34 HOW TO TREAT : CONSTIPATION IN OLDER PEOPLE
34 HOW TO TREAT : CONSTIPATION IN OLDER PEOPLE
10 MAY 2024 ausdoc . com . au domains , including physical functioning , mental health , general health perception and report more pain , in comparison to those without constipation . 8 Constipation also negatively affects the social lives of older individuals .
The condition is also associated with lower levels of psychological general wellbeing and correlates with lower scores in domains related to anxiety , depression and self-control . 8 These scores improve as bowel movements increase with appropriate treatment . 60 It is also important to note that complications arising from constipation ( see box 1 ) can significantly impact the morbidity and mortality of older individuals .
CASE STUDIES
Case study one
BERNARD , a 75-year-old man , presents to his GP complaining of vague abdominal discomfort that he attributes to constipation . He was diagnosed with Parkinson ’ s disease two-and-a-half years ago and his carbidopa / levodopa medication was recently increased . Bernard reports intermittent constipation and uses laxatives prn . Over the past six months his constipation had worsened . His bowels previously opened 2-3 times weekly but now were only opening 1-2 times weekly despite using docusate sodium . He strains very hard to pass a bowel motion and the faeces is small in volume and hard in consistency .
On physical examination , there is some minor tenderness on deep palpation around the epigastric quadrant . PR examination reveals an empty rectum . An FBC and an abdominal X-ray are ordered . The X-ray shows faecal loading in the right side of the colon and there seems to be a transition in the mid-transverse colon with the descending colon appearing quite empty . The FBC shows an anaemia with a haemoglobin of 8g / dL ( normal 13g / dL or higher ). A colonoscopy is arranged with a surgeon and this demonstrates a circumscribing obstructive cancer in the transverse colon ( see figure 11 ).
This case illustrates that a recent change in bowel habit may signal a more sinister cause , other than known causes of constipation , such as Parkinson ’ s disease . A careful approach is recommended when faced with unusual signs / symptoms that may be red flags .
Case study two
Arthur , an 84-year-old man , was admitted to hospital with faecal impaction and urinary retention . He had experienced constipation for the past three weeks , passing only ‘ cat ’ s droppings ’ that required straining . In the past , his bowels would open regularly . He had noticed some blood in the faeces , as well as on toilet paper .
There is no history of colon cancer and his diet is high in fibre . Arthur does not report any weight loss but feels fatigued . He is not taking any opioid analgesics or other drugs that may cause constipation . He has not been exercising recently and as a result has been drinking reduced amounts of fluids .
How to Treat Quiz .
1 . Which THREE may be complications of constipation ? a Haemorrhoids and rectal prolapse . b Diverticular disease . c Bowel obstruction . d Negative impact on quality of life .
2 . Which TWO statements regarding the epidemiology of constipation are correct ? a Constipation is more common in men . b Constipation and laxative use are higher in residential care than in the community . c Low socioeconomic status is associated with increased prevalence of constipation . d Opioid-induced constipation in the older person is well recognised and well treated .
3 . Which ONE drug does not commonly cause constipation ? a Opiates . b Paracetamol . c Iron supplements . d Antipsychotics .
4 . Which THREE red flags may suggest colorectal cancer ? a Anorexia and unintentional weight loss . b Rectal loss of blood , stool mixed with blood or mucus . c Fever , night sweats . d Anaemia or iron deficiency .
5 . Which THREE are appropriate initial investigations for constipation ? a Thyroid function test . b FBC and FOBT if colon cancer is suspected . c EUC in dehydration . d A plain abdominal X-ray for faecal impaction involving the right side of the colon .
6 . Which THREE are appropriate in the management of constipation in older people ? a Regular laxatives as first-line treatment in all patients . b Exclusion of surgical emergencies and structural abnormalities . c Identification and treatment of reversible causes . d Lifestyle and dietary modifications .
