Combating Constipation in the Elderly

As seen in Consultant Connection June / July 2012 Issue
Heidi Trautwein, PharmD, RPh. Consultant Pharmacist, ICP, Inc.

Constipation can best be defi ned as unsatisfactory defecation characterized by infrequent stool, difficult stool passage or both. Difficult stool passage may include straining, hard stools, a feeling of incomplete evacuation or the need to use manual maneuvers to assist with defecation. Constipation is one of the most common gastrointestinal complaints and accounts for more than 2.5 million physician visits a year, and ranks among the most frequent reasons for self-medication, particularly in the elderly. Constipation is a troubling condition for older adults, often resulting in anxiety and diminished quality of life.

The prevalence of chronic constipation averages between 12-15% of the population in the United States depending on how constipation is defined. However, this number is believed to be higher due to under-reporting symptoms to their doctors for a variety of reasons, including the relative low cost of over-the-counter therapies, a misunderstanding of their symptoms as "normal" and not indicative of an underlying problem, or simple embarrassment. The rise in prevalence of chronic constipation is particularly dramatic after the age of 65. Constipation is nearly three times more common among females than males and is more prevalent among nonwhites than whites.

Although constipation is more common among those over age 65, it is probably not a consequence of normal aging. Rather there are a number of comorbidities among patients in this age group which likely contribute to their increased risk of developing chronic constipation. These potential risk factors include: immobility, concomitant chronic illness, polypharmacy, and underlying neurologic disease, the most important being dementia although cerebrovascular disease, Parkinson's disease and Multiple Sclerosis also represent signifi cant risk factors.

The onset of constipation is generally unrelated to any known event. Early in the course of constipation, infrequent or difficult evacuation may represent the only symptom. As constipation progresses in severity, patients typically develop bloating and mild cramping type abdominal pain that is frequently worse after meals. Patients who have suffered from constipation for many years may additionally note fatigue, malaise and anorexia.

Constipation appears to be a slowly progressive disorder that rarely resolves. Long-standing constipation has been associated with several potentially serious complications. The most common of these is fecal impaction, which is a particular risk among the elderly and even more so among the institutionalized elderly.

Indeed, it is of such concern that a fecal impaction is now a reportable quality event in nursing homes. If severe and prolonged, fecal impaction can lead to colonic perforation. Chronic constipation sufferers also are at risk of developing a sigmoid volvulus, or "twist" of the colon.

A volvulus typically results from elongation and redundancy of the sigmoid colon. Once the sigmoid has suffi ciently elongated, it twists around itself leading to obstruction and subsequent ischemia of the colon at the level of the volvulus. If not resolved, the ischemia also may lead to colonic perforation. A third potential complication of chronic constipation is the formation of a stercoral ulcer. A stercoral ulcer is a pressure ulcer of the sigmoid or rectum which results from stool remaining in the colon for long periods of time, applying pressure to the colon wall. If this condition is prolonged, again, colonic perforation may occur.

Given the potential for serious complications among elderly patients with constipation, particularly those who are institutionalized, it is important to provide effective therapy with consistent follow-up to ensure that these patients fi rst and foremost are comfortable, but also to optimize their quality of life and to ensure that these potentially serious complications of constipation are avoided.

Once diagnosis of constipation has been established there are basic laboratory tests for these individuals including a complete blood count, serum blood urea nitrogen, serum creatinine, serum sodium, serum calcium, serum magnesium, a thyroid-stimulating hormone level, and stool for occult blood.

Sigmoidoscopy or colonoscopy should be considered for any person with prolonged chronic constipation. An abdominal x-ray is also important to exclude fecal impaction. Additional tests that may be helpful include colon transit measurements, colonic manometry, anorectal manometry, balloon expulsion testing, and defecography.

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