Australian Doctor 10th May issue 2024 | Page 32

32 HOW TO TREAT : CONSTIPATION IN OLDER PEOPLE

32 HOW TO TREAT : CONSTIPATION IN OLDER PEOPLE

10 MAY 2024 ausdoc . com . au
can experience bloating and excess
as clinical syndromes is still a mat-
flatulence . Advise patients to take
ter of debate , and discontinuation of
additional fluids to avoid the potential drug-induced complication of intestinal obstruction . 48 Older individuals at risk of dehydration including those
stimulant laxatives seems to reverse these alterations . 52 , 53 Additionally , there are currently no reliable data establishing a connection between
with immobility , cognitive impairment
chronic use of stimulant laxatives
or swallowing issues should avoid
and colorectal cancer . While the
bulk-forming laxatives . Also avoid
chronic use of these laxatives may
bulk-forming laxatives in the setting of
result in a benign condition called
faecal impaction and opioid-induced constipation . 49 Opioids hinder the peristalsis needed to propel the increased
melanosis coli ( see figure 10 ), characterised by darkened colonic mucosa , it holds no pathological signifi-
bulk , which aggravates abdominal
cance . However , daily ingestion of
pain and can ultimately contribute to
these laxatives can potentially lead
bowel obstruction . 49
to complications such as hypokal-
There is more evidence for the effectiveness of psyllium than bran in treating constipation in older people . 50 A small number of studies in older adults demonstrated equiva-
aemia , protein-losing enteropathy , and salt depletion . 54 Overall , caution should be exercised when considering the chronic use of stimulant laxatives , especially in older individuals ,
lent effectiveness of methyl cellulose
as long-term safety evidence in this
and polycarbophil to psyllium . 51
population is still lacking . 37
STIMULANTS
STOOL SOFTENERS AND
These agents include diphenylmeth-
LUBRICANTS
ane derivatives ( phenolphthalein
Stool softeners ( docusate sodium )
and bisacodyl ) as well as anthraqui-
and lubricants ( mineral oils ) emul-
nones ( senna and cascara ). They
sify stools and provide lubrication
directly act on the mucosa by stim-
for the passage of faecal pellets .
ulating the myenteric plexus and
They may be given orally or as reten-
altering water and electrolyte secre-
tion enema . Although stool softeners
tion . The onset of action varies
possess a more desirable side effect
from 10 minutes to 12 hours . There is conflicting evidence regarding the long-term safety of stimulant laxatives . Studies from the 1960s- 70s suggest the rare possibility of enteric neuropathies with chronic
profile , they are less effective than other laxatives . 3 Aspiration of mineral oil can cause lipoid pneumonia , while long-term use can cause malabsorption of fat-soluble vitamins and foreign body reactions in
Figure 5 . Abdominal X-ray showing faecal loading .
use ; however , recent studies with
the intestinal mucosa and regional
more advanced technology have
lymph nodes . 55
enemas can lead to disturbances in
can cause harm to the rectal mucosa ,
OTHER
not confirmed these findings . Long-
fluid and electrolyte balance , as well
while regular use of phosphate ene-
In laxative-refractory patients with
term utilisation of stimulant laxatives has been linked to a condition known as ‘ cathartic colon ’, charac-
ENEMAS AND SUPPOSITORIES Enemas and suppositories can be used for faecal impaction and as an
as irritation of the rectal mucosa . Improper administration techniques may result in mechanical injury . It
mas may result in hyperphosphataemia . 55 As a safer alternative , warm tap water can be used , as can glyc-
chronic constipation , novel pro-secretary agents which promote electrolyte efflux and diffusion of water
terised by the presence of luminal dilation and loss of haustration as observed in barium enema examina-
alternative in individuals who cannot tolerate oral laxatives . 47 Enemas induce defecation by causing
is important to note that rectal perforation can occur , particularly if manual disimpaction has not been
erin suppositories . Patients with intractable constipation may require referral for surgical treatment . The
into gut lumen have been developed but evidence for use in older people is limited . Prucalopride is a selective
tions . However , the extent to which
rectal distension and flushing out
performed beforehand . Frequent
usual approach is subtotal colectomy
agonist of serotonin 5-HT4 which
these radiological changes manifest
faecal matter . However , the use of
use of phosphate and soap enemas
with ileorectal anastomosis . 56
is available in Australia , however it
A
Supine . Upright .
Dr James Heilman / CC BY-SA 3.0 / bit . ly / 3OsNLtZ
B
Dr James Heilman / CC BY-SA 3.0 / bit . ly / 45rb5iR
Figure 6 . Abdominal film of a patient with a large bowel obstruction . Note dilated loops of bowel .