What is Constipation? How Does it Affect Older People?

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.

The prevalence of constipation is even higher in nursing homes, with up to 50 percent of residents experiencing constipation and 74 percent using daily laxatives [1].

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.

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.

How Severe is Constipation in the Elderly?

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 [1].

If you have chronic constipation, you should seek treatment.

What Causes Constipation in Older Adults?

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 be on medications that can cause constipation [1].

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

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.

How Do You Treat 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, there are several other ways to relieve constipation.

Complications of Untreated Constipation

There are many dangers associated with untreated constipation, 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)

Diverticula in the large intestine.

Constipation Treatment in the Elderly

The goal of treatment should be to improve symptoms and pass soft, formed stool without straining a minimum of three times a week [2].

If you cannot discontinue an offending agent or have something else causing your constipation, there are multiple methods 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 [3].

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

Non-medication Management 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)
• Legumes (e.g., beans and lentils)

Grains and Legumes

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 symptoms of gas, bloating, and fiber-associated stomach pain [4]. Taking a fiber supplement ensures you drink enough fluids to avoid excessive bulk [1].

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

While no studies confirm the benefit of water alone in treating constipation, intaking 1.5 to 2 liters of water daily improves the frequency of bowel movements [5].

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 [5].

Medications to Treat Constipation

If lifestyle changes alone do not help your constipation, several medications treat constipation.

Most seniors that 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 [5].

Approved Medications For Constipation

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” [2]. Bulking agents’ common side effects include gas, bloating, and a swollen abdomen. These symptoms improve with time [1].

Bulk Laxatives

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 up to 75 years of age showed that PEG was more effective and had fewer side effects than lactulose.

Lactulose may cause diarrhea in those that 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 [2].

Osmotic Laxatives

Stimulant Laxatives

Stimulant laxatives are medications that stimulate the bowels to empty.

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

Stimulant laxatives increase the intestine’s muscle contractions and speed up the passage of stool through the intestines1. 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 use3. Stimulant laxatives are best if you have failed treatment with fiber and osmotic laxatives [2].

Stimulant Laxatives

Stool Softeners

Stool softeners work by making the stool’s consistency softer. However, they are not very effective in treating constipation1. They are best used in certain situations as a preventative measure, such as after surgery [3].

OTC Stool Softeners

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 constipation treatments 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 [2].

Other Prescription Medications for Constipation

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 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
• In many cases, 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

References

1. Vazquez Roque M, Bouras EP. Epidemiology and management of chronic constipation in elderly patients. Clin Interv Aging. 2015 Jun 2;10:919-30. doi: 10.2147/CIA.S54304. PMID: 26082622; PMCID: PMC4459612.
2. Mounsey A, Raleigh M, Wilson A. Management of Constipation in Older Adults. Am Fam Physician. 2015 Sep 15;92(6):500-4. PMID: 26371734.
3. Jani B, Marsicano E. Constipation: Evaluation and Management. Mo Med. 2018 May-Jun;115(3):236-240. PMID: 30228729; PMCID: PMC6140151.
4. Deb B, Prichard DO, Bharucha AE. Constipation and Fecal Incontinence in the Elderly. Curr Gastroenterol Rep. 2020 Aug 24;22(11):54. doi: 10.1007/s11894-020-00791-1. PMID: 32839874.
5. Mounsey A, Raleigh M, Wilson A. Management of Constipation in Older Adults. Am Fam Physician. 2015 Sep 15;92(6):500-4. PMID: 26371734.