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As many as one in five people experiences chronic constipation, a condition that's even more common in women as they get older. It's something that can easily creep up on you if you're not paying attention, with many factors, from diet to other health conditions, contributing to the problem. Here's what you need to know about constipation symptoms, causes, prevention and when to see a doctor.
Most people think constipation means not having frequent enough bowel movements. In reality, constipation is more complicated and more subtle than that, with a range of symptoms that you may not always recognize. People may think if they are having a bowel movement every day, they can't be constipated, but you can meet the medical definition of constipation with just one of these symptoms:
Depending on the severity, constipation can cause problems such as abdominal pain and gas. Excessive straining during bowel movements may also cause:
Constipation has a wide range of causes and risk factors ranging from poor diet to more serious disorders. In terms of how our bodies operate, the causes of constipation fall into three categories:
The good news is that if you have mild constipation, simple lifestyle changes can help manage the condition. Prevention tips include:
If increasing fiber intake, exercise and hydration don't solve the problem, your constipation may be characterized as chronic. Depending on the cause of chronic constipation, you may need physical therapy or even low-dose laxatives to treat the problem. For chronic constipation, it's important to meet with a professional who can help guide you to the right kind of therapy. This is especially important if you have any warning signs of disease, such as weight loss, bleeding or pain, or stools that become pencil-thin and stay that way. All things considered, you should see a doctor if constipation or any other physical discomfort is interfering with your daily life.
Constipation happens when fecal material (stool) moves through the large bowel (colon) too slowly. The fluid portion of the stool is absorbed back into the body, so the stool becomes hard and dry. This makes it difficult to pass the stool. What causes constipation?Poor nutrition, inadequate sleep, limited exercise, anxiety, emotional stress and age may cause constipation. Certain disease also can cause constipation, and are usually associated with a sudden change in bowel habits, pain, weight loss, fatigue or bloody stools. Contact your doctor if you experience these symptoms. Some medications cause constipation – talk to your doctor if you think your medications are causing constipation. Can eating more fiber help with constipation?Yes. Fiber is the part of plant food that is not digested. There are two kinds of fiber: soluble and insoluble. Soluble fiber gives stool bulk. Foods that are good sources of soluble fiber include apples, bananas, barley, oats, and beans. Insoluble fiber helps speed up the transit of food in the digestive tract and helps prevent constipation. Good sources of insoluble fiber include whole grains, most vegetables, wheat bran, and legumes. Foods that have fiber contain both soluble and insoluble fibers. A good goal for dietary fiber is a total of about 20 to 30 grams each day. Guidelines to Treat ConstipationNutrition
Exercise and Sleep
Stress and Anxiety
Can Fam Physician. 2015 Feb; 61(2): 152–158. Stepwise approach to keep things moving Brenda G. Schuster, PharmD ACPR FCSHP Clinical Pharmacist in the Academic Family Medicine Unit, Regina Division, at the University of Saskatchewan, and Academic Detailer for the RxFiles Academic Detailing Program. Rejina Kamrul, MB BS CCFP Rejina Kamrul, Assistant Professor in the Academic Family Medicine Unit, Regina Division. Constipation is a common complaint and challenge for older adults. The prevalence of constipation increases with age and differs among settings. In individuals 65 years of age or older in the community, the prevalence is 26% for women and 16% for men.1 This rate increases to 34% for women and 26% for men in those 84 years of age and older.1 For long-term care residents, the prevalence is as high as 80%.1,2 The objective of this article is to discuss a stepwise approach for the management of constipation in older adults. Clinical pearls for successful nonpharmacologic or lifestyle measures and pharmacotherapeutic tips are provided. Case
Stepwise approach to constipationThe following stepwise approach can be used when managing a patient with constipation. A systematic approach is especially important in older adults with multiple comorbidities and medications. Step 1: Establish that the patient is suffering from constipation and identify the predominant symptomSeveral definitions and tools are available for diagnosing constipation (Box 1),1,3–5 but simply put, constipation is unsatisfactory defection owing to infrequent stools or difficult or incomplete evacuation.4,6 Constipation is symptom-based and subjective, as what is “normal” in terms of bowel movements varies among individuals. While researchers and health care providers often rely on the frequency or consistency of bowel movements to define constipation, patients tend to use symptoms such as straining, hard stools, and bloating.2,6,7 Box 1.Definitions and tools for diagnosing constipationThe Rome III Criteria for Adults3 are often cited in the literature for diagnosing constipation, but are used more in research than in clinical practice. Constipation is diagnosed when
