The Big No Go

Understanding, Treating and Preventing Constipation In Older Adults

Bowel movements are one of the body’s most essential yet complex functions. A successful bowel movement involves the brain, spinal cord, involuntary, and voluntary smooth muscle, a slew of hormones and several cell wall transport systems. But each part of the system can be thrown off by things as varied as emotions, stress, diet, drugs, hormones, genetic mutations and even changes in biorhythms. It’s no wonder it goes awry so often.

Constipation impacts 15% of the total population, 30% of people over age 60, and a whopping 50% of people in nursing homes.

If you’ve ever walked the aisles of your neighborhood drugstore, you won’t be surprised to learn that many people suffer from intermittent constipation, but did you know it’s a serious health risk for seniors?

One article labeled constipation in older adults an epidemic, which is not an exaggeration. We don’t talk about constipation in polite company, but the management of constipation shouldn’t be the sole domain of health care professionals, but also of caregivers and people who are interested in better self-care as they age.

Constipation impacts 15% of the total population, 30% of people over age 60, and a whopping 50% of people in nursing homes. Chronic constipation in older adults significantly impacts their quality of life, and may also be linked to shorter life spans. Emergency physicians and nurses dread the older patient with a rectum full of hard stool they cannot pass because the treatment is both painful and mortifying.

Older Adults Have Multiple Risks

Older adults are less mobile, more likely to be on constipating medications, and have overall lower levels of hormones which regulate gut transit time. In fact, many people don’t realize that when an older person is incontinent of stool, it can be because of severe constipation and blockage.

Severe constipation lands older people (>60 yrs) in the hospital more than you’d guess, and its often necessary to perform painful procedures like enemas and manual removal of impacted stool to relieve them of their misery. Untreated, severe constipation can lead to bowel obstructions, fluid, and electrolyte disturbances and even death.

Intermittent Constipation

There are many medical conditions that cause chronic constipation, like colon cancer and neurologic diseases like multiple sclerosis and spinal cord injuries. Medical conditions such as Parkinson’s Disease and cancer lead to constipation and their treatments make matters even worse. I will address medication-related constipation and will focus on intermittent, constipation in older adults, including the best practices for “keeping regular.” Medications to alleviate the problem will also be covered; both the old standards and newer pharmaceuticals pouring onto the market.

Diet, Diet Diet

When we talk about diet and bowel movements, the first and last word is fiber.

The old saying, ‘The quality of what goes in determines what comes out’ couldn’t be more true about our gastrointestinal system. For this reason, looking at diet is a crucial step to relieving constipation, and when we talk about diet and bowel movements, the first and last word is fiber.

There are two types of fiber, soluble and insoluble. It turns out both are helpful with constipation. An easy way to distinguish soluble and insoluble fiber is that soluble fiber gets sticky when water is added. Think oatmeal and dried pasta. Soluble fiber can help pull more water into the stool, making it softer, larger and easier to pass, that’s how Metamucil works.

Unfortunately, some soluble fiber (pasta, processed wheat and rice) are also high in digestible sugars. They decrease colonic transit time as the body tries to reabsorb water, causing stool to become hard and dry.

Insoluble fiber, found in vegetable matter, doesn’t get sticky but adds bulk to stool because it’s undigested. This helps stimulate the peristaltic reflex needed for defecation.

The best bet is to increase intake of insoluble fiber and indigestible sugars. These include:

  • whole grains, such as bran or whole wheat
  • vegetables low in starch, like spinach, collards, chard, kale, and broccoli
  • beans
  • most fruits, especially prunes
  • artificial sweeteners and polyethylglycocolate (PEG or Miralax)

Insoluble sugars and fibers create an osmotic gradient which coaxes water out of the blood, back and back into the stool, making it easier to pass. Unfortunately, the diets of most seniors in nursing homes are not as fiber-rich as they should be, but simple interventions like adding prunes at each meal can make a big difference.

Medication as a Cause of Constipation

Of all the things that set an older person up to be constipated, medications are probably the most significant. Even healthy older adults are on a supplement or two, and those taking medicine for pain, heart disease, or Parkinson’s is a set up for gut motility problems.

One way to remember the effect of supplements is: Calcium Constipates, Magnesium Moves (the bowel) and Iron brings the train to a stop.

