CONSTIPATION IN OLD

AGE

IVONNE HALWOODI
GROUP: LA-1 152-1
 Pathophysiology of constipation, with focus on
changes with aging
 Assessment and diagnosis of constipation
 Standard of care treatment for constipation
 Constipation and survey implications
 Feeling of constipation is defined differently
by different people
 Defined by self-report or objective
assessment-based
 Clinical – finding fecal loading in the rectum
on exam and/or colonic fecal loading on xray
 Subtype – rectal outlet delay
 Feeling of anal blockage at least a quarter of the
time and prolonged defecation (>10 min to
complete bowel movement) or need for self-
digitization on any occasion
 • Chronic constipation must include 2 or
more of the following: (self-report)
During at least 25% of defecations

Sensation of Manual
Sensation of <3
Lumpy or Anorectal Maneuvers
Straining Incomplete Defecations
Hard Stools Obstruction/ to Facilitate
Evacuation per Week
Blockage Defecations

• Loose stools are rarely present without the use of laxatives

• There are insufficient criteria for IBS

*Criteria fulfilled for at least 3 months, with symptom onset at least 6 months prior to diagnosis.
IBS = irritable bowel syndrome.
Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491.
 • North America: estimates range from 2% to
28%; 15% ≈ 63 million North Americans fulfill
criteria for constipation
– Variations due to
• Criteria/symptoms definitions used (multiple definitions)
• Survey collection methods
• Self-report vs diagnosis

• Worldwide
– Similar rates in developed and undeveloped countries
– 14%-30% (Spain, Sweden, Australia, China)
Higgins PD, et al. Am J Gastroenterol. 2004;99:750-759.
Pare P, et al. Am J Gastroenterol. 2001;96:3130-3137.
Garrigues V, et al. Am J Epidemiol. 2004;159:520-526.
Walter S, et al. Scand J Gastroenterol. 2002;37:911-916.
Chiarelli P, et al. Int Urogynecol J. 2000;11:71-78.
Cheng C, et al. Aliment Pharmacol Ther. 2003;18:319-326.
 †
Study 1* Study 2
N=42,375 N=NR
12 12
10
Prevalence (%)

Prevalence (%)
10
8 8
6 6
4 4
2 2
0 0
9

4
59

79

4
4
8
0
0

5
-4

-6

-7
-6
-4
<1
≥8
<4

≥7
-

-
40

60

65
50

70

45
18
Age (Years) Age (Years)

*Harari D, et al. Population: NHIS 1987; criteria: self-report; †Johanson JF, et al. Population: NHIS 1983-
1987; criteria: self-report.
NHIS = National Health Interview Survey.
Higgins PDR, et al. Am J Gastroenterol. 2004;99:750-759.
• Unable to report bowel-related symptoms
• Have regular bowel movements despite have
rectal or colonic fecal impaction
• Have impaired rectal sensation and inhibited
urge to go and so be unaware of rectal stool
impaction
• Nonspecific symptoms associated with
colonic fecal impaction (e.g., delirium,
anorexia, functional decline)
• Collagen deposition in the left side of the
colon increases
• Total number of neurons in the myenteric
plexus is decreased
• Decrease in internal sphincter tone
• Decline in external anal sphincter and pelvic
muscle strength
• Reduction in rectal motility with normal aging
 Primary Secondary
• Slow-transit • Lifestyle
constipation • Organic GI disease
• Dyssynergic defecation • Medications
• Normal-transit • Metabolic
constipation • Postsurgical
– IBS-C
• Psychological
• Neurological
• Systemic disorders

IBS-C = irritable bowel syndrome with a predominant bowel complaint of constipation

