Constipation: Outpatient Management of Constipation in Older Adults
Constipation is common in older adults. Up to 28% of individuals over age 65 experience constipation, and it is the reason for more than 2.5 million office visits to primary providers each year in the US. Although constipation is common in older adults, it should not be considered normal. When evaluating patients who have constipation, clinicians should seek to identify reversible causes with the goal of improving quality of life and avoiding complications that include risk for fecal impaction and incontinence, hemorrhoids, anal fissure, organ prolapse, and bowel obstruction.
|TIPS FOR DEALING WITH CONSTIPATION IN OLDER ADULTS|
Patients and clinicians often have different ideas about what is normal when it comes to bowel movements. To help define and diagnose constipation, the American Gastroenterological Association (AGA) refers to otherwise uncomplicated constipation as “functional” constipation and recommends using the Rome III criteria for diagnosis. The Rome III criteria specify that the first symptoms of constipation should have begun at least 6 months previously and that two of the following must be present for at least 3 months: (a) fewer than three defecations per week or any of the following during at least 25% of defecations: (b) lumpy or hard stools, (c) a sensation of incomplete evacuation, (d) a sensation of anorectal obstruction/ blockage, or (e) the need for manual maneuvers, like digital stimulation. In addition, loose stools should rarely be present and the patient should not meet criteria for irritable bowel syndrome (IBS). A key difference between constipation and IBS is that IBS involves pain relieved by defecation, while constipation by itself is not painful.
Factors That Can Cause or Contribute to Constipation
Constipation in older adults almost always involves multiple contributing causes (Table 1), all of which should be considered during the evaluation. The history should include questions about medical conditions, medications, prior surgeries, and pelvic floor trauma. Questions should also specifically ask about “red flags,” such as acute onset, weight loss, rectal bleeding, and a personal or family history of colorectal cancer, any of which might indicate malignancy as the cause of constipation.
|Table 1. Factors That Can Cause or Contribute to Constipation|
– Anorectal pathology (fissures, strictures, prolapse, hemorrhoids)
The AGA recommends performing a complete blood count, thyroid function tests, and a basic metabolic panel. Colonoscopy should be performed if there is concern about cancer or if the patient is due for routine colon cancer screening. Other tests, such as colonic transit testing, anorectal manometry, and balloon expulsion testing, should only be done when patients fail a therapeutic trial of laxatives and increased dietary fiber.
Treatment for Constipation
Medical conditions that may be contributing to constipation should be treated and controlled. Constipating medications should be discontinued whenever possible or changed to agents with similar action but less potential for constipation. Counsel patients to respond to the urge to defecate when it occurs and to develop a schedule for bowel movements. The bowels are most active in the morning and 30-60 minutes after meals, so patients should be taught to take advantage of these times to use the bathroom. Institutionalized patients should be given enough time and privacy to have bowel movements. Valsalva should be avoided in cardiac patients as it can result in bradycardia and death. Although increasing mobility is effective for preventing constipation, there is no evidence that it is effective once constipation develops. Similarly, there is no evidence to support fluid status as a factor contributing to constipation. Increasing fluid intake in older adults, many of whom have a delicate fluid balance at baseline, should be avoided. Dietary fiber, however, is effective and intake should be increased. The increase should occur slowly (over the course of a few weeks) to the goal intake of 25-35 grams daily. Increasing too quickly can result in bloating and flatulence.
There is no good evidence to guide drug treatment of constipation in older adults. Medications are, however, considered appropriate to use when the response to nonpharmacological treatment has been inadequate. To decrease adverse effects, the choice of laxative should be made with the patient’s comorbidities in mind. Table 2 describes available laxatives and gives guidance on how to choose an appropriate agent. Enemas and suppositories should only be used to treat acute constipation. Patients taking laxatives should ensure good fluid intake to avoid dehydration. Those requiring opioids should receive prophylactic bowel regimens to prevent constipation. Lubiprostone, promoted for treating constipation in the general population, has not been studied in older adults. New evidence supports the use of probiotics to prevent constipation in hospitalized patients, but more research is needed before this can be considered standard care. Biofeedback is only effective when treating constipation caused by anorectal dysfunction and is not appropriate for patients with cognitive impairment. Surgery, such as subtotal or total colectomy for treatment of colonic inertia, should only be considered for severe recalcitrant cases.
|Table 2. Selecting Laxatives for Constipation in Older Adults|
|Type of Laxative||Examples||Key Side Effects||What to Consider|
|Bulk Laxatives||Psyllium Methylcellulose||Bloating, flatulence, impaction above strictures||Can decrease absorption of some medications, including warfarin, aspirin, digoxin|
|Emollient Laxatives (Stool softeners)||Docusate Sodium|
|Fecal soiling||Not recommended for chronic treatment|
|Osmotic Laxatives||Polyethylene Glycol||Bloating, flatulence, pulmonary edema||Avoid in patients at risk for aspiration|
|Lactulose, Sorbitol||Bloating, flatulence||Recommend for patients in nursing homes|
|Watery stools, urgency,|
magnesium toxicity, hyperkalemia
|Avoid in patients with renal insufficiency|
|Stimulant Laxatives||Bisacodyl, Senna||Cramping, gastric and rectal|
irritation, melanosis coli
|Recommended only for short-term use; avoid in patients with bowel obstruction|
References and Resources
- Dukas L, Willett WC, Giovannucci EL. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. American Journal of Gastroenterology. 2003;98:1790-6.
- Hsieh C. Treatment of Constipation in Older Adults. American Family Physician. 2005;72:2277-2284.
- Gallagher P, O’Mahony D. Constipation in Old Age. Best Practice and Research Clinical Gastroenterology. 2009;23:875-887.
- Locke G, Pemberton J, Phillips S. American Gastroenterological Association Medical Position Statement: Guidelines on Constipation. Gastroenterology. 2000;119:1761-1778.
- Longstreth G, Thompson W, Chey W, et al. Functional Bowel Disorders. Gastroenterology 2006;130:1480-1491.
- McCrea G, Miaskowski C, Stotts N, et al. Pathophysiology of constipation in the older adult. World Journal of Gastroenterology. 2008; 14:2631-2638.
National Editorial Board: Theodore M Johnson II, MD, MPH, Emory University; Jenny Jordan, PT, DPT, Sacred Heart Hospital, Spokane, WA; Jane Marks, RN, MS, FNGNA, Johns Hopkins University; Josette Rivera, MD, University of California San Francisco; Jean Yudin, CRNP, University of Pennsylvania
Interprofessional Associate Editors: Carleigh High, PT, DPT; David Coon, PhD; Marilyn Gilbert, MS, CHES; Jeannie Lee, PharmD, BCPS; Marisa Menchola, PhD; Francisco Moreno, MD; Linnea Nagel, PA-C, MPAS; Lisa O’Neill, DBH, MPH; Floribella Redondo; Laura Vitkus, MPH, CHES