Constipation is inconsistently defined by both patients and healthcare providers alike (Rao, 2017). Constipation may be described as difficulty with the act or inability to defecate, despite the urge. Constipation can also be considered infrequent or hard stools. No matter the descriptors, the experience of constipation is subjective. Every individual has a different perception of what it means to have normal bowel movements. Due to these discrepancies, an elite group of professionals at an International Congress of Gastroenterology meeting developed the Rome Criteria to define functional constipation (McKay, Fravel, & Scanlon, 2012). The diagnostic Rome criteria must include experiencing two or more of the following symptoms during at least one quarter of all bowel movements over the last three to six months. The symptoms are straining, having lumpy or hard stools, the sensation of incomplete emptying, having the feeling of a blockage, using manual tactics to expel stool, and having less than three bowel movements per week (Rome Foundation, 2013). Constipation can occur at any life stage from infancy to the death. However, Emmanuel et al (2013) stated that the incidence of constipation in people aged 60 and older is 33.5%. There are colonic changes in the elderly but the increased frequency of constipation is not considered to be primarily due to normal physiological changes (Acosta, Tangalos, & Harari, 2017). Many factors contribute to secondary constipation in the elderly including medications, decreased physical activity, comorbidities, diet, and dehydration among a myriad of others (Acosta, Tangalos, & Harari, 2017).
The elderly often present with complaints of the symptoms of constipation as stated above. Those unable to communicate their needs such as those with Alzheimer’s disease or dementia may not show signs or symptoms until constipation progresses to an intestinal blockage or even a potentially fatal bowel perforation. This population may only show vague signs or symptoms such as pain, confusion, or changes in mood (Craft & Prahlow, 2011).
Due to the incongruence and subjectivity of symptoms of constipation, it often goes underdiagnosed or misdiagnosed. Many patients believe providers do not consider constipation to warrant an office visit. Conversely, many providers overlook the importance of treating constipation. Education of both providers and regularly assessing patient’s bowel patterns is a way to identify and combat constipation in the elderly. Constipated patients can experience perianal fecal soiling or loose, watery stools called overflow incontinence that may be misdiagnosed as diarrhea (Acosta, Tangalos, & Harari, 2017). Also, constipation can be a common symptom of irritable bowel syndrome (IBS). However, the details of the history of constipation and IBS differ. To diagnose IBS there must be a long-standing history of recurrent abdominal pain that is relieved by having a bowel movement that is typically hard and irregularly occurring (Stern & Davis, 2016).
Managing the treatment of the individual with constipation is difficult. The plan of care must be individualized to meet the needs of each person. Managing this syndrome can become costly, especially if not identified early, complications arise, and hospitalization occurs. Constipation can create a sequela of events that interfere with the quality of a person’s life such as social withdraw, decreased activity due to discomfort or pain, or embarrassment of fecal incontinence (Emmanuel et al, 2017). Any disruption in those aspects of an elderly person’s life can produce great consequences such as deconditioning, loss of functional abilities, or depression.
To accurately assess for constipation, a thorough history and physical exam are warranted. Invariably creating a timeline for onset and occurrence of symptoms of constipation is fundamental in accurately diagnosing constipation. Having a person keep a written record of bowel movements can help if they are able (Wald, 2017). For the older patients that are unable to communicate, it is increasingly important to monitor their baseline bowel habits, intake and output, changes in mood, as well as pain assessments. A careful review of diet, medications, and hydration status is essential to ruling out modifiable causes for secondary constipation (Rao, 2017). Questioning the presence of blood in the stool that is black or red could be an indication of a complication or constipation or something worse such as a structural change like a tumor or a gastrointestinal (GI) bleed. Assessing for the impact on their quality of life as well as outlook on the symptoms of constipation should be included in the history (Acosta, Tangalos, & Harari, 2017). Assessing an elderly person’s nutrition, hydration status, and functional ability is important. The provider must ensure they have access to healthy, fiber containing foods, can prepare it, are able to feed themselves, and can safely chew and swallow. If these needs are not met, the provider should endorse modifications. Assistance could include anything from supplements, meals on wheels, occupational or speech therapy, etc.
