nutritional intervention targeted at reducing the absorption of some nutrients. With the continued characterization of the proteins involved in sterol and fatty acid absorption, therapeutic interventions to modify absorption may become available in the future.

Drug metabolism and drug interactions in the elderly

In the elderly concomitant use of several drugs (polypharmacy) is very common. Thus, the risk for drug interactions might be increased in this population. Since most drugs are hepatically eliminated by various metabolic pathways, liver function has to be considered as an additional factor modifying drug response. This chapter focuses on the hepatic mechanisms of interactions, especially on various inhibitors and inducers of the most important cytochrome P450 isoenzymes involved in drug metabolism. In addition, age-dependent changes in liver function are addressed. Based on pharmacokinetic results with different probe drugs, some inconsistencies in this area are discussed. The most important metabolic drug-drug interactions are independent of the age of the patients. However, since elderly patients consume a greater proportional share of drugs, they represent a population at risk for interactions. Awareness of this clinical problem may help to diminish those risks.

Nutrition in the elderly

Nutrition is a prime concern for the optimal health of older persons. Nutritional requirements for older persons must take into account the physiologic changes that occur with aging. The gastrointestinal tract is the site of key structural and functional changes that affect nutrient intake and assimilation. A working knowledge of nutritional screening, assessment, and interventions can assist the practitioner in providing quality care for the older patient.

Diarrhea and malabsorption in the elderly

Physicians who care for elderly patients should be alert to the possible presence of diarrhea and malabsorption. Older patients may not admit to having chronic diarrhea, particularly if they also are incontinent. If diarrhea is of short duration, an infectious cause is at least as common as in the young. Institutionalized elderly are particularly prone to gastrointestinal infections, but the manifestations may not be overt. When an intestinal infection and potential medication-induced gastrointestinal disturbances have been excluded, the differential diagnosis of diarrhea in the elderly is the same as in the young. Causes include intestinal malabsorption, even though diarrhea is a less common manifestation of malabsorption in the old than in younger patients. In the elderly, micronutrient deficiency is a common presenting clinical picture; because the symptoms of malabsorption are covert, the diagnosis often is delayed, and nutritional deficiencies are more common and more severe than in the young. Because the elderly have less nutritional reserve than the young, these deficiencies are clinically much more devastating in the elderly. Although the causes of malabsorption, as a whole, are similar in older and younger patients, chronic pancreatic insufficiency of unknown cause and intestinal bacterial overgrowth without an anatomic abnormality of the small intestine are syndromes that are specific to the elderly and must be considered in any older patient with unexplained weight loss or failure to thrive. Often, therapeutic trials are necessary to establish a potential diagnosis.

Factors in aging that effect the bioavailability of nutrients

Until a few years ago, little was known about bioavailability of micronutrients in elderly humans. It was assumed by many basic investigators and geriatricians that malabsorption of both macronutrients and micronutrients was a common problem among elderly persons. We now know that this is not the case; elderly persons who malabsorb macronutrients do so because of disease, not because of age. This report will be divided into three sections. The first section focuses on the general principles of absorptive processes in elderly persons. The second section focuses on the bioavailability of specific micronutrients in elderly persons, with specific examples of "problem" nutrients. The third section lays out a proposed research agenda for studying the bioavailability of nutrients and other active components of dietary supplements in elderly persons.

Fatores que afetam o consumo alimentar e a nutrição do idoso

Os fatores que afetam o consumo alimentar das pessoas idosas são reconhecidos como de risco para o desenvolvimento da má nutrição. Este artigo busca fazer uma revisão abrangente sobre esses fatores, procurando também elucidar as condições de nutrição dos idosos brasileiros. A compreensão desses fatores pelos profissionais de saúde amplia o entendimento das condições peculiares que determinam o estado nutricional do idoso e que devem ser trabalhadas de forma interligada, para manutenção ou restauração da eutrofia.

