Constipation in the Elderly
Constipation in the Elderly
Nonpharmacologic Approaches are Safe and Effective
By Timothy Baum, MS, CRNP
In some cases, Mom doesn't know best. "The part about eating your vegetables was perfect, but you don't need to have a bowel movement every day," I once advised a pleasant woman in her 70s. She had been abusing laxatives for years, her regular regimen of magnesium hydroxide was not working, and now, like many older patients, she was having bothersome constipation. Her story is all too common.
The young old--patients between the ages of 65 and 74--report constipation twice as often as the general population (4.5% compared with 2%).1 People older than 75 report it five times as often (10%).1 As constipation complaints increase, so does laxative use.2 Most patients discharged from hospitals leave with prescriptions for stool softeners, laxatives or both.3 Chronic constipation is common among residents of long-term care facilities, and laxatives are one of the most common types of drugs prescribed in that setting.4 Most clinicians agree that constipation in the elderly a common problem, but there is no universal agreement about its definition or treatment.5
Finding a Definition
Testing the assumption that one bowel movement per day was normal, a 1965 study of an industrial English community found that 99% of subjects had at least three bowel movements per week and 4% of subjects reported constipation.6
One definition of constipation is stool that is hard and formed or defecation that occurs less than three times a week.7 The Rome criteria state that at least two or more of the following symptoms must be present for someone to be diagnosed with constipation: experiencing less than two bowel movements per week; a stool weight of less than 35 g/dL; straining and hard stools; or a feeling of incomplete evacuation more than 25% of the time.8
But studies show that patient reports of constipation do not follow the Rome criteria. In a study in which 4% of subjects reported constipation, roughly 33% had neither hard stool nor less than three bowel movements per week.6 Another study found a 3% prevalence of constipation (meeting Rome criteria) with little increase as subjects aged, while others have found marked increases in older subjects who report constipation.1,8 Some studies have documented no decrease in defecation frequency with age, but an increase in seniors reporting constipation and laxative use.9 What is it about aging that causes this phenomenon?
The time required for food to travel from mouth to cecum remains stable over the lifespan, but with decreased small bowel mucosal surface after age 65, absorption declines.10 Transit time through the colon increases with normal aging. This may be due to a decrease in gut muscle strength, atrophy of mucus-producing glands in the colon, and decreased blood supply secondary to arteriosclerosis. More commonly, constipation in the elderly is due to changes in the rectum. More stool is required to produce a sensation of the need to defecate. The internal sphincter may also be thicker and less responsive. The ability to squeeze and increase intra-abdominal pressure may decline, especially in postmenopausal women.10 Greater changes occur over time in patients who abuse laxatives, fail to heed the urge to defecate, or have low dietary fiber intake.11
The perception of constipation and the need for laxatives among the elderly could be the result of a cohort effect. When today's elderly population was young, a popular theory was that the bowels needed to be cleansed to prevent the build-up of toxins. A variety of enemas and laxatives were available for this purpose. Older people may also spend more time thinking about bowel function.2
Causes of Constipation
Many factors can lead to constipation, and they can be divided into four major categories: situational, maturational, treatment-related or pathophysiologic.7,12
Situational factors that may lead to constipation in the elderly are: inability to get to the store (leading to an unbalanced diet), bedrest, decreased mobility, situational stress, lack of exercise, poor diet and inadequate hydration. Improper toileting and lack of privacy are situational factors among the institutionalized.2,5,7,12
Age-related changes may lead to constipation. Activity may decrease due to retirement or energy decline. Seniors may ingest less fiber and bulk for reasons such as change in taste, dentition, food preference or diminishing ability or desire to cook. Abdominal muscle tone may decline with aging. Reduced fluid intake may result from decreased thirst sensation. Dehydration may also result from the inability to concentrate urine, or the decrease in renin, aldosterone and angiotensin II that leads to water loss.5,7
Constipation can also be treatment-related.7 A variety of medications are potentially constipating, including anesthetics, analgesics, antacids and anticholinergics, which include antidepressants, neuroleptics, antihistamines, anti-Parkinson's drugs and antispasmodics.11 Other drugs that have this effect are calcium channel blockers, diuretics, ganglion blockers, iron, hypotensives, monoamine oxidase inhibitors, metals, opiates and paralytic agents. Laxative abuse causes damage to the myenteric plexus, decreasing the drugs' ability to relieve constipation. Radiation treatment can cause bowel fibrosis, slowing transit time. Surgical patients who receive anesthesia and patients on fluid restrictions are also at risk.12
The pathophysiologic causes of constipation are numerous.7 Dementia reduces the ability to heed the urge to defecate and generally precludes a patient's ability to provide an accurate bowel history.12 Besides the bowel-tranquilizing effects of tricyclics and anxiolytics, depression may lead to inactivity and lowered intake of food and fluid.5 Several metabolic and endocrine disorders have been implicated, such as hypercalcemia, hyperparathyroidism, hypothyroidism, hypokalemia and diabetes.5 Slower stool passage may be due to a tumor, enlarged prostate, pelvic floor obstructions, hernia or adhesions.12 Fear of painful defecation because of hemorrhoids or spinal tumors may lead to postponement of elimination.5 Other causes are hypoxic peristalsis, irritable bowel syndrome, colon cancer, diverticulitus, uremia, dehydration, fever, endometriosis and pheochromocytoma.5 Many problems lead to diminished food intake, such as poor dentition, anorexia, dysphagia or upper GI lesions.12 Innervation of the bowel can be disrupted by problems such as cerebrovascular disease, Parkinson's disease, dementia, spinal cord injuries, amyotrophic lateral sclerosis, and multiple sclerosis.2,5,12 Patients with diabetic neuropathy may be unable to sense the need to defecate.5
