Constipation in the Elderly

Related Subjects: Pharmacology in the Elderly Capacity in Older Adult Role of Urinary Catheters in the Elderly Constipation in the Elderly Falls Post Falls Assessment DNACPR in the Older Person Treatment Escalation Plans (TEP) in the Elderly Caring for Patients with Dementia Surgical Liaison in Older Patients Quality & Silver Trauma (UK)

Constipation = infrequent, hard or difficult stool passage, often <3 bowel motions per week or requiring straining/manual assistance. Prevalence in older adults: up to 30% in community;>50% in institutional care. Causes are usually multifactorial.

⚙️ Pathophysiology in Ageing

• 🧠 ↓ Autonomic function and slowed colonic transit.
• 🦴 ↓ Mobility & muscle tone.
• 🧬 Pelvic floor dysfunction & weak abdominal muscles.
• 🛏️ Institutionalisation and dependence on carers.
• 💊 Polypharmacy: anticholinergics, opioids, calcium channel blockers, iron, diuretics, TCAs.

🔎 Common Causes (Mnemonic: “DOPED”)

• Drugs – opioids, anticholinergics, calcium supplements, iron, antidepressants.
• Obstipation – bowel obstruction, cancer, strictures.
• Painful conditions – fissures, haemorrhoids, immobility.
• Endocrine/metabolic – hypothyroidism, diabetes, hypercalcaemia, hypokalaemia.
• Dehydration/diet – low fibre, low fluid intake, malnutrition.

🚨 Red Flags (need urgent investigation)

• 💔 Unintentional weight loss.
• 💉 Anaemia (iron deficiency).
• 🩸 Rectal bleeding or melaena.
• 🧠 Family history of bowel cancer.
• ⚡ New-onset constipation in >50 years.
• ⛔ Abdominal distension + vomiting (obstruction).

🧑‍⚕️ Assessment

• 📋 History: bowel frequency, stool type (Bristol Stool Chart), diet, mobility, drugs, pain, red flags.
• 👩‍⚕️ Exam: abdominal exam, PR exam (faecal loading, masses, rectal tone, prostate in men).
• 🧪 Investigations: U&E (dehydration), Ca (hypercalcaemia), TFTs, glucose. Consider colonoscopy if red flags.

🛠️ Management – Stepwise

1️⃣ General Measures

• 💧 Adequate hydration (≥1.5 L/day if safe).
• 🥗 High-fibre diet (fruits, vegetables, wholegrains).
• 🚶 Encourage mobility & exercise.
• 🪑 Regular toileting routine, optimise privacy & dignity.
• 👓 Ensure sensory aids (glasses, hearing aids) for toileting independence.

2️⃣ Medication Review

• 🔍 Stop or switch constipating drugs if possible (opioids, anticholinergics, iron, CCBs).
• 💊 Consider opioid antagonists (e.g. naloxegol) for refractory opioid-induced constipation.

3️⃣ Laxatives (NICE CG99, BGS guidance)

• 💦 Osmotic: First-line for chronic constipation (e.g. macrogol [Movicol], lactulose). Draws water into bowel.
• 🌱 Bulk-forming: (e.g. ispaghula husk/Fybogel) if adequate hydration & no obstruction.
• ⚡ Stimulant: (e.g. senna, bisacodyl) if inadequate response. Stimulates peristalsis.
• 🛑 Stool softeners: (e.g. docusate sodium) useful if hard stool.
• 💉 Suppositories/enemas: (glycerol, phosphate enema) for impaction or rapid relief.

4️⃣ Faecal Impaction Management

• Step 1: High-dose oral macrogol (up to 8 sachets/day, taper when disimpacted).
• Step 2: Add stimulant laxative (senna/bisacodyl).
• Step 3: Suppositories (glycerol, bisacodyl) or phosphate enema if refractory.
• Step 4: Manual evacuation in resistant cases (specialist care).

🛡️ Special Considerations in Elderly

• 🧠 Dementia/delirium: constipation may present as agitation or confusion.
• 🛏️ Immobility: regular bowel charts and proactive laxatives often required.
• 🧾 Polypharmacy: always review meds - opioids, anticholinergics, calcium, iron.
• ⚖️ Dignity: private toileting, avoid unnecessary catheterisation or diapers if constipation-related incontinence is reversible.
• 🏥 Care homes: bowel charts, PR exams often neglected - must be routine.

📝 OSCE / Exam Pearls

• ❓ "Elderly with acute confusion" → always consider constipation.
• 📋 Always mention hydration, mobility, fibre, medication review before laxatives.
• ⚡ For opioid-induced constipation: use stimulant ± osmotic from the outset (don’t wait for constipation to develop).
• 🚨 Never prescribe bulk-forming laxatives if bowel obstruction suspected.
• 🧠 In OSCE: demonstrate Bristol Stool Chart knowledge.

🧑‍⚕️ Case Examples - Constipation in the Elderly

• Case 1 (Medication-induced): 💊 An 82-year-old woman with osteoarthritis and atrial fibrillation presents with infrequent, hard stools and straining. She is on codeine for chronic pain and verapamil for rate control. Examination is unremarkable. Diagnosis: Opioid and calcium channel blocker–induced constipation. Managed by reviewing analgesia (consider stopping codeine), introducing a stimulant laxative (senna) plus a stool softener, and encouraging hydration and mobility.
• Case 2 (Slow transit + immobility): 🪑 A 90-year-old man in a nursing home has constipation, bloating, and decreased appetite. He is largely chair-bound after a hip fracture. Abdominal exam shows mild distension but no masses. Diagnosis: Slow transit constipation due to reduced mobility and frailty. Managed with regular osmotic laxatives (lactulose or macrogol), mobilisation support with physiotherapy, and ensuring adequate dietary fibre and fluids.
• Case 3 (Secondary to obstruction): 🚨 A 77-year-old woman presents with progressive constipation, weight loss, and iron-deficiency anaemia. On exam, she has a palpable left iliac fossa mass. Colonoscopy confirms an obstructing sigmoid carcinoma. Diagnosis: Constipation secondary to colorectal cancer. Managed with surgical resection after staging and optimisation, alongside palliative laxatives for symptomatic relief.