What is Constipation?

Constipation is a common gastrointestinal (GI) disorder that presents as infrequent or incomplete bowel movements, hard stools, and abdominal pain.

Anywhere from two to 27 percent of the general population experiences constipation.

The elderly population, however, reports a higher incidence of constipation than their younger counterparts.

Approximately 20 percent of seniors experience chronic constipation.

Constipation is even higher in nursing homes, with up to 50 percent of residents experiencing constipation and 74 percent using daily laxatives.

Fortunately, there are effective strategies for the effective treatment of constipation.

Constipation vs. Obstipation: Most people tend to be constipated versus obstipated.

Constipation refers to a condition in which you may have fewer than three bowel movements in a week.

Constipation is not life-threatening and is usually not an emergency.

However, chronic constipation can cause changes in your GI tract, leading to uncomfortable GI symptoms.

You may experience indigestion, stomach cramping, bloating, heartburn, burping, nausea, or vomiting.

If you have chronic constipation, you should seek treatment.

Obstipation is a medical emergency.

This condition develops when you are so constipated that you cannot have any bowel movements.

As you can imagine, not treating this problem promptly can have life-threatening consequences.

Causes of Constipation

There are various reasons why constipation occurs in older adults.

Potential causes include pelvic floor dysfunction (PFD), slowed digestion, lifestyle, prescription agents such as opioid pain medications, or a combination of factors.

These factors are outlined below:

Pelvic floor dysfunction

Your body coordinates a series of muscle movements in the pelvic floor and anal sphincter to pass a bowel movement.

PFD occurs when this coordination is disrupted.

In PFD, you may have irregular relaxation or contraction of the pelvic floor muscles.

Additionally, the muscle force needed to pass a bowel movement may be too weak.

This can make it challenging to have a bowel movement, causing constipation.

Slow colon transit

When you eat food, that food undergoes digestion throughout various body parts to form a bowel movement.

As we age, the rate at which food and bowel movements move through the body decreases.

This can cause you to feel “backed up” or constipated.

Other factors can influence your digestion speed, such as medications and PFD.

Lifestyle

Our daily behaviors can contribute to the severity and frequency of constipation.

Older adults are often sedentary and stall movement within the body, specifically digestion.

Older adults may also have different dietary intake, drink less water, and take medications that can cause constipation.

Certain conditions can cause constipation and contribute to intestinal obstruction.

Such diseases include, but are not limited to:

• Dementia
• Parkinson’s disease
• Multiple sclerosis
• Colon cancer
• Diabetes
• Hypothyroidism
• Anticholinergic medications

The video below from the Mayo Clinic describes the causes and symptoms of constipation:

Medications That Cause Constipation In The Elderly

Certain medications can slow colonic transit time, causing or worsening constipation. These include some of the drugs listed in the table below.

 

Class	Examples
Pain medications	Opioids, non-steroidal anti-inflammatory drugs (NSAIDs), tramadol
Anticholinergic agents	Atropine, oxybutynin, dicyclomine, scopolamine
Calcium channel blockers (Heart)	Diltiazem, verapamil
Tricyclic antidepressants	Amitriptyline, nortriptyline
Parkinson’s medications	Trihexyphenidyl
Antacids	Aluminum, calcium
Calcium supplements	Calcium carbonate
Iron supplements	Ferrous sulfate
Antihistamines	Diphenhydramine, hydroxyzine
Diuretics (“water pills”)	Hydrochlorothiazide, furosemide
Antipsychotics	Clozapine, olanzapine
Anticonvulsants	Phenytoin, clonazepam

Treatment Of Constipation Caused By Medications

If a medication is causing your constipation, your doctor may discontinue the medication or switch you to a new one to relieve your symptoms.

DO NOT stop taking a medication unless instructed by your doctor.

If the drug cannot be stopped, several other ways exist to relieve constipation.

Complications of Untreated Constipation

There are many dangers if treatment of constipation is ignored, some of which can be life-threatening.

When constipation is left untreated, it can lead to:

• Increased pressure in the lower abdomen, causing a hernia
• Diarrhea
• Worsen medical conditions such as IBS and chronic pain
• Fecal impaction (build-up of dry, hard feces in the rectum and colon that can cause discomfort, constipation, and even sepsis.)
• Hemorrhoids (rectal bleeding)
• Anal fissure (painful tears in the thin, moist tissue that lines the anus)
• Rectal prolapse (rectum slips out of the anus)
• Diverticulitis (pouches that form in your intestines, which then become infected – see image below)

 

The goal of treatment of constipation should be to improve symptoms and pass soft, formed stool without straining a minimum of three times a week.