In the ED , he is given an enema and prescribed docusate sodium 50mg / total sennosides 8mg along with macrogol , one sachet bd . CT abdomen shows no abnormality apart from faecal loading in the colon . A dipstick urine test shows leucocytes +++ and is positive for nitrites and a urine specimen is sent off for culture .
Arthur ’ s constipation improves with an enema and the laxatives . He is subsequently able to pass urine
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7 . Which TWO statements regarding laxatives are correct ? a Stool softeners are an alternative to laxatives . b Bulk-forming laxatives are preferred over osmotic laxatives in older patients . c Avoid osmotic laxatives in older individuals at risk of dehydration . d Natural fibre may cause bloating and excess flatulence .
8 . Which THREE statements regarding laxatives are correct ? a Daily use of stimulant laxatives may lead to hypokalaemia , protein-losing enteropathy , and salt depletion . b Enemas can lead to disturbances in fluid and electrolyte balance . c Stool softeners are more effective than other laxatives and have a limited side effect profile . d Patients with intractable constipation may require referral for surgical treatment .
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Yeh YS et al . BMC Cancer 2017 / CC BY 4.0 / bit . ly / 45k2UES
Figure 11 . Colonoscopy showing an approximately 4 / 5 circumferential obstructing ulcerative tumour in the proximal transverse colon near the hepatic flexure .
CONSTIPATION IN OLDER PEOPLE
again . He is also given a dose of IV gentamicin because of the high possibility of a UTI secondary to urine stasis ( positive leucocytes and nitrite ). This is subsequently confirmed with pure growth of Escherichia coli in the urine culture .
Post-discharge from ED , he is advised to exercise and increase his fluid intake . FOBT is ordered to screen for colon cancer that may have been masked on CT scan by the faecal matter . Although colonoscopy is discussed
9 . Which TWO modalities may be used to treat faecal impaction in older people ? a Enemas and suppositories for a distal impaction . b Use of larger oral volumes for proximal impaction as this is usually more severe in older people . c Addressing possible aetiologies following treatment , and institute preventive therapy to avoid recurrence . d No treatment is needed if there is a negative digital rectal examination .
10 . Which THREE statements regarding constipation are correct ? a Constipation significantly impacts quality of life . b Constipation negatively affects the social lives of older individuals . c Psychological and general wellbeing improves as bowel movements increase with appropriate treatment . d Complications of constipation only rarely impact the morbidity and mortality of older individuals . as an investigative option , Arthur declines this option . Arthur ’ s GP is asked to monitor him for ‘ red flags ’ given the episode of bloody stools in hospital and the history of fatigue . Arthur is advised to seek medical attention early if the constipation recurs .
This case demonstrates that faecal impaction can occur abruptly in someone without a prior history of constipation and that urinary retention and UTI may result from faecal impaction . Early attention to and treatment of constipation could have avoided the impaction and urinary complications .
CONCLUSION
CONSTIPATION is extremely common in older people . It has a negative impact on quality of life and may signify more sinister underlying problems . Relevant history , examination and investigations can identify surgical emergencies , detect red flags , and uncover common correctible contributing factors including medications , and avoid certain pitfalls . The latter include neglecting the investigation of possible causes and only treating the symptom with laxatives . This may result in misdiagnosis of surgical obstructive causes , continuation of drugs that can cause constipation or worsen it despite better alternatives being available , and chronic abuse of laxatives .
A thorough assessment can uncover uncommon organic causes of constipation such as hypothyroidism , and lifestyle factors contributing to constipation . A stepwise management approach involves lifestyle modifications , bowel retraining and judicious prescription of appropriate laxatives . Trial non-pharmacological treatment before laxatives as chronic use of the latter can lead to dependency and abuse .
RESOURCES
• Victorian Government : Better Health Channel — Constipation betterhealth . vic . gov . au / health / conditionsandtreatments / constipation
• Department of Health and Aged Care — Bladder and bowel bit . ly / 3tyVGzc
References Available on request from howtotreat @ adg . com . au