Constipation in the elderly All backed up and no where to go Annette T. Carron, DO Director Geriatrics and Palliative Care Botsford Hospital

Constipation in the elderlyAll backed up and no where to go

Annette T. Carron, DO

Director Geriatrics and Palliative Care

Botsford Hospital

Pathophysiology of constipation, with focus on

changes with aging Assessment and diagnosis of constipation Standard of care treatment for constipation Constipation and survey implications

Feeling of constipation is defined differently by different people

Defined by self-report or objective assessment-based

Clinical – finding fecal loading in the rectum on exam and/or colonic fecal loading on xray

Subtype – rectal outlet delay Feeling of anal blockage at least a quarter of the

time and prolonged defecation (>10 min to complete bowel movement) or need for self-digitization on any occasion

*Criteria fulfilled for at least 3 months, with symptom onset at least 6 months prior to diagnosis.IBS = irritable bowel syndrome.Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491.

During at least 25% of defecations

Straining Lumpy or

Hard Stools

Sensation of Incomplete Evacuation

Manual Maneuvers to Facilitate Defecations

<3 Defecations

per Week

Sensation of Anorectal

Obstruction/Blockage

• Loose stools are rarely present without the use of laxatives

• There are insufficient criteria for IBS

• Chronic constipation must include 2 or more of the following: (self-report)

• North America: estimates range from 2% to 28%; 15% ≈ 63 million North Americans fulfill criteria for constipation– Variations due to

• Criteria/symptoms definitions used (multiple definitions)

• Survey collection methods

• Self-report vs diagnosis

• Worldwide– Similar rates in developed and undeveloped countries

– 14%-30% (Spain, Sweden, Australia, China)Higgins PD, et al. Am J Gastroenterol. 2004;99:750-759. Pare P, et al. Am J Gastroenterol. 2001;96:3130-3137. Garrigues V, et al. Am J Epidemiol. 2004;159:520-526. Walter S, et al. Scand J Gastroenterol. 2002;37:911-916. Chiarelli P, et al. Int Urogynecol J. 2000;11:71-78. Cheng C, et al. Aliment Pharmacol Ther. 2003;18:319-326.

Pre

vale

nce

(%

)

Age (Years)

0

2

4

6

8

10

12

Study 2†

N=NR

<18

18-4

4

45-6

4

65-7

4≥7

5

Study 1*N=42,375

Age (Years)

<40

40-4

9

50-5

9

60-6

9

70-7

9≥8

0

Pre

vale

nce

(%

)

0

2

4

6

8

10

12

*Harari D, et al. Population: NHIS 1987; criteria: self-report; †Johanson JF, et al. Population: NHIS 1983-1987; criteria: self-report.NHIS = National Health Interview Survey.Higgins PDR, et al. Am J Gastroenterol. 2004;99:750-759.

• Unable to report bowel-related symptoms

• Have regular bowel movements despite have rectal or colonic fecal impaction

• Have impaired rectal sensation and inhibited urge to go and so be unaware of rectal stool impaction

• Nonspecific symptoms associated with colonic fecal impaction (e.g., delirium, anorexia, functional decline)

• Collagen deposition in the left side of the colon increases

• Total number of neurons in the myenteric plexus is decreased

• Decrease in internal sphincter tone• Decline in external anal sphincter and pelvic

muscle strength• Reduction in rectal motility with normal

aging

Primary • Slow-transit

constipation• Dyssynergic defecation• Normal-transit

constipation– IBS-C

Secondary• Lifestyle• Organic GI disease• Medications• Metabolic• Postsurgical• Psychological• Neurological• Systemic disorders

IBS-C = irritable bowel syndrome with a predominant bowel complaint of constipation

CLASS CLASS EXAMPLES EXAMPLES

PRESCRIPTION DRUGS

Opiates

Anticholinergic agents

Tricyclic antidepressants

Calcium channel blockers

Anti-Parkinsonian drugs

Sympathomimetics

Antipsychotics

Diuretics

Antihistamines

Morphine

Benztropine, oxybutynin

Amitriptyline > nortriptyline

Verapamil hydrochloride

Amantadine hydrochloride

Albuterol

Haloperidol, risperidone

Furosemide

Diphenhydramine

NONPRESCRIPTION DRUGS

Antacids, especially calcium-containing

Calcium supplements

Iron supplements

Antidiarrheal agents

Nonsteroidal anti-inflammatory agents Loperamide, attapulgite

Ibuprofen

Locke GR III, et al. Gastroenterology. 2000;119:1766-1778. *This is not a complete list

Causes of Constipation in the Elderly

Aluminum hydroxide–containing antacids

Hypothyroidism

Anticholinergics Immobility/Inactivity

Calcium channel blockers Iron supplements

Dehydration Low-fiber and carbohydrate diet

Diabetes mellitus Narcotics

Diuretics Parkinson’s disease

Hypercalcemia/hypokalemia Stroke

De Lillo AR, et al. Am J Gastroenterol. 2000;95:901-905.

