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conditions are also closely related
16 , 17 with constipation in older people . For example , 36-90 % of older adults with chronic pain and 40-86 % of older adults with cancer-related pain are prescribed opioid analgesics . Studies suggest that opioid-induced constipation in the older person is often undertreated and under-recognised . 18
Finally , the recognition and management of constipation in older people is likely to be suboptimal . This is supported by the poor association
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Apostolos Stamatiadis / CC BY-SA 2.5 / bit . ly / 3KBXVHH |
have a diet low in fibre or inadequate fluid intake ( dehydration ), or they may have experienced a recent change in mobility status because of hospitalisation or institutionalisation . Depression is another associated factor . 32 Eliciting such a history is important for management considerations .
EXAMINATION
A targeted physical examination guided by history is useful . Assess
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between self-reported constipation |
the patient ’ s hydration and mobil- |
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and laxative use in the community- |
ity status . The presence of a lump in |
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dwelling older population . 19 |
the abdomen may suggest colon can- |
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PATHOPHYSIOLOGY
CONSTIPATION can be classified as
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cer or a diverticular mass . A tense , distended or tender abdomen may reflect faecal impaction or a surgical |
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primary , secondary or idiopathic . 20 Primary colorectal dysfunction |
emergency such as bowel adhesions or an obstructed hernia . Also palpate |
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can be categorised into three sub- |
for tenderness at a hernia orifice as |
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types — slow transit constipation , |
obstruction may be painful . |
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dyssynergic defecation and irrita- |
Palpate the left lower quadrant |
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ble bowel syndrome . 20 |
for the presence of faecal material . |
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Slow transit constipation refers |
Rectal examination is important to |
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to the prolonged transit time of |
inspect for impacted stool or a low |
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stool through the colon and , often , |
rectal / anal mass . An empty rectum , |
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reduced rectal sensitivity . Patients with chronic constipation demon- |
Figure 1 . Grade 4 haemorrhoids . |
however , does not rule out the possibility of a stool impaction or a more |
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strated deficient high amplitude |
proximal obstructive mass . |
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propagated contractions and gastrocolic reflexes compared with healthy controls . 21 There are also alterations in enteric neurons and glial cells that are associated with diminished co-ordination between colonic segments . 21 Depletion of enteric interstitial cells of Cajal ( cells that generate electrical slow waves in gastrointestinal smooth muscles ) may also |
Dr KH Günther / CC BY 3.0 / bit . ly / 3OxKxFw |
Less common but important causes , such as Parkinson ’ s disease , warrant a focused neurological examination , while a thyroid-related examination may be required if hypothyroidism is suspected .
INVESTIGATIONS
THE need for investigation depends on the clinical situation and the over-
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influence neuro-mediated mecha- |
all goal of management . For example , |
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nisms . Specifically in older people , |
extensive investigation may not be |
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increased collagen deposition in the |
warranted in a palliative patient . |
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ascending colon may cause motor |
An FBC and FOBT may be indi- |
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and compliance modifications and |
cated if colon cancer is suspected , |
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provide increased binding sites for |
while EUC is helpful for dehydration . |
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plasma endorphins , which may con- |
Hypercalcaemia and hypothyroidism |
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tribute to slow transit . 17 |
are causes , albeit uncommon . |
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Dyssynergic defecation is the ina- |
A plain abdominal X-ray can |
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bility to expel stool from the anorec- |
aid in detecting faecal impaction |
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tum that may result from impaired |
involving the right side of the colon , |
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co-ordination between abdominal , |
which is missed on rectal examina- |
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recto-anal , and pelvic floor muscles |
tion . Faecal loading is a common |
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during defecation . Specifically , this |
X-ray finding , although not specific , |
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relates to either paradoxical anal |
and does not necessarily represent |
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contraction , inadequate anal relax- |
