What is the best laxative for elderly patients with constipation?

Best Laxative for Elderly Patients with Constipation

Polyethylene glycol (PEG) 17g daily is the best laxative for elderly patients with constipation due to its efficacy and favorable safety profile. 1, 2

First-Line Treatment Options

Polyethylene Glycol (PEG)

• PEG 17g daily offers an efficacious and tolerable solution for elderly patients with constipation 1
• Has demonstrated safety and efficacy for up to 12 months 2
• Good safety profile makes it particularly suitable for older adults 1
• Does not require increased fluid intake like bulk-forming laxatives

Stimulant Laxatives

• Can be used as an alternative first-line option or added to PEG if needed 2
• Bisacodyl 10-15mg daily (maximum 15mg for elderly) 2, 3
• Senna can be used as an alternative stimulant laxative 4
• Should be used with awareness of potential for abdominal cramping

Treatment Algorithm

1. Start with PEG 17g daily

   • Goal: One non-forced bowel movement every 1-2 days
   • Assess response after 1-2 days

2. If inadequate response:

   • Add stimulant laxative (bisacodyl 10mg, not exceeding 15mg daily in elderly)
   • OR consider combination therapy with osmotic and stimulant laxatives

3. For refractory cases:

   • Consider prescription medications such as linaclotide (72-145μg daily)
   • Consider rectal measures (suppositories or enemas) if oral medications fail
   • Isotonic saline enemas are preferable to sodium phosphate enemas in older adults 1

Important Considerations for Elderly Patients

Avoid These Laxatives

• Bulk-forming laxatives should be avoided in non-ambulatory patients with low fluid intake due to risk of mechanical obstruction 1, 5
• Liquid paraffin should be avoided in bed-bound patients and those with swallowing disorders due to risk of aspiration pneumonia 1
• Magnesium-based laxatives should be used with caution due to risk of hypermagnesaemia, especially in those with renal insufficiency 1, 2

Supportive Measures

• Ensure adequate fluid intake (at least 2.0 L of drinks daily unless contraindicated) 1
• Provide access to toilets, especially for patients with decreased mobility 1
• Optimize toileting schedule: educate patients to attempt defecation at least twice a day, usually 30 minutes after meals 1
• Aim for adequate dietary fiber intake (25g daily) if appropriate 1, 6
• Review and discontinue non-essential constipating medications 2

Monitoring and Follow-up

• Monitor for adverse effects such as abdominal cramping or diarrhea 2
• Regular monitoring of kidney/heart function when using laxatives in patients on diuretics or cardiac glycosides 1
• Assess response to treatment after 1-2 days and adjust as needed 2
• For patients with swallowing difficulties or repeated fecal impaction, consider rectal measures 1

Special Situations

• For opioid-induced constipation, consider adding peripherally acting mu-opioid receptor antagonists 1, 6
• For fecal impaction, perform disimpaction (usually through digital fragmentation and extraction of the stool) before implementing a maintenance bowel regimen 1

The evidence strongly supports PEG as the first-line laxative for elderly patients with constipation, with stimulant laxatives as an alternative or adjunct therapy when needed 1, 2, 5, 6.