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.

Approximately half of residents in nursing homes have constipation

• Fecal impaction– Identified in up to 40% of elderly adults hospitalized in the United

Kingdom

• Rare complications– Obstipation: obstruction with stool

– Urinary and fecal incontinence

– Stercoral ulceration: rectal “pressure” ulcers from impacted stool and obstipation

– Megacolon: dilation of the colon that is not caused by obstruction (rectosigmoid diameter >6.5 cm)

– Bowel perforation (new onset or from above etiologies)

Read NW, et al. J Clin Gastroenterol. 1995;20:61-70. De Lillo AR, et al. Am J Gastroenterol. 2000;95:901-905.Read NW, et al. Gastroenterology. 1985;89:959-966.

• Fecal incontinence• Fecal impaction• Urinary retention• Sigmoid volvulus• Rectal prolapse• Diverticular disease• Impaired quality of life• Agitation in dementia patients

• Direct costs (typically individual or third party)– Physician visits

– Diagnostic tests

– Medications

• Indirect costs (individual or societal)– Reduced productivity

– Lost wages

– Impaired QOL

QOL = quality of life.

• In 2 large cross-sectional surveys of community-dwelling older adult patients:– Laxatives were third and fourth most frequently

used nonprescription drugs

• In cross-sectional survey of 4136 participants– Stimulant and bulking laxatives were most

commonly used

Ruby CM, et al. Am J Geriatr Pharmacother. 2003;1:11-17.Passmore AP. Pharmacoeconomics. 1995;7:14-24.

Rao SSC, et al. Gastroenterology. 2005;128:A-123.

Dyssynergia (n = 76)Slow transit (n = 38)Controls (n = 54)

* P < 0.05 vs controls

0

20

40

60

80

100

Physicalfunctioning

Role physical Bodily pain General health

Su

bsc

ale

Sco

re (

Mea

n ±

S.E

.M.)

* * * *

* ** *

• Impact of chronic constipation on quality of life in Olmsted County, Minnesota residents aged ≥ 65 years

• Lower score indicates worse quality of life

100

80

60

40

20

0

Mea

n M

OS

Sco

re

Physical functioning

Health perception

Mental health

Social functioning

Role functioning

Bodily pain

No GI symptoms Constipation

Talley NJ. Rev Gastroenterol Disord. 2004;4(suppl 2):S3-S10.

MOS = medical outcomes survey

• In another study, only 13% of individuals with constipation reported having <3 BMs per week

Pare P, et al. Am J Gastroenterol. 2001;96:3130-3137. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.

Pat

ien

ts (

%)

8172

54

39 3728

36

0

10

20

30

40

50

60

70

80

90

Straining Hard orlumpystools

Incompleteemptying

Stoolcannot

bepassed

Abdominalfullness or

bloating

<3 BMs per

week

Need topress on

anus

Physicians think: <3 BMs per week

Patient Descriptions

Recurrent abdominal pain/ discomfort with:

• Improvement with defecation

• Onset associated with change in frequency of stool

• Onset associated with change in form (appearance) of stool

Must include ≥ 2 of:• Hard or lumpy stool• Straining• Incomplete evacuation• Sensation of anorectal

obstruction/blockage • Manual maneuvers • < 3 defecations/week

• Pain not usually present

Symptoms for 3 months, onset ≥ 6 months

IBS-CChronic Constipation

Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491.

Nyam DCNK, et al. Dis Colon Rectum. 1997;40:273-279.

N=1009

0

10

20

30

40

50

60

70

Normaltransit +

defecatory function(n=597)

Defecatory disorder(n=249)

Slow transit(n=131)

Slow transit + defecatory

disorder(n=32)

Pre

vale

nce

(%

)

• Slow-transit constipation – “colonic inertia” – Slower than normal movement of contents from the

proximal to the distal colon and rectum

• Dyssynergic defecation (pelvic floor dysfunction) – Inability or difficulty with evacuation of stool from

the rectum in patients with normal or slowed colonic transit

• IBS-C– Abdominal pain or discomfort associated with normal-

or slow-transit constipation or pelvic floor dysfunction

Locke GR III, et al. Gastroenterology. 2000;119:1761-1778.Rao SSC. Gastroenterol Clin North Am. 2003;32:659-683.

Subtypes of Constipation

IBS with constipation

Slow-transit constipation

Defecatory dysfunction

Normal-transit constipation

Intestinal transit and stool frequency are within normal range The most common subtype

Bosshard W, et al. Drugs Aging. 2004;21:911-930.



