What are the possible causes of intermittent nausea in a 67‑year‑old patient?

Causes of Intermittent Nausea in a 67-Year-Old Patient

In a 67-year-old patient with intermittent nausea, the most common causes are medication side effects, gastroparesis (especially if diabetic), gastroesophageal reflux disease, metabolic abnormalities (hypercalcemia, electrolyte disturbances), and cyclic vomiting syndrome—with medication review being the single most critical first step. 1, 2

Medication and Toxin-Related Causes

• Review all current medications immediately, as drug adverse effects are among the most common reversible causes of nausea in older adults 3, 1
• Check blood levels of digoxin, phenytoin, carbamazepine, and tricyclic antidepressants if the patient takes these medications 4
• Consider polypharmacy as a contributing factor, which is particularly prevalent in this age group 3
• Obtain a urine drug screen to assess for cannabis use, as Cannabis Hyperemesis Syndrome can present with intermittent symptoms even in older adults 5

Gastrointestinal Causes

• Gastroparesis is a leading cause, occurring in 20-40% of diabetic patients and 25-40% of those with functional dyspepsia 4
• Gastroesophageal reflux disease and gastritis commonly cause intermittent nausea and can be confused with primary nausea by patients 4, 5
• Gastric outlet obstruction should be considered if there is postprandial fullness or early satiety 4
• Perform gastric emptying scintigraphy with a 4-hour protocol (not 2-hour) to accurately diagnose gastroparesis, as shorter durations are inaccurate 4
• Obtain one-time esophagogastroduodenoscopy to exclude obstructive lesions, but avoid repeated endoscopy unless new symptoms develop 5

Metabolic and Endocrine Causes

• Obtain complete blood count, comprehensive metabolic panel including calcium, glucose, liver function tests, lipase, and urinalysis 5
• Check for hypercalcemia, which frequently causes nausea and is common in older adults 4, 6
• Test thyroid function and consider adrenal insufficiency if clinically indicated 5, 7
• Monitor for electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which can both cause and result from nausea 5, 6

Cyclic Vomiting Syndrome

• Consider Cyclic Vomiting Syndrome (CVS) if episodes are stereotypical, self-limited, and separated by symptom-free intervals 4
• CVS can present later in life and is characterized by episodes lasting less than 7 days with at least 1 week between episodes 4
• Look for typical comorbid conditions including anxiety, postural orthostatic tachycardia syndrome, and migraine headaches 4
• A subset of patients develop "coalescent CVS" with chronic baseline nausea punctuated by more severe episodic vomiting, which poses diagnostic challenges 4
• Detailed history should reveal a pattern of episodic symptoms that preceded any coalescent phase 4

Neurologic Causes

• Vestibular disturbances and migraine-associated nausea can present with intermittent symptoms 1, 2
• Central nervous system pathology should be considered if there are associated neurological symptoms 7, 2

Critical Diagnostic Pitfalls to Avoid

• Do not assume physiological aging causes nausea—it does not, and a specific etiology should be sought 3
• Symptoms are poor predictors of functional versus pathological illness, so objective testing is essential 7
• Never dismiss cannabis use history; Cannabis Hyperemesis Syndrome requires 6 months of cessation or 3 typical cycle lengths without vomiting for definitive diagnosis 5
• Avoid repeated imaging or endoscopy without new symptoms, as this increases cost without improving outcomes 5

Initial Management Approach

• Correct any identified metabolic abnormalities first (hypercalcemia, electrolyte disturbances, hyperglycemia) 5, 6
• If gastroparesis or gastritis is suspected, initiate a proton pump inhibitor and metoclopramide 10-20 mg three to four times daily, which provides both antiemetic and prokinetic effects 5, 6
• For nonspecific intermittent nausea, start with dopamine receptor antagonists (metoclopramide, prochlorperazine 5-10 mg four times daily, or haloperidol 0.5-1 mg every 6-8 hours) 4, 5, 6
• Add ondansetron 4-8 mg two to three times daily if symptoms persist after 4 weeks of first-line therapy 5, 6
• Monitor for extrapyramidal symptoms with metoclopramide, particularly dystonic reactions, and treat immediately with diphenhydramine 50 mg if they develop 8, 5
• Be aware that metoclopramide carries risk of tardive dyskinesia with chronic use in elderly patients 8