From the Guidelines
For managing constipation in a 77-year-old patient, I recommend starting with lifestyle modifications and then progressing to medications if needed, prioritizing the use of polyethylene glycol (MiraLAX) 17g dissolved in 8oz of water once daily as the first-line treatment, as suggested by the most recent and highest quality study 1.
Lifestyle Modifications
Begin by increasing fluid intake to 6-8 glasses of water daily, adding more dietary fiber (aim for 25-30g daily) through fruits, vegetables, and whole grains, and encouraging regular physical activity such as daily walking for 20-30 minutes.
- Increase dietary fiber intake to help soften stool and improve bowel movements
- Encourage regular physical activity to stimulate bowel movements
- Ensure adequate fluid intake to help prevent constipation
Medications
If lifestyle modifications are insufficient, start with an osmotic laxative like polyethylene glycol (MiraLAX) 17g dissolved in 8oz of water once daily. This medication works by drawing water into the intestines to soften stool and is generally well-tolerated in older adults.
- Polyethylene glycol (MiraLAX) 17g dissolved in 8oz of water once daily as the first-line treatment
- For occasional use, a stimulant laxative such as bisacodyl (Dulcolax) 5-10mg orally or senna (Senokot) 8.6-17.2mg at bedtime can provide relief within 6-12 hours
- Avoid long-term use of stimulant laxatives as they can cause dependence
Underlying Conditions
For this age group, it's essential to review all medications as many (including calcium channel blockers, opioids, anticholinergics, and some antidepressants) can worsen constipation. Ensure adequate toilet time with proper positioning using a footstool if needed. If constipation persists despite these measures, consider evaluation for underlying conditions such as hypothyroidism, diabetes, or neurological disorders that may contribute to constipation in older adults.
- Review all medications to identify potential causes of constipation
- Evaluate for underlying conditions that may contribute to constipation
- Ensure adequate toilet time with proper positioning using a footstool if needed
Additional Considerations
If constipation persists, consider consulting a specialist or referring to specialized palliative care services or hospice, as suggested by the NCCN clinical practice guidelines in oncology: palliative care 1.
From the FDA Drug Label
USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days ASK A DOCTOR BEFORE USE IF YOU HAVE • nausea, vomiting or abdominal pain • a sudden change in bowel habits that lasts over 2 weeks • irritable bowel syndrome For a 77-year-old patient with constipation, polyethylene glycol (PO) may be used to relieve occasional constipation. However, it is recommended to ask a doctor before use if the patient has any underlying conditions such as nausea, vomiting, or abdominal pain, or if there has been a sudden change in bowel habits lasting over 2 weeks 2. The patient should also be monitored for any signs of a serious condition, such as rectal bleeding or worsening nausea, bloating, cramping, or abdominal pain, and stop use and ask a doctor if any of these symptoms occur 2.
From the Research
Management of Constipation in Older Adults
The management of constipation in older adults, such as a 77-year-old patient, involves a combination of lifestyle modifications, dietary changes, and pharmacological interventions.
- Lifestyle modifications include scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake 3, 4, 5, 6.
- Dietary changes, such as increased fiber intake, can be achieved through the consumption of foods high in fiber or the use of fiber supplements like polycarbophil, methylcellulose, or psyllium 3, 4, 5, 6.
- Pharmacological interventions may include the use of osmotic laxatives, such as polyethylene glycol, stool softeners, such as docusate sodium, and stimulant laxatives 3, 4.
Treatment Options
Treatment options for constipation in older adults may vary depending on the underlying cause and severity of the condition.
- Fecal impaction can be treated with mineral oil or warm water enemas 3.
- Opioid-induced constipation can be managed with peripherally acting mu-opioid antagonists, although these medications can be expensive 3.
- Biofeedback is an effective treatment option for dyssynergic defecation 5, 6.
- Other treatment options, such as acupuncture, botulinum toxin, and surgery, may be considered in certain cases, although their use in older adults is limited and requires further clarification 4.
Diagnostic Evaluation
The diagnostic evaluation of constipation in older adults typically begins with a focused history and physical examination, including an anorectal examination 5, 6.