Constipation in the older adult
- Satish SC Rao, MD, PhD, FRCP
Satish SC Rao, MD, PhD, FRCP
- Chief, Gastroenterology/Hepatology
- Georgia Regents University
- Section Editors
- Nicholas J Talley, MD, PhD
Nicholas J Talley, MD, PhD
- Section Editor — Motility Disorders
- Professor of Medicine, University of Newcastle, Australia
- Adjunct Professor of Medicine and Epidemiology and Consultant, Mayo Clinic, Rochester, MN
- Adjunct Professor, University of North Carolina
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
Constipation is a common complaint in older adults. It has a major impact on healthcare costs in the United States because it results in several office visits, specialty referrals, hospital admissions, and surgical procedures. It also affects health-related quality of life [1,2].
This topic will review the clinical approach to the diagnosis and management of constipation in the older adult. The approach to diagnosis and management of constipation in children and adults in general are presented separately. (See "Constipation in infants and children: Evaluation" and "Chronic functional constipation and fecal incontinence in infants and children: Treatment" and "Etiology and evaluation of chronic constipation in adults" and "Management of chronic constipation in adults".)
DEFINITION OF CONSTIPATION
The term constipation is variably defined by patients and physicians .
According to the Rome III criteria, functional constipation is defined as any two of the following features: straining, lumpy hard stools, sensation of incomplete evacuation, use of digital maneuvers, sensation of anorectal obstruction or blockage with 25 percent of bowel movements, and decrease in stool frequency (less than three bowel movements per week). The above criteria must be fulfilled for the last three months with symptom onset six months prior to diagnosis, loose stools should rarely be present without the use of laxatives, and there must be insufficient criteria for a diagnosis of irritable bowel syndrome.
EPIDEMIOLOGY AND RISK FACTORS
The prevalence of constipation in the older adult has not been well defined. Studies have reported that the prevalence of constipation in the older adult ranges from 24 to 50 percent [4-12]. Laxatives are used daily by 10 and 18 percent of community dwelling older adults and 74 percent of nursing home residents [9,13-16].
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- Ruby CM, Fillenbaum GG, Kuchibhatla MN, Hanlon JT. Laxative use in the community-dwelling elderly. Am J Geriatr Pharmacother 2003; 1:11.
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- Stewart WF, Liberman JN, Sandler RS, et al. Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features. Am J Gastroenterol 1999; 94:3530.
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- American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005; 100 Suppl 1:S1.
- Lindeman RD, Romero LJ, Liang HC, et al. Do elderly persons need to be encouraged to drink more fluids? J Gerontol A Biol Sci Med Sci 2000; 55:M361.
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- Brandt LJ, Prather CM, Quigley EM, et al. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol 2005; 100 Suppl 1:S5.
- Garlehner G, Jonas DE, Morgan LC, et al. Drug class review on constipation drugs, Oregon Health & Science University, Portland, OR 2007.
- Lederle FA, Busch DL, Mattox KM, et al. Cost-effective treatment of constipation in the elderly: a randomized double-blind comparison of sorbitol and lactulose. Am J Med 1990; 89:597.
- Passmore AP, Davies KW, Flanagan PG, et al. A comparison of Agiolax and lactulose in elderly patients with chronic constipation. Pharmacology 1993; 47 Suppl 1:249.
- Kamm MA, Mueller-Lissner S, Wald A, et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol 2011; 9:577.
- Ori Y, Rozen-Zvi B, Chagnac A, et al. Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas: a single center's experience. Arch Intern Med 2012; 172:263.
- FDA warns of possible harm from exceeding recommended dose of over-the-counter sodium phosphate products to treat constipation. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm380757.htm (Accessed on January 08, 2014).
- Mendoza J, Legido J, Rubio S, Gisbert JP. Systematic review: the adverse effects of sodium phosphate enema. Aliment Pharmacol Ther 2007; 26:9.
- Johanson JF, Morton D, Geenen J, Ueno R. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of lubiprostone, a locally-acting type-2 chloride channel activator, in patients with chronic constipation. Am J Gastroenterol 2008; 103:170.
- Barish CF, Drossman D, Johanson JF, Ueno R. Efficacy and safety of lubiprostone in patients with chronic constipation. Dig Dis Sci 2010; 55:1090.
- Lembo AJ, Kurtz CB, Macdougall JE, et al. Efficacy of linaclotide for patients with chronic constipation. Gastroenterology 2010; 138:886.
- Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med 2011; 365:527.
- FDA approves Linzess to treat certain cases of irritable bowel syndrome and constipation. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm317505.htm (Accessed on September 04, 2012).
- Quigley EM, Vandeplassche L, Kerstens R, Ausma J. Clinical trial: the efficacy, impact on quality of life, and safety and tolerability of prucalopride in severe chronic constipation--a 12-week, randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther 2009; 29:315.
- Müller-Lissner S, Rykx A, Kerstens R, Vandeplassche L. A double-blind, placebo-controlled study of prucalopride in elderly patients with chronic constipation. Neurogastroenterol Motil 2010; 22:991.
- Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 2007; 5:331.
- Chiarioni G, Whitehead WE, Pezza V, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 2006; 130:657.
- Chiarioni G, Salandini L, Whitehead WE. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology 2005; 129:86.
- Heymen S, Scarlett Y, Jones K, et al. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum 2007; 50:428.
- DEFINITION OF CONSTIPATION
- EPIDEMIOLOGY AND RISK FACTORS
- Primary colorectal dysfunction
- - Slow transit constipation
- - Dyssynergic defecation
- - Irritable bowel syndrome
- Secondary causes for constipation
- Chronic idiopathic constipation
- CLINICAL MANIFESTATIONS
- Physical examination
- Laboratory testing
- Physiologic testing
- Lifestyle modification
- Diet and fiber
- - Bulk forming laxatives
- - Osmotic laxatives
- - Stimulant laxatives
- Stool softeners, suppositories, and enemas
- Other therapies for chronic constipation
- - Colonic secretagogues
- - Opioid antagonists
- - 5HT(4) receptor agonists
- FECAL IMPACTION
- SUMMARY AND RECOMMENDATIONS