Constipation in Long-Term Care
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Author Affiliations: Dr. Tariq is former Associate Professor of Internal Medicine and Geriatrics, Medical Director of the Acute Care of Elderly (ACE Unit), Division of Geriatric Medicine, Saint Louis University; and currently a Fellow, Division of Gastroenterology & Hepatology, St. Louis University School of Medicine, MO.
The intestine tends to become sluggish with age.
—Hippocrates
No organ in the body is so misunderstood, so slandered and maltreated as the colon.
—Sir Arthur Hurst, 1935
Constipation is reported in over 33 million adults, which makes it one of the most common problems in the United States. It accounts for 2.5 million physician visits and 92,000 hospitalizations each year. Constipation is seen in 25% of older persons.
The term constipation can be very confusing. While patients describe constipation as passing hard stool or straining to have a bowel movement, physicians, on the other hand, describe constipation as fewer than three bowel movements per week. Thus, both patient and physician are likely to be talking about two different sets of symptoms. For this very reason, there is little correlation between self-reported constipation and number of bowel movements in epidemiologic surveys.
The diagnostic criteria for constipation was created by a consensus conference in Rome, Italy, with the most recent updated information known as the Rome III Diagnostic Criteria.
Epidemiology
Frailty in older persons is very common and is associated with immobility, poor intake, and dehydration.1,2 It is, therefore, not surprising that constipation has been reported in 45% of frail elderly persons.3 The use of laxatives in the nursing home (NH) is reported in 50% to 65% of residents.4-8 Half of these older persons took a daily laxative, yet only 62% of them actually met the criteria for constipation. Hence, there was minimal concordance between nurses and the NH residents for whether they were constipated. The use of laxatives is more common in those who are immobile, had Parkinson’s disease or diabetes mellitus, or took iron supplements, calcium-channel antagonists, or antidepressants with anticholinergic activity.4
In a study of 21,012 persons using the Minimum Data Set in NHs, the prevalence of constipation was 12.5%. The 3-month incidence was 7%. Some of the risk factors associated with constipation were race, decreased fluid intake, pneumonia, Parkinson’s disease, and the presence of allergies. Congestive heart failure and the use of a feeding tube were two factors identified as having a protective effect.9
Economic Impact and Quality of Life
The National Health Service in the United Kingdom reported annual prescription laxative cost at 43 million pounds,10 while the average cost of treating constipation in the United States in NHs is $2253 per resident per year.11
Constipation in older persons is associated with a decline in quality of life, a decrease in functional ability, increased pain, dysuria, fecal incontinence, stercoral ulcers, and fecaloma.12-17 One of the major problems associated with constipation is the development of fecal impaction leading to intestinal obstruction, bowel perforation, and even death.18,19
Delirium is a common reason for hospital admission,20 and constipation is a common cause of delirium.21 Constipation is also reported to be associated with physical and verbal aggression.22 The cost of treating constipation does not include the adverse outcomes resulting from not treating constipation appropriately.
Causes of Constipation
The causes of constipation can be divided into mechanical causes, metabolic causes, neurologic diseases, psychiatric diseases, and medications. Mechanical obstruction is caused by colon cancer, strictures, and anal stenosis. Diabetes mellitus is associated with autonomic neuropathy and altered colonic transit time. Hypercalcemia and hypomagnesia slow intestinal transit.
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