Management of Constipation in Older Adults

 


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Am Fam Physician. 2015 Sep 15;92(6):500-504.

  Patient information: A handout on constipation, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Chronic constipation is common in adults older than 60 years, and symptoms occur in up to 50% of nursing home residents. Primary constipation is also referred to as functional constipation. Secondary constipation is associated with chronic disease processes, medication use, and psychosocial issues. Fecal impaction should be treated with mineral oil or warm water enemas. Most patients are initially treated with lifestyle modifications, such as scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake. Additional fiber intake in the form of polycarbophil, methylcellulose, or psyllium may improve symptoms. Fiber intake should be slowly increased over several weeks to decrease adverse effects. The next step in the treatment of constipation is the use of an osmotic laxative, such as polyethylene glycol, followed by a stool softener, such as docusate sodium, and then stimulant laxatives. Long-term use of magnesium-based laxatives should be avoided because of potential toxicity. If symptoms do not improve, a trial of linaclotide or lubiprostone may be appropriate, or the patient may be referred for further diagnostic evaluation. Peripherally acting mu-opioid antagonists are effective for opioid-induced constipation but are expensive.

Chronic constipation occurs in 16% of adults, with older patients experiencing constipation more often.1 About one-third of adults 60 years or older report at least occasional constipation1, and in nursing home residents, the prevalence is 50% or more.2 Approximately 33 million adults in the United States have constipation resulting in 2.5 million physician visits and 92,000 hospitalizations each year.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Increased exercise does not improve symptoms of constipation in nursing home residents or older adults.

A

810

Polyethylene glycol (Miralax) is preferred over lactulose for the treatment of constipation because it is more effective and has fewer adverse effects.

A

29

Linaclotide (Linzess) and lubiprostone (Amitiza) are more effective than placebo for chronic constipation.

B

24, 31

Peripherally acting mu-opioid antagonists are more effective than placebo for chronic opioid-induced constipation.

B

23, 34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Increased exercise does not improve symptoms of constipation in nursing home residents or older adults.

A

810

Polyethylene glycol (Miralax) is preferred over lactulose for the treatment of constipation because it is more effective and has fewer adverse effects.

A

29

Linaclotide (Linzess) and lubiprostone (Amitiza) are more effective than placebo for chronic constipation.

B

24, 31

Peripherally acting mu-opioid antagonists are more effective than placebo for chronic opioid-induced constipation.

B

23, 34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Definitions

Constipation is a clinical diagnosis based on symptoms of incomplete elimination of stool, difficulty passing stool, or both. Patients typically experience other symptoms such as hard stools, abdominal bloating, pain, and distention. Constipation may be present with normal stool frequency, defined as at least one stool three times per week, or with daily bowel movements.1 Chronic constipation is characterized by the presence of symptoms for at least three months out of the preceding 12 months.

PRIMARY CONSTIPATION

Primary constipation, or functional constipation, is classified into three subtypes: normal transit constipation, slow transit constipation, and disorders of defecation. Often, more than one subtype occurs simultaneously.4 Normal transit constipation is the most common. Patients report hard stool or difficulty with defecation, but have normal stool frequency.4 Slow transit constipation, caused by abnormal innervation of the bowel or visceral myopathy, leads to increased transit time of stool through the colon with infrequent defecation, bloating, and abdominal discomfort.5 Disorders of defecation can occur in any age group but are particularly common in older patients.6 Defecation may be impaired by decreased smooth muscle contraction in the rectum or the inability to relax the muscles of defecation. In older adults,

The Authors

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ANNE MOUNSEY, MD, is a professor of clinical medicine at the University of North Carolina, Chapel Hill....

MEGHAN RALEIGH, MD, is a sports medicine fellow at the Uniformed Services University of the Health Sciences in Bethesda, Md. At the time the article was submitted, Dr. Raleigh was a faculty development fellow at the University of North Carolina, Chapel Hill.

ANTHONY WILSON, MD, is an assistant professor of family medicine at the University of Tennessee Medical Center in Knoxville, Tenn. At the time the article was submitted, Dr. Wilson was a faculty development fellow at the University of North Carolina, Chapel Hill.

Address correspondence to Anne Mounsey, MD, University of North Carolina, 590 Manning Dr., Chapel Hill, NC 27514 (e-mail: anne_mounsey@med.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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