The Canadian Association of Gastroenterology defines constipation as symptom based, including a combination of fewer than 3 stools per wk, stool form that is mostly hard or lumpy, and difficult stool passage (need to strain or incomplete evacuation) for more than 6 mo.3 Questions to ask your patients to determine whether they are constipated
The Bristol Stool Scale5 is a validated tool that correlates stool consistency with colonic transit time. The scale can be helpful for patient assessment and monitoring, and as a clinical communication aid to help patients discuss their bowel movements with their physicians. The Bristol Stool Scale is available from CFPlus.* Stool types 1 and 2 indicate constipation, with types 3 and 4 being the ideal stools (especially the latter), as they are easy to defecate while not containing any excess liquid. Types 5, 6, and 7 tend toward diarrhea. Straining is often the predominant symptom in the elderly. It occurs in up to 65% of community-based individuals older than 65 years of age, and hard stools are reported in approximately 40% of these individuals.1,8 Stool frequency and consistency, along with symptoms (ie, straining), are used to confirm constipation in Mrs N.M. The patient and her daughter are able to provide this information; however, older individuals with impaired cognition or ability to communicate might present with nonspecific symptoms (eg, agitation, anorexia, or decline in function).9 Step 2: Conduct a physical examination and rule out alarm featuresA visual and digital anal-rectal examination is recommended for identifying local anorectal disease, which can contribute to pelvic floor dysfunction. During the digital rectal examination, feel for masses or strictures, note sphincter tone, and rule out fecal impaction, which is particularly important in patients with dementia or who are bedridden. Negative digital rectal examination findings do not rule out a proximal impaction, and an abdominal x-ray scan is necessary when there is a high degree of suspicion. In older adults presenting with loose stools, digital rectal examination is also useful for assessing overflow incontinence due to fecal impaction. A misdiagnosis can lead to erroneous treatment with antidiarrheal medications that will worsen the condition. Patients should also be assessed for alarm features (Box 2) that require additional investigations to rule out structural diseases (eg, colon cancer).10,11 Mrs N.M. does not have any alarm features. Box 2.Alarm features of constipationMost important questions to ask your patient:
Other alarm features:
Step 3: Identify and treat reversible causesA number of diseases and conditions have been suspected of causing constipation (Box 3).2,11,12 Optimizing the management of these diseases, when possible, should be attempted in an effort to lessen or resolve the constipation.11 However, constipation is often multifactorial, especially in the elderly, and laxatives might still be required. Box 3.Diseases and conditions that can cause constipationCauses of constipation
Mrs N.M.’s older age along with her history of diabetes and depression might all be contributing to her constipation. There is no evidence to suggest that gastrointestinal transit time is slower with increasing age, except in the frail elderly, particularly in those who are bed-bound.2,13 The higher prevalence of constipation in older individuals is thought to be owing to a greater number of diseases and medications in this population.2 The exact mechanism of diabetes-induced constipation is unclear, but it appears to have a stronger link to poor glycemic control versus the presence of autonomic neuropathy.12 Mrs N.M.’s diabetes is under control, and her most recent hemoglobin A1c level was 7%. The link between depression and constipation is not fully understood. It might be attributed to the effect depression has on lifestyle (eg, loss of appetite, decreased activity) or the anticholinergic properties of certain antidepressants (eg, tricyclic antidepressants, paroxetine). Mrs N.M. is taking citalopram and her depression is in remission. Step 4: Identify medications that might cause constipationBalance the risk of constipation versus the benefit of the medications. If possible, decrease the dose, discontinue the medication, or switch to another agent with a lower incidence of constipation. Numerous prescription and over-the-counter medications can cause or contribute to constipation (Box 4).1,4,8,14 The Beers and STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria are often used to identify medications that might be unsuitable for elderly patients.15–17 Both lists include medications that can cause or exacerbate constipation in older adults.15–17 Box 4.Examples of medications that can cause constipationMedications that can cause constipation:
