Constipation in the Elderly

DAVID C. SCHAEFER, M.D., PH.D., and LAWRENCE J. CHESKIN, M.D., Johns Hopkins University School of
Medicine, Baltimore, Maryland
Am Fam Physician. 1998 Sep 15;58(4):907-914.

Constipation affects as many as 26 percent of elderly men and 34 percent of elderly women and is a problem
that has been related to diminished perception of quality of life. Constipation may be the sign of a serious
problem such as a mass lesion, the manifestation of a systemic disorder such as hypothyroidism or a side
effect of medications such as narcotic analgesics. The patient with constipation should be questioned about
fluid and food intake, medications, supplements and homeopathic remedies. The physical examination may
reveal local masses or thrombosed hemorrhoids, which may be contributing to the constipation. Visual
inspection of the colon is useful when no obvious cause of constipation can be determined. Treatment
should address the underlying abnormality. The chronic use of certain treatments, such as laxatives, should
be avoided. First-line therapy should include bowel retraining, increased dietary fiber and fluid intake, and
exercise when possible. Laxatives, stool softeners and nonabsorbable solutions may be needed in some
patients with chronic constipation.

More than 2,500 years ago, Hippocrates noted that “the intestines tend to become sluggish with age.”1
Constipation, defined as decreased or difficult evacuation of the feces, has both functional and organic causes.
It is a problem that occurs in fewer than 2 percent of persons in the nonelderly population but affects as many
as 26 percent of men and 34 percent of women over 65 years of age.2,3 At least 75 percent of elderly
hospitalized patients and nursing home residents use laxatives for bowel regulation.4

Complaints related to constipation account for over 2.5 million physician visits every year.5 In addition, persons
seeking symptomatic relief of constipation spend more than $400 million per year on laxatives.6

Constipation is more than an annoying problem. Persons with chronic constipation have been shown to have a
diminished perception of their quality of life.7 Fecal impaction, incontinence, colonic dilatation and even
perforation can complicate constipation. In addition, constipation may signal more troubling underlying
problems, such as colonic dysmotility or mass lesions.

Definition
Patients and medical professionals frequently define constipation differently. Patients often define the condition
based on the degree of straining associated with defecation or the consistency of their stools rather than the
frequency of stooling. Normal stooling frequency ranges from three times a day to three times a week. A
stooling frequency of fewer than three times per week may still be considered normal if the pattern does not
represent a change in the patient's baseline stooling frequency and defecation is not associated with
discomfort. Furthermore, it has been shown that patients are apt to underestimate their stool frequency.8
A rule of thumb for physicians is that a patient has constipation if defecations decrease sufficiently to cause
discomfort. Another way to define constipation is by mechanism, such as functional causes versus
rectosigmoid outlet impedance (Table 1).9 Most cases of chronic constipation (i.e., those lasting months or
longer) are caused by underlying motility disorders or the use of constipating drugs.

View/Print Table
TABLE 1
Definition of Constipation

Functional constipation*

Straining at least 25 percent of the time

Lumpy or hard stools at least 25 percent of the time

Feeling of incomplete evacuation at least 25 percent of the time

Fewer than two bowel movements in a week

Rectal outlet delay

Anal blockage more than 25 percent of the time

and

Prolonged defecation or manual disimpaction (when necessary)

*—For the diagnosis of functional constipation, the patient must have had two or more of the listed
complaints for at least 12 months but not be taking laxatives.

Delay in transit within the colon is the most frequent nonobstructive cause of constipation. In animal models,
colonic transit times are significantly delayed with aging. Although some human studies have noted similar
findings,10 other investigations have found no difference in colonic transit time between younger and older
subjects.11  Colonic motility can be altered by many factors, including endocrine abnormalities, neurogenic
causes and medical therapy. Consequently, a wide variety of possible causes should be considered in the
constipated patient (Table 2).