If you cannot discontinue an offending agent or have something else causing constipation, multiple methods exist to help improve your bowel movements.

The first step includes lifestyle and behavioral changes. You should increase your fiber and fluid intake, exercise regularly, and stay hydrated.

Some people will also require laxatives.

These solutions are outlined in the rest of the article.

Typically, your provider will manage your constipation according to the algorithm below:

 

Management of Chronic Constipation
Step 1	Eliminate any constipating medications
Step 2	Lifestyle and behavioral changes
Step 3	Polyethylene glycol (Miralax)
Step 4	Stool softener plus stimulant laxative

Non-medication Treatment of Constipation

Older adults often do not intake enough dietary fiber. Increasing the fiber you get from your diet can help constipation symptoms.

Fiber increases the rate at which food moves through your intestines.

Fiber-rich foods include:

• Fresh fruit and vegetables (e.g., apples, oranges, broccoli, and carrots)
• Whole grains (e.g., grain cereal and oatmeal – read my article on the 24 best high-fiber cereals here)
• Legumes (e.g., beans and lentils)

When increasing your fiber intake, start with low amounts and slowly increase to 25 to 20 grams of fiber daily.

A gradual increase will reduce gas, bloating, and fiber-associated stomach pain symptoms.

Taking a fiber supplement ensures you drink enough fluids to avoid excessive bulk.

My top recommendation for fiber mixes is the Vegetable and Fruit Fiber Prebiotic Mix from Supergut®.

I use it daily and feel I don’t need any other product to help keep my bowels moving regularly.

Their “Add-To-Anything Prebiotic Fiber Mix is incredibly effective, as seen in the customer reviews below:

 

This easy-to-use unflavored powder made with unripened green bananas, oat beta-glucan, resistance potato starch, and soluble vegetable fiber comes in small sachets you can carry in your bag or purse.

Here are some important highlights:

• 8g of fiber.
• 1g net carbs.
• 0g sugar.
• 15 calories.
• Can be easily mixed into coffee, oatmeal, soup, or anything you’d like!

Click the image below to learn more and purchase directly from the official company website.

Regular physical activity and adequate fluid intake may also decrease constipation.

While no studies confirm the benefit of water alone in treating constipation, consuming 1.5 to 2 liters of water daily improves the frequency of bowel movements.

You could also try using a step stool when having a bowel movement.

Once seated on the toilet, place your feet on a small step stool instead of the floor.

This position can sometimes make it easier to pass a bowel movement.

Medications For The Treatment Of Constipation

If lifestyle changes alone do not help your constipation, several medications can help with the treatment of constipation.

Most seniors who have chronic constipation will need a laxative to relieve symptoms.

The table below lists different medication classes that treat constipation and how they work.

These will be discussed in further detail throughout the rest of the article.

 

Approved Medications For Constipation

Medication class	How they work	Examples
Bulking agents	Add bulk to the stool	Metamucil, Konsyl (Psyllium), FiberCon (polycarbophil), Citrucel (methylcellulose )
Stimulant laxatives	Cause rhythmic contractions in your intestinal muscles to help eliminate stool	Senna, bisacodyl
Osmotic laxatives	Moisten the stool by drawing in water from the intestines	Lactulose, polyethylene glycol (PEG), Milk of Magnesia, Magnesium Citrate, Sorbitol, Enemas
Lubricants	Help stool move more easily through your colon	Mineral oil
Stool softeners	Moisten the stool by drawing in water from the intestines	Docusate sodium
Chloride channel activators	Move water into the intestinal space	Lubiprostone (Amitiza)
Guanylate cyclase-C agonists	Increase fluid production and movement in the intestine	Linaclotide (Linzess)
Peripherally acting mu-opioid antagonists	Interact with receptors outside the central nervous system (CNS)	Methylnaltrexone (Relistor), naloxegol (Movantik)

Bulk Laxatives (Fiber supplements)

Bulking agents absorb water from the intestine, softening and bulking the stool.

These agents are categorized as either “soluble” or “insoluble”.

Bulking agents’ common side effects include gas, bloating, and a swollen abdomen.

These symptoms improve with time.

 

Bulk Laxatives

Agent	Dose	Onset Time	Side Effects
Methylcellulose (Citrucel) powder	19 g daily	12 to 72 hours	None
Polycarbophil (Fibercon) tablets	1,250 mg one to four times daily	12 to 72 hours	None
Psyllium (Metamucil) powder	1 packet or 1 tsp one to three times daily	12 to 24 hours	Bloating, swollen abdomen

Click the image below to purchase psyllium husk powder from Amazon:

Osmotic Laxatives

Osmotic laxatives include agents such as lactulose and PEG (Miralax).