Slow-transitconstipation



Characterized by decreased intestinal transit time

Neurohormonal control abnormal? Decreased nitric oxide production, impaired gastrocolic response, alteration of

neuropeptides (VIP, substance P), decreased interstitial cells of Cajal

Bosshard W, et al. Drugs Aging. 2004;21:911-930. VIP = vasoactive intestinal polypeptide





Pelvic floor dyssynergia, megarectum, rectocele, perineal descentMore frequent in older women – childbirth trauma

Pathogenesis may be multifactorial – structural problem

Bosshard W, et al. Drugs Aging. 2004;21:911-930.



Bosshard W, et al. Drugs Aging. 2004;21:911-930.Hadley SK, et al. Am Fam Physician. 2005;72:2501-2506.




Brain-gut axis is impaired? Stress, visceral hypersensitivity, abnormal brain activation, altered colonic motility, inflammation, bradykinins, adenosine, and 5-hydroxytryptamine


• Weight loss

• Rectal bleeding

• Occult blood in stool

• Older age of onset/new onset

• Vomiting

• Family history of colon cancer

• Family history of inflammatory bowel disease

Lembo A, et al. N Engl J Med. 2003;349:1360-1368.Brandt LJ, et al. Am J Gastroenterol. 2005;100(Suppl 1):S5-21.

• Among chronic constipation patients without alarm symptoms or signs, routine use of diagnostic tests is not recommended– The routine approach to a patient with symptoms of

chronic constipation without alarm signs or symptoms should be empiric treatment without performance of diagnostic testing

• Diagnostic studies are indicated in patients with alarm signs or symptoms

• Routine use of colon cancer screening tools is recommended in patients aged ≥ 50 years

Brandt LJ, et al. Am J Gastroenterol. 2005;100(Suppl 1):S5-S21.ACG = American College

of Gastroenterology

• Multidisciplinary approach– MD, nursing, pharmacist, dietician

• MDS initial evaluation– Bowel function– Ability to use toilet

• Accurate bowel history– From resident, if possible

• Rule out secondary factors– Medications, disease states, diet

• Immobility

• Inadequate fluid intake

• Diet – not enough fiber, reduced intake

• Medications– Narcotics– Iron– Anticholinergic side effects

• 59%-78% of residents use laxatives at least on an intermittent basis

• 50% were on more than 1 laxative

• Most commonly used:– Stool softeners– Saline laxatives– Stimulant laxatives– Osmotic laxatives

Phillips C, et al. J Am Med Dir Assoc.2001;2:149-154.

• 41% of patients on long-term opioids develop constipation– Delayed gastric emptying

– Delayed stool transit throughout the GI tract

– Decreased peristalsis

– These changes can be seen almost immediately, therefore, start laxatives prophylactically

• Treat with stimulant or osmotic laxatives

Kalso E, et al. Pain.2004;112:372-380.

• Trials of fiber have been inconsistent, but generally fiber in diet leads to laxative use and bowel movements

• No set guidelines for the elderly– American Dietetic Association– 10-13

Gm/1000 kcal

• Studies have used:– “laxative” pudding (dates & prunes)– Bran, applesauce, & prune juice mixture– Fiber-rich porridge


• May only be helpful in dehydrated patients, not in chronic constipation

• Adequate hydration is important to general health

Exercise• Convincing data is lacking as to efficacy,

but overall well-being may improve

• Set time for defecation– Morning or 30 minutes after meal

• Comfortable, safe toilet or commode

• Privacy

Generic Name Brand Name Usual Dosage

Bulk Formers

Psyllium Metamucil 1-2 Tbsp 1-3 times daily

Methylcellulose Citrucel 1 Tbsp 1-3 times daily

Stool Softeners (Emollients)

Docusate Na Colace 100-300 mg / day

Osmotic Agents

Lactulose Enulose, Constulose 15-30 ml 1-2 times daily

Sorbitol 70% --------------- 15-150 ml / day in divided doses

Polyethylene Glycol (PEG)

MiraLax 17 Gm once daily (1 capful)

Magnesium Hydroxide Milk of Magnesia 15-60 ml once daily (bedtime)

Stimulants

Senna Senokot 8.6-17.2 mg daily (1-2 tablets)

Bisacodyl Dulcolax 5-15 mg once daily (1-3 tablets)

Chloride Channel Activator

Lubiprostone Amitiza 24 mcg twice daily

Laxative Level of Evidence Strength of Recommendation

Polyethylene glycol I A

Tegaserod (suspended from market, March 2007)

I A

Lactulose II B

Psyllium II B

Sorbitol III C

Magnesium hydroxide III C

Stimulants (no good studies)

III C

Methylcellulose III C

Bran III C

Calcium polycarbophil III C

Colchicine III C

Misoprostol III C

Stool softeners III CRamkumar D, et al. Am J Gastroenterol. 2005;100:936-971.