The aging process as a modifier of metabolism

Because elderly adults have distinct metabolic characteristics that alter various nutrient requirements, simple extrapolations of nutrient requirements for younger adults are not warranted. Gastrointestinal function is well preserved with aging regarding the digestion and absorption of macronutrients, but the aging gastrointestinal tract becomes less efficient in absorbing vitamin B-12, vitamin D, and calcium. The new dietary reference intakes considered recent studies in aging adults and concluded that the recommended dietary allowances (RDAs) should be 1200 mg and 15 microg for calcium and vitamin D, respectively, for persons over the age of 70 y. The new RDAs for riboflavin, niacin, thiamine, folate, vitamin B-6, and vitamin B-12 are not different for persons in the oldest age category (>70 y) than for those aged 51-70 y. Because this is a quickly advancing field, it will be important to closely follow new research on nutrient requirements and aging over the next several years.

D-xylose testing

The literature on D-xylose testing has been reviewed, stressing advances in our understanding of absorption in general (including D-xylose absorption), the relationship of D-xylose testing to the development of excellent serologic tests for the diagnosis of celiac disease, the use of D-xylose testing in the evaluation of diarrhea in acquired immunodeficiency syndrome, new information on breath testing for the evaluation of malabsorption, and recent information on the understanding of D-xylose absorption compared with transcellular vs. paracellular transport. The authors suggest ways in which D-xylose testing might be employed in malabsorption or diarrhea evaluations, including some algorithms.

Nutrition in the exercising elderly

When making nutrition recommendations to the exercising elderly population, four important areas should be taken into consideration: (1) the changing needs that occur with age; (2) the changing needs that occur with exercise; (3) the presence of any chronic illnesses or diseases; and (4) whether one is exercising for fitness, recreation, or competition. For the most part, these four areas have been researched separately, and recommendations for elderly athletes need to be synthesized from this information. The nutrients for which food consumption is often inadequate and has the largest impact on the exercising elderly population include vitamin B6, vitamin B12, calcium, and vitamin D. The exercising elderly population needs to be aware of their bodies changing needs with exercise and should focus on maintaining energy balance while selecting a wide variety of foods high in complex carbohydrates. When adequate dietary intakes cannot be obtained, supplementation with a multivitamin of no more than 100% of the RDA is recommended.

Steatorrhea and weight loss in a 72-year-old man: primary biliary cirrhosis? Celiac disease? Bacterial overgrowth? What else?

Unintentional weight loss is an ominous sign, particularly when it occurs in the elderly; concern for malignancy is especially worrisome. In this report, we describe a 72-yr-old man who presented with weight loss and was found to have massive steatorrhea. An extensive evaluation revealed evidence of primary biliary cirrhosis (PBC), celiac disease, and small intestinal bacterial overgrowth. No malignancy was identified. The weight loss was attributed to severe steatorrhea due, in part, to intraluminal bile salt deficiency, small bowel mucosal disease, and bacterial overgrowth. Several points are discussed regarding gastrointestinal function in elderly patients with chronic liver disease secondary to PBC. The rare association between PBC and celiac disease in adults is also discussed. Finally, we suggest that bacterial overgrowth plays a significant role in the development of steatorrhea in some persons with PBC and that an assessment for bacterial overgrowth should be performed on persons with steatorrhea and PBC.

Proliferating cell nuclear antigen expression is increased in small bowel epithelium in the elderly

Although previous studies suggest that in aging animals the small intestine is in a hyperproliferative state, no information is currently available on the influence of age on the proliferation pattern of human small bowel enterocytes. The immunohistochemical expression of the proliferating cell nuclear antigen (PCNA), the villous height to total mucosal thickness ratio and the enterocyte height were evaluated in a panel of duodenal biopsy specimens obtained from 18 subjects aged less and 14 subjects aged more than 65 years. There was a significant positive correlation (P < 0.001) between age in years and percent of positive PCNA enterocytes both at the level of crypts (rs = 0.50) and villi (rs = 0.77). Moreover, the percentage of PCNA+ enterocytes was significantly higher in elderly versus adult subjects, both at the level of villi (6.5 vs 0%; P < 0.001) and of crypts (40.0 vs 23.7%; P < 0.01). No correlation was found between the percentage of PCNA + enterocytes and enterocyte height or villous height to total mucosal thickness ratio. Our results show that PCNA reactivity increases with advancing age both in crypts and villi. This abnormality of the proliferation pattern may explain the coexistence of normal morphology and impaired absorptive function in the elderly.

