Management of Nausea and Vomiting in Geriatric Patients
Start with metoclopramide 5 mg orally or IV three times daily as first-line treatment, using doses reduced by 25-50% compared to standard adult regimens, while simultaneously identifying reversible causes such as medication adverse effects, constipation, gastroesophageal reflux, metabolic abnormalities, and gastroparesis. 1
Initial Diagnostic Evaluation
The evaluation must focus on specific high-yield elements rather than generic assessment:
Critical History Elements
- Medication review: Identify drugs with psychoactive properties (benzodiazepines, corticosteroids, anticholinergics, opioids) that commonly cause nausea in elderly patients 2
- Timing patterns: Determine if symptoms occur with position changes (orthostatic), after meals (gastroparesis), or are constant (metabolic/central causes) 3, 4
- Associated symptoms: Look for constipation/fecal impaction, heartburn, abdominal pain, neurologic changes, or dehydration 1, 5
- Red flags: Hematemesis, severe abdominal pain, sudden onset with cardiac symptoms, or syncope require urgent evaluation 2, 6
Physical Examination Priorities
- Volume status: Assess mucous membrane moisture, skin turgor, orthostatic vital signs to gauge dehydration severity 6
- Abdominal examination: Palpate for distension, masses, tenderness; perform rectal exam to rule out fecal impaction 1, 5
- Neurologic screening: Check for confusion, focal deficits, or signs of increased intracranial pressure 5
Laboratory Testing
- Electrolytes, calcium, glucose: Rule out hypercalcemia, hyponatremia, hyperglycemia, and other metabolic derangements 1, 5
- Renal function: Essential for medication dosing adjustments in elderly patients 1
- Consider additional tests based on clinical suspicion: liver enzymes, thyroid function, drug levels 3, 4
Stepwise Pharmacologic Treatment Algorithm
First-Line: Dopamine Antagonists
Metoclopramide 5-10 mg PO/IV three times daily is the preferred initial agent, with elderly patients requiring the lower end of dosing 1. This targets dopaminergic pathways in the chemoreceptor trigger zone and enhances gastric emptying 2, 5.
Alternative first-line option: Haloperidol 0.5-1 mg PO/IV every 4-6 hours (maximum 5 mg/day in elderly, compared to 10 mg/day in younger adults) 1. Haloperidol can be given subcutaneously if oral route is not feasible 1.
Critical geriatric consideration: All dopamine antagonists carry risk of extrapyramidal side effects, which are more common in elderly patients; monitor closely and treat with diphenhydramine 50 mg IV if symptoms develop 1, 6.
Second-Line: Add 5-HT3 Antagonist
If symptoms persist after 24-48 hours of first-line therapy, add ondansetron 4-8 mg PO/IV 2-3 times daily 2, 1, 5. The key principle is adding agents from different drug classes rather than switching, as different neuroreceptors mediate the emetic response 5.
Practical tip: Ondansetron sublingual tablets improve absorption in actively vomiting patients 5.
Third-Line Options for Refractory Symptoms
When combination dopamine antagonist plus 5-HT3 antagonist fails:
- Olanzapine 2.5-5 mg PO daily: Particularly effective in palliative care settings and for refractory symptoms 1, 5
- Dexamethasone 2-8 mg PO/IV 2-3 times daily: Especially useful for bowel obstruction or intracranial hypertension 2
- Lorazepam 0.25-0.5 mg PO/sublingual 2-3 times daily (maximum 2 mg/24 hours): For anxiety-related nausea, but use cautiously given fall risk and cognitive effects in elderly 1
Route of Administration Considerations
The oral route is often not feasible during active vomiting 5. Alternative options include:
- Sublingual formulations (ondansetron, lorazepam) 1, 5
- Subcutaneous administration (haloperidol, metoclopramide) 1
- Rectal suppositories (prochlorperazine, promethazine) 5
- Continuous subcutaneous infusion via syringe driver for severe, persistent symptoms 1
Cause-Specific Management
Gastroesophageal Reflux/Gastritis
Add proton pump inhibitor (omeprazole 20 mg daily) or H2 receptor antagonist to antiemetic regimen 1, 5, 6. Patients may confuse heartburn with nausea, making acid suppression therapeutic 6.
Severe Constipation/Fecal Impaction
Aggressive bowel regimen with stimulant laxatives and manual disimpaction if needed before expecting antiemetics to work effectively 1, 5.
Medication-Induced
Discontinue or reduce offending agents (opioids, antibiotics, NSAIDs, digoxin) when possible 1, 3. This is often the most effective intervention.
Gastroparesis
Metoclopramide is specifically indicated as it enhances gastric motility; use scheduled dosing (every 6-8 hours) rather than as-needed 5, 6.
Bowel Obstruction (Malignant)
Octreotide should be utilized to reduce secretions and control symptoms 2. Avoid metoclopramide in complete mechanical obstruction 5.
Critical Geriatric-Specific Precautions
Dose Reduction Imperative
All antiemetics require 25-50% dose reduction compared to standard adult regimens in elderly patients 1. This accounts for:
- Reduced renal clearance 1
- Increased sensitivity to CNS effects 1
- Higher risk of extrapyramidal symptoms 1, 6
Benzodiazepine Cautions
Avoid long-term benzodiazepine use due to dependence risk, falls, and cognitive impairment 1. When used, start lorazepam at 0.25 mg (half the typical starting dose) and taper gradually when discontinuing 1.
Monitoring Requirements
- Extrapyramidal symptoms: Akathisia, dystonia, parkinsonism with dopamine antagonists 1, 6
- QTc prolongation: Particularly with haloperidol and ondansetron in combination 2
- Sedation and fall risk: With all antiemetics, especially when combining agents 1
Supportive Care Essentials
Fluid and Electrolyte Management
Administer isotonic IV fluids (normal saline or lactated Ringer's) to correct dehydration 6. Monitor and correct hypokalemia, hypomagnesemia, and hypochloremia, which are common with persistent vomiting 6.
Non-Pharmacologic Measures
- Small, frequent meals rather than large meals 3
- Avoid trigger foods (fatty, spicy, or strong-smelling foods) 3
- Optimize environment: Adequate lighting, familiar surroundings, caregiver involvement to reduce anxiety 1
When to Escalate Care
Hospitalize for:
- Hematemesis or signs of gastrointestinal bleeding 6
- Severe dehydration unresponsive to oral rehydration 6
- Suspected bowel obstruction or other surgical emergency 5
- Intractable symptoms despite maximal outpatient therapy 7
Consider palliative sedation as last resort for intractable symptoms in end-of-life care when all other interventions have failed 2, 1.
Common Pitfalls to Avoid
- Using as-needed dosing instead of scheduled prophylactic administration: Scheduled dosing is more effective for persistent symptoms 6
- Switching between antiemetics rather than adding agents: Combination therapy targeting multiple pathways is superior 5
- Neglecting to address underlying causes: Treating fecal impaction or stopping offending medications is often more effective than escalating antiemetics 1, 5
- Using standard adult doses: Always reduce initial doses by 25-50% in elderly patients 1
- Continuing oral medications during active vomiting: Switch to parenteral, sublingual, or rectal routes 5