What are the treatment options for constipation in the elderly?

Treatment Options for Constipation in the Elderly

The most effective approach to managing constipation in elderly patients includes both non-pharmacological and pharmacological interventions, with polyethylene glycol (PEG) being the first-line laxative treatment due to its efficacy and safety profile. 1, 2

Initial Assessment and Prevention

• Rule out fecal impaction (especially if diarrhea accompanies constipation) and obstruction through physical examination and abdominal x-ray if needed 1
• Discontinue any non-essential constipating medications 1
• Evaluate for underlying causes such as hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus, or medication side effects 1

Non-Pharmacological Interventions

• Ensure access to toilets, especially for those with decreased mobility 1, 2
• Increase fluid intake to maintain adequate hydration 1
• Increase dietary fiber if the patient has adequate fluid intake and physical activity 1
• Encourage appropriate exercise within the patient's capabilities 1
• Optimize toileting habits by educating patients to attempt defecation twice daily, preferably 30 minutes after meals, and to strain no longer than 5 minutes 1, 2
• Consider abdominal massage to improve bowel efficiency, particularly in patients with neurological problems 1

Pharmacological Management

First-Line Treatment

• Polyethylene glycol (PEG) 17 g/day is recommended as the first-line laxative due to its efficacy, good safety profile, and tolerability in elderly patients 1, 2

Second-Line Options

• Osmotic laxatives (lactulose, sorbitol) if PEG is insufficient 1
• Stimulant laxatives (senna, bisacodyl) can be used but with awareness of potential abdominal pain and cramps 1

For Fecal Impaction

• Glycerin suppository ± mineral oil retention enema 1
• Manual disimpaction following pre-medication with analgesic ± anxiolytic 1
• Isotonic saline enemas are preferable in older adults due to fewer adverse effects 1, 2

For Persistent Constipation

• Consider adding other laxatives such as bisacodyl suppository (one rectally daily-BID), lactulose (30-60 mL BID-QID), sorbitol (30 mL every 2 hours × 3, then PRN), magnesium hydroxide (30-60 mL daily-BID), or magnesium citrate (8 oz daily) 1
• For opioid-induced constipation, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (not more than once daily) 1

Special Considerations and Cautions

• Magnesium-based laxatives should be used cautiously in patients with renal impairment due to risk of hypermagnesemia 1, 2
• Avoid bulk-forming agents (psyllium, methylcellulose) in:
  • Non-ambulatory patients with low fluid intake due to risk of mechanical obstruction 1, 2
  • Patients with opioid-induced constipation 1, 3, 4
• Avoid liquid paraffin in bed-bound patients and those with swallowing disorders due to risk of aspiration lipoid pneumonia 1, 2
• Enemas are contraindicated for patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, anal trauma, or severe colitis 1
• Regular monitoring is necessary for patients with chronic kidney/heart failure when using laxatives with concomitant treatment with diuretics or cardiac glycosides 1, 2

Treatment Algorithm Based on Life Expectancy

For Long-Term Management (Years)

• Focus on lifestyle modifications: increased fluids, dietary fiber, exercise, and prophylactic medications 1
• PEG is the preferred long-term laxative option 1, 2, 5

For Months to Weeks

• More aggressive management with combination therapy may be needed 1
• Consider rectal measures for more immediate relief 1

For Terminal Patients (Weeks to Days)

• Increase dose of laxative ± stool softener (senna ± docusate, 2-3 tablets BID-TID) with goal of 1 non-forced bowel movement every 1-2 days 1

Monitoring and Follow-up

• Aim for one non-forced bowel movement every 1-2 days 1
• Regularly reassess for adequacy of constipation management, patient comfort, and quality of life 1
• Monitor for dehydration and electrolyte imbalances, especially in patients with chronic kidney/heart failure 1, 2

Recent research has shown that fiber supplementation can be effective in reducing laxative use in geriatric patients when properly implemented with adequate fluid intake 6, 7, but this approach requires careful monitoring and may not be suitable for all elderly patients, particularly those with swallowing difficulties or inadequate fluid intake 1, 2.