The aging gut. Nutritional issues

With improvements in health care, living standards, and socioeconomic status, more adults are living to old age. As the population ages, it is increasingly important to understand the factors that affect the nutritional status and thus the health status of older adults. Many factors contribute to inadequate nutrition, including health status, financial capacities, mobility, exercise, and physiologic needs. This article considered only the potential changes in nutritional needs because of alterations in the gastrointestinal tract owing to aging. One of the most remarkable changes with aging is the frequent development of atrophic gastritis and the inability to secrete gastric acid. This process affects approximately a third of older adults in the United States and only recently was recognized to be due to infection by H. pylori in the majority of cases. The lack of gastric acid in atrophic gastritis may lead to small intestinal bacterial overgrowth and influences the absorption of a variety of micronutrients, including iron, folate, calcium, vitamin K, and vitamin B12. Lactose maldigestion is a frequent condition in older adults and is extremely common worldwide. The intolerance of dairy products leads to avoidance of these foods and likely contributes to the development of osteopenia. Overall, the small intestine and pancreas undergo astonishingly few clinically significant changes with aging. The relative preservation of overall gastrointestinal function with aging is likely due to the large reserve capacity of this multiorgan system. Further research is needed to define the precise nutritional needs for older adults because simple extrapolation of values from younger adults is now recognized to be insufficient. In addition, it is no longer acceptable to define adequate nutriture in terms of amounts of vitamins needed to maintain serum levels of a nutrient. Further RDAs must consider the functional implications of adequate nutrition. Nutrients in the elderly will be measured as to whether they result in improvements in markers of chronic disease such as homocysteine or, most importantly, in the prevention of chronic disease such as osteoporosis and cardiovascular disease.

Intestinal lipid esterification and aging in mice and rats

The effects of aging on lipid absorption, particularly on fatty acid glycerophospholipid and triacyl-glycerol esterification, were investigated in 2.5-, 12- and 24-month-old mice and rats. Two intestinal mucosa microsomal enzymes, involved in the dietary fatty acid absorption, were assayed: acylCoA:2-monoacylglycerol acyltransferase and acylCoA:1-lysophosphatidylcholine acyltransferase. In both mice and rats, the activities of both enzymes varied with the nature of the acyl-CoA. Indeed acylCoa:2-monoacylglycerol acyltransferase activities were significantly higher with oleoyl-CoA and linoleoyl-CoA than with palmitoyl-CoA and arachidonoyl-CoA, while acylCoA:1-lysophosphatidylcholine acyltransferase activities were highest with arachidonoyl-CoA. AcylCoA:2-monoacylglycerol acyltransferase activity did not decrease significantly with aging in mice or rats, whatever the acyl-CoA used. In contrast, acylCoA:1-lysophosphatidylcholine acyltransferase activity in the 24-month-old rats was significantly lower (-47%) than in 2.5-month-old rats, with oleoyl-CoA, linoleoyl-CoA and arachidonoyl-CoA. Simultaneously we observed that less glycerophospholipid esterification of oleic and linoleic acid occurs in older rats than in 2.5-month-old rats.

Postprandial triglyceride-rich lipoprotein changes in elderly and young subjects

To determine whether an increased risk for atherosclerosis in older humans is related to changes in postprandial lipoprotein metabolism, we compared the dynamic profiles (0-10 hours) of triglyceride (Tg)-rich lipoproteins and the Tg content in VLDL subfractions in elderly and young subjects after an oral fat load. The plasma Tg response curves displayed significant differences between the groups at all times. Postprandial triglyceridemia was quantified from the plasma response curves as an incremental area, and was significantly different in the two groups (young subjects 231.9 +/- 199.6 vs elderly subjects 511.0 +/- 305.6 mg/dL x 10 hr, p = 0.036). The more scattered VLDL-Tg values were significantly different compared to values at baseline and 6 hours after fat load. Tg baselines in the four VLDL subfractions (expressed as percentages) were higher in the larger particles (B Sf = 175-400) in the elderly subjects, and in the smaller, denser particles (D Sf = 20-100) in the young subjects. In both groups, postprandial hyperlipidemia increased the Tg content of the larger, less dense particles (Sf more than 400), and reduced that of the denser particles. These variations usually coincided with the plasma Tg and VLDL peaks: 63% to 70% above the Tg baseline between the 2nd and 4th hour in all the young subjects: 48% to 68% above the baseline between the 4th and the 6th hour in all the elderly subjects. Total cholesterol variations showed no significant differences between the two groups at any time. All subjects tested for the missense mutation at codon 188 of the human lipoprotein lipase (LPL) gene resulted noncarriers of LPL mutant alleles. Our data show that, after a fatty meal, healthy elderly subjects tend to present prolonged postprandial hypertriglyceridemia, suggesting an atherogenic behavior of their lipid metabolism.