*Lubiprostone was not approved at the time of this analysis

• MOA: absorbs water from intestinal lumen, softens stool, decreases bowel transit time

• Not suitable for acute relief

• Requires adequate fluid intake

• Avoid in patients with dysphagia

• Potential for drug interactions (digoxin, warfarin, salicylates, ciprofloxacin)

• AEs: flatulence, abdominal pain, GI obstruction

Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.

• MOA: act as surfactants, lowering surface tension and facilitating the mixing of aqueous and fatty substances in the intestinal lumen

• Primarily used for patients with painful defecation due to hemorrhoids or anal fissures

• No role in chronic constipation

• AE’s: potential diarrhea, mild cramping

Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21.


• MOA: draws fluid into the intestinal lumen by osmotic action, thus increasing intraluminal pressure & stimulating gut motility

• PEG – no studies yet in older adults

• Lactulose & sorbitol – similar effects in older adults

• Saline laxatives can cause electrolyte imbalance– Avoid use in patients with renal impairment

• AE’s: diarrhea, abdominal discomfort, flatulence


• MOA: stimulates nerve plexus of intestines, increases peristalsis, increases secretion of fluid & electrolytes

• Use in lowest effective dose

• Chronic use leads to tolerance

• Useful in opioid-induced constipation

• AE’s: abdominal pain, electrolyte imbalance, melanosis coli (long-term use)


• Metoclopramide & erythromycin work on the upper GI tract to promote peristalsis

– Little benefit for constipation

• Tegaserod was approved for chronic constipation in persons <65 yo, but voluntarily suspended from market by the manufacturer in March 2007 after a pooled analysis of 29 placebo-controlled short-term trials found a statistically significant increase in cardiovascular ischemic events, including heart attack, angina, and stroke – July 2007 – FDA approved restricted use under

investigational treatment protocol for women <55 yo with IBS-C or chronic idiopathic constipation


• MOA: enhances chloride-rich fluid secretion into intestinal lumen without affecting Na+, K+, or Cl- levels. No effect on selected smooth muscle (ileum longitudinal smooth muscle, ileum circular smooth muscle, vas deferens, and iris sphincter) contraction

• Approved for treatment of chronic idiopathic constipation in adults

• Minimal systemic absorption, no significant drug interactions

• Compared to placebo, increases bowel movements, decreases straining, improves stool consistency

Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.Johanson JF, et al. Gastroenterology.2004;126(Suppl 2): A100. Abstract 749.Johanson JF. Gastroenterology. 2003;124:A-48.

• Reserve for acute situations

• Avoid soap suds

• Small volume tap water enemas are preferred

• Phosphate containing enemas may cause hyperphosphatemia, especially in renal impairment

• Watch for abuse in the elderly


• Refractory constipation for anorectal testing• Dyssynergic defecation may benefit from

biofeedback therapy• Alarm symptoms or over age 50 for

colonoscopy• Surgery for severe colonic inertia• If chronic complaint but having BMs –

consider depression, refer psych

Approach to Management


Subjective c/o constipation

• Adequate hydration and fiber in diet• Exercise if mobile• Eliminate drugs that cause constipation

Constipation with mental status changes or abdominal pain and/or bleeding

• R/O delirium• R/O impaction or

obstruction• Treat the underlying

problem Iron deficiency anemia Stool for blood Digital rectal exam Abdominal X-Ray TSH, calcium, magnesiumExclude depression

Refer to GIFor colonoscopy/

transit studies

Avoiddocusate (Colace)

Empirically treat1. Sorbitol/lactulose/polyethylene glycol2. Stimulant laxative short term3. If none of the above measures work, use Lubiprostone

No Improvement

Switch empiricagents & try adifferent agent

Improved

?

Constipation in Long Term Care

Acute Chronic

No ImprovementImproved

• Care plan

• Quality of Life evaluation

• Medication review

• Scheduled treatment, not prn

• Know adult bowel history

• Doctor involved

• Refer when appropriate

• Quality Indicator

• F309 Quality of Care –Each resident must receive and the facility must provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care– May include fecal impaction

• F309- Highest possible level of functioning and well-being, limited by individual recognized pathology and normal aging– Determine if avoidable or unavoidable– Need:

• Accurate and complete assessment• Care plan• Evaluation of the results of the interventions and

revising the interventions as necessary

• Know your patient

• Common problem in elderly related to aging process and multiple illnesses in elderly

• Medications for etiology and treatment

• Exercise/increase activity

• Fiber

• Care plan

• Quality of life

Documents

Constipation in the elderly All backed up and no where to go Annette T. Carron, DO Director Geriatrics and Palliative Care Botsford Hospital