Our entire gastrointestinal system is filled with nerve endings, earning it the nickname, “the second brain.” This is why any medication that affects nerves or pain receptors also affects the gut. That includes the non-steroidal anti-inflammatories like Aleve and Motrin.

Our entire gastrointestinal system is filled with nerve endings, earning it the nickname, “the second brain.” That is why any medication that affects nerves or pain receptors also affects the gut.

The most well-known class of constipating medications are opiates. For most people, it is a temporary condition, but for chronic pain patients, opiate-induced constipation is an on-going challenge. Opiates slow down the transit time of the gut by binding directly to the many opiate nerve receptors in the gut and also in the part of the brain that regulates the gut. But, did you know that other over-the-counter pain relievers like ibuprofen can also cause constipation?

The five classes of medications that are most associated with constipation are the opiates (morphine, codeine, hydrocodone etc) the anticholinergics and antihistamines (Benadryl, Claritin, Pepcid). The other big categories are the neurologically active drugs like antidepressants (SSRIs), antipsychotics, and medications that treat Parkinson’s.

Finally, the diuretics, like Lasix (furosemide) and Microzide (hydrochlorothiazide) are frequent causes of constipation in the very elderly or medically complex patients. Diuretics are commonly prescribed, but they decrease the amount of water in the body, which makes the stool hard, dry and more difficult to pass.

Inactivity and Muscle Mechanics

Like any muscle group, our gut slows down when we don’t move. Neural pathways that are activated by exercise also make the bowels contract, but also because successful defecation requires strong muscles. Like any other health problem, inactivity makes constipation worse. Inactivity is especially risky for the older and frail person who may be wheelchair bound.

Furthermore, the group of muscles that don’t get exercised enough in most people as they age, are the muscles in the pelvis. Women are often prescribed pelvic floor muscle exercises for urinary incontinence, but pelvic floor exercises may help with constipation too.

Potty Posture

Some experts point out that it’s not only our Western diet that predisposes us to difficulty with bowel movements, but our modern toilets too. Until we had modern toilets, all humans squatted low to the ground to have a bowel movement, and many people around the world still do. Squatting maintains a straighter path for the feces to pass compared to sitting high on a toilet seat.

Some entrepreneurs have invented a low-tech solution, a foot stool they’ve branded the Squatty Potty (with an funny and irreverent marketing campaign)! Although it may be more useful for younger and middle aged people with chronic constipation, it’s probably not as practical for the very old.

Gastrointestinal Hormones

With the exception of insulin, they’re not household names, but the hormones of the gastrointestinal tract have a lot more to do with our well- being than we probably know, including our ability to have a good bowel movement. Gastrin, Motilin, Secretin, Somatostatin and Cholecystokinin play important roles in digestion, satiety, insulin secretion and even anxiety. They interact with our brains and nervous system in complex ways and almost certainly play a role in constipation. Understanding gastrointestinal hormones can help you understand why sometimes a fatty meal will result in a bowel movement, while most fried foods contribute to the problem. Read more about them here.

Thyroid Hormone

The thyroid is a gland in our neck that produces Thyroid Hormone, a powerful molecule that regulates how our body metabolizes energy and rebuilds itself. Like other hormone levels, production of thyroid hormone decreases as we age and that has an outsized effect on the smooth muscle function of the intestines. Therefore, one of the first things physicians check in new onset constipation is thyroid hormone levels. Luckily, treating hypothyroidism with thyroid hormone usually relieves constipation too.

Go Forth With Caution

About treating constipation in older people, Sarah Szanton, a Professor of Geriatric Nursing at Johns Hopkins says:

“We mostly focus on the old fashioned ‘fluids and exercise’ and keeping tabs on diuretics and increasing fiber with things like Metamucil.”

However, treating constipation with fiber alone can be counter-productive in older adults because they don’t have enough total body water to soften up the bulk, so added fiber should be used gently.

Eliminating or reducing medication should be the first-step before other medicines are added to treat the problem. As Dr. David Juurlink told me,

We tend to just add the med(s) without considering the reversible causes – the Iron and Calcium supplements….the anticholinergics, and especially the opioids….we tend to think about addressing the problem with another medication, rather than addressing the cause by eliminating one. It’s one of those subtle prescribing cascades that tends to go overlooked.