 CLASS EXAMPLES
PRESCRIPTION DRUGS
Opiates Morphine
Anticholinergic agents Benztropine, oxybutynin
Tricyclic antidepressants Amitriptyline > nortriptyline
Calcium channel blockers Verapamil hydrochloride
Anti-Parkinsonian drugs Amantadine hydrochloride
Sympathomimetics Albuterol
Antipsychotics Haloperidol, risperidone
Diuretics Furosemide
Antihistamines Diphenhydramine
NONPRESCRIPTION DRUGS
Antacids, especially calcium-containing
Calcium supplements
Iron supplements
Antidiarrheal agents
Loperamide, attapulgite
Nonsteroidal anti-inflammatory agents
Ibuprofen

Locke GR III, et al. Gastroenterology. 2000;119:1766-1778. *This is not a complete list

 Causes of Constipation in the Elderly
Aluminum hydroxide–containing Hypothyroidism
antacids
Anticholinergics Immobility/Inactivity
Calcium channel blockers Iron supplements
Dehydration Low-fiber and
carbohydrate diet
Diabetes mellitus Narcotics
Diuretics Parkinson’s disease
Hypercalcemia/hypokalemia Stroke
Approximately half of residents in nursing homes have constipation
De Lillo AR, et al. Am J Gastroenterol. 2000;95:901-905.
Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
 • Fecal impaction
– Identified in up to 40% of elderly adults hospitalized in the United
Kingdom

• Rare complications
– Obstipation: obstruction with stool
– Urinary and fecal incontinence
– Stercoral ulceration: rectal “pressure” ulcers from impacted stool and
obstipation
– Megacolon: dilation of the colon that is not caused by obstruction
(rectosigmoid diameter >6.5 cm)
– Bowel perforation (new onset or from above etiologies)

Read NW, et al. J Clin Gastroenterol. 1995;20:61-70.

De Lillo AR, et al. Am J Gastroenterol. 2000;95:901-905.
Read NW, et al. Gastroenterology. 1985;89:959-966.
• Fecal incontinence
• Fecal impaction
• Urinary retention
• Sigmoid volvulus
• Rectal prolapse
• Diverticular disease
• Impaired quality of life
• Agitation in dementia patients
 • Direct costs (typically individual or third party)
– Physician visits
– Diagnostic tests
– Medications
• Indirect costs (individual or societal)
– Reduced productivity
– Lost wages
– Impaired QOL

QOL = quality of life.

 • In 2 large cross-sectional surveys of
community-dwelling older adult patients:
– Laxatives were third and fourth most frequently
used nonprescription drugs
• In cross-sectional survey of 4136
participants
– Stimulant and bulking laxatives were most
commonly used
Ruby CM, et al. Am J Geriatr Pharmacother. 2003;1:11-17.
Passmore AP. Pharmacoeconomics. 1995;7:14-24.
 * P < 0.05 vs controls Dyssynergia (n = 76)
100 Slow transit (n = 38)
Subscale Score (Mean ± S.E.M.)

Controls (n = 54)

80 * * * *
* *
* *
60

40

20

0
Physical Role physical Bodily pain General health
functioning

Rao SSC, et al. Gastroenterology. 2005;128:A-123.

 No GI symptoms Constipation

100
Mean MOS Score

80

60

40

20
MOS = medical outcomes survey
0
Physical Role Social Mental Health Bodily
functioning functioning functioning health perception pain

• Impact of chronic constipation on quality of life in Olmsted

County, Minnesota residents aged ≥ 65 years
• Lower score indicates worse quality of life

Talley NJ. Rev Gastroenterol Disord. 2004;4(suppl 2):S3-S10.

 Patient Descriptions
90 81
80 72 Physicians think:
70 <3 BMs per week
Patients (%)

60 54
50
39 37 36
40
28
30
20
10
0
Straining Hard or Incomplete Stool Abdominal <3 BMs Need to
lumpy emptying cannot fullness or per press on
stools be bloating week anus
passed
• In another study, only 13% of individuals with constipation reported having <3 BMs
per week
Pare P, et al. Am J Gastroenterol. 2001;96:3130-3137.
Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.
 Symptoms for 3 months, onset ≥ 6 months
Chronic IBS-C
Constipation Recurrent abdominal pain/
Must include ≥ 2 of: discomfort with:
• Hard or lumpy stool • Improvement with
• Straining defecation
• Onset associated with
• Incomplete evacuation change
• Sensation of anorectal
in frequency of stool
• Onset associated with
obstruction/blockage change
• Manual maneuvers in form (appearance) of
stool
• < 3 defecations/week
• Pain not usually present

Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491.

