From the Guidelines
For older patients with constipation, a stepwise approach is recommended, starting with lifestyle modifications and considering polyethylene glycol (PEG) as a first-line treatment option, as it offers an efficacious and tolerable solution with a good safety profile 1.
Key Considerations
- Lifestyle modifications include increased fluid intake, dietary fiber, and regular physical activity as tolerated.
- PEG (17 g/day) is a recommended treatment option for elderly patients due to its efficacy and safety profile 1.
- Laxatives must be individualized and targeted to the older person’s medical history, drug interactions, and adverse events 1.
- Regular monitoring of chronic kidney/heart failure is necessary when concomitant treatment with diuretics or cardiac glycosides is prescribed 1.
Treatment Approach
- Start with lifestyle modifications, including increased fluid intake (6-8 glasses of water daily), dietary fiber (aim for 25-30g daily through fruits, vegetables, and whole grains), and regular physical activity as tolerated.
- Consider over-the-counter osmotic laxatives like PEG (MiraLAX, 17g in 8oz water daily) or lactulose (15-30ml daily) if lifestyle modifications are insufficient.
- Stimulant laxatives such as senna (8.6-17.2mg at bedtime) or bisacodyl (5-10mg daily) can be used short-term but may cause cramping.
- Avoid bulk-forming laxatives in dehydrated patients as they can worsen constipation.
- Enemas should be reserved for severe cases, and rectal measures (enemas and suppositories) can be the preferred choice of treatment if swallowing difficulties or repeated fecal impaction present 1.
From the FDA Drug Label
USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days Uses Relieves occasional constipation (irregularity) Generally causes bowel movement in 6 to 12 hours For older patients with constipation, treatment options include:
- Polyethylene glycol (PO): may relieve constipation in 1 to 3 days 2
- Senna (PO): may cause a bowel movement in 6 to 12 hours 3 When choosing a treatment, consider the onset of action and individual patient needs.
From the Research
Treatment Options for Constipation in Older Patients
- Lifestyle modifications are often the first step in treating constipation, including scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake 4, 5, 6, 7, 8
- Additional fiber intake in the form of polycarbophil, methylcellulose, or psyllium may improve symptoms, but should be slowly increased over several weeks to decrease adverse effects 4
- Osmotic laxatives, such as polyethylene glycol, are often recommended as a first-line treatment for constipation in older adults, followed by stool softeners and stimulant laxatives 4, 5, 6
- Long-term use of magnesium-based laxatives should be avoided due to potential toxicity 4
- Newer agents, such as linaclotide and lubiprostone, may be effective for treating constipation in older adults, but are often reserved for patients who do not respond to other treatments 4, 7
- Peripherally acting mu-opioid antagonists may be effective for opioid-induced constipation, but are expensive 4
Considerations for Older Adults
- Constipation is a common problem in older adults, affecting up to 50% of nursing home residents 4, 6
- Decreased mobility and other comorbid medical conditions may contribute to the prevalence of constipation in older adults 5, 7, 8
- Healthcare providers should proactively identify older constipated patients who are self-medicating or not receiving treatment 5
- Awareness of constipation, its complications, and treatment options needs to be increased among healthcare providers, patients, and carers 5