constipation ( see figure 5 ). Erect ( or |
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ation , or impaired rectal / abdominal propulsive forces . 22 Anorectal structural abnormalities or urogynae- |
decubitus ) and supine X-rays may be useful in bowel obstruction ( hernia , volvulus , mass lesion ) as fluid |
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cological disease such as rectocele may play a role in obstructing per- |
Figure 2 . Rectal prolapse . |
levels and bowel distension may be demonstrated ( see figure 6 ). |
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ineal transit . In older people there |
Flexible sigmoidoscopy and colo- |
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may be several contributing factors including atrophy of muscle mass , |
( such as cancer , diverticulosis , faecal impaction , hernia ). 17 |
of constipation : functional constipation , irritable bowel syndrome |
agents . 28 Moreover , impaction or other causes of bowel obstruction can |
noscopy may be required to exclude colon cancer or diverticular disease . |
pudendal nerve damage , decreased |
Chronic idiopathic constipation |
with constipation , opioid-induced |
cause nausea and vomiting , which |
Other advanced investigations to dif- |
elasticity of the rectal wall , increased thickness of the internal anal sphincter , and impaired rectal and perineal |
or functional constipation is defined as the infrequent , difficult / persistent passage of stools or incomplete defe- |
constipation and functional defecation disorders ). 27 However , this is not commonly used by GPs who |
can lead to the incorrect prescription of antiemetics . 29
It is also important to ask about
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ferentiate between pelvic floor dysfunction and slow colonic transit time may include defecography and the |
sensation . 23 Irritable bowel syndrome with |
cation , which does not meet irritable bowel syndrome criteria and is usu- |
may have different perceptions of constipation . 27 |
blood in the stool . Fresh blood that appears on toilet paper may suggest |
use of a wireless motility capsule . 33 These tests usually require a referral |
predominant constipation is charac- |
ally associated with no physiological |
As constipation may mean differ- |
the presence of haemorrhoids , while |
to a specialist centre . |
terised by abdominal pain that typically resolves with evacuation . 24 The pathophysiology is poorly understood but various factors , such as |
abnormality . 20
HISTORY
THE patient ’ s definition of consti-
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ent things to different individuals , it is important to quantify weekly bowel motions . Passing fewer than three motions / week and a recent |
blood and / or mucus mixed with a motion may imply a more sinister cause , such as colon cancer .
Because medications are a com-
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TREATMENT
FOLLOWING exclusion of surgical emergencies ( see figure 7 ) and
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food intolerances , gut dysbiosis , dys- |
pation may differ between individu- |
reduction in stool frequency are both |
mon cause of constipation , taking |
structural abnormalities , a stepwise |
motility , visceral hypersensitivity , |
als . It often refers to a need to strain |
significant . Recent and progressive |
a medication history is crucial ( see |
approach is recommended ( see fig- |
brain – gut interactions , and psycho- |
to defecate with the passage of hard |
constipation raises the possibility |
figure 4 and box 4 ). |
ure 8 ). |
social status , may play a role . 24 There are multiple secondary causes for constipation in older people ( see box 3 , DONE mnemonic ). 20 The drugs commonly associated |
stools , or infrequent , incomplete defecation accompanied by a small volume of firm to hard faecal material . 26 Sometimes , the patient may be referring to the acute cessation of |
of colon cancer , while obstruction secondary to adhesions and bowel strangulation is usually acute . 26
Associated symptoms , including anorexia , weight loss , abdominal
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A history of existing medical comorbidities may reveal neurological disease ( eg , stroke , dementia , Parkinson ’ s disease ), endocrine disease ( such as hypothyroidism , |
Reversible causes
Identify and treat reversible causes .
This includes the medical conditions listed in box 3 . If medications
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with constipation appear in box 4 |
bowel motions , the cause of which |
pain , abdominal distension , fullness , |
diabetes ) and electrolyte distur- |
( see box 4 ) such as opioids are con- |
( ACID mnemonic ). Common medical |
could be a surgical emergency , such |
bloating or vomiting , are important . |
bance , which may be associated |
tributing , consider reducing the dose |
conditions causing constipation in |
as a strangulated hernia or bowel |
Red flags appear in table 1 . Faecal |
with constipation . 30 |
or switching drugs when appropri- |
older patients include dehydration , conditions that lead to immobil- |
adhesions . The Rome criteria are utilised as a unifying tool for diagnos- |
impaction can cause overflow incontinence , which can be mistaken as |
Finally , dietary , mobility and psychosocial history may reveal |
ate . Constipation often remains as a persistent problem , even in patients |
ity ( eg , Parkinson ’ s disease , stroke , dementia ) and obstructive causes |
ing constipation in research studies ( there are four categories of disorders |
diarrhoea , resulting in the erroneous prescription of antidiarrhoeal |
important factors contributing to constipation . 31 The patient may |
who are able to tolerate other opioid side effects . 34 Tapentadol , a |