View/Print Table
TABLE 2
Constipation: Causes and Treatments

CAUSES TREATMENTS

Idiopathic (possible mechanisms)

Dietary factors (low residue) Increase dietary fiber

Motility disturbances (colonic Increase dietary fiber, and give medication based on the
inertia or spasm such as underlying disorder (e.g., antispasmodic drugs for
inirritable bowel syndrome) irritable bowel syndrome)

Sedentary living Increase physical activity level

Structural abnormalities Local treatment

Anorectal disorders (fissures,

thrombosed hemorrhoids,
rectocele)

Strictures

Tumors

Evaluation
HISTORY
The history provides useful information about what the problem of constipation means to the patient. In
addition, possible contributing factors can be identified. The patient's dietary history and activity level should be
reviewed, because low fiber intake and a sedentary lifestyle are predisposing factors for constipation. The
patient should be asked specific questions about intake of noncaffeinated fluids. In the elderly, diminished
sensitivity to thirst may lead to decreased fluid delivery to the gut and consequent constipation.

Questions about the patient's use of both prescription medications and over-the-counter preparations can
identify agents with side effect profiles that contribute to constipation (Table 2). This inquiry is especially
important in older patients who may be taking more than a dozen medications and supplements. The content
of health food supplements, vitamins and homeopathic remedies is not regulated, and these items may contain
agents that contribute to constipation (e.g., anticholinergic agents).

Acute or chronic symptoms of constipation suggest that the mechanism may be a motility disorder, an
obstructive process or a medication. Concomitant systemic symptoms may indicate a systemic process such
as hypothyroidism, hyperparathyroidism or scleroderma.

The patient should also be asked about rectal bleeding, abdominal pain or narrowed stool caliber. The patient
with any of these symptoms should be evaluated for mass lesions or other organic problems.

Physical Examination
The physical examination should focus on identifying the underlying cause(s) of the patient's constipation.
Obvious signs of systemic illness or an abdominal mass must be specifically investigated. A careful
examination of the rectal area can detect local masses, external hemorrhoids or stigmata of recent bleeding. A
digital rectal examination may identify redundant or thrombosed internal hemorrhoids, fissures, a stenosis or a
mass. During the digital examination, external anal tone and voluntary control can be approximated. (Note,
however, that unless the rectal vault is clearly patulous, little concordance exists between this estimation and
actual anal manometry measurements of rectal tone.) The digital examination can also detect a rectocele.
Finally, the stool should be screened for occult blood in all patients with constipation.

Diagnostic Procedures
Flexible sigmoidoscopy should be performed in the patient who has recently become constipated without an
obvious cause. Even if a benign distal process is identified, the colon must be examined thoroughly because a
change in an elderly patient's stool habits may be caused by an underlying neoplasm.

Flexible sigmoidoscopy with a barium enema is readily available to primary care physicians and is a good first-
line evaluation. Colonoscopy is an alternative diagnostic procedure. When colonoscopy is the choice, the patient
only undergoes one procedure, and intervention (e.g., biopsy or polypectomy) is possible if a lesion is identified.
All mass lesions should be biopsied because gross appearance may not correlate with pathologic findings.

Inflamed hemorrhoids and fissures found during an examination may explain a patient's constipation. Painful
defecation may cause the patient to “hold back” stool (functional constipation). The endoscopic examination
may reveal brown to black leopard-like spotting of the colonic mucosa. This condition, known as melanosis coli,
is a benign, reversible process resulting from anthraquinone laxative abuse (e.g., cascara, senna or aloe
products). Either viral or syphilitic condyloma is another anorectal condition that can cause constipation.

Imaging Studies
Radiographic studies may be helpful in pinpointing the cause of a patient's constipation. Plain abdominal films
can determine the extent of fecal retention and can detect bowel obstructions, megacolon, volvulus and mass
lesions.

An enema with the contrast agent diatrizoate meglumine (Gastrografin) is useful in the patient with suspected
megarectum. This study may be done without prior bowel preparation because the enema preparation contains
a wetting agent that enables it to pass an impaction. Barium enemas require bowel preparation but may reveal a
point of obstruction or narrowed segment. Radiographic transit studies using ingested radiopaque polyvinyl
chloride (Sitzmark) are useful in patients suspected of having a colonic dysmotility syndrome.

Defecography (radiographs or videotapes of contrast medium expelled from the rectum) can demonstrate
rectocele, deangulation of the rectal muscular sling during defecation or paradoxic external anal sphincteric
contraction with attempted defecation. This procedure has the added benefit of not requiring bowel preparation.
However, defecography is not routinely performed in all radiology departments. Figure 1 provides an algorithm
for the evaluation of constipation in the elderly.

View/Print Figure

FIGURE 1.

Suggested algorithm for the evaluation of constipation in the elderly.