Metabolism of aminopyrine and derivatives in man: in vivo study of monomorphic and polymorphic metabolic pathways

1. The main metabolic pathways involved in the biodisposition of aminopyrine have been monitored in vivo in 60 healthy volunteers by measuring the amount of parent drug and metabolites recovered in the urine 24 h after oral administration of 250 mg aminopyrine. 2. The amount of metabolites in the 24-h urine was (mean +/- SD of 60 individuals): unchanged aminopyrine, 0.2 +/- 0.2 mg; methyl aminoantipyrine, 4.5 +/- 2.8 mg; formyl aminoantipyrine, 18.5 +/- 10.1 mg; aminoantipyrine, 9.2 +/- 6.6 mg; and acetyl aminoantipyrine, 31.8 +/- 21.1 mg. 3. Large interindividual differences (12-200-fold changes) are present in all the metabolic steps involved in aminopyrine biotransformation. These differences are not related to gender, intake of caffeine or alcohol, or known drug-metabolizing polymorphisms such as those involved in debrisoquine or mephenytoin metabolism. In contrast, smoking resulted in a decrease in the N(4)-demethylation ratio (p = 0.011). 4. The interindividual differences followed an apparently normal distribution in the N(4)- and N(2)-dimethylation and formylation pathways (p > 0.1). In contrast, acetylation follows a polymorphic distribution (p < 0.03), with an apparent antimode ratio close to 4. With the exception of the acetylation pathway, all of the metabolic ratios correlated between themselves (p < 0.001).

Changes in small-intestine permeability with aging

OBJECTIVE

To evaluate small-intestine mucosal integrity and permeability with advancing age as measured by the lactulose/mannitol absorption test in healthy subjects.

DESIGN

Prospective cohort study.

SETTING

Clinical research unit of the USDA Human Nutrition Research Center on Aging.

STUDY PARTICIPANTS

Fifty-six subjects were recruited in three age groups: 20 to 39 years (n = 20), 40 to 59 years (n = 19), and > or = 60 years (n = 17). Subjects were healthy, community-dwelling volunteers.

INTERVENTION

After an 8-hour fast, all subjects ingested 10 g of lactulose and 5 g of mannitol. Urine was collected for 6 hours and analyzed for lactulose and mannitol by high performance liquid chromatography. Twenty-four-hour urinary creatinine clearances were determined.

MAIN OUTCOME MEASURES

Percentages of lactulose and mannitol excreted, the lactulose/mannitol ratio (x100), and the 24-hour creatinine clearance.

RESULTS

With increasing age, both the percentage of lactulose excreted (P = 0.09) and the percentage of mannitol excreted (P = 0.05) tended to decrease progressively. The lactulose/mannitol ratio (x100) did not change with increasing age (P = 0.65) because both the percentages of lactulose and mannitol excreted declined. The creatinine clearance decreased markedly with advancing age (P < .001) and accounted for the decline in percentages of lactulose and mannitol excreted (P < .02).

CONCLUSIONS

There is a progressive decline in the ability to excrete lactulose and mannitol with increasing age. This is probably attributable to a decline in renal function with advancing age. However, because of parallel decreases in lactulose and mannitol excretion, the lactulose/mannitol ratio does not change. Thus small-intestine "leakiness" does not increase with aging as measured by the lactulose/mannitol absorption test.