Treating Constipation with Medication


Mechanisms of Action of Constipation Medications

Even when the diet and fluid intake are optimized and medication regimens are trimmed, some people will need medication to help them go. They won’t have any trouble finding something to try either. There aren’t more products in any other section of the pharmacy than to treat this common affliction.

Most of them target the water content of the stool in the colon by creating an atmosphere that promotes water retention so that the stool stays soft, yet has enough bulk to promote contraction of the bowel muscles. A few others provide lubrication to ease elimination.

The new kids on the block, like Linaclotide (Linzess) and Lubiprostone (Amitiza) are sophisticated remedies that target receptors in the colonic smooth muscle to both increase retention of fluid and blunt the pain signals coming from the gut muscle to promote defecation.

Dr. Annette Kwon, a gastroenterologist in San Francisco says of the new drugs, “None are game-changers.”

All of them are expensive too. Still, for people with chronic constipation who’ve tried the “tried and true” with limited success, LINZESS and AMTIZIA are worth a go.

Relistor (methylnaltrexone) is another new prescription medication for constipation is designed to counteract the constipating effects of opiates. There are others in this class as well, all formulations of the opiate antagonist, naloxone. However, for opiate-related constipation, most experts agree that the more standard form of constipation prevention and treatment such as bulk-forming agents and osmotics should be tried first.


Bulking AgentsOsmoticsLubricantsStimulantsReceptor/Channel
Blockers
MetamucilMiralaxMineral OilSennalubiprostone
CitrucelMagnesiumColaceBisacodyllinactolide (LINZESS)
Sorbitolglycerin suppsmethylnaltrexone
(RELISTOR)
Location and mechanism of action of common over-the-counter constipation medicines.
Location and mechanism of action of common over-the-counter constipation medicines. Illustration by Zina Deretsky.
Mechanism of action of new prescription medicine for the treatment of constipation.
Mechanism of action of new prescription medicine for the treatment of constipation. Illustration by Zina Deretsky.

Time to Ditch Some Old Favorites

There are some medications it’s best not to use in the older adult population. Phosphate-containing enemas (Fleets) are dangerous in older adults because they can cause electrolyte disturbances. Mineral oil or warm sterile water enemas are preferred for treating impaction.

The other drug that has fallen out of favor is docusate, also known as Colace. Its effectiveness has been called into question, therefore, exposing an older person to its side effect profile isn’t worth the risk. I heard one geriatrician sum it up this way: “Docusate creates the mush without the push.”

An excellent review of a step-wise approach to constipation in older adults can be found in this article in American Family Physician.

Desperate Measures

For some older people with chronic and intractable constipation, surgery is the only solution. Needless to say, it should be undertaken with extreme caution if at all in patients with dementia or other complex diseases like Parkinson’s. The type of surgical procedure depends on the underlying cause of constipation, but the most drastic procedure is to remove part of the colon.

The Special Case of the Hospice Patient

See this GeriPal article and video about what medicines should and should NOT be given to someone to treat constipation who is very old, frail or near the end of life or on hospice. Spoiler, it is almost all of them.

In Summary

The old standards for treating constipation, i.e. increasing dietary fiber, paying attention to hydration and keeping active still apply.

The first place to look for the cause of new or worsening constipation is the person’s medication list (both prescription and over-the-counter).

Thyroid Hormone levels should be checked in new or worsening constipation in the older adult.

Keeping a senior active and possibly adding pelvic floor therapy to their exercise regimen is a good strategy to prevent constipation.

For more complicated or stubborn constipation, an osmotic laxative (ie Miralax, Sorbitol or Magnesium containing products) is suggested.

Senna and Bisacodyl should be used only for short periods of time. Colace, aka docusate, a stool softener, has many adverse effects in older people and is not very effective to boot.

Severe cases of constipation or impaction should trigger a deeper look at causes such as hypothyroidism or an obstructive lesion.

Treatment for impaction should be with warm sterile water enema and or mineral oil by mouth. Avoid enemas that contain phosphate, such as Fleets.

Surgery is a last resort.

All interventions for constipation should be considered carefully in the very aged or dying patient; a careful balance between managing symptoms and minimizing side effects of any laxative treatment.

References

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