Chapter 3
Geriatrics - Constipation

1. Constipation, one of the most common complaints of the elderly, is, nonetheless, poorly defined. Different people mean different things by "constipation".

2. Various complaints sometimes called Constipation:

1. Straining at stool
2. Painful bowel movements (dyschesia)
3. Perception of infrequency of bowel movements
4. Abdominal discomfort relieved by bowel movements
5. Dementia (Forgetting bowel movements)
6. When taking a history of constipation, the clinician must probe, so to speak, to get at what is really meant by the word, just as one must do with the term dizzy or depressed.

Causes of Constipation

1. Chronic Slow transit constipation

This is life-long constipation. It's not rare but unusual; there is a history back to adolescence or childhood.

2. Pelvic dysynergia

Pelvic dysynergia is a failure of the rectum, the anal sphincters and the pelvic floor muscles, not to mention the voluntary contractions of the abdominal wall to act together to produce a bowel movement. It is common in old age and Parkinson's Disease.

3. Irritable bowel syndrome

A life-long syndrome of abdominal pain or discomfort and alternating constipation and diarrhea without organic changes.

4. Environmental

Mainly referring to restraint, inability to move to the BR or inaccessibility of facilities.

5. Immobility

6. Poor hydration

7. Dietary deficiency of bulk and fiber

8. Psychological Factors

9. Depression

Constipation is a cardinal features of depression.

10. Bowel Obsession

A number of elderly people feel that a regular bowel movement at least every day is imperative. They were taught this by their mothers who learned it from their doctors in the early part of the twentieth century when the medical profession was obsessed with regular bowel movements. So doctors shouldn't feel too superior about it, because it was their profession that started it.

11. Iatrogenic

The chief culprits are anticholinergic drugs, but verapamil and the other calcium channel blockers are a problem. Immobility, bed rest and nothing by mouth orders also cause constipation.

12. Laxative Habituation

A close ally of bowel obsession. Very difficult to treat.

13. Mass in the Colon

Not to be forgotten, especially when the caliber or nature of the stool are altered

14. Cancer

15. Diverticulitis

16. Bowel obstruction

17. Anal Stricture and/or fissure


Treatment of Constipation

1. Be Certain of the Diagnosis

Especially in frail elders, a rectal exam needs to be performed at some point before extensive therapy is undertaken to detect impaction or mass.
Distinctions must be made between the syndromes of bowel obsession, serious infrequency, and painful or difficult bowel movements before extensive therapy is initiated.

2. Hygiene

1. Diet

1. Bulk

The need for large and adequate sources of undigestible substance in the diet can't be over-emphasized. Many people have difficulty with flatulence when fiber is increased. The walk after dinner to allow socially acceptable passage and some exercise may help.

2. Fluid

Most old people don't drink enough water. Then doctors sometimes put them on fluid restriction and make matters worse. If you use artificial sources of fiber and don't have adequate fluid, the fiber can be constipating, defeating your purpose.

2. Exercise

3. Fiber supplements

Don't give up if one doesn't work. There are many and a person might tolerate another if one doesn't sit well. It is also important to dose fiber like a drug. If gas and belly discomfort are a problem, reduction in dose, rather than giving up might be in order. If it doesn't work, increasing the dose might be the answer.

4. Serene, unhurried and private toilet time.

This is a rare commodity in some settings. People with pelvic dyssynergia need to take their time on the toilet so that the various components of defecation can be coordinated.

5. Consider sinister causes

If basic hygeine has not been effective, consider diverticulitis, cancer or other bowel obstruction.
Investigate with imaging and/or endoscopy if constipation is unrelenting, or recent and severe and if surgery would be performed if indicated.

6. Basic Bowel Regimen

This is my method; there are others equally good, no doubt.

1. Hygiene as above
2. Remove constipating drugs
3. Milk of Magnesia or Sorbitol at night.
- Sorbitol is equivalent to the much more expensive lactulose and is given in equivalent doses. Milk of Magnesia must be avoided in renal failure.
4. Senna if above ineffective
- Senna is fairly well tolerated. It is the strongest oral bowel stimulant I use becuase stimulating the whole gut for a rectal problem doesn't seem useful and because of the danger of habituation.

5. In diabetics or if true slow transit constipation appears likely, a propulsive agent such as cisapride (Propulsid®) or metoclopramide (Reglan®) may be used.

6. Digitally disimpact if necessary
- Certainly a rectal examination must be done by this point.

7. Suppositories

1. Glycerin suppositories are cheap and occasionally effective
2. Bisocodyl (Dulcolax®) if above ineffective

8. Enemas

1. Mineral Oil is comfortable and probably safe
2. Water or saline if above ineffective
3. Milk and Molasses is my favorite last resort enema, 50-50, about a pint. Most doctors would use Fleet's Phospho-soda but the sodium load is significant and the stimulation can be distressing.
4. Regular enemas may be useful for people with no bowel awareness including demented people. They are also occasionally necessary in severe laxative habituation.

9. Although rarely indicated, surgical intervention is occasionally indicated for severe cases

10. Rectal and anal problems such as hemorrhoids or fissure may require specific surgical attention.


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