Management of Chronic Constipation in Older Adults
Polyethylene glycol (PEG) at 17 g/day is the recommended first-line pharmacological treatment for chronic constipation in older adults due to its efficacy and good safety profile. 1, 2
Initial Assessment and Non-Pharmacological Management
- Particular attention should be paid to the assessment of elderly patients, including complete medication review and identification of comorbidities 3
- Ensure access to toilets, especially for those with decreased mobility 3, 2
- Provide dietetic support to address nutritional needs and manage decreased food intake related to aging 3
- Optimize toileting habits by educating patients to attempt defecation twice daily, preferably 30 minutes after meals, and to strain no longer than 5 minutes 3, 2
- Increase fluid intake within patient limits 3, 4
- Increase physical activity, even if limited to bed-to-chair movement 3, 5
- Consider abdominal massage, which can be efficacious in reducing gastrointestinal symptoms, particularly in patients with concomitant neurogenic problems 3
Pharmacological Management Algorithm
First-Line Treatment
- PEG (17 g/day) is the first-line laxative for elderly patients with constipation due to its efficacy, good safety profile, and tolerability 1, 2
Second-Line Options
- If PEG is insufficient or not tolerated, consider other osmotic laxatives (lactulose) or stimulant laxatives (senna, bisacodyl, sodium picosulfate) 3, 1
- Stimulant laxatives can be used but be aware of potential abdominal pain and cramps 3, 2
For Fecal Impaction
- Suppositories and enemas are preferred first-line therapy when digital rectal examination identifies a full rectum or fecal impaction 3, 2
- Isotonic saline enemas are preferable in older adults due to fewer adverse effects compared to sodium phosphate enemas 3, 2
Medications to Use with Caution or Avoid
- Saline laxatives containing magnesium (e.g., magnesium hydroxide) should be used cautiously due to risk of hypermagnesemia, particularly in patients with renal impairment 3, 1
- Bulk-forming agents (psyllium, methylcellulose) should be avoided in non-ambulatory patients with low fluid intake due to increased risk of mechanical obstruction 3, 2
- Liquid paraffin should be avoided in bed-bound patients and those with swallowing disorders due to risk of aspiration lipoid pneumonia 3, 2
- Bulk laxatives are not recommended for opioid-induced constipation 3
Special Considerations
Opioid-Induced Constipation
- Unless contraindicated by pre-existing diarrhea, all patients receiving opioid analgesics should be prescribed a concomitant laxative 3
- Osmotic or stimulant laxatives are generally preferred for opioid-induced constipation 3, 4
- For refractory opioid-induced constipation, consider peripherally acting mu-opioid antagonists, though these can be expensive 4
Patients with Comorbidities
- For patients with renal impairment, avoid or use magnesium-based laxatives with extreme caution 1, 2
- For patients with cardiac conditions, regularly monitor for dehydration and electrolyte imbalances when using laxatives with concomitant treatment with diuretics or cardiac glycosides 3, 2
- For patients with swallowing difficulties or repeated fecal impaction, consider rectal measures as the preferred treatment option 3, 2
Newer Treatment Options
- Linaclotide is FDA-approved for chronic idiopathic constipation in adults and may be considered if other treatments fail 6, 4
- In clinical trials, linaclotide improved stool frequency, consistency, and reduced straining with bowel movements 6
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 3, 2
- Monitor for dehydration and electrolyte imbalances, especially in patients with chronic kidney/heart failure 3, 2
- If constipation is refractory to medical treatment, further diagnostic evaluation may be warranted to assess for colonic transit time and anorectal dysfunction 7