Constipation in Long-Term Care

Author Affiliations: Dr. Tariq is former Associate Professor of Internal Medicine and Geriatrics, Medical Director of the Acute Care of Elderly (ACE Unit), Division of Geriatric Medicine, Saint Louis University; and currently a Fellow, Division of Gastroenterology & Hepatology, St. Louis University School of Medicine, MO.

The intestine tends to become sluggish with age.

—Hippocrates

No organ in the body is so misunderstood, so slandered and maltreated as the colon. —Sir Arthur Hurst, 1935

Constipation is reported in over 33 million adults, which makes it one of the most common problems in the United States. It accounts for 2.5 million physician visits and 92,000 hospitalizations each year. Constipation is seen in 25% of older persons. The term constipation can be very confusing. While patients describe constipation as passing hard stool or straining to have a bowel movement, physicians, on the other hand, describe constipation as fewer than three bowel movements per week. Thus, both patient and physician are likely to be talking about two different sets of symptoms. For this very reason, there is little correlation between self-reported constipation and number of bowel movements in epidemiologic surveys. The diagnostic criteria for constipation was created by a consensus conference in Rome, Italy, with the most recent updated information known as the Rome III Diagnostic Criteria.

Epidemiology

Frailty in older persons is very common and is associated with immobility, poor intake, and dehydration.^1,2 It is, therefore, not surprising that constipation has been reported in 45% of frail elderly persons.³ The use of laxatives in the nursing home (NH) is reported in 50% to 65% of residents.^4-8 Half of these older persons took a daily laxative, yet only 62% of them actually met the criteria for constipation. Hence, there was minimal concordance between nurses and the NH residents for whether they were constipated. The use of laxatives is more common in those who are immobile, had Parkinson’s disease or diabetes mellitus, or took iron supplements, calcium-channel antagonists, or antidepressants with anticholinergic activity.⁴ In a study of 21,012 persons using the Minimum Data Set in NHs, the prevalence of constipation was 12.5%. The 3-month incidence was 7%. Some of the risk factors associated with constipation were race, decreased fluid intake, pneumonia, Parkinson’s disease, and the presence of allergies. Congestive heart failure and the use of a feeding tube were two factors identified as having a protective effect.⁹

Economic Impact and Quality of Life

The National Health Service in the United Kingdom reported annual prescription laxative cost at 43 million pounds,¹⁰ while the average cost of treating constipation in the United States in NHs is $2253 per resident per year.¹¹ Constipation in older persons is associated with a decline in quality of life, a decrease in functional ability, increased pain, dysuria, fecal incontinence, stercoral ulcers, and fecaloma.^12-17 One of the major problems associated with constipation is the development of fecal impaction leading to intestinal obstruction, bowel perforation, and even death.^18,19 Delirium is a common reason for hospital admission,²⁰ and constipation is a common cause of delirium.²¹ Constipation is also reported to be associated with physical and verbal aggression.²² The cost of treating constipation does not include the adverse outcomes resulting from not treating constipation appropriately.

Causes of Constipation

The causes of constipation can be divided into mechanical causes, metabolic causes, neurologic diseases, psychiatric diseases, and medications. Mechanical obstruction is caused by colon cancer, strictures, and anal stenosis. Diabetes mellitus is associated with autonomic neuropathy and altered colonic transit time. Hypercalcemia and hypomagnesia slow intestinal transit. Hypothyroidism commonly presents with constipation. Amyloidosis and scleroderma are rare causes of constipation. Cancer and terminal illness commonly are associated with constipation.²³ Parkinson’s disease, stroke, dementia, and depression are all associated with constipation.

Older persons tend to be taking large numbers of medicines, a number of which are related to constipation.²⁴ The best recognized of these are opiates and iron and calcium supplements; with the increased awareness of the dangers of osteoporosis in older persons, there is increasing use of calcium supplements.²⁵ Antidepressants with anticholinergic activity, which include both tricyclics and selective serotonin reuptake inhibitors (eg, paroxetine), lead to constipation, as do antipsychotics and antihistamines. Diuretics result in dehydration. Antiparkinsonian agents, such as L-dopa and bromocriptine, slow intestinal transit. Perhaps the major unrecognized cause of constipation in older persons are calcium-channel antagonists.

Evaluation of Constipation

When evaluating a patient with constipation it is important to look for red flag signs such as acute onset of constipation, weight loss, rectal bleeding, iron deficiency anemia, and family history of colon cancer. If any of the red flag signs are present, patients need urgent evaluation and referral to a gastroenterologist for colonoscopy. A careful general physical examination is required to explore evidence for possible systemic disorder, excluding fecal impaction and assessment of anorectal function. Inspection and digital rectal examination of the anal sphincter at rest, with squeezing, and with straining, are important in determining sphincter integrity, perineal descent, and rectal masses.

