What is the recommended laxative treatment for constipation in the elderly?

Recommended Laxative Treatment for Constipation in the Elderly

Polyethylene glycol (PEG) at 17 g/day is the recommended first-line laxative for constipation in elderly patients due to its efficacy, good safety profile, and tolerability. 1

Initial Assessment and Prevention Measures

Before initiating pharmacological treatment, consider these prevention approaches:

• Ensure access to toilets, especially for those with decreased mobility 1
• Provide dietetic support to address nutritional needs 1
• Manage decreased food intake related to aging (chewing difficulties, anorexia of aging) 1
• Optimize toileting habits: educate patients to attempt defecation twice daily, preferably 30 minutes after meals, and to strain no longer than 5 minutes 1

Pharmacological Management Algorithm

First-Line Treatment

• Polyethylene glycol (PEG) 17 g/day - offers efficacious and tolerable solution with good safety profile 1, 2
  • Can be used safely for long-term management (up to 6 months) 2
  • Monitor for side effects: abdominal distension, loose stool, flatulence, and nausea 1

Second-Line Options

• Stimulant laxatives (senna, bisacodyl) - can be used when PEG is insufficient 1
  • Be aware of potential for abdominal pain and cramps 1
  • Should not be used for longer than one week unless directed by a doctor 3

For Specific Situations

• For fecal impaction: Rectal measures (suppositories and enemas) are preferred first-line therapy 1

  • Isotonic saline enemas are preferable in older adults due to fewer adverse effects than sodium phosphate enemas 1
  • Follow with maintenance bowel regimen to prevent recurrence 1

• For swallowing difficulties: Consider rectal measures (enemas and suppositories) 1

Medications to Use with Caution or Avoid

• Saline laxatives (e.g., magnesium hydroxide) - use with caution due to risk of hypermagnesaemia, especially in renal impairment 1

  • Regular monitoring required if used with diuretics or cardiac glycosides 1

• Bulk-forming agents (psyllium, methylcellulose) - avoid in:

  • Non-ambulatory patients with low fluid intake due to risk of mechanical obstruction 1
  • Patients with opioid-induced constipation 1
  • If used, must be taken with at least 8 ounces of fluid 4, 5

• Liquid paraffin - avoid in bed-bound patients and those with swallowing disorders due to risk of aspiration lipoid pneumonia 1

Special Considerations

• For opioid-induced constipation: Osmotic or stimulant laxatives are generally preferred 1

  • All patients receiving opioid analgesics should be prescribed a concomitant laxative unless contraindicated 1

• For patients with renal impairment: Monitor closely when using magnesium-based laxatives due to risk of hypermagnesaemia 1

• For patients with cardiac conditions: Regular monitoring of chronic kidney/heart failure when using laxatives with concomitant treatment with diuretics or cardiac glycosides 1

Monitoring and Follow-up

• Individualize laxative regimens based on the older person's medical history, particularly cardiac and renal comorbidities, potential drug interactions, and adverse effects 1
• Monitor for dehydration and electrolyte imbalances, especially in patients with chronic kidney/heart failure 1
• Assess response to treatment and adjust as needed 1