Treatment of constipation, particularly by physicians, has been by custom or anecdotal evidence. No widely endorsed guidelines exist for the day-to-day management of constipation.2
Much of the research about constipation centers around diet. Epidemiologic studies show that chronic constipation in the elderly is not a problem in the rural Third World. This may be due to high-fiber diets, which may also explain inhabitants' low rates of ischemic heart disease, high cholesterol, gallstones, diverticular disease, hiatal hernia, hemorrhoids, varicose veins, colorectal cancer and diabetes. Rural Third World residents consume an average of 60 grams of dietary fiber per day, with stools of 300 grams to 500 grams passing in 30 to 35 hours. Young healthy Westerners have oro-anal transit times of 3 days; in the elderly, passage takes up to 2 weeks. The stools of Westerners average 100 grams.13 Almost all constipation in the Western world is related to a lack of dietary fiber, the literature shows.8
Dietary fiber is what remains after digestion of a plant. Dietary fibers that are insoluble in water increase colon transit time and soften stool. Vegetables, wheat and some other grains and cereals are high in this nonsoluble form, while fruits, barley and oats are high in the water-soluble form. Bran is considered the richest high-fiber food, with 9 grams of dietary fiber in 1/3 cup. Two slices of whole-wheat bread provide 2.6 grams of the same fiber.11 The mechanism by which fiber affects the bowel is still hypothetical, but one theory proposes that the fiber makes the stool attract water like a sponge, increasing its size and softness and decreasing transit time. A meta-analysis of fiber research shows that bran increases the frequency of bowel movements, especially in patients diagnosed with constipation. The fiber decreases oro-anal transit time by half.14
In one study, a physician placed his laxative-using patients on a 10-grams-per-day dietary fiber regimen. The patients obtained the fiber via 3 tablespoons of raw bran. Laxative usage declined in almost all patients, with only one-third taking laxatives occasionally.13
Several clinical research studies show the efficacy of increasing dietary fiber.
A study of 41 men and women, almost all confined to bed or wheelchair, documented a decrease in laxative use with a 2- to 4-gram bran supplement. The subjects reduced their pharmacy spending by an average of 43% with the decreased laxative use. Subjects obtained bran from a mixture of 2 cups each of Kellogg's All-Bran cereal, 2 cups applesauce and 1 cup of prune juice. Doses were 30 mL to 60 mL a day. Weekly fluid intake averaged 1,400 mL and subjects had an average of 3.2 bowel movements per week.15
In another study, 16 elderly homebound patients were given 30 mL of a mixture of whole prune, bran, applesauce and whipped topping daily.3 Their bowel movements increased from 0 to 3.5 per week to 3 to 6 per week. Only half increased fluids, which did not correlate with increased frequency. Activity level did not seem to be a factor either.
Another study used a different delivery vehicle for fiber, incorporating fiber-rich cookies and muffins into the daily diet. Increased dietary fiber and fluid intake by hospitalized immobile vascular surgical patients resulted in a decrease in constipation from 59% to about 9%.4 Laxative use changed by about the same amount. Minimum fluid requirements were 1,500 mL per day, and increased activity was required.4
Regular toileting can also be a tool for managing constipation, but research about it is scarce. The best results are obtained when regular voluntary toileting takes place along with the gastro-colic reflex, a naturally occurring large bowel reflex that starts about 10 minutes after a meal and helps initiate defecation.5
The Role of Medications
If dietary, fluid and activity improvements don't provide sufficient relief, pharmacologic intervention may be necessary. First consider a synthetic bulk agent such as methylcellulose or psyllium.5,11 Fluid intake is essential for patients who use these agents, since inadequate fluids can cause the drugs to worsen constipation. Psyllium may be an alternative for patients who complain of bloating from raw bran, but there is not much research about its use or effectiveness.2
As the next line of therapy, consider a stool softener or lubricant. Stool softeners such as docusate (Colace, Dialose) are detergents that help wet the stool and are routinely given to geriatric patients to prevent constipation. They have no laxative effect and may be no better than placebo, however.2,11 Mineral oil taken by mouth may help soften stool, but aspiration is a risk.11
Hyperosmotic agents should only be used when the possibility of impaction is imminent or the patient has no response to the interventions mentioned. This includes magnesium and sodium sulfate, sorbitol, mannitol and lactulose. Although lactulose is widely prescribed for constipation in the elderly, sorbitol may be less expensive and have a similar effect.11 Magnesium hydroxide works quickly and is best avoided in the elderly for this reason. They may have difficulty getting to the toilet in time, putting them at risk for falls.2
Likewise, local agents such as tap water enemas or glycerin suppositories are best used infrequently. Tap water enemas are effective in removing impacted stool. They work by distending the colon and rectum, causing an evacuation. Nothing should be added because this would cause a secondary irritating stimulant effect. If enemas are performed frequently, muscle tone in the lower bowel is lost, leading to constipation.5,11 Glycerin suppositories may be helpful during initiation of a regular toileting plan.5
Irritant laxatives such as bisacodyl (Dulcolax), cascara, danthron, castor oil, aloe, rhubarb and senna should be avoided. Repeated use over several years can lead to degeneration of the myenteric ganglion, making the bowel less reactive to any therapy.2,5,11
For patients already taking laxatives regularly, introduce dietary fiber while weaning from the laxative. Clinical judgment, patient education and a strong patient-provider relationship are key to a successful transition.