 70
60
50 N=1009
Prevalence (%)

40
30
20
10
0
Normal Defecatory Slow Slow transit
transit + disorder transit + defecatory
defecatory (n=249) (n=131) disorder
function (n=32)
(n=597)

Nyam DCNK, et al. Dis Colon Rectum. 1997;40:273-279.

 • Slow-transit constipation – “colonic inertia”
– Slower than normal movement of contents from the
proximal to the distal colon and rectum
• Dyssynergic defecation (pelvic floor dysfunction)
– Inability or difficulty with evacuation of stool from
the rectum in patients with normal or slowed
colonic transit
• IBS-C
– Abdominal pain or discomfort associated with normal-
or slow-transit constipation or pelvic floor dysfunction

Locke GR III, et al. Gastroenterology. 2000;119:1761-1778.

Rao SSC. Gastroenterol Clin North Am. 2003;32:659-683.
 Subtypes of Constipation

Normal-transit Slow-transit Defecatory IBS with

constipation constipation dysfunction constipation

Intestinal transit and stool frequency are within normal range

The most common subtype

Bosshard W, et al. Drugs Aging. 2004;21:911-930.

 Subtypes of Constipation

Normal-transit Slow-transit Defecatory IBS with

constipation constipation dysfunction constipation

Characterized by decreased intestinal transit time

Neurohormonal control abnormal? Decreased nitric oxide
production, impaired gastrocolic response, alteration of
neuropeptides (VIP, substance P), decreased interstitial cells of Cajal

Bosshard W, et al. Drugs Aging. 2004;21:911-930. VIP = vasoactive intestinal polypeptide

 Subtypes of Constipation

Normal-transit Slow-transit Defecatory IBS with

constipation constipation dysfunction constipation

Pelvic floor dyssynergia, megarectum, rectocele, perineal descent

More frequent in older women – childbirth trauma
Pathogenesis may be multifactorial – structural problem

Bosshard W, et al. Drugs Aging. 2004;21:911-930.

 Subtypes of Constipation

Normal-transit Slow-transit Defecatory IBS with

constipation constipation dysfunction constipation

Brain-gut axis is impaired?

Stress, visceral hypersensitivity, abnormal brain
activation, altered colonic motility, inflammation,
bradykinins, adenosine, and 5-hydroxytryptamine

Bosshard W, et al. Drugs Aging. 2004;21:911-930.

Hadley SK, et al. Am Fam Physician. 2005;72:2501-2506.
 • Weight loss
• Rectal bleeding
• Occult blood in stool
• Older age of onset/new onset
• Vomiting
• Family history of colon cancer
• Family history of inflammatory
bowel disease
Lembo A, et al. N Engl J Med. 2003;349:1360-1368.
Brandt LJ, et al. Am J Gastroenterol. 2005;100(Suppl 1):S5-21.
 • Among chronic constipation patients without
alarm symptoms or signs, routine use of
diagnostic tests is not recommended
– The routine approach to a patient with symptoms of chronic
constipation without alarm signs or symptoms should be
empiric treatment without performance of diagnostic testing
• Diagnostic studies are indicated in patients with
alarm signs or symptoms
• Routine use of colon cancer screening tools is
recommended in patients aged ≥ 50 years
ACG = American College
Brandt LJ, et al. Am J Gastroenterol. 2005;100(Suppl 1):S5-S21. of Gastroenterology
• Multidisciplinary approach
– MD, nursing, pharmacist, dietician
• MDS initial evaluation
– Bowel function
– Ability to use toilet
• Accurate bowel history
– From resident, if possible
• Rule out secondary factors
– Medications, disease states, diet
• Immobility
• Inadequate fluid intake
• Diet – not enough fiber, reduced intake
• Medications
– Narcotics
– Iron
– Anticholinergic side effects
 • 59%-78% of residents use laxatives at
least on an intermittent basis
• 50% were on more than 1 laxative
• Most commonly used:
– Stool softeners
– Saline laxatives
– Stimulant laxatives
– Osmotic laxatives