Mrs N.M. is currently taking 5 medications that can contribute to constipation: amitriptyline, calcium, dimenhydrinate, metoprolol, and hydrochlorothiazide. Amitriptyline and dimenhydrinate are listed in the Beers and STOPP criteria as medications to avoid in the elderly owing to the increased risk of constipation, cognitive impairment, and other anticholinergic side effects.15,17 Mrs N.M. is talking amitriptyline and dimenhydrinate as sleep aids. She agrees to taper both of these medications and is provided with information on sleep hygiene. (Suggestions for managing insomnia in older adults are available from CFPlus.*) An online calcium calculator18 is used to assess Mrs N.M.’s dietary calcium intake. She agrees to add 1 daily serving of calcium-rich food to her diet, which allows a reduction in her calcium supplement to 500 mg once daily. Her metoprolol and digoxin were prescribed for heart rate control secondary to atrial fibrillation. Dihydropyridine calcium channel blockers might be used for the same indication; however, these agents cause more constipation (1% for metoprolol vs 2% to 4% for diltiazem or 12% for verapamil)19–21 and are also listed in the Beers criteria.15 As such, her metoprolol is continued. Theoretically, diuretics can cause constipation secondary to fluid loss.13,14 Hydrochlorothiazide causes diuresis during the first 4 to 6 weeks of therapy.22 Plasma volume and extracellular fluid normalizes after this point and antihypertensive properties of the medication are maintained by other mechanisms.22 Mrs N.M. confirms that she has been taking hydrochlorothiazide for years; therefore there is no need to change this medication with regard to her constipation. Step 5: Recommend lifestyle changes (ie, activity, fibre and fluid intake, regular toilet routine) for patients with deficiencies (eg, low fibre or fluid intake, inactivity) and when interventions are safeThere is limited evidence that lifestyle changes resolve constipation, but it is universally accepted as a first-line approach. Studies assessing the effect of physical activity on constipation in the elderly were unable to show an improvement in bowel movements; however, exercise has been shown to enhance quality of life in this population.23 Low fluid intake has been associated with constipation in nursing home residents,24 but there was no association in older individuals from a variety of settings.25 Increasing fluid intake can be recommended for patients with low intake or who are taking bulk-forming agents, provided there are no fluid restrictions (eg, heart or kidney failure); however, there is little guidance on how much fluid should be consumed. Apple, pear, and prune juices contain sorbitol and might assist with laxation. The studies that assessed dietary fibre in the elderly reported mixed results and were of low quality.2,10 Soluble fibre (eg, psyllium) has better evidence than insoluble fibre (eg, bran) and is preferred.10 Fibre should be titrated gradually (eg, increased by 5 g per week) to minimize gastrointestinal side effects (eg, flatulence, bloating) to up to 20 to 30 g per day.2,10 Patients with confirmed slow-transit constipation or pelvic floor dyssynergia respond poorly to a high-fibre diet and fibre supplements. Minimize dietary fibre intake in these individuals and encourage them to purée or thoroughly cook and chew fibre-rich foods.1 One randomized crossover trial compared 50 g of prunes twice a day (approximately 12 prunes, which is equal to 6 g of fibre per day and 14.7 g of sorbitol per day) to 11 g or 1 tablespoon of psyllium twice a day (6 g of fibre per day) over 8 weeks (n = 40, mean age 38 years).10,26,30 The prunes resulted in 1 extra bowel movement per week and improved stool consistency, but there was no difference in straining between the treatment arms, although both groups improved compared with baseline.10,26,27 Of note, 50 g of prunes per day equates to 120 calories. A regular toilet routine is also recommended for elderly individuals suffering from constipation. For example, recommend that within 1 hour of waking patients engage in mild physical activity (eg, walking, swimming, yoga, tai chi) and consume a hot beverage (preferably caffeinated) and a fibre cereal. They should also have regular toileting in the morning, even without urge, and end the day with a fibre supplement.1 Mrs N.M.’s mobility is limited owing to her arthritis. She agrees to reschedule her acetaminophen (1300 mg every 12 hours) in an effort to optimize her pain management, which might in turn increase her activity level. She is encouraged to increase her dietary fibre by eating more fruit (including prunes), vegetables, and bran. Regarding her concern about water consumption and voiding, she is instructed to limit caffeinated and alcoholic beverages, which have a diuretic effect, and to increase the amount of water and juice she drinks. Step 6: Initiate or alter laxative therapy and monitor efficacy and safetyThere are no studies assessing a stepwise approach to laxative therapy. It is recommended that therapy begin with a bulk-forming agent, then an osmotic laxative followed by a stimulant laxative, if needed.10,23 There is insufficient evidence to recommend docusate for the prevention or treatment of constipation10,28; anecdotal experience suggests it might alleviate straining in selected patients (eg, those who recently underwent rectal surgery or had myocardial infarction). The Beers criteria state that mineral oil should be avoided in older adults owing to concerns about aspiration; safer alternatives are available.15 Recommendations for laxatives in older adults are similar to those used in the general adult population.2 Bulking agents (eg, psyllium) are effective in the management of constipation in patients who can drink 1 glass of water with each dose. Mrs N.M. has tried psyllium, which resulted in fecal impaction due to low fluid intake. Treatment of impaction would include manual disimpaction using 2% lidocaine gel to anesthetize and lubricate the rectum and anus.29 A mineral oil enema would be preferred over a sodium phosphate enema. Repeat mineral oil enemas daily, for up to 3 days if required. If the stool is located higher up in the intestine and manual disimpaction and enemas are ineffective, try 2 L of oral PEG 3350 with electrolytes