These medications also work by drawing water into the intestine, which helps to soften the stool and promote bowel movements.

Osmotic laxatives can be taken orally or rectally and come in both prescription and over-the-counter forms.

A study comparing PEG and lactulose in individuals over 75 years of age showed that PEG was more effective and had fewer side effects than lactulose.

Lactulose may cause diarrhea in those who are lactose intolerant.

There are few studies on the safety and effectiveness of magnesium in older adults, and there are concerns surrounding its use in renal disease.

 

Osmotic Laxatives

Agent	Dose	Onset Time	Side Effects
Polyethylene Glycol (Miralax) powder	17 g daily	24-48 hours	Gas, cramping
Lactulose solution	15 to 30 g daily	24-48 hours	Nausea, cramping, bloating

Stimulant Laxatives

Stimulant laxatives are medications that stimulate the bowels to empty.

They treat constipation and clean out the bowel before surgery or other procedures.

Stimulant laxatives increase the intestine’s muscle contractions and speed up the passage of stool through the intestines.

Older adults are at risk of the long-term effects of stimulant laxatives.

They also may cause excess cramping and should, therefore, be limited in use.

Stimulant laxatives are best if you have failed treatment of constipation with fiber and osmotic laxatives.

 

Stimulant Laxatives

Agent	Dose	Onset Time	Side Effects
Senna Tablets	15 mg daily	6 to 12 hours	Stomach Pain
Bisacodyl (Dulcolax) Tablets	5 to 15 mg daily	6 to 10 hours	Stomach pain, Diarrhea

Stool Softeners

Stool softeners work by making the stool’s consistency softer.

However, they are ineffective in treating constipation, and I do not recommend them.

To learn more, read my article 7 Best Stool Softeners For Elderly.

They are best used in certain situations as a preventative measure, such as after surgery.

 

OTC Stool Softeners

Agent	Dose	Onset Time	Side Effects
Docusate Sodium (Colace) capsules	100 mg twice daily	24 to 48 hours	None

Other Prescription Medications for Constipation

Lubiprostone is effective at treating constipation in seniors.

However, its use is limited by the side effect of nausea, which occurs in roughly 25 to 30 percent of patients with chronic constipation.

Lubiprostone is more expensive than other medications indicated for the treatment of constipation and should only be used when your symptoms persist after trying different medications.

Linaclotide is another agent indicated for those with chronic constipation and irritable bowel syndrome.

The most common side effect is diarrhea.

Peripherally acting mu-opioid antagonists include medications such as methylnaltrexone and naloxegol.

These reduce the GI effects associated with opioids.

Other Prescription Medications for Constipation

Agent	Dose	Onset of Action	Side Effects
Lubiprostone (Amitiza)	24 mcg twice daily	24 hours	Nausea, Diarrhea, Headache
Linaclotide (Linzess)	145 mcg once daily	Approximately 1 week	Diarrhea
Methylnaltrexone (Relistor)	Weight-based dosing, injected once daily under the skin	Within 4 hours	Stomach pain, Diarrhea
Naloxegol (Movantik)	25 mg once daily	6 to 12 hours	Stomach pain

Summary

• Constipation is a common problem, affecting approximately 42 million people in the United States.
• Elderly adults are at a higher risk for constipation because of several factors, including changes in diet and mobility, medications, and health conditions.
• Constipation in the elderly may be caused by pelvic floor dysfunction, poor diet, dehydration, or medications and can seriously impact the quality of life.
• Many commonly prescribed medications can cause constipation and can easily be managed with appropriate bowel medications.
• The most common symptoms of constipation are difficulty passing hard, dry stool, straining, and feeling bloated.
• Treatment for constipation depends on the underlying cause.
• Lifestyle changes such as adding more fiber to the diet or increasing physical activity can help relieve symptoms. If lifestyle changes do not help, medications or other treatments may be needed.
• While there is no one-size-fits-all answer to resolving this common issue, many medications are available to help ease the discomfort.
• Preventing medication-induced constipation using simple bowel medications such as stimulants is easier than treating it later.
• Many instances of constipation can be effectively managed with non-medication methods.
• There are many medication options to treat constipation that non-medication methods cannot manage.
• It is important to talk with your doctor first to identify the causes of your constipation – DO NOT STOP any prescribed medications or take over-the-counter bowel medications unless directed by your medical provider.