Phillips C, et al. J Am Med Dir Assoc.2001;2:149-154.

 • 41% of patients on long-term opioids develop
constipation
– Delayed gastric emptying
– Delayed stool transit throughout the GI tract
– Decreased peristalsis
– These changes can be seen almost immediately,
therefore, start laxatives prophylactically
• Treat with stimulant or osmotic laxatives

Kalso E, et al. Pain.2004;112:372-380.

 • Trials of fiber have been inconsistent, but
generally  fiber in diet leads to  laxative
use and  bowel movements
• No set guidelines for the elderly
– American Dietetic Association– 10-13
Gm/1000 kcal
• Studies have used:
– “laxative” pudding (dates & prunes)
– Bran, applesauce, & prune juice mixture
– Fiber-rich porridge

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.

• May only be helpful in dehydrated patients,
not in chronic constipation
• Adequate hydration is important to
general health
Exercise
• Convincing data is lacking as to efficacy,
but overall well-being may improve
• Set time for defecation
– Morning or 30 minutes after meal
• Comfortable, safe toilet or commode
• Privacy
 Generic Name Brand Name Usual Dosage
Bulk Formers
Psyllium Metamucil 1-2 Tbsp 1-3 times daily
Methylcellulose Citrucel 1 Tbsp 1-3 times daily
Stool Softeners (Emollients)
Docusate Na Colace 100-300 mg / day
Osmotic Agents
Lactulose Enulose, Constulose 15-30 ml 1-2 times daily
Sorbitol 70% --------------- 15-150 ml / day in divided
doses
Polyethylene Glycol MiraLax 17 Gm once daily (1 capful)
(PEG)
Magnesium Hydroxide Milk of Magnesia 15-60 ml once daily (bedtime)
Stimulants
Senna Senokot 8.6-17.2 mg daily (1-2 tablets)
Bisacodyl Dulcolax 5-15 mg once daily (1-3 tablets)
Chloride Channel Activator
 Laxative Level of Evidence Strength of
Recommendation
Polyethylene glycol I A
Tegaserod (suspended I A
from market, March 2007)
Lactulose II B
Psyllium II B
Sorbitol III C
Magnesium hydroxide III C
Stimulants (no good III C
studies)
Methylcellulose III C
Bran III C
Calcium polycarbophil III C
Colchicine III C
Misoprostol
*Lubiprostone III
was not approved at the time of this analysis C
Stool D,
Ramkumar softeners III
et al. Am J Gastroenterol. 2005;100:936-971. C
 • MOA: absorbs water from intestinal lumen,
softens stool, decreases bowel transit time
• Not suitable for acute relief
• Requires adequate fluid intake
• Avoid in patients with dysphagia
• Potential for drug interactions (digoxin,
warfarin, salicylates, ciprofloxacin)
• AEs: flatulence, abdominal pain, GI
obstruction

Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
 • MOA: act as surfactants, lowering surface
tension and facilitating the mixing of
aqueous and fatty substances in the
intestinal lumen
• Primarily used for patients with painful
defecation due to hemorrhoids or anal
fissures
• No role in chronic constipation
• AE’s: potential diarrhea, mild cramping
Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.
Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
 • MOA: draws fluid into the intestinal lumen by
osmotic action, thus increasing intraluminal
pressure & stimulating gut motility
• PEG – no studies yet in older adults
• Lactulose & sorbitol – similar effects in older
adults
• Saline laxatives can cause electrolyte imbalance
– Avoid use in patients with renal impairment
• AE’s: diarrhea, abdominal discomfort, flatulence

Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
 • MOA: stimulates nerve plexus of
intestines, increases peristalsis, increases
secretion of fluid & electrolytes
• Use in lowest effective dose
• Chronic use leads to tolerance
• Useful in opioid-induced constipation
• AE’s: abdominal pain, electrolyte
imbalance, melanosis coli (long-term use)

Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
 • Metoclopramide & erythromycin work on the
upper GI tract to promote peristalsis
– Little benefit for constipation
• Tegaserod was approved for chronic constipation
in persons <65 yo, but voluntarily suspended from
market by the manufacturer in March 2007 after a
pooled analysis of 29 placebo-controlled short-
term trials found a statistically significant increase
in cardiovascular ischemic events, including heart
attack, angina, and stroke
– July 2007 – FDA approved restricted use under
investigational treatment protocol for women <55
yo with IBS-C or chronic idiopathic constipation
Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
 • MOA: enhances chloride-rich fluid secretion into
intestinal lumen without affecting Na+, K+, or Cl- levels.
No effect on selected smooth muscle (ileum longitudinal
smooth muscle, ileum circular smooth muscle, vas
deferens, and iris sphincter) contraction
• Approved for treatment of chronic idiopathic constipation
in adults
• Minimal systemic absorption, no significant drug
interactions
• Compared to placebo, increases bowel movements,
decreases straining, improves stool consistency
Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
Johanson JF, et al. Gastroenterology.2004;126(Suppl 2): A100. Abstract 749.
Johanson JF. Gastroenterology. 2003;124:A-48.
 • Reserve for acute situations
• Avoid soap suds
• Small volume tap water enemas are
preferred
• Phosphate containing enemas may cause
hyperphosphatemia, especially in renal
impairment
• Watch for abuse in the elderly

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.

• Refractory constipation for anorectal testing
• Dyssynergic defecation may benefit from
biofeedback therapy
• Alarm symptoms or over age 50 for
colonoscopy
• Surgery for severe colonic inertia
• If chronic complaint but having BMs –
consider depression, refer psych
 Approach to Management
Constipation in Long Term Care
Subjective c/o constipation

Constipation with mental status • Adequate hydration and fiber in diet

changes or abdominal pain • Exercise if mobile
and/or bleeding • Eliminate drugs that cause constipation
• R/O delirium
Acute Chronic
• R/O impaction or
obstruction
• Treat the underlying
problem
 Iron deficiency anemia
 Stool for blood
 Digital rectal exam
Avoid

Refer to GI ? docusate
(Colace)
 Abdominal X-Ray
 TSH, calcium, magnesium
For colonoscopy/ Exclude depression
transit studies

Empirically treat
1. Sorbitol/lactulose/polyethylene glycol
2. Stimulant laxative short term
No Improvement
3. If none of the above measures work, use Lubiprostone

Switch empiric
agents & try a No Improvement Improved
Improved different agent

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.

• Care plan
• Quality of Life evaluation
• Medication review
• Scheduled treatment, not prn
• Know adult bowel history
• Doctor involved
• Refer when appropriate
• Quality Indicator
• F309 Quality of Care –Each resident must
receive and the facility must provide the
necessary care and services to attain the
highest practicable physical, mental and
psychosocial well-being, in accordance with
the comprehensive assessment and plan of
care
– May include fecal impaction
• F309- Highest possible level of functioning
and well-being, limited by individual
recognized pathology and normal aging
– Determine if avoidable or unavoidable
– Need:
• Accurate and complete assessment
• Care plan
• Evaluation of the results of the interventions and
revising the interventions as necessary
• Know your patient
• Common problem in elderly related to aging
process and multiple illnesses in elderly
• Medications for etiology and treatment
• Exercise/increase activity
• Fiber
• Care plan
• Quality of life