A comprehensive assessment should be conducted keeping in mind that the history is of utmost importance because a physical exam could potentially be normal in the person experiencing constipation. Assessing the person’s vital signs, weight, and general appearance can be helpful in diagnosing a complication of constipation such as infection, impaction, or perforation. Taking note of the person’s skin color, temperature, pallor, and presence of tenting is significant. Looking for signs of dehydration and malnourishment must be done. Assessing the oral cavity for moist mucous membranes, adequate dentition for eating, and good oral health is a component. These things all contribute to a person’s desire and ability to eat and drink which can ultimately result in constipation. Through an abdominal assessment, the severity or degree of complications of constipation can be identified. By visualizing the abdomen, you can tell if a patient has distention, bulges, or discoloration. With auscultation for normal bowel sounds you may be able to tell if there is decreased bowel sounds that could indicate a blockage or ischemia in the intestines. Through palpation you can tell if there is organomegaly that could indicate another underlying disease that could be contributing to constipation. With constipation or impaction, in some individuals you can palpate the area of concern. Sometimes, lymphadenopathy can be felt in the abdomen or groin indicating infection or malignancy. If a perforation has occurred, the stomach can become rigid and tense. Palpating for areas of tenderness or pain can be telling. Visualizing the anus for fissures or hemorrhoids must be done as these can result from constipation (Rao, 2017). A digital rectal exam needs to be conducted. Stool may or may not be observed in the rectal vault. The stool may be hard or soft. The absence of stool does not indicate an impaction or constipation should be ruled out as it could be located higher in the colon and unreachable by the examiner (Craft & Prahlow). The sphincter tones should be evaluated. In women, a rectocele can contribute to constipation and must be considered. Therefore, a vaginal exam may be warranted (Wald, 2017).
Typically, with proper history and examination, no further testing needs to be done (Acosta, Tangalos, & Harari, 2017). If practical, medications contributing to constipation should be stopped before further testing is done (American Gastroenterological Guidelines, 2017). A plain abdominal x-ray can be performed if impaction or perforation is suspected or in patients that report constipation symptoms despite treatment (Acosta, Tangalos, & Harari, 2017). Radiography or endoscopic studies are not recommended for constipated patients unless there is concerning accompanying symptoms such as occult blood, weight loss that is greater than ten pounds, or familial history of colon cancer or inflammatory bowel disease (Wald, 2017). If the history and physical warrant further blood testing, a basic metabolic panel can be collected to evaluate glucose, calcium, thyroid stimulating hormone as these can reveal underlying processes that can contribute to constipation (American Gastroenterological Guidelines, 2017). Otherwise, if the clinical picture does not warrant these tests or previous baseline blood testing has been established, a complete blood count is the only necessary blood test (American Gastroenterological Guidelines, 2017).
As mentioned before education and communication is the best way to prevent constipation. Once constipation has been diagnosed, each plan of management should be individualized. Functional ability is of concern when choosing interventions if accessing the commode or incontinence is an issue. The most common etiology of constipation in the United States is inadequate dietary fiber in the diet (Thomas & Dunn, 2015). The first step in most treatment plans involve removing contributing medications, increasing dietary fiber to 20-30 grams per day, increasing physical activity (Acosta, Tangalos, & Harari, 2017). The next step is adding bulk laxatives such as psyllium if dietary and activity modifications do not produce the desired effect (Rao, 2017). A concern with this is that an increase in fluid intake is a requirement with bulk laxatives that some older adults simply cannot meet (Emmanuel et al, 2017). If the provider feels it is warranted, an osmotic or stimulant laxative may be initiated but these side effects can cause issues with adherence (Stern & Davis, 2016). Laxative use has also been shown to create dependence and misuse (Acosta, Tangalos, & Harari, 2017). In a study by Emmanuel et al (2017), osmotic laxatives were found the be the most effective treatment in the general population and is recommended first by guidelines in Germany, the Netherlands, Spain, France, Canada, and the USA. Choosing which medication to use should be based on history, comorbidities, current medications, and possible side effects (Rao, 2017). Saline laxatives such as magnesium hydroxide carry a risk of increasing magnesium levels, have not been well studied in geriatrics, and should have limited use (Rao, 2017). Stool softeners, suppositories, and enemas have not been proven helpful with treating constipation in the elderly (Acosta, Tangalos, & Harari, 2017). The American Gastroenterological Guidelines (2017) recommend performing further motility studies if constipation is refractory to treatment with laxatives. This should only be considered once other organic causes have been ruled out (Ward, 2017). There is a new drug class available for chronic constipation known as colonic secretagogues. Lupiprostone is one that is recommended for intractable cases and is safe for geriatric use (Emmanuel et al, 2017).
The current guidelines for managing constipation do not recommend using stool softeners, suppositories, or enemas to manage constipation yet they are widely utilized in practice. Educating providers on current recommendations is essential to providing quality care to geriatrics suffering from constipation. The evidence available shows conflicting recommendations on which class of laxative to use and which drugs are the most effective. Further research should be conducted on laxative use as well as the newer drug classes and their efficacy in treating geriatric constipation.