Treatment of Constipation in Older Adults

CHRISTINE HSIEH, M.D., Thomas Jefferson University, Philadelphia, Pennsylvania

Constipation is a common complaint in older adults. Although constipation is not a physiologic

consequence of normal aging, decreased mobility and other comorbid medical conditions may
contribute to its increased prevalence in older adults. Functional constipation is diagnosed when
no secondary causes can be identified, such as a medical condition or a medicine with a side
effect profile that includes constipation. Empiric treatment may be tried initially for patients
with functional constipation. Management of chronic constipation includes keeping a stool
diary to record the nature of the bowel movements, counseling on bowel training, increasing
fluid and dietary fiber intake, and increasing physical activity. There are a variety of over-the-
counter and prescription laxatives available for the treatment of constipation. Fiber and laxatives
increase stool frequency and improve symptoms of constipation. If constipation is refractory to
medical treatment, further diagnostic evaluation may be warranted to assess for colonic transit
time and anorectal dysfunction. Alternative treatment methods such as biofeedback and surgery
may be considered for these patients. (Am Fam Physician 2005;72:2277-84, 2285. Copyright
2005 American Academy of Family Physicians.)

C
S

Patient information: onstipation is common in older In clinical practice, constipation is gener-

A handout on constipa- adults and accounts for about ally defined as fewer than three bowel move-
tion, written by the author
of this article, is provided 2.5 million physician office vis- ments per week. A working group of experts
on page 2285. its annually.1 The estimated prev- at an international congress of gastroenter-
alence of constipation varies from 22 to ology developed a consensus definition of
28 percent,3 and the number of persons constipation, known as the Rome II criteria
reporting constipation increases with age.4 (Table 16).
Constipation is more common in women,
blacks, persons from lower socioeconomic Causes of Constipation
levels,4 and persons living in rural areas and Constipation is not a physiologic consequence
northern states.5 of normal aging. Many age-related problems
(e.g., decreased mobility, comorbid medical
conditions, increased use of medications with
TABLE 1
a side effect profile that includes constipa-
Rome II Criteria for Defining Chronic
Functional Constipation in Adults
tion, and changes in diet) may contribute to
the increased prevalence of constipation in
Two or more of the following for at least 12 weeks in the
older adults. A thorough medical history and
preceding 12 months: physical examination are needed to exclude
Straining in more than 25 percent of defecations constipation secondary to an underlying con-
Lumpy or hard stools in more than 25 percent of defecations dition. Constipation can be divided into pri-
Sensation of incomplete evacuation in more than 25 percent mary and secondary causes.
of defecations
PRIMARY CONSTIPATION
Sensation of anorectal obstruction or blockade in more than
25 percent of defecations Primary causes of constipation can be clas-
Manual maneuvers (e.g., digital evacuation, support of the sified into three groups: normal transit
pelvic floor) to facilitate more than 25 percent of defecations constipation, slow transit constipation, and
Fewer than three defecations per week anorectal dysfunction. Normal transit con-
stipation, also known as functional con-
Adapted with permission from Thompson WG, Longstreth GF, Drossman DA, Heaton
KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal stipation, is the most common. In patients
pain. Gut 1999;45(suppl 2):II45. with functional constipation, stool passes
through the colon at a normal rate. Slow

December 1, 2005 U Volume 72, Number 11 www.aafp.org/afp American Family Physician 2277
Constipation in Older Adults

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Review the patients medication list to evaluate for medications that may cause constipation. C 15
Encourage patients to attempt to have a bowel movement soon after waking in the morning C 18
or 30 minutes after meals to take advantage of the gastrocolic reflex.
Increasing dietary fiber intake to 25 to 30 g daily may improve symptoms of constipation. C 19
Encourage physical activity to improve bowel regularity. B 21, 24, 25
If nonpharmacologic approaches fail, recommend increased fiber intake and/or laxatives to B 26
increase bowel movement frequency and improve symptoms of constipation.
Biofeedback therapy is the treatment of choice for anorectal dysfunction. B 43
Surgery is reserved for persistent and intractable constipation in patients who have been B 42, 44
evaluated and proven to have slow transit constipation.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 2160 or
http://www.aafp.org/afpsort.xml.