Refer patients who do not respond to pharmacologic and nonpharmacologic measures to a gastroenterologist. Surgery is sometimes recommended for patients with prolonged colonic transit times. Biofeedback is successful in about 70% of patients with pelvic floor dysfunction.8
Nonpharmacologic Measures Best
According to published research, nearly all cases of constipation in the elderly can be solved with nonpharmacologic means and, in a limited number of cases, the addition of some carefully selected drugs. Research to identify strategies for weaning community-dwelling seniors from laxative abuse is needed. *
1. Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958 to 1986. Dig Dis Sci. 1989;34:606-611.
2. Minaker KL, Harari D. Constipation in the elderly. Hospital Practice. 1995:67-76.
3. Neal LJ. "Power pudding": natural laxative therapy for the elderly who are homebound. Home Healthcare Nursing. 1995;13:66-71.
4. Hall GR, Karstens M, Rakel B, Swanson E, Davidson A. Managing constipation using a research-based protocol. Medsurg Nursing. 1995;4:11-20.
5. Allison OC, Porter ME, Briggs GC. Chronic constipation: assessment and management in the elderly. Journal of the American Academy of Nurse Practitioners. 1994;6:311-317.
6. Connell AM, Hilton C, Irvine E, Lennard-Jones JE, Misiewicz JJ. Variation in bowel habit in two population samples. British Medical Journal. 1965;2:1095-1099.
7. Carpenito LJ. Nursing Diagnosis: Application to Clinical Practice. Philadelphia: J.B. Lippincott; 1993.
8. Camilleri M, Thompson WG, Fleshman JW, Pemberton JH. Clinical management of intractable constipation. Annals of Internal Medicine. 1994;121:520-528.
9. Harari D, Gurwitz JH, Avorn J, Bohn R, Minaker KL. Bowel habit in relation to age and gender. Archives of Internal Medicine. 1996;156:315-320.
10. Lovat LB. Age related changes in gut physiology and nutritional status. Gut. 1996;38:306-309.
11. Castle SC. Constipation: endemic in the elderly? Medical Clinics of North America. 1989;73:1497-1509.
12. Wright BA, Staats IO. The geriatric implications of fecal impaction. The Nurse Practitioner. 1986;11:53-59.
13. Burkitt DP, Meisner P. How to manage constipation with high-fiber diet. Geriatrics. 1979;34:33-40.
14. Hillemeier C. An overview of the effects of dietary fiber on gastrointestinal transit. Pediatrics. 1995;96:997-999.
15. Brown MK, Everett I. Gentler bowel fitness with fiber. Geriatric Nursing. 1990;11:26-27.
Bran, Prune and Applesauce15
2 cups All-Bran cereal, 2 cups applesauce, 1 cup 100% prune juice
Dose: 30 mL to 60 mL per day.
1/2 cup prune juice, 1/2 cup applesauce, 1/2 cup wheat bran flakes,
1/2 cup whipped topping, 1/2 cup canned stewed prunes
Dose: 1/4 cup with breakfast
1/3 cup white granulated sugar
1 stick butter
1/3 cup molasses or dark syrup
2.5 oz egg substitute
1/2 cup skim milk
1/4 tsp cinnamon
1/8 tsp ground clove
1 tsp baking powder
2 1/2 cups all-purpose flour
1 cup old-fashioned oatmeal
1 cup psyllium powder
1/2 cup raisins
Cover raisins with tap water and let stand 10 minutes. Cream sugar and butter. Add molasses and egg; cream for 3 minutes. Mix in milk. Mix in dry ingredients. Drain raisins and mix in.
Drop golf-ball size spoonfuls of batter onto lightly greased baking sheet; flatten slightly. Bake at 350 degrees for 12 minutes.
Yield: 2 dozen scones, each containing about 5 grams of fiber and 160 calories