Australian Doctor 10th May issue 2024 | Page 29

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NEED TO KNOW
Avoid the diagnostic pitfalls of surgical causes of an acute abdomen or obstruction .
Carefully evaluate pros and cons of prescribing medications that may cause constipation .
Ask if newly introduced drugs are causing or worsening constipation , eg , oral iron supplements , opiates , antipsychotics , calcium-channel blockers or anticholinergic effects with antidepressants .
Rule out any developing conditions ( surgical or non-surgical ) that may require attention .
Use laxatives as secondline treatment after nonpharmacological treatment is trialled , such as diet , lifestyle and bowel retraining .
Ensure laxatives are not continued long-term if not indicated .
Remain wary of the risk of chronic laxative abuse .
Opioid-induced constipation can be prevented by using less constipating products such as oxycodone / naloxone or tapentadol .
Osmotic laxatives are preferred over bulk-forming laxatives in older people .
The long-term safety of stimulant laxatives in older people is not well studied .

Constipation in older people

Dr Luke Chan ( left ) Intern , Gold Coast University Hospital and associate lecturer at Griffith University School of Medicine and Dentistry , Queensland .
Professor Daniel Chan ( right ) Director of aged care and rehabilitation at Bankstown-Lidcombe Hospital and professor of geriatric medicine at UNSW Sydney .
First published online on 1 March 2024
INTRODUCTION
CONSTIPATION is a common gastrointestinal
disorder in the older population . The age of 65 is often used to delineate an older person , however , also consider the person ’ s ‘ physiological age ’ in addition to their chronological age . Constipation is usually defined as less than three bowel motions / week . 1 The prevalence is reported to be 24-50 % in community-dwelling older people , and up to 74-80 % in residents of institutions . 2 About one-third of older people have symptomatic complaints regarding infrequency of stool motion , straining at defecation , or frequent laxative use . 3 Quality of life is greatly impacted in chronic constipation , which has psychological and social ramifications . The complications that may arise appear in box 1 .
Chronic constipation carries a significant economic burden in the US , leading to approximately 2.5 million visits to doctors and 100,000 hospitalisations annually . 4 In Australia , there were nearly 4000 emergency admissions for constipation in Victorian hospitals in 2010 – 11 at a cost of $ 8.3 million , with 38 % of
Box 1 . Possible complications of constipation
• Faecal impaction ( and overflow faecal incontinence ).
• Urinary retention and infection .
• Haemorrhoids ( see figure 1 ) and rectal prolapse ( see figure 2 ).
• Bowel ulceration from retained faeces in the colon and anal fissures .
• Bowel obstruction ( see figure 3 ).
• Sigmoid volvulus .
• Delirium .
• Syncope .
• Reduced quality of life .
these patients aged older than 75 . 5 These figures highlight the rising burden of illness and emphasise the need to identify and effectively manage constipation in older individuals .
This How to Treat covers the epidemiology , pathophysiology and clinical aspects ( history , examination , investigations and treatment ) of constipation with case illustrations , and aims to simplify the management of constipation in older persons and avoid pitfalls .
EPIDEMIOLOGY
THE prevalence of constipation rises with increasing age , particularly after age 65 . 6 Its prevalence is higher in older women . 7 In community-dwelling individuals aged 65 and older , the prevalence is 26 % for women and 16 % for men . 7 This rate increases to 34 % for women and 26 % for men in those aged 84 and older . 7 A higher prevalence is reported in those in institutions ( 74-80 %) compared with those in the community ( 24-50 %). 8-11 Similarly , laxatives are used daily by 10-18 % of community-dwelling older adults compared with 74 % of residential aged care residents . 12
The prevalence of constipation also varies with socioeconomic status . Low socioeconomic status is associated with increased prevalence of constipation . 13 Constipation was more prevalent in the older population of Greater Western Sydney ( 33.9 %) compared with similar demographic groups across Sydney ( 30.7 %), Australia ( 20.3 %) and New Zealand ( 27.7 %). 13
Cultural or ethnic background can also affect the prevalence of constipation . For instance , the prevalence of constipation in North America ,
Box 2 . Important risk factors for constipation in the elderly
• Immobility .
• Weakness of abdominal and pelvic floor muscles associated with ageing .
• Ageing effects on colonic motility .
• Rectal hyposensitivity .
• Ignoring a ‘ defecation call ’.
• Chronic medical conditions ( metabolic , neurologic , cardiovascular ).
• Chronic medication use ( opioid analgesics , calcium-channel blockers , antihypertensives , antipsychotics ).
• Malnutrition .
• Depression and anxiety .
Northern Europe and Australia is
13 , 14 higher than in South-East Asia . Similarly , the prevalence of constipation in the Han Chinese is lower when compared with the other ethnic minorities in China . 15 This discrepancy may be due to a difference in dietary habits or lifestyle .
Other risk factors for constipation in older people appear in box 2 . 16 Some chronic medical and psychiatric