Constipation in the older adult

Definition:
- Per Rome III Criteria
o 2 of the following for the last 3 months and with onset of >6mo, insufficient
criteria for IBS
Straining, lumpy hard stools, sensation of incomplete evacuation, use of
digital maneuvers, sensation of anorectal obstruction/blockage with 25%
of bowel mvmts, decrease in stool freq (<3/week)
Epidemiology:
- Prevalence 24-50%
- Laxatives used daily for 10-18% community dwelling elderly, and up to74% of
nursing home residents
- Risk factors
o Age itself is a risk factor
o Other risk factors include female gender, physical inactivity, low education,
low income, concurrent medication use, depression
o Possibly consuming fewer calories/meals
Pathophysiology
- Can be primary colorectal dysfunction or secondary to several other factors
- Primary Colorectal Dysfunction (3 subtypes)
1. Slow transit constipation
a. Myopathy or neuropathy or 2/2 dyssynergic defecation
2. Dyssyergic defecation
a. difficulty with or inability expelling stool from the anorectum
3. IBS
a. Irritable bowel syndrome with predominant constipation (IBS-C) is
characterized by abdominal pain with altered bowel habits. These
patients may or may not have slow colonic transit or dyssynergia, and
many have visceral hypersensitivity

Constipation in the older adult

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Secondary Causes
o Conditions associated with
constipation include endocrine or
metabolic disorders, neurologic
disorders, myogenic disorders,
and medications.
o Opioid induced constipation is
common in those suffering from
chronic or cancer-related pain
- Chronic Idiopathic Constipation
o Estimated prevalence 4-20%
o Defined as the infrequent,
persistently difficult passage of
stools or seemingly incomplete
defecation, which does not meet
IBS criteria
Evaluation:
- History and Physical
o Note alarm symptoms such as
hematochezia, positive fecal
occult blood test, obstructive
symptoms, acute onset of
constipation, severe persistent
constipation that is unresponsive to treatment, weight loss 10 pounds, a
change in stool caliber, family history of colon cancer or inflammatory bowel
disease
o Note comorbidities and medication
o PE should include rectal exam to palpate for hard stool, assess for masses,
anal fissures, hemorrhoids, sphincter tone, push effort during attempted
defecation, prostatic hypertrophy in males, and posterior vaginal masses in
females
- Labs
o CMP, CBC, Thyroid function can be useful, however, without alarm sx the
American College of Gastroenterology dues not have any recommendation
of routine labs
- Imaging
o Except for colonoscopy in those with alarm symptoms, no real useful
imaging tests recommended
Treatment:
- Lifestyle and dietary modification is always the first step. Adding Bulk
laxatives(Metamucil, mehylcellulose, benefiber) is the next step. Those who do
not respond should be given a trial of osmotic laxatives(Low-dose polyethylene
glycol, lactulose, sorbitol). Stool softeners, suppositories and enemas actually
have limited efficacy in chronic constipation. Caution with saline laxatives such
as magnesium hydroxide in elderly due to risk of hypermagnesemia. Stimulant
laxatives can be trialed at this point(senna, bisacodyl). Avoid sodium
phosphate enemas due to risk of hypotension and volume depletion,

Constipation in the older adult

hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe

hypocalcemia, renal failure, and EKG changes (prolonged QT interval)
In those with dyssynergic defecation, biofeedback therapy may be helpful