Constipation in the elderly

Contributed by:

Amber Peters, MD, CCFP (COE) – View bio

Case

Ms. Oddring is 83 and presenting with a three-to-four-year history of intermittent fecal incontinence/seepage. She has no abdominal pain and cannot tell when she has been incontinent. Her past medical history includes aortic stenosis, COPD, depression, type 2 diabetes, remote left breast cancer, hypertension, insomnia and dementia. She is on amlodipine 10 mg bid, escitalopram 10 mg daily, gliclazide 30 mg daily, metformin 1000 mg bid, ramipril 10 mg daily and zopiclone 7.5 mg qhs prn for sleep. She uses loperamide 2 mg at least once daily for her incontinence. An abdominal exam shows only mild distension and digital rectal exam (DRE) is unremarkable. An abdominal x-ray shows moderate fecal loading.

Issue

Constipation is common in elderly patients for a variety of reasons and can present with overflow incontinence. How can constipation be recognized and managed effectively in this population?

Background

Constipation is common in the elderly population, affecting an estimated 40% of community dwelling seniors,¹ and 75% of those residing in nursing homes.² Constipation can result in hospital admission if severe and, even in milder cases, reduces quality of life.¹⁴ Risk factors for constipation include female sex, decreased dietary intake, inactivity,³ medication burden,⁴ increasing age and cognitive impairment.⁵

Evidence

The Rome IV criteria define chronic idiopathic constipation as two or more of:⁶

• straining >25% of the time
• lumpy or hard stool >25% of the time
• sensation of incomplete evacuation >25% of the time
• sensation of anorectal blockage >25% of the time
• manual maneuvers needed to evacuate >25% of the time (e.g., digital dis-impaction)
• fewer than three bowel movements (BMs) per week
• loose stools rarely present without laxative use
• insufficient criteria for IBS

A detailed history should be taken to rule out any red flags, including rectal bleeding, change in stool caliber, weight loss, symptoms of anemia or a family history of colorectal cancer.⁷ The history should also include duration of symptoms, frequency of BMs, associated symptoms (e.g., abdominal pain, bloating), use of laxatives or other treatments and symptoms of pelvic floor dysfunction (e.g., history of perineal trauma, sense of incomplete evacuation and sense of blockage at the anus).⁸ Elderly patients, particularly those in institutional settings, have a high incidence of fecal incontinence in the context of constipation.^5,9 As such, it is important to include questions about fecal incontinence in the history and to consider constipation as a cause of “diarrhea” in the elderly. In addition, a detailed review of medications, including over the counter, and past medical history should be done to assess for secondary causes of constipation.⁸ Elderly patients often have a combination of factors that contribute to constipation, and these vary from patient to patient: 

Table 1. Common Causes of Constipation in the Elderly^{5, 15}

Medications Anticholinergic agents Antihistamines Antacids Antipsychotics Anticonvulsants Antiemetics (Ondansetron) Calcium supplements Calcium channel blockers Diuretics Dopaminergic agents Iron supplements Tricyclic antidepressants	Organic GI Problems Colorectal cancer Extraintestinal abdominal mass Post-inflammatory state Ischemia Surgical stenosis/adhesions
Endocrine or Metabolic Diabetes mellitus Hypothyroidism Hypercalcemia CKD Hypermagnesemia Hypokalemia Hyperparathyroidism	Lifestyle Factors Low-fiber diet Dehydration Physical inactivity
Neurologic Spinal cord injury Parkinson disease MS Autonomic neuropathy	Myopathic Disorders Dermatomyositis Scleroderma Amyloidosis

A DRE is recommended to assess for sphincter tone, rectal masses, prolapse or impacted stool in the rectum.^7,8 Abdominal exam may be significant for distension and mild tenderness.⁷

Constipation, in the absence of alarm symptoms, does not typically require any additional investigations.⁷ Bloodwork to assess for common causes of secondary constipation, such as hypothyroidism or hypercalcemia, can be helpful in patients with other signs and symptoms suggestive of these disorders, but is not helpful in most patients with constipation. Colonoscopy is only recommended if the patient meets the criteria for general screening, or if they have alarm symptoms.⁷ Abdominal x-rays are not routinely required but can be helpful to assess the degree of fecal loading/impaction and rule out obstruction,⁵ particularly in patients who cannot provide an accurate history and those with fecal incontinence. More in depth testing, such as anorectal manometry, colon transit investigations or MRI defecography are not recommended; these are reserved for patients who fail multiple courses of treatment.^5,7 Practically, these are rarely, if ever, ordered in this population.

