CONSTIPATION IN THE ELDERLY

PHILIPPINE COLLEGE OF GERANTOLOGY AND

GERIATRICS
CPM 7th EDITION constipation in the elderly

Philippine College of Gerontology and Geriatrics, Inc.

Mezzanine 21, Medical Center Manila
Tel # 521 6560
Fax # 521 2710 loc. 5332

Officers and Board of Directors

President Carlos S. Angeles, M.D., D.M.D.

Vice President Gary S. Sy, M.D.
Secretary Eva Irene Y. Maglonzo, M.D
Assistant Secretary Imelda Y. Lim, M.D.
Treasurer Eleanor A. Singson, M.D.
Assistant Treasurer Soledad T. Consing, M.D.
Auditor Luzviminda L. Paragas, M.D.
PRO Gerardo T. Nallas, M.D.
Liaison Officer Jaime D. Cheng, M.D.
Sandy Talag De Santos, M.D.

Board of Directors

Chairman Concordia M. Pascual, M.D.
Members Teresita P. Castillo, M.D.
Josephine C. Dizon, M.D.
Edwin M. Fortuno, M.D.
Carmelita S. Mendoza, M.D.
Marciano G. Uy, M.D.

Adviser Guillerma N. Sahagun, M.D.

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CPM 7th EDITION constipation in the elderly
Constipation in the Elderly
Introduction
More than 2,500 years ago, Hippocrates noted that “the
intestines tend to become sluggish with age.” 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. Constipa-
tion, 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 non-elderly population but affects as many as
26 percent of men and 34 percent of women over 65
years of age.
At least 75 percent of elderly hospitalized patients and
nursing home residents use laxatives for bowel regula-
tion. Constipation is more than an annoying problem.
Persons with chronic constipation have been shown
to have a diminished perception of their quality of
life. 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.
Patients and medical professionals frequently define
constipation differently. Patients often define the con-
dition 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 fre-
quency and defecation is not associated with discomfort.
Furthemore, it has been shown that patients are apt to
underestimate their stool frequency.
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. Most cases of chronic
constipation (i.e., those lasting months or longer) are
caused by underlying motility disorders or the use of
constipating drugs.
Delay in transit within the colon is the most frequent
non-obstructive cause of constipation. In animal models,
colonic transit times are significantly delayed with ag-
ing. Although some human studies have noted similar
findings, other investigations have found no difference
in colonic transit time between younger and older sub-
jects. 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.
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. When possible,
treatment should be directed at correcting the under­lying
abnormality. The chronic use of laxatives, especially
stimulant laxatives, should be strongly discouraged.
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. 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 obstruc-
tive 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 examina-
tion of the rectal area can detect local masses, external
he­mor­rhoids or stigmata of recent bleeding. A digital
rectal examination may identify redundant or throm­
bosed internal hemorrhoids, fissures, stenosis or mass.
During digital examination, external anal tone and
volun­tary control can be approximated. The digital
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constipation in the elderly cpm 7th eDITION
exami­nation can also detect a rectocele. Finally, the
stool should be screened for occult blood in all patients
with constipation.
Diagnostic Procedures
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.
Colonoscopy is an alternative diagnostic procedure.
When colonoscopy is the choice, the patient only un-
dergoes one procedure, and intervention (e.g., biopsy
or polypectomy) is possible if a lesion is identified. All
mass lesions should be biopsied because gross appear-
ance may not correlate with pathologic findings.
Inflamed hemorrhoids and fissures found during an ex-
amination 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 an-
thraquinone 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.
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.
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 mis-
conceptions and providing information to patients about
normal stooling patterns are therapeutic in­terventions in
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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.
Bowel Retraining
Bowel retraining is essentially a form of behav-
ior 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
5 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 gener-
ally work by distending the rectal ampulla, which
stimulates the defecatory urge and process. Lukewarm
tap-water enemas are the ideal because all other solu-
tions irritate the colonic mucosa if used repeatedly.
Carbon dioxide-releasing suppositories (sodium bicar-
bonate-potassium bitartrate) distend the rectal ampulla.
Bisacodyl suppositories are generally more effective
than glycerin-based suppositories. Unfor­tunately,
chronic use of bisacodyl suppositories even­tually ir-
ritates 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 gas-
trointestinal disorders, including diverticular disease and
colorectal cancer. Fiber appears to increase stool bulk
and weight and to speed intestinal transit time. 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. It may also be reasonable to add a com­mercial fiber
preparation (e.g., psyllium) to the high-fiber diet.
CPM 7th EDITION constipation in the elderly
To ensure that fiber itself does not become consipating,
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 non­
caffeinated fluids) is 8-oz glasses, assuming that the
patient has no cardiac or renal problems that prohibit
intake of this amount of fluid.
Laxatives
As an initial step in treatment, the patient should
be advised to follow a diet rich in fiber. It may
al­so be reasonable to add a commercial fiber prepara-
tion to the high-fiber diet. 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.
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 symp­
toms 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-form-
ing laxative at less than the recommended dosage and
gradually increasing to the recommended level over a
few weeks.
Stool softeners, such as docusate, decrease surface
tension and therefore allow stool to absorb more water.
Stool softeners are generally well-tolerated but are inef-
fective if fluid intake is inadequate.
Saline laxatives create an osmotic gradient within
the gut, thereby attracting fluid into the intestinal
lumen. They may also trigger the release of cholecys­
tokinin,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 colonos-
copy, such as polyethylene glycol, act as non-absorbed
osmotic agents and therefore are preferable in patients
with renal failure. Sorbitol and lactulose are also osmotic
agents. They are broken down into non-absorbable or-
ganic 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 pre-
scribed 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 deri­
vatives 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. (Phenol­
phthalein 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 medi-
cal treatment. Patient satisfaction with the outcome of
this procedure is reported to be high. 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 laxative 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.
References:
1. Primrose WR, Capewell AE, Simpson GK, Smith RG. Prescribing
patterns observed in registered nursing homes and long-stay geriatric
wards. Age Ageing 1987; 16:25-8.
2. Whitehead WE, Drinkwater D, Cheskin LJ, Heller BR, Schuster MM.
Constipation in the elderly living at home: definition, prevalence,
and relationship to lifestyle and health status. J Am Geriatr Soc
1989;37:423-9.
3. Harari D, Gurwitz JH, Minaker KL. Constipation in the elderly. J
Am Geriatr Soc 1993;41:1130-40.
4. Talley NJ, O’Keele EA, Zinsmeister AR, Melton LJ 3d. Prevalence
of gastrointestinal symptoms in the elderly: a population-based study.
Gastroenterology 1992;102:895-901.
5. Eastwood HD. Bowel transit studies in the elderly: radio-opaque
markers in the investigation of constipation. Gerontol Clin 1972;
14:154-9.
6. Tramonte SM, Brand MB, Mulrow CD, Amato MG, O’Keefe; ME,
Ramirez G. The treatment of chronic constipation in adults: a sys-
tematic review. J Gen Intern Med 1997;12:15-24.
7. Marlett JA. Content and composition of dietary fiber in 117 frequently
consumed foods. J Am Diet Assoc 1992;92:175-86.
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constipation in the elderly cpm 7th eDITION

Drugs Mentioned in the Treatment Guideline

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs
can be found in PPD reference systems.

Laxatives/Enemas
Clyss-Go
Dulcolax
Duphalac
Duphalac Dry
Fibrosine
Fleet Enema
Importal
Laxoberal
Mucofalk Apple/Orange
Granules
Philips Milk of Magnesia
Rhea Glycerin Suppository
Senokot/Senokot Forte

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