for 1 to 2 days30 or 1 L of oral PEG 3350 with electrolytes for 3 days.31,32 Additional laxatives (oral or suppositories) or dose adjustments to maintenance therapy might be required. Avoid bulk-forming laxatives in the setting of impaction. The next step for patients with inadequate response to a bulking agent, or in those who have contraindications to this class, is the addition of an osmotic laxative such as lactulose or PEG 3350.10,27 Polyethylene glycol 3350 is considered to be more effective (number needed to treat [NNT] of 3) than lactulose (NNT of 4)33–35 for stool frequency per week, form of stool, relief of abdominal pain, and the need for additional laxatives.33 Mrs N.M. is currently taking PEG 3350, an osmotic laxative. Stimulant laxatives are recommended if constipation continues despite taking osmotic laxatives (NNT of 3)33; however, there is limited evidence to support routine use.1 Bisacodyl and sodium picosulfate are considered effective, but be cautious with the use of sodium picosulfate in the elderly. Mrs N.M. agrees to add a stimulant laxative (eg, a 5-mg bisacodyl tablet at bedtime 3 times a week), but questions whether her bowels will become dependent on them. Myenteric plexus or smooth muscle damage due to stimulant laxatives is rare, and it is unclear if this is due to constipation rather than laxative use.35 The prevailing opinion is that stimulant laxatives are safe to use up to 3 times per week, when fibre or osmotic laxatives have failed to provide a sufficient response (the exception would be daily stimulant laxative use for opioid-induced constipation).36–38 Chronic laxative use might potentially alter electrolytes, but data are limited. Older adults with a history of electrolyte imbalances should use laxatives with caution. Other side effects specific to stimulants include potential abdominal cramping, bloating, and nausea. Some patients might not be able to control or predict the need to defecate; therefore, caution should be used when prescribing stimulant laxatives to elderly patients who have mobility issues and risk of falls. Newer agents available in Canada to treat constipation include linaclotide and prucalopride. Linaclotide is an intestinal secretagogue that has been studied for chronic constipation and constipation-predominant irritable bowel syndrome in women.39 Prucalopride is a highly selective serotonin agonist (5-HT4) that stimulates gastrointestinal motility. It is officially indicated for chronic idiopathic constipation in women in whom laxatives failed to provide adequate relief.40 Both agents have only been compared with placebo, have limited evidence for use in older adults, and should be reserved for patients who have failed to respond to standard therapy prescribed by a clinician with experience in treating chronic constipation.41 Table 1 lists laxatives that can be used in older adults, and Table 2 lists laxatives to avoid or use with caution in this population.42 Table 1.Features of laxatives used in older adults LAXATIVE TYPEFEATURES
Dose-dependent nausea, abdominal bloating, cramping, diarrhea, and flatulence can occur with both PEG 3350 and lactulose; however, PEG 3350 has a higher incidence of diarrhea in elderly patients but a lower incidence of flatulence Some find lactulose too sweet, but the taste can be masked by diluting it in water, fruit juice, milk, or desserts PEG 3350 is a tasteless, odourless powder that is dissolved in 250 mL of water, juice, coffee, or tea Lactulose is less expensive at starting doses (15 mL every night costs $13/mo) compared with PEG 3350 ($24/mo) Glycerin is less effective if stool is dry and hard
Table 2.Laxatives to avoid or use with caution for elderly patients LAXATIVEPRECAUTIONS
ConclusionConstipation is a common concern in older adults. A stepwise approach is especially important given the multiple risk factors, comorbidities, and medication-induced causes. Management of medication-induced causes, lifestyle modification, and nonpharmacologic therapies should be the first step to avoiding unnecessary drug therapy. There is limited evidence to guide the order in which the agents should be used, but often initiation of a bulk-forming agent would be first, except in those who are bedridden, are cognitively impaired, or have other contraindications. For patients with a contraindication or lack of response to a bulking agent, the initiation or addition of an osmotic agent, such as PEG 3350 or lactulose, is indicated. Patient preferences such as taste, cost, and tolerance for flatulence might guide selection of lactulose versus PEG 3350. Optimize the dose of an osmotic agent, then add a stimulant laxative if necessary, with the goal of preventing and treating constipation and avoiding fecal impaction. The Geri-RxFiles section on the management of constipation in older adults is available from CFPlus.* Geri-RxFiles is an RxFiles initiative that focuses on drug therapy in older adults and long-term care residents. Footnotes*The Chronic Insomnia in Older Adults document, the Constipation in Older Adults document, and the Bristol Stool Scale are available at www.cfp.ca. Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page. Competing interests RxFiles and contributing authors do not have any commercial competing interests. RxFiles Academic Detailing Program is funded through a grant from Saskatchewan Health to Saskatoon Health Region; additional “not for profit; not for loss” revenue is obtained from sales of books and online subscriptions. 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