Treatment of Constipation In Older Adults | Definitive Guide
Kobi NathanWhat is Constipation?
Constipation is a common gastrointestinal (GI) disorder that presents as infrequent or incomplete bowel movements, hard stools, and abdominal pain.
Anywhere from two to 27 percent of the general population experiences constipation.
The elderly population, however, reports a higher incidence of constipation than their younger counterparts.
Approximately 20 percent of seniors experience chronic constipation.
Constipation is even higher in nursing homes, with up to 50 percent of residents experiencing constipation and 74 percent using daily laxatives.
Fortunately, there are effective strategies for the effective treatment of constipation.
Constipation vs. Obstipation:
Most people tend to be constipated versus obstipated.
Constipation refers to a condition in which you may have fewer than three bowel movements in a week.
Constipation is not life-threatening and is usually not an emergency.
However, chronic constipation can cause changes in your GI tract, leading to uncomfortable GI symptoms.
You may experience indigestion, stomach cramping, bloating, heartburn, burping, nausea, or vomiting.
If you have chronic constipation, you should seek treatment.
Obstipation is a medical emergency.
This condition develops when you are so constipated that you cannot have any bowel movements.
As you can imagine, not treating this problem promptly can have life-threatening consequences.
Causes of Constipation
There are various reasons why constipation occurs in older adults.
Potential causes include pelvic floor dysfunction (PFD), slowed digestion, lifestyle, prescription agents such as opioid pain medications, or a combination of factors.
These factors are outlined below:
Pelvic floor dysfunction
Your body coordinates a series of muscle movements in the pelvic floor and anal sphincter to pass a bowel movement.
PFD occurs when this coordination is disrupted.
In PFD, you may have irregular relaxation or contraction of the pelvic floor muscles.
Additionally, the muscle force needed to pass a bowel movement may be too weak.
This can make it challenging to have a bowel movement, causing constipation.
Slow colon transit
When you eat food, that food undergoes digestion throughout various body parts to form a bowel movement.
As we age, the rate at which food and bowel movements move through the body decreases.
This can cause you to feel “backed up” or constipated.
Other factors can influence your digestion speed, such as medications and PFD.
Lifestyle
Our daily behaviors can contribute to the severity and frequency of constipation.
Older adults are often sedentary and stall movement within the body, specifically digestion.
Older adults may also have different dietary intake, drink less water, and take medications that can cause constipation.
Certain conditions can cause constipation and contribute to intestinal obstruction.
Such diseases include, but are not limited to:
- Dementia
- Parkinson’s disease
- Multiple sclerosis
- Colon cancer
- Diabetes
- Hypothyroidism
- Anticholinergic medications
The video below from the Mayo Clinic describes the causes and symptoms of constipation:
Medications That Cause Constipation In The Elderly
Certain medications can slow colonic transit time, causing or worsening constipation.
These include some of the drugs listed in the table below.
Medication Classes and Examples
| Class | Examples |
|---|---|
| Pain medications | Opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol |
| Anticholinergic agents | Atropine, oxybutynin, dicyclomine, scopolamine |
| Calcium channel blockers (Heart) | Diltiazem, verapamil |
| Tricyclic antidepressants | Amitriptyline, nortriptyline |
| Parkinson’s medications | Trihexyphenidyl |
| Antacids | Aluminum, calcium |
| Calcium supplements | Calcium carbonate |
| Iron supplements | Ferrous sulfate |
| Antihistamines | Diphenhydramine, hydroxyzine |
| Diuretics (“water pills”) | Hydrochlorothiazide, furosemide |
| Antipsychotics | Clozapine, olanzapine |
| Anticonvulsants | Phenytoin, clonazepam |
Treatment Of Constipation Caused By Medications
If a medication is causing your constipation, your doctor may discontinue the medication or switch you to a new one to relieve your symptoms.
DO NOT stop taking a medication unless instructed by your doctor.
If the drug cannot be stopped, several other ways exist to relieve constipation.
Complications of Untreated Constipation
There are many dangers if treatment of constipation is ignored, some of which can be life-threatening.