transit constipation is characterized by prolonged delay examination and in those with concomitant rectal bleed-
in the passage of stool through the colon.7 Patients may ing or weight loss.
complain of abdominal bloating and infrequent bowel An important secondary cause of constipation is
movements.8 The causes for slow transit constipation the use of medications, especially those that affect the
are unclear; the postulated mechanisms include abnor- central nervous system, nerve conduction, and smooth
malities of the myenteric plexus, defective cholinergic muscle function. The most common medicines associ-
innervation, and anomalies of the noradrenergic neuro- ated with constipation are listed in Table 3.11 In a study15
muscular transmission system.7 Anorectal
dysfunction is the inefficient coordination
of the pelvic musculature in the evacuation TABLE 2
9
mechanism. These patients are more likely Causes of Secondary Constipation
to complain of a feeling of incomplete evac-
uation, a sense of obstruction, or a need for Endocrine and metabolic diseases Psychological conditions
8
digital manipulation. Anorectal dysfunc- Diabetes mellitus Anxiety
tion may be an acquired behavioral disorder, Hypercalcemia Depression
or the process of defecation may not have Hyperparathyroidism Somatization
been learned in childhood. 10 Hypothyroidism Structural abnormalities
Uremia Anal fissures, strictures,
SECONDARY CONSTIPATION Myopathic conditions hemorrhoids
Table 211-13 lists medical and psychiatric con- Amyloidosis Colonic strictures
ditions that are potential causes of second- Myotonic dystrophy Inflammatory bowel disease
ary constipation. These conditions may be Scleroderma Obstructive colonic mass
lesions
excluded by a thorough history and physical Neurologic diseases
Rectal prolapse or rectocele
examination. A consensus guideline14 from Autonomic neuropathy
the American Gastroenterological Associa- Other
Cerebrovascular disease
tion (AGA) also recommends that most Irritable bowel syndrome
Hirschsprungs disease
patients have tests for a complete blood Pregnancy
Multiple sclerosis
count and serum glucose, thyroid stimulat- Parkinsons disease
ing hormone, calcium, and creatinine levels. Spinal cord injury, tumors
A sigmoidoscopy or colonoscopy to exclude
colon cancer is indicated in patients older Information from references 11 through 13.
than 50 years who have not had a recent

2278 American Family Physician www.aafp.org/afp Volume 72, Number 11 U December 1, 2005
 Constipation in Older Adults

referred to a specialist for further diagnostic evaluation.

TABLE 3 This may include measurement of colonic transit time,
Medications Commonly Associated anorectal manometry, defecography, or a balloon expul-
with Secondary Constipation sion test to assess colonic transit and anorectal function.
In rare cases, biofeedback therapy or surgery may be
Antacids* Levodopa (Larodopa) warranted.14
Anticholinergics Narcotics
Antidepressants Nonsteroidal anti- Nonpharmacologic Treatments
Antihistamines inflammatory drugs
A stool diary may be helpful for some patients to record
Calcium channel blockers Opioids
the nature of the complaint in terms of stool frequency,
Clonidine (Catapres) Psychotropics
consistency, size, and degree of straining. Many patients
Diuretics Sympathomimetics
incorrectly believe that they need to have a bowel move-
Iron ment every day; counseling on simple lifestyle changes
may improve their perception of bowel regularity. Most
*Antacids containing aluminum or calcium.
importantly, patients should be educated on recognizing
Adapted with permission from Prather CM, Ortiz-Camacho CP. Evalua-
tion and treatment of constipation and fecal impaction in adults. Mayo and responding to the urge to defecate.
Clin Proc 1998;73:882.
BOWEL TRAINING