Constipation in elderly patients typically requires pharmacologic management;^2,13 increasing dietary fiber, physical activity and fluids are recommended,^7,8 but these measures can be challenging to implement, particularly for institutionalized or cognitively impaired seniors.^5,13 Stool bulking agents, such as psyllium or bran, are options for treatment, but the efficacy in elderly patients is often limited by inadequate fluid intake and adverse events, such as bloating and cramping.^8,10 Bulking agents should not be used if there is fecal impaction.¹³ Osmotic agents, such as PEG 3350 or lactulose, are safe and effective options to treat constipation.^7,8 PEG is typically better tolerated and more effective than lactulose and thus is often chosen as the first line treatment for constipation in the elderly.^10,11 Stimulant laxatives are readily available and include senna and bisacodyl.¹⁰ There is no evidence that they cause colonic injury or physical dependence, however there are limited studies in elderly patients in terms of efficacy.^5,10 Stimulant laxatives can be used if a patient is not responding to or is intolerant of osmotic agents.^13,10 Prokinetic agents and secretagogues, such as prucalopride and linaclotide respectively,⁸ are often included in treatment algorithms. The use of these agents in the elderly is limited by cost and availability and they are recommended only if less expensive treatments, such as those listed above, have failed.^7,8,13 Enemas should not be used routinely if it can be avoided due to the risk of electrolyte abnormalities with phosphate enemas and the risk of mucosal damage with soapsuds enemas.⁵ If needed to prevent impaction, tap water enemas are safest.^2,5 Stool softeners, such as docusate sodium, are ineffective and not recommended.^2,10

Summary

Ms. Oddring was told to stop using her loperamide and her family removed it from her suite. She was started on PEG 17 g po bid initially, then stepped down to once daily once she started having regular, formed bowel movements. Her fecal incontinence completely resolved.

Constipation is common in elderly patients and requires a thorough history and physical exam. Regular use of osmotic laxatives is the safest and most effective treatment of constipation in the elderly,⁷ though stimulant laxatives are also inexpensive and have not been shown to cause any harm.⁷ Treatment of constipation should be individualized, as every patient has a different constellation of risk factors and comorbidities and will respond differently to therapy.

References

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2. Rao SSC, Go JT. Update on the management of constipation in the elderly: new treatment options. Clin Interv Aging. 2010 Jun; 5: 163-71.
3. Towers AL, Burgio KL, Locher JL, Merkel IS, Safaeian M, Wald A. Constipation in the elderly: influence of dietary, psychological, and physiological factors. J Am Geriatr Soc. 1994; 42: 701-6. 
4. 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. 
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6. Rome Foundation [Internet]. [Place unknown]: Rome Foundation; 2021 [cited 2023 May 1]. Available from: https://theromefoundation.org/rome-iv/rome-iv-criteria/.
7. Paquette IM, Varma M, Ternent C, Melton-Meaux G, Rafferty JF, Feingold D, Steele SR. The American society of colon and rectal surgeons’ clinical practice guideline for the evaluation and management of constipation. Dis Colon Rectum. 2016; 59: 479–92.
8. Alberta Health Services [Internet]. Alberta: Primary Care Networks; 2020 [cited 2023 May 1]. Available from: https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-dh-pathway-constipation.pdf. 
9. Harari D, Gunoitz JH, Avorn J, Choodnovskiy I, Minaker KL. Constipation: assessment and management in an institutionalized elderly population. J Am Geriatr Soc. 1994; 42: 947-52.
10. Brandt LJ, Prather CM, Quigley EMM, Schiller LR, Schoenfeld P, Talley NJ. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005; 100: S5-22.
11. Attar A, Lémann M, Ferguson A, Halphen M, Boutron M-C, Flourié B, et al. Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation. Gut. 1999; 44: 226-30. 
12. Wald A. Constipation: advances in diagnosis and treatment. JAMA. 2016; 315: 185-91. 
13. Mounsey A, Raleigh M, Wilson A. Management of constipation in older adults. Am Fam Physician. 2015; 92: 500-4. 
14. Stern T, Davis A. Evaluation and treatment of patients with constipation. JAMA. 2016; 315: 192-3. 
15. Rao S. Constipation in the older adult. In: Talley NJ, Schmader KE, Grover S, editors. UpToDate [Internet]. Waltman (DC): Wolters Kluwer; 2022 [updated 28 Jul 2022; cited 1 May 2023]. Available from: UpToDate.