When constipation is left untreated, it can lead to:
- Increased pressure in the lower abdomen, causing a hernia
- Diarrhea
- Worsen medical conditions such as IBS and chronic pain
- Fecal impaction (build-up of dry, hard feces in the rectum and colon that can cause discomfort, constipation, and even sepsis.)
- Hemorrhoids (rectal bleeding)
- Anal fissure (painful tears in the thin, moist tissue that lines the anus)
- Rectal prolapse (rectum slips out of the anus)
- Diverticulitis (pouches that form in your intestines, which then become infected - see image below)
[caption id="attachment_3635" align="alignnone" width="300"]
Diverticula in the large intestine.[/caption]
The goal of treatment of constipation should be to improve symptoms and pass soft, formed stool without straining a minimum of three times a week.
If you cannot discontinue an offending agent or have something else causing constipation, multiple methods exist to help improve your bowel movements.
The first step includes lifestyle and behavioral changes.
You should increase your fiber and fluid intake, exercise regularly, and stay hydrated.
Some people will also require laxatives.
These solutions are outlined in the rest of the article.
Typically, your provider will manage your constipation according to the algorithm below:
Management of Chronic Constipation
| Step | Management Approach |
|---|---|
| Step 1 | Eliminate any constipating medications |
| Step 2 | Lifestyle and behavioral changes (diet, fiber, hydration, activity) |
| Step 3 | Polyethylene glycol (Miralax) |
| Step 4 | Stool softener plus stimulant laxative |
Non-medication Treatment of Constipation
Older adults often do not intake enough dietary fiber.
Increasing the fiber you get from your diet can help constipation symptoms.
Fiber increases the rate at which food moves through your intestines. Fiber-rich foods include:
- Fresh fruit and vegetables (e.g., apples, oranges, broccoli, and carrots)
- Whole grains (e.g., grain cereal and oatmeal
- Legumes (e.g., beans and lentils)
Grains and Legumes[/caption]
When increasing your fiber intake, start with low amounts and slowly increase to 25 to 20 grams of fiber daily.
A gradual increase will reduce gas, bloating, and fiber-associated stomach pain symptoms.
Regular physical activity and adequate fluid intake may also decrease constipation.
While no studies confirm the benefit of water alone in treating constipation, consuming 1.5 to 2 liters of water daily improves the frequency of bowel movements.
You could also try using a step stool when having a bowel movement.
Once seated on the toilet, place your feet on a small step stool instead of the floor.
This position can sometimes make it easier to pass a bowel movement.
Medications For The Treatment Of Constipation
If lifestyle changes alone do not help your constipation, several medications can help with the treatment of constipation.
Most seniors who have chronic constipation will need a laxative to relieve symptoms.
The table below lists different medication classes that treat constipation and how they work.
These will be discussed in further detail throughout the rest of the article.
Approved Medications for Constipation
| Medication Class | How They Work | Examples |
|---|---|---|
| Bulking agents | Add bulk and absorb water to make stool softer and easier to pass | Metamucil (psyllium), Konsyl, FiberCon (polycarbophil), Citrucel (methylcellulose) |
| Stimulant laxatives | Stimulate intestinal muscle contractions to move stool | Senna, bisacodyl |
| Osmotic laxatives | Draw water into the intestines to soften stool and increase bowel movements | Lactulose, polyethylene glycol (PEG), milk of magnesia, magnesium citrate, sorbitol, enemas |
| Lubricants | Coat stool to help it pass more easily through the colon | Mineral oil |
| Stool softeners | Increase water and fat in stool to make it easier to pass | Docusate sodium |
| Chloride channel activators | Increase intestinal fluid secretion to ease stool passage | Lubiprostone (Amitiza) |
| Guanylate cyclase-C agonists | Increase fluid secretion and intestinal movement | Linaclotide (Linzess) |
| Peripherally acting mu-opioid antagonists | Block opioid effects in the gut to restore bowel function | Methylnaltrexone (Relistor), naloxegol (Movantik) |
Bulk Laxatives (Fiber supplements)
Bulking agents absorb water from the intestine, softening and bulking the stool.
These agents are categorized as either “soluble” or “insoluble”.