Having a bowel movement may be partly a conditioned

of patients who considered themselves constipated, reflex. One study17 showed that most patients with a regu-
40 percent were using medications known to cause lar bowel pattern empty their bowels at approximately the
constipation. Over-the-counter medications, such as same time every day. The optimal times to have a bowel
calcium- or aluminum-containing antacids and iron movement typically are soon after waking and after meals,
supplements, may also cause constipation. when colonic activity is greatest.18 Patients should be
Irritable bowel syndrome is a common cause of con- encouraged to attempt defecation first thing in the morn-
stipation. It can be distinguished from functional con- ing, when the bowel is more active, and 30 minutes after
stipation because it is usually accompanied by cramps meals, to take advantage of the gastrocolic reflex.
and lower abdominal pain that are typically relieved by
DIETARY FIBER INTAKE
defecation, and by periods of diarrhea.
Inadequate fiber intake is a common reason for con-
Overview of Constipation Treatment stipation in Western society. Studies19 have shown that
If a medication or a medical condition is the cause of increased dietary fiber intake leads to decreased colonic
constipation, eliminating the offending medication or transit time and to bulkier stools. A dietary diary may be
treating the underlying medical condition may relieve helpful to assess whether an adequate amount of fiber is
the constipation. However, certain conditions require consumed daily. Most healthy Americans consume 5 to
the use of a medication despite its side effects. Although 10 g of fiber daily.12 The daily recommended fiber intake
opioid therapy almost always causes some degree of is 20 to 35 g daily.12 If fiber intake is substantially less
constipation, individual opioids induce constipation than this, patients should be encouraged to increase their
to different degrees. One study16 found that fentanyl intake of fiber-rich foods such as bran, fruits, vegetables,
(Duragesic) was less likely to cause constipation than and nuts. Prune juice is commonly used to relieve con-
oral morphine. In most cases, a prophylactic laxative stipation. The recommendation is to increase fiber by 5 g
should be considered when prescribing chronic opioid per day each week until reaching the daily recommended
therapy because tolerance to the constipating effects of intake.12 Adding fiber to the diet too quickly may cause
opioids does not develop over time. excessive gas and bloating.
When no secondary cause of constipation is identi-
FLUID INTAKE
fied, empiric treatment should be tried initially for
functional constipation. Management should begin with Adequate hydration is considered to be important in
nonpharmacologic methods to improve bowel regularity maintaining bowel motility. However, despite the belief
and should proceed to the use of laxatives if nonpharma- that a lack of fluid increases the risk of constipation, few
cologic methods are not successful. If the constipation is studies have provided evidence that hydration is associ-
refractory to medical treatment, the patient should be ated with the incidence of constipation.20 Decreased

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Constipation in Older Adults

Treatment of Adult Patients with Functional, Normal Transit Constipation

Normal transit constipation

Increase fiber intake, magnesium hydroxide

(Milk of Magnesia), exercise, bowel education.

Improvement of symptoms: No improvement of symptoms:

continue regimen. add bisacodyl (Dulcolax).

Improvement of symptoms: No improvement of symptoms: add

continue regimen. polyethylene glycol (Golytely, Colyte).

Improvement of symptoms: No improvement of symptoms:

continue regimen. adjust medications as needed.

Figure 1. Algorithm for the treatment of adult patients with functional, normal transit constipation.
Adapted with permission from Locke GR III, Pemberton JH, Phillips SF. American Gastroenterological Association Medical Position Statement: guidelines
on constipation. Gastroenterology 2000;119:1764.

fluid intake may play a greater role in the development There also are limited data about long-term benefits
of fecal impaction.21 and risks of laxatives and fiber preparations.26 The for-
mulations, dosages, and costs of commonly used laxa-
REGULAR EXERCISE tives, stool softeners, and prokinetic agents are listed in
The National Health and Nutrition Examination Sur- Table 4.27 There are no evidence-based guidelines on
vey22 found that a low physical activity level is associated the preferred order of using different types of laxatives;
with a twofold increased risk of constipation. Another however, the AGA has developed a treatment algorithm
epidemiologic study23 showed that patients who are sed- for patients with functional, normal transit constipation
entary are more likely to complain of constipation. Pro- (Figure 1).14
longed bedrest and immobility are often associated with
BULK LAXATIVES
constipation. Although patients should be encouraged to
be as physically active as possible, there is no consistent Bulk laxatives may contain soluble (psyllium, pectin,
evidence that regular exercise relieves constipation.24 or guar) or insoluble (cellulose) products. They are
However, the Nurses Health Study,25 which followed a hydrophilic, absorbing water from the intestinal lumen
cohort of 62,036 women, found that physical activity two to increase stool mass and soften the stool consistency,
to six times per week was associated with a 35 percent and are generally well tolerated by most patients. Patients
lower risk of constipation. with functional normal transit constipation benefit the
most from treatment with bulk laxatives. However,
Pharmacologic Treatment patients with slow transit constipation or anorectal
A systematic review26 found that increased fiber intake dysfunction may not be helped by bulking agents.28 A
and the use of laxatives improved the frequency of bowel systematic review26 found that bulk laxatives improve
movements compared with placebo in adults. However, symptoms of constipation such as stool consistency and
the data concerning the superiority of individual treat- abdominal pain. As with increased dietary intake of foods
ments were inconclusive because of the limited number rich in fiber, bloating and excessive gas production may
of studies, small sample size, or methodologic flaws.26 be a complication of bulk laxatives.