Basic tests for an individual with chronic constipation include a complete blood count, serum blood urea nitrogen, serum creatinine, serum sodium, serum calcium, serum magnesium, a thyroid-stimulating hormone level, and stool for occult blood. Sigmoidoscopy or colonoscopy should be considered for any person with prolonged chronic constipation. An abdominal x-ray is also important to exclude fecal impaction. Some of the additional tests that can be helpful include colon transit measurements, colonic manometry, anorectal manometry, balloon expulsion testing, and defecography.^26,27

Management of Constipation:

The basic management of constipation includes:

• Adequate fluid intake

• Bulking agents

• Toileting

• Exercise

Fiber is generally a safe, inexpensive, first-line approach, which improves stool consistency and accelerates colon transit time. Increase in fluid intake may be helpful in persons with dehydration but rarely improves symptoms of constipation in the individual with chronic constipation.²⁸ Similarly, increase in physical activity is also recommended without any clear evidence.^29,30 Studies with psyllium generally show improvement in stool form and frequency.^31,32 Stool softeners in the treatment of chronic constipation have not been shown to be superior to psyllium.^33,34 Osmotic laxatives include polyethylene glycol (PEG), lactulose, sorbitol, magnesium salts, and saline salts. Saline and magnesium salts should not be used in persons with renal or liver disease or heart failure.

One study showed that lactulose improved stool frequency, reduced need for enemas, and reduced fecal impaction over a 12-week period.³⁵ In a randomized controlled trial of lactulose and sorbitol, there was no difference in the laxative effect or strong preference of one laxative over another in the study population.³⁶ Abdominal symptoms were similar between the two groups except for greater complaints of nausea in lactulose group. The cost of sorbitol is generally less and makes it a preferred agent for many persons.³⁶ Stimulant laxatives, when used in recommended doses and for short duration, are less likely to harm the colon.

However, stimulant laxatives do result in electrolyte imbalance or abdominal pain in some persons. Combination laxatives, including a senna-containing concentrate or a stool softener and fiber, resulted in improved bowel evacuation and prevention of fecal impaction in NH residents.³⁷ The role of an enema in the treatment of constipation is limited to acute situations. Any enema must be used with caution owing to the risk of colonic perforation. Soap enemas should not be used. Small-volume tap water enemas may be helpful in emptying the rectum; large-volume can also be used but can result in hyponatremia. Enemas containing phosphate are described to cause hyperphosphatemia, especially in persons with renal insufficiency.

Lubiprostone is the latest drug approved for the treatment of chronic idiopathic constipation by the Food and Drug Administration (FDA). It activates the specific chloride channels (CIC-2) in the lining of the small intestine after oral administration, thereby increasing intestinal fluids. Lubiprostone 24 mcg twice daily results 57% of the time in spontaneous bowel movement within 24 hours as compared to placebo 37%. The major side effects of lubiprostone are nausea, diarrhea, headache, abdominal pain, flatulence, sinusitis, and vomiting. In clinical trials, lubiprostone 24 mcg is used, administered twice daily orally. Lubiprostone should be used when the currently available agents are not effective in the treatment of constipation.³⁸

Two studies showed the long-term effects of PEG in the treatment of chronic constipation, evaluating the safety and efficacy at 6 months and 1 year. Although it is not approved by the FDA, in clinical practice it is a reasonable option for selected patients.^39,40 Refractory constipation is rare in older adults. Although data show that younger patients with refractory constipation and slow transit time may benefit from subtotal colectomy and ileorectostomy, this is rarely required, as most patients respond to laxatives.

Summary of Nursing Home Protocol

Any older person who complains of constipation should have depression considered as a diagnosis and should increase fluid and fiber (if mobile), toilet after meals, and increase exercise. In all persons with chronic constipation, any offending agent that could cause constipation should be stopped if possible. Thyroid-stimulating hormone, calcium magnesium, and stool checks for blood should be done. An osmotic laxative such as sorbitol, lactulose, or PEG should be used in selected individuals. If the person has weight loss, rectal bleeding, or iron deficiency anemia, a colonoscopy should be obtained. If there is no response to an osmotic laxative, lubiprostone 24 mcg twice daily should be used. Treatment should be continued for 4 weeks and then withdrawn. If there is a relapse, one should try the osmotic laxative, and/or short-term use of stimulant and/or an enema if the individual desires. If there is no response, the individual should be restarted on lubiprostone. If problems with constipation continue, a referral to a gastroenterologist is mandatory.

The author has received speaker honoraria from Sucampo Pharmaceuticals.