For several months, 99-year-old white man in an assisted-living facility has experienced bouts of explosive diarrhea. It occurred every day and only after breakfast. Restricting the patient’s dairy intake led to some improvement. After being placed on a gluten-free diet, the frequency has lessened to two to three times per week, but the diarrhea has not resolved.

The patient’s medications are furosemide [Delone, Furocot, Lasix, Lo-Aqua], low-dose aspirin and vitamin D. His weight and vital signs have been stable; physical examination was unremarkable except for cool extremities and trace pitting edema to the legs.

A complete blood count (CBC) and comprehensive metabolic profile (CMP) were within normal limits. A stool culture taken three years ago was negative for Clostridium difficile. The family does not want any invasive testing. An abdominal CT taken four years ago was unremarkable. Where can I go from here? — Mary Keane, GNP-BC, Saginaw, Mich.

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This patient’s condition may be related to dietary issues. I recommend eliminating any artificially sweetened foods, which can also contribute to diarrhea in older adults living in long-term-care facilities.

Although the diagnostic tests are not current, it is unlikely that this man would be suffering from C. difficle or other infectious causes while maintaining a normal weight, vital signs, CBC and CMP.

Lactose malabsorption is more prevalent in individuals older than age 74 years. Restricting foods that contain milk and milk products should continue to be helpful. Be sure that the patient is not impacted. If impaction is not present, an empiric trial of such bile-acid-binding resins as cholestyramine is the least expensive way to diagnose bile-acid-induced diarrhea and increase bulk in his stools. Consider repeating stool cultures, including C. difficle and ova and parasites. — Deborah L. Cross, MPH, CRNP, ANP-BC (169-3)