[CI], 0.51–0.72) and 0.85 (95% CI, 0.68–1.03), respectively, compared with individuals <40 years of age.3 Thus, age alone is not an independent risk factor for reduced stool frequency. Likewise, little evidence exists to support low‐fibre diets, lack of fluid, or reduced exercise as contributing to constipation in the otherwise healthy older patient.7,8 Elderly women are two to three times more likely to report constipation than their male counterparts.9 Non‐whites and individuals of lower socioeconomic status report fewer stools.10 In community‐dwelling frail elders, up to 45% report constipation as a health concern.11 The prevalence is higher in nursing home residents, with 74% of people symptomatic of constipation and requiring laxatives.12 In older people, the development of constipation is often multifactorial and typically represents the effects of medications, reduced dietary fibre intake, immobility, and comorbid diseases.13 The traditional perception of constipation due to ageing no longer holds; the healthy older person is not predestined to develop constipation.
Elders reporting constipation more often describe straining and hard bowel movements than reduced stool frequency.3,14,15 Population‐based prevalence of constipation includes 40% of community‐dwelling adults over the age of 64.16 The presence of constipation is also associated with medication use, including beta blockers, calcium channel blockers, anticholinergic drugs, and opiates.17 Despite the lack of difference in risk factor–adjusted constipation rates between elders and younger individuals, elders more frequently use laxatives. Up to 50% of elderly women report the use of laxatives. Overall, 20–30% of community‐dwelling elders use laxatives on at least a weekly basis. In the United States, a systematic review of the economic burden of IBS and chronic constipation showed that per patient, between $1912 to $7522 per year was spent on medications, hospitalization, outpatient clinics, emergency visits, and laboratory tests.18 Most elders self‐treat with over‐the‐counter products; hence the economic impact of laxative use is probably considerably higher than this estimate.
The findings of similar stool frequency but increased defecatory difficulty parallel the reported physiological changes that occur in the digestive tract with ageing. Colon transit overall is generally well preserved with ageing in humans.19 Changes in pelvic floor function may contribute to defecatory difficulty, with older women demonstrating reduced opening of the anorectal angle and a greater degree of perineal descent compared with younger women.20 Pudendal neuropathy also occurs more commonly with ageing and may negatively affect pelvic floor function.21 Other factors correlated with constipation in ageing include reduced caloric intake, use of multiple medications, haemorrhoids, and pain in the abdomen.22,23 Many diseases that occur more commonly in elders also contribute to the development of constipation, such as diabetes mellitus, Parkinson’s disease, and stroke. Prior surgery may also affect bowel function in elders. In women over 50 years of age, hysterectomy results in prolonged colon transit time and greater complaints of constipation and straining than in controls.24 Since ageing alone has little influence on the development of constipation, when complaints of constipation occur in elders, it commonly relates to medical comorbidities and increased defecatory difficulty.
Constipation is a frequently reported bowel symptom in the elderly, with a considerable impact on quality of life and health expenses. The consequences of constipation in elders make it a significant health problem. Chronic constipation impacts functioning in daily living, and elders with these complaints rate their health lower than people without gastrointestinal symptoms.25 These findings were not confounded by the presence of other chronic illnesses or medication use. Health‐related quality of life is reduced in patients with chronic constipation.26 The presence of constipation has also been hypothesized to increase urinary tract symptoms, with the treatment of constipation resulting in reduced urinary frequency, urgency, and dysuria.27 Increased weekly bowel movements due to laxative use also led to patients reporting better sexual function and improved mood and depression.12
Constipation is also associated with bowel incontinence, and treatment of constipation reduces incontinence episodes.28,29 Faecal impaction is a common problem in the elderly; it is estimated that 7% of institutionalized elderly have impacted faeces on rectal examination.30 The first indication of impaction may be overflow diarrhoea and rectal incontinence; if a rectal examination is not performed, there is a risk of impaction being misdiagnosed and treated with antidiarrheal agents.31 Immobile or cognitively impaired individuals with constipation face an increased risk of faecal impaction, stercoral ulceration, and colon perforation.28,32 Constipation reduces quality of life and diminishes self‐perceived health in community‐dwelling elders.25 More effective strategies are needed for reducing the burden of illness and costs associated with constipation.
Aetiology of constipation
Of the multiple causes of constipation in older people, most relate to medication use or coexisting medical illness (Tables 20.2 and 20.3). The most commonly implicated medications are opiates, calcium channel blockers, non‐steroidal anti‐inflammatory drugs (NSAIDs), and medications with anticholinergic effects. Although immobility and reduced fluid and fibre intake are often implicated in the development of constipation, there is little evidence to support this folklore. Increased physical activity does not reliably improve constipation.33 Reduced caloric intake correlates more closely with constipation in elders than do differences in fibre intake.22 Likewise, reduced fluid intake showed no significant association with chronic constipation. Increased psychological distress correlates with reports of constipation by elders, although the mechanism for this association remains unknown.15,22
Table 20.2 Medications commonly associated with constipation.
| Anticonvulsants: gabapentin, phenytoin, pregabalin |
| Antidepressants: SSRIs (selective serotonin reuptake inhibitors), TCAs (tricyclic antidepressants) |
| Antihistamines: hydroxyzine Anticholinergic drugs: antipsychotics, oxybutynin |
| Parkinson’s drugs: bromocriptine, amantadine, pramipexole, levodopa |
| Antihypertensives: calcium channel blockers, beta blockers, diuretics |
| Cation agents: antacids (calcium and aluminium), ferrous gluconate, ferrous sulphate |
| Analgesia: non‐steroidal anti‐inflammatory drugs, opiates |
| Antiemetics: ondansetron, prochlorperazine |
Table 20.3 Medical conditions commonly associated with constipation.
| Mechanical obstruction |
|---|
| Colonic neoplasia |
| Colonic stricture (intrinsic or extrinsic) |
| Anal stenosis |
| Metabolic |
| Amyloidosis |
| Chronic kidney disease |
| Diabetes mellitus |
| Electrolyte disturbance (hypercalcaemia, hypomagnesaemia) |
| Hyperparathyroidism |
| Hypothyroidism |