2280 American Family Physician www.aafp.org/afp Volume 72, Number 11 U December 1, 2005
 Constipation in Older Adults
TABLE 4
Medications for Treatment of Chronic Constipation

Agent Formula/strength Adult dosage Cost*

Bulk laxatives
Methylcellulose (Citrucel) Powder: 2 g (mix with One to three times daily $13.05 for 840 g
8 oz liquid) 2 tablets up to six times $20.76 for 164 tablets
Tablets: 500 mg (take with daily
8 oz liquid)

Polycarbophil (Fibercon) Tablets: 625 mg 2 tablets one to four $10.80 for 90 tablets
times daily

Psyllium (Metamucil) Powder: 3.4 g (mix with One to four times daily $12.55 for 870 g
8 oz liquid)

Stool Softeners
Docusate calcium (Surfak) Capsules: 240 mg Once daily $16.92 for 100 capsules

Docusate sodium (Colace) Capsules: 50 or 100 mg 50 to 300 mg 50 mg: $14.50 for

Liquid: 150 mg per 15 mL 60 capsules
Syrup: 60 mg per 15 mL 100 mg: $17.71 for
60 capsules
Liquid: $7.90 for 30 mL
Syrup: $21.66 for 473 mL

Osmotic laxatives
Lactulose Liquid: 10 g per 15 mL 15 to 60 mL daily $36.35 for 480 mL

Magnesium citrate Liquid: 296 mL per bottle 0.5 to 1 bottle per day $2.29 for 296 mL

Magnesium hydroxide Liquid: 400 mg per 5 mL 30 to 60 mL once daily $2.64 for 12 fl oz

(Milk of Magnesia)

Polyethylene glycol 3350 Powder: 17 g Once daily $25.34 for 12 packets

(Miralax) (mix with 8 oz liquid)

Sodium biphosphate Liquid: 45 mL, 90 mL (mix 20 to 45 mL daily $2.65 for 90 mL

(Phospho-Soda) with 4 oz water, then
follow with 8 oz water

Sorbitol Liquid: 480 mL 30 to 150 mL daily $7.57 to $25 for 480 mL

Stimulant laxatives
Bisacodyl (Dulcolax) Tablets: 5 mg 5 to 15 mg daily $13.46 for 100 tablets

Cascara sagrada Liquid: 120 ml 5 mL once daily $3.75 for 120 mL

Tablets: 325 mg 1 tablet daily $4.50 for 100 tablets

Castor oil Liquid: 60 ml 15 to 60 mL once daily $8.35 for 120 mL

Senna (Senokot) Tablets: 8.6 mg 2 or 4 tablets once or $21.04 for 100 tablets
twice daily

Prokinetic Agents
Tegaserod (Zelnorm) Tablets: 2 mg, 6 mg Two times daily $169.15 for 60 tablets
2 mg or 6 mg

*Average wholesale cost, based on Red Book. Montvale, N.J.: Medical Economics Data, 2005. Costs listed are brand name versions; generic
versions are available for some of these medications.
May be taken in divided doses.
Used for constipation related to irritable bowel syndrome in women.
Information from reference 27.

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Constipation in Older Adults

