Annals of Long Term Care

Constipation in the elderly is common and has a significant impact on quality of life and use of healthcare resources in long-term care settings. A careful history, medication assessment, and physical examination are helpful in obtaining relevant clues that help direct management. Fiber supplementation and osmotic laxatives are effective for many patients. Simplifying bowel programs saves time and energy and provides a more unified approach to care. Special effort should be taken to identify features inherent to the elderly, and treatment should be based on the patient’s overall clinical status and capabilities. Facilities should establish policies and procedures that promote good bowel function, understand the factors that contribute to this problem, and approach each resident to best meet his or her expectations. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[9]:22-24)

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Constipation is variably defined, and its diagnosis is often arbitrary. Chronic constipation (CC) is a common problem in the elderly, with a variety of etiologies including pelvic floor dysfunction, medication effects, and numerous age-specific conditions. Most epidemiologic studies demonstrate a higher prevalence of constipation and laxative use in the elderly,1,2 particularly in the institutionalized, where studies suggest a prevalence for constipation as high as 50%, with up to 74% of nursing home residents using daily laxatives.3 The more patient-centered we make our approach to constipation, the greater the variability and the higher both the incidence and prevalence of symptoms.

In addition to advanced age, risk factors for CC include female sex, nonwhite race, physical inactivity, low income and education level, medications, dietary intake, and depression.4 Severe constipation is seen almost exclusively in women, with elderly women having rates of constipation two to three times higher than that of their male counterparts.5 The elderly, who often underestimate their stool frequency, frequently plan their days around their bowel movements, and treatments often precipitate loose stools and incontinence.

Treatment of CC depends on the underlying physiologic etiology, being mindful of other factors that may influence the presentation, as shown in the “The Ten ‘D’s’ of Constipation” in Table I.

As a general rule, patients who do not respond to fiber supplementation can be advanced to osmotic laxatives, which can be titrated to clinical response. Stimulant laxatives and prokinetic agents are typically reserved for patients with more refractory constipation. No single agent or program is best for all patients or situations. The commonly used categories of agents are listed in Table II.

Treatment needs to be tailored not only to etiology but also to medical history, medications, overall clinical status, mental and physical abilities, tolerance to various agents, and realistic treatment prospects. Monitoring bowel movement frequency, stooling patterns, fecal soiling, and use of laxatives may help in the development of an overall treatment regimen tailored to the individual patient. Specific issues for institutionalized patients need to be addressed with standardized, supervised bowel programs. Each facility should have a program and policy in place that is easy to understand and simple to implement.

Clinicians should also be mindful of what evidence exists for our patient population in treating their condition. The last definitive word from the American College of Gastroenterology was published in 20051 (Table III), though at least one newer agent, lubiprostone, has shown effectiveness in a population over age 65.6 The task force cited insufficient data to make recommendations for all other treatments, including combination laxatives.

There are also a number of interventions that take excessive time and provide very little benefit.