A few tertiary medical centers perform complete specialized tests for colonic motility. These tests may be
particularly useful when the cause of a patient's constipation is not successfully diagnosed with traditional
studies or if the constipation does not respond to empiric treatment. Motility studies are performed by placing
pressure transducers in the rectum and sigmoid colon. Variations in intracolonic pressures and sensitivity
thresholds induced by rectal balloon insufflation can identify specific subclasses of constipation. High-
amplitude phasic contractions occur spontaneously (as well as in response to stimulation) and are sometimes
associated with pain. This pain may cause constipation by impeding the distal flow of luminal contents.
Alternatively, in a patient with an atonic motility pattern, decreased response to stimulation and loss of
resistance to distention can lead to constipation.12

Treatment
The availability of many different pharmacologic agents for constipation makes symptomatic treatment
alluring. When possible, however, treatment should be directed at correcting the underlying abnormality. The
chronic use of laxatives, especially stimulant laxatives, should be strongly discouraged.

Successful therapy must include a discussion of the broad range of normal stooling function and the patient's
own concepts of normal stooling. Often, identifying misconceptions and providing information to patients about
normal stooling patterns are therapeutic interventions in themselves. It may be helpful to identify the patient's
expectations for treatment. Compared with placebo, laxatives and fiber have been shown to increase stool
frequency. Other agents, such as lactulose, improve stool consistency.13
Bowel Retraining
Bowel retraining is essentially a form of behavior modification and is particularly useful in the patient who does
not have a readily identifiable cause of constipation. The patient should be encouraged to have a regular daily
routine, with time set aside for having a bowel movement. Preferably this time should be within five to 10
minutes after a meal, thereby taking advantage of the gastrocolic reflex. Such a routine encourages the patient
to attend to signals and respond to the urge to defecate.

In the chronically constipated patient, enemas or suppositories may occasionally be required to aid in the
defecatory urge. These interventions generally work by distending the rectal ampulla, which stimulates the
defecatory urge and process. Lukewarm tap-water enemas are the ideal because all other solutions irritate the
colonic mucosa if used repeatedly. Carbon dioxide–releasing suppositories (sodium bicarbonate–potassium
bitartrate; Ceo-two) distend the rectal ampulla. Bisacodyl suppositories (Dulcolax) are generally more effective
than glycerin-based suppositories. Unfortunately, chronic use of bisacodyl suppositories eventually irritates
colonic tissues.

Diet
Diet plays a critical role in bowel function, especially in the elderly. Strong epidemiologic evidence has shown
that greater amounts of crude dietary fiber are associated with a lesser prevalence of constipation and other
gastrointestinal disorders, including diverticular disease and colorectal cancer.14 Fiber appears to increase stool
bulk and weight and to speed intestinal transit time.15 Several mechanisms may account for these
observations:

1. Fiber may act as a bulk-forming agent.

2. Fiber may bind fecal bile salts, which have a pronounced cathartic effect.
3. Fiber is metabolized by colonic bacteria to nonabsorbable, volatile fatty acids, which may act as an
osmotic cathartic.

The low-fiber diet generally consumed in the United States, along with other variables such as sedentary
lifestyle and poor fluid intake in some elderly persons, may account for the large number of older patients who
complain of constipation. As an initial step in treatment, the patient should be advised to follow a diet rich in
fiber (Table 3).16 It may also be reasonable to add a commercial fiber preparation (e.g., psyllium; Metamucil) to
the high-fiber diet.

TABLE 3
Fiber Content of Various Foods
The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the
original print version of this publication.

To ensure that fiber itself does not become constipating, adequate fluid intake is necessary. This is especially
true in the patient who is already taking a diuretic. The recommended daily requirement for water (or
noncaffeinated fluids) is eight 8-oz glasses, assuming that the patient has no cardiac or renal problems that
prohibit intake of this amount of fluid.

Laxatives
Clearly, many physicians and patients consider laxatives the mainstay of constipation treatment.
Pharmaceutical companies have responded to this demand, as evidenced by the more than 700 commercially
available products touted to relieve the symptoms of constipation. These formulations are not without side
effects, some of them quite significant (Table 4).