EMOLLIENT LAXATIVES normal stool by day seven compared with laxatives con-
Emollient laxatives or stool softeners, (e.g., docusates), taining senna, anthraquinone derivatives, or bisacodyl
act by lowering surface tension, allowing water to enter (Dulcolax). In a multicenter, placebo-controlled trial32
the bowel more readily. They are generally well tolerated of 150 patients, PEG 3350 was found to be an effective
but are not as effective as psyllium in the treatment of agent for softening stools and increasing stool frequency.
constipation. A study29 comparing a stool softener with In a comparison study33 of 99 patients with chronic con-
psyllium found that psyllium was more effective in reliev- stipation, PEG 3350 was found to be more effective and
ing constipation. Stool softeners are ineffective in chroni- caused less flatulence than lactulose.
cally ill older adults.30 Stool softeners may be more useful
STIMULANT LAXATIVES
for patients with anal fissures or hemorrhoids that cause
painful defecation. Mineral oil is not recommended Stimulant laxatives include products containing senna
because of the potential to deplete fat-soluble vitamins and bisacodyl. These laxatives increase intestinal motil-
and the risk of aspiration.13 ity and secretion of water into the bowel. They generally
produce bowel movements within hours, but may cause
OSMOTIC LAXATIVES abdominal cramping because of the increased peristal-
Saline or osmotic laxatives are hyperosmolar agents sis. Stimulant laxatives should not be used in patients
that cause secretion of water into the intestinal lumen with suspected intestinal obstruction. Chronic use of
by osmotic activity. The most commonly used osmotic stimulant laxatives containing anthraquinone may cause
laxatives are oral magnesium hydroxide (Milk of Mag- a brown-black pigmentation of the colonic mucosa
nesia), oral magnesium citrate, and sodium biphosphate known as melanosis coli. This condition is benign and
(Phospho-Soda). In general, these agents are considered may resolve when the stimulant laxative is discontin-
relatively safe because they work within the colonic ued.34 Colonic inertia is seen in some chronic users of
lumen and do not have a systemic effect. However, they stimulant laxatives, but it is unclear if this is related to
have been associated with electrolyte imbalance within their prolonged use.13 In a trial35 of 77 nursing home
the colonic lumen and may precipitate hypokalemia, residents, a combination of senna and bulk laxative
fluid and salt overload, and diarrhea. Therefore, they was demonstrated to be more effective than lactulose in
should be used carefully in patients with congestive improving stool frequency and consistency and also was
heart failure and chronic renal insufficiency. Chronic lower in cost.
use of magnesium-containing laxatives may contribute
PROKINETIC AGENTS
to hypermagnesemia in patients with chronic renal
insufficiency. A number of prokinetic agents have been studied for
Alternative hyperosmotic laxatives are sorbitol, lactu- the treatment of slow transit constipation. The most
lose, and polyethylene glycol (PEG) 3350. Sorbitol and successful of these are colchicine36 and misoprostol
lactulose are undigestible agents that are metabolized by (Cytotec).37 Both of these agents accelerate colonic tran-
bacteria into hydrogen and organic acids. Poor absorp- sit time and increase stool frequency in patients with
tion of these agents may lead to flatulence and abdomi- constipation, although neither has been approved by the
nal distention. In a multicenter trial31 of 164 patients, U.S. Food and Drug Administration for this indication.
lactulose was found to be more effective in producing a A study38 of 12 patients with developmental challenges
who required three or more laxatives to manage their
chronic constipation found that colchicine increased the
The Author number of bowel movements and decreased the number
CHRISTINE HSIEH, M.D., is an instructor in the Department of of rectal laxatives used. In a more recent study39 of 16
Family Medicine at Thomas Jefferson University, Philadelphia, women with chronic constipation who were receiving
where she also coordinates the geriatric curriculum for residency
colchicine, the number of bowel movements improved
education. She received her medical degree from the Medical
College of Virginia in Richmond. Dr. Hsieh completed a residency significantly and the initial side effect of abdominal
in family medicine and a fellowship in geriatrics at Thomas pain decreased with continued treatment. Larger tri-
Jefferson University Hospital in Philadelphia. als are needed to confirm the efficacy and safety of the
long-term use of colchicine for the treatment of chronic
Address correspondence to Christine Hsieh, M.D., Thomas
Jefferson University, Department of Family Medicine, 1015 Walnut
constipation.
St., Suite 401, Philadelphia, PA 19107. Reprints are not available In women with irritable bowel syndrome character-
from the author. ized by constipation, tegaserod (Zelnorm) is a colonic

2282 American Family Physician www.aafp.org/afp Volume 72, Number 11 U December 1, 2005
 Constipation in Older Adults

prokinetic agent that improves stool consistency and This project was supported by funds from the Division of State,
Community, and Public Health, Bureau of Health Professions (BHPr),
frequency.40 A recent systematic review41 evaluated Health Resources and Service Administration (HRSA), Department of
eight short-term, placebo-controlled studies conducted Health and Human Services (DHHS), under grant number 1 KO1 HP
mainly in women and found that although tegaserod 00073-01, Geriatric Academic Career Award. The information or content
increased the number of bowel movements, it did not and conclusions are those of the author and should not be construed
as the official position or policy of, nor should any endorsements be
significantly improve patients symptoms of abdominal inferred by, the BHPr, HRSA, DHHA, or the U.S. Government.
pain and discomfort. Patients on higher doses of tegas-
erod (12 mg) experienced more diarrhea.41
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2284 American Family Physician www.aafp.org/afp Volume 72, Number 11 U December 1, 2005