Bulking agents' common side effects include gas, bloating, and a swollen abdomen.
These symptoms improve with time.
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Osmotic Laxatives
Osmotic laxatives include agents such as lactulose and PEG (Miralax).
These medications also work by drawing water into the intestine, which helps to soften the stool and promote bowel movements.
Osmotic laxatives can be taken orally or rectally and come in both prescription and over-the-counter forms.
A study comparing PEG and lactulose in individuals over 75 years of age showed that PEG was more effective and had fewer side effects than lactulose.
Lactulose may cause diarrhea in those who are lactose intolerant.
There are few studies on the safety and effectiveness of magnesium in older adults, and there are concerns surrounding its use in renal disease.
Stimulant Laxatives
| Agent | Dose | Onset Time | Side Effects |
|---|---|---|---|
| Senna (Tablets) | 15 mg daily | 6 to 12 hours | Stomach pain |
| Bisacodyl (Dulcolax) Tablets | 5 to 15 mg daily | 6 to 10 hours | Stomach pain, diarrhea |
Stimulant Laxatives
Stimulant laxatives are medications that stimulate the bowels to empty.
They treat constipation and clean out the bowel before surgery or other procedures.
Stimulant laxatives increase the intestine's muscle contractions and speed up the passage of stool through the intestines.
Older adults are at risk of the long-term effects of stimulant laxatives.
They also may cause excess cramping and should, therefore, be limited in use.
Stimulant laxatives are best if you have failed treatment of constipation with fiber and osmotic laxatives.
Stool Softeners
Stool softeners work by making the stool’s consistency softer.
However, they are ineffective in treating constipation, and I do not recommend them.
They are best used in certain situations as a preventative measure, such as after surgery.
Other Prescription Medications for Constipation
Lubiprostone is effective at treating constipation in seniors.
However, its use is limited by the side effect of nausea, which occurs in roughly 25 to 30 percent of patients with chronic constipation.
Lubiprostone is more expensive than other medications indicated for the treatment of constipation and should only be used when your symptoms persist after trying different medications.
Linaclotide is another agent indicated for those with chronic constipation and irritable bowel syndrome.
The most common side effect is diarrhea.
Peripherally acting mu-opioid antagonists include medications such as methylnaltrexone and naloxegol.
These reduce the GI effects associated with opioids.
Other Prescription Medications for Constipation
| Agent | Dose | Onset of Action | Side Effects |
|---|---|---|---|
| Lubiprostone (Amitiza) | 24 mcg twice daily | ~24 hours | Nausea, diarrhea, headache |
| Linaclotide (Linzess) | 145 mcg once daily | Within 24 hours (full effect ~1 week) | Diarrhea |
| Methylnaltrexone (Relistor) | Weight-based, subcutaneous injection daily | Within 4 hours | Abdominal pain, diarrhea |
| Naloxegol (Movantik) | 25 mg once daily | 6 to 12 hours | Abdominal pain |
Summary
- Constipation is a common problem, affecting approximately 42 million people in the United States.
- Elderly adults are at a higher risk for constipation because of several factors, including changes in diet and mobility, medications, and health conditions.
- Constipation in the elderly may be caused by pelvic floor dysfunction, poor diet, dehydration, or medications and can seriously impact the quality of life.
- Many commonly prescribed medications can cause constipation and can easily be managed with appropriate bowel medications.
- The most common symptoms of constipation are difficulty passing hard, dry stool, straining, and feeling bloated.
- Treatment for constipation depends on the underlying cause.
- Lifestyle changes such as adding more fiber to the diet or increasing physical activity can help relieve symptoms. If lifestyle changes do not help, medications or other treatments may be needed.
- While there is no one-size-fits-all answer to resolving this common issue, many medications are available to help ease the discomfort.
- Preventing medication-induced constipation using simple bowel medications such as stimulants is easier than treating it later.
- Many instances of constipation can be effectively managed with non-medication methods.
- There are many medication options to treat constipation that non-medication methods cannot manage.
- It is important to talk with your doctor first to identify the causes of your constipation – DO NOT STOP any prescribed medications or take over-the-counter bowel medications unless directed by your medical provider.