The effect of diarrhea on fecal fat excretion

To determine whether diarrhea increases fecal fat excretion, fecal fat output was measured during three consecutive days in normal subjects and in normal subjects in whom diarrhea was purposefully induced. Mean fecal fat output in normal subjects was 3.4 g/day; the upper limit of normal was 6.4 g/day. Twenty-one percent of subjects with mild to moderate diarrhea (fecal weight 200-800 g/day) and 58% of subjects with severe diarrhea (fecal weight greater than 800 g/day) had fecal fat excretion above the upper limit of normal, with values as high as 13.6 g/day. It is concluded that (a) diarrhea itself can induce mild secondary steatorrhea, and (b) when the quantitative fecal fat test is used in patients with diarrhea, mild abnormalities (up to 14 g/day) are not specific for a primary defect in fat digestion or absorption, i.e., they may represent false-positive results.

Effect of aging and other factors on monocyte aryl hydrocarbon hydroxylase activity

A measure of the activity of macrophage drug metabolizing enzymes through assay of peripheral monocytes was used to assess the hepatic enzymatic status and thereby evaluate age related changes in drug metabolism. Blood was obtained from elderly subjects (aged 74.8 +/- 5.2, mean +/- S.E., n = 16) and a young control group (aged 23.5 +/- 2.0, n = 27). Monocyte AHH activity was used as an index of liver drug metabolism, ALT activity as an index of liver function, monocyte media IL-1 and as an index of macrophage activation and serum IL-1 levels as a measure of endogenous pyrogenic activity. The medium collected from the cultured monocytes was also assessed for the presence of AHH inhibitory activity. Subjects provided information relating to their age, sex, alcohol consumption, cigarette smoking, recent infection, recent surgery, disease status and medications which could alter drug metabolism. Elderly patients were drawn both from independent seniors living at home and seniors visiting a geriatric day hospital and compared to a control group of young healthy volunteers. Using the experimental design AHH activity did not differ within experimental error between aged (0.832 +/- 0.32 nmol/mg prot. per h, n = 16) and young control subjects (0.452 +/- 0.17, n = 27). ALT activity did not differ between aged (2.83 I.U. +/- 0.46) and young (4.24 +/- 0.82). Monocyte AHH activity did not differ between males (0.45 +/- 0.14, n = 33) compared to females (0.65 +/- 0.18, n = 29), but was significantly higher in smokers (2.5 +/- 1.0, n = 5) compared to non-smokers (0.35 +/- 0.05, n = 52). Mild to moderate alcohol use showed no significant effect on AHH activity. There was no significant difference between the mean level of MCM inhibition of murine hepatocyte AHH between elderly (44.3 +/- 8.32%, n = 8) and control (31.5 +/- 6.21%, n = 15) subjects, but a larger proportion of the elderly population demonstrated such an effect. Serum IL-1 levels (range 0-55.9 pg/ml) were compared to MCM IL-1 and AHH inhibitory activity in the elderly and young group.

Postprandial plasma retinyl ester response is greater in older subjects compared with younger subjects. Evidence for delayed plasma clearance of intestinal lipoproteins

Postprandial vitamin A and intestinal lipoprotein metabolism was studied in 86 healthy men and women, aged 19-76 yr. Three independent experiments were carried out. In the first experiment, a supplement dose of vitamin A (3,000 retinol equivalents [RE]) was given without a meal to 59 subjects, aged 22-76 yr. In the second experiment, 20 RE/kg body wt was given with a fat-rich meal (1 g fat/kg body wt) to seven younger subjects (aged less than 50 yr) and seven older subjects (aged greater than or equal to 50 yr). In both experiments, postprandial plasma retinyl ester response increased significantly with advancing age (P less than 0.05). In the third experiment, retinyl ester-rich plasma was infused intravenously into nine young adult subjects (aged 18-30 yr) and nine elderly subjects (aged greater than or equal to 60 yr), and the rate of retinyl ester disappearance from plasma during the subsequent 3 h was determined. Mean (+/- SE) plasma retinyl ester residence time was 31 +/- 4 min in the young adult subjects vs. 57 +/- 8 min in the elderly subjects (P less than 0.05). These data are consistent with the concept that increased postprandial plasma retinyl ester concentrations in older subjects are due to delayed plasma clearance of retinyl esters in triglyceride-rich lipoproteins of intestinal origin.