Introduction
Constipation is a common problem in the elderly population. Epidemiological studies show that the incidence of constipation increases from the age of 65 by 25-50%. The frequency of constipation may be as high as 75% of patients who are in senior care facilities, hospitals or other institutions and in particular if they suffer from dementia, stroke, Parkinson’s disease or other degenerative neurological conditions. Constipation is also more common in patients taking medications that may affect bowel motility as discussed below.
Constipation is a problem that affects the quality of life, causes discomfort and many times significant concern that often results in several office visits, specialty referrals, hospital admissions, and surgical procedures. Constipation has therefore, a major impact on healthcare costs in the United States.
What is constipation?
The term constipation for everyone means different things. In general, it can mean a change in bowel habits, the production of hard stools, the production of small stools, difficulty in defecation, straining, reduced stool frequency, the feeling of incomplete evacuation, and so on. It is therefore very important to understand exactly what the patient is complaining about when he says that he suffers from constipation. Taking a detailed medical history is perhaps the most important factor in understanding and addressing the patient’s problem.
Medical history
As we explained earlier it is important to figure out what the term constipation means for the patient, to look for possible accompanying symptoms such as abdominal pain, bleeding, weight loss, discuss the patient’s diet, his medical treatment, his previous medical history, possible abdominal surgery in the past, etc.
The duration of the symptoms, any accompanying symptoms and other evidence from the medical history and physical examination will determine whether or not there is a need for laboratory, imaging examinations (e.g. CT scan) or endoscopic examinations (e.g. colonoscopy).
Causes of constipation
The causes of constipation are several and relate to problems of the bowel, but also other systems of the body, which can indirectly affect the intestine. In older people the causes of constipation are usually multifactorial. Trying to classify the causes of constipation, we can distinguish the following categories:
- Obstructive causes: Colorectal cancer, narrowing of the bowel due to ischemia (poor blood circulation), inflammation of the bowel or external pressure from tumours and growths from neighbouring organs, etc.
- Endocrine and Metabolic Causes: Diabetes, hypothyroidism (hypoactive thyroid), hypercalcaemia (high calcium in the blood), chronic kidney failure, etc.
- Neuromuscular causes: Spinal cord injuries, Parkinson’s disease, multiple sclerosis, amyloidosis, scleroderma, myotonic dystrophy, etc.
- Medicines: Opioids, antihypertensives, antidepressants, antiparkinsonian, antipsychotics, etc.
- Other causes: diet low in fiber, dehydration, sedentary life, being bedridden, etc.
Management
The ways we deal with constipation depend on the severity of the symptoms, the causes, the accompanying diseases, and so on. Generally high fiber diet, hydration, daily regular toilet visit and exercise help the patient suffering from constipation. Many times, however, especially in the elderly, the above tactics do not help effectively or are not very practical. We therefore need to resort to some kind of pharmaceutical intervention for these patients. It is important to stress that the use of pharmaceuticals should be done with care and should be under medical supervision.
Categories of laxatives we use:
Stool bulking agents: The substances used contain natural or synthetic fiber in various forms. They are the first line of treatment for constipation and they work by increasing the volume of stools. Insoluble fiber has the tendency to cause gas and it is advisable to increase the dose gradually.
Osmotic laxatives: Osmotic laxatives consist of substances that are not absorbed by the digestive tract and thus remaining in the intestine retain a greater amount of water and as a result they soften the faeces.
Stimulant laxatives: These laxatives are based on senna or other synthetic substances and cause an increase in intestinal peristalsis (movement).
Fecal emollients / suppositories and enemas: This category is useful in cases where we suspect fecal impaction. They are usually combined with some oral laxatives for best results. Fecal impaction is more common in bedridden patients, neurological patients, people in nursing homes, and so on. These patients have a low sensitivity in the rectum, so they do not perceive the presence of stools. As stools accumulate in the rectum, they are dehydrated and cause paradoxical diarrea. This is confusing many times and delays the diagnosis which is established only with a rectal digital examination.
Summary
Patients aged over 65 often experience constipation, especially if they are suffering from neurological, metabolic or other systemic conditions, if they are taking certain medicines, are not being properly fed, or have reduced mobility. Good history and physical examination are often enough to assess the possible cause of constipation, but may sometimes require laboratory or other examinations to rule-out more serious conditions. Diet adaptation or simple pharmaceutical approaches are often enough to address the symptoms of constipation. However, there are cases where the severity or chronicity of constipation requires the help of a specialist.
