What is the recommended emergency room management for constipation in the elderly?

Emergency Room Management for Constipation in the Elderly

For elderly patients with constipation in the emergency room setting, digital rectal examination should be performed first to rule out fecal impaction, followed by polyethylene glycol (PEG) 17g/day as the first-line pharmacological treatment due to its efficacy and good safety profile. 1

Initial Assessment

• Perform digital rectal examination to rule out fecal impaction and overflow incontinence 2
• If fecal impaction is present, disimpaction should be performed (through digital fragmentation and extraction of the stool) 3
• For fecal impaction, suppositories and enemas are preferred first-line therapy when digital rectal examination identifies a full rectum 3, 1
• Isotonic saline enemas are preferable in older adults due to fewer adverse effects compared to sodium phosphate enemas 3, 1

Pharmacological Management Algorithm

First-line Treatment:

• Polyethylene glycol (PEG) 17g/day is recommended as first-line treatment for elderly patients due to its efficacy, good safety profile, and tolerability 1, 4
• PEG does not require increased fluid intake, making it particularly suitable for frail elderly patients 4

Second-line Options:

• Osmotic laxatives such as lactulose (30-45mL containing 20-30g lactulose, 3-4 times daily) 5
• Stimulant laxatives (senna, bisacodyl, sodium picosulfate) can be used when osmotic laxatives are insufficient, but be aware of potential abdominal pain and cramps 3, 1

For 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, 1
• Bulk laxatives such as psyllium are not recommended for opioid-induced constipation 3

Medications to Use with Caution or Avoid

• Saline laxatives (e.g., magnesium hydroxide) should be used with caution due to risk of hypermagnesemia, especially 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 risk of mechanical obstruction 3, 1
  • Patients with opioid-induced constipation 3
• Liquid paraffin should be avoided in bed-bound patients and those with swallowing disorders due to risk of aspiration lipoid pneumonia 3, 1

Special Considerations for Elderly Patients

• Regular monitoring of chronic kidney/heart failure is necessary when using laxatives with concomitant treatment with diuretics or cardiac glycosides 3, 1
• Ensure access to toilets, especially for those with decreased mobility 1
• Optimize toileting habits by educating patients to attempt defecation twice daily, preferably 30 minutes after meals 3, 1
• Provide dietetic support to address nutritional needs and manage decreased food intake related to aging 3, 1

Common Pitfalls and Caveats

• Avoid long-term use of magnesium-based laxatives due to potential toxicity, especially in elderly patients 6
• Enemas are contraindicated for patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal or gynecological surgery, recent anal or rectal trauma, severe colitis, inflammation or infection of the abdomen, toxic megacolon, undiagnosed abdominal pain, or recent radiotherapy to the pelvic area 3
• Many elderly patients are reluctant to discuss bowel problems, so healthcare providers should proactively identify constipated patients who may be self-medicating or not receiving treatment 7
• Despite appropriate management, some elderly patients may remain constipated due to dementia, immobility, or comorbid conditions 2