View/Print Table
TABLE 4
Laxative Effects and Side Effects

TYPE OF LAXATIVE MECHANISM OF ACTION ONSET OF ACTION POTENTIAL ADVERSE EFFECTS

Bulk laxative Increases fecal 12 to 24 hours Increased gas; bloating;

bulk as well as or more bowel obstruction if
Psyllium seed the fluid retained strictures present;
in the bowel choking if powder forms
Bran lumen are not taken with
enough liquid

Calcium
polycarbophil

Emollients and stool Lubricates and 24 to 48 hours Minor effects such as

softeners softens fecal bitter taste and nausea
mass
Dioctyl sodium

Calcium
sulfosuccinate
(docusate
sodium)

Stimulants and irritants Alters intestinal 10 minutes Dermatitis; electrolyte

(
Bulk-forming laxatives are natural or synthetic polysaccharide or cellulose derivatives that cause water to be
retained in the colon and thereby increase stool bulk. These laxatives have few potential adverse effects and are
effective in slowly reversing the symptoms of constipation. In fact, their use is essentially the same as
increasing fiber in the diet. However, a number of bulking agents, psyllium in particular, at least initially result in
gas formation and bloating. These problems may be partially overcome by starting a bulk-forming laxative at
less than the recommended dosage and gradually increasing to the recommended level over a few weeks.

Stool softeners such as docusate (Colace) decrease surface tension and therefore allow stool to absorb more
water. Stool softeners are generally well tolerated but are ineffective if fluid intake is inadequate.

Saline laxatives (e.g., Fleet Phospho-Soda) create an osmotic gradient within the gut, thereby attracting fluid into
the intestinal lumen. They may also trigger the release of cholecystokinin, which, among other effects, causes
colonic prokinesis. However, in patients with renal insufficiency, saline laxatives may lead to hypermagnesemia
or to hypocalcemia from hyperphosphatemia. Commercially available cleansing preparations used before
colonoscopy, such as polyethylene glycol (Golytely), act as nonabsorbed osmotic agents and therefore are
preferable in patients with renal failure. Sorbitol and lactulose are also osmotic agents. They are broken down
into nonabsorbable organic acids in the gut. Lactulose is considerably more expensive than sorbitol but is the
agent of choice in patients with hepatic failure.

Stimulant laxatives are by far the most frequently prescribed and purchased class of laxatives. These agents
promote stooling by altering electrolyte transport in the intestinal mucosa and increasing colonic motility. With
chronic use, however, stimulant laxatives may damage the myenteric plexus and result in colonic dysmotility. As
previously noted, anthraquinone derivatives such as senna, cascara and aloe may cause colonic mucosal
pigmentation and are thought to directly damage the myenteric nerves. Phenolphthalein, a common ingredient
in some over-the-counter laxative preparations, has been associated with photosensitivity, dermatitis and the
Stevens-Johnson syndrome. (Phenolphthalein is no longer on the market in the United States but is still
available elsewhere in the world.)

Special Considerations
Patients with extreme chronic constipation have been treated with a variety of surgical procedures, including
hemicolectomies and semicolectomies. For example, subtotal colectomy with ileorectal anastomosis has been
used to treat patients with severe, idiopathic slow-transit constipation that did not respond to medical
treatment. Patient satisfaction with the outcome of this procedure is reported to be high.17 Unless constipation
is caused by mass obstruction or recurrent volvulus, however, surgery has little role in the elderly.

The bedridden or chair-bound patient presents special problems. The use of potent laxatives may lead to fecal
soiling because the patient may not be able to identify or rapidly respond to the defecatory urge. However,
bulking agents may promote regularity and soft stools. Behavioral programs (i.e., stool training or timing) are
especially important. Positioning the patient over the toilet and using tap-water enemas may also be successful.

The Authors show all author info

DAVID C. SCHAEFER, M.D., PH.D., is currently in private practice with the Digestive Diseases Center at Apple Hill
Medical Center, York, Pa. Dr. Schaefer received his medical degree from Eastern Virginia Medical School of the
Medical College of Hampton Roads, Norfolk, and completed a residency in internal medicine at York (Pa.)
Hospital. In addition, he completed a fellowship in gastroenterology at the Johns Hopkins University School of
Medicine, Baltimore, and earned both a master of science degree and a doctorate in clinical psychology from
Virginia Commonwealth University, Richmond....

REFERENCES show all references

1. Aphorisms section II. In: Lloyd GE, ed. Hippocratic writings. Hammondsworth, N.Y.: Penguin Books, 1978:53....

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