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Chronic Constipation: Considerations for Primary and Geriatric Care Practitioners

7/29/2011

It is a general rule that intestines become sluggish with age.
-Hippocrates

Chronic constipation accounts for more than 2.5 million physician visits a year, and ranks among the most frequent reasons for self-medication, particularly in the elderly.(1) Constipation is a troubling condition for older adults, often resulting in anxiety and diminished quality of life. It can be a challenge to treat in community dwelling adults for a variety of reasons, including its varied etiologies, symptoms, and treatment options. Also complicating treatment is the fact that patients and practitioners often have distinct, sometimes contradictory, definitions of constipation. Most patients consider constipation to be passing of hard stools or straining to have a bowel movement. Most clinicians, on the other hand, take constipation to mean a decrease in frequency of stools. Thus, patients and practitioners may be talking about entirely different sets of symptoms, with entirely different root causes and options for treatment.

Bowel habits vary widely, and perceptions of what constitutes normal function are diverse; there is little correlation between self-reported constipation and number of bowel movements in epidemiologic surveys.(1-4) In a survey of community-dwelling persons aged 65-93 years, 30% of men and 29% of women described themselves as constipated at least once a month. However, only 3% of men and 2% of women reported that their average stool frequency was less than three per week, highlighting the variety of definitions of constipation among older persons.(3)

Consensus criteria help clinicians to identify those with functional etiologies (see below).

Rome Diagnostic Criteria* for Chronic Constipation (5)

1. Must include two or more of the following:
   
    a. Straining during at least 25% of defecations
    b.
Lumpy or hard stools in at least 25% of defecations
    c.
Sensation of incomplete evacuation for at least 25% of defecations
    d.
Sensation of anorectal obstruction/blockage for at least 25% of defecations
   
e. Manual maneuvers to facilitate at least 25% of defecations
   
f. Fewer that three defecations per week
 
2. Loose stools are rarely present without the use of laxatives
3. There are insufficient criteria for irritable bowel syndrome

*Criteria should be fulfilled for the last 3 months with symptom onset at least 6 months prior to the diagnosis.
Note: This definition was proposed for the purpose of standardizing clinical trials rather than for clinical practice. There is no generally accepted definition of constipation in clinical practice.

The primary care clinician or geriatrician must be able to detect any underlying pathology and provide symptomatic relief and reassurance to those with functional etiologies. It is also imperative that the clinician be knowledgeable about the actions and adverse effects of all therapeutic options for constipation. Following are some important items for primary and geriatric care practitioners to consider when visiting with their patients.

  • Discussing constipation can be embarrassing for many people; many patients choose to self medicate and never bring it up with their practitioners. Encourage patients to discuss anything that is troubling them.
  • Consider patient priorities as well as any pressing medical issues at every visit. When patients come in with disorders like hypertension, diabetes, and COPD, the amount of time spent on those conditions does not always allow sufficient time to address issues that the physician might consider of "secondary importance," like constipation. When these conditions are prioritized from a traditional point of view, everything comes before constipation. But when the patient is asked what is most troubling to them on a daily basis, they may point to the constipation.
  • Thoroughly evaluate any complaint of constipation; inadequate evaluation can lead to overly aggressive or inappropriate therapy for self-reported constipation.
  • Evaluation of any complaint of constipation should begin with a definition of the size, character, and frequency of bowel movements, as well as a determination of how long this has been a problem for the patient. Acute constipation is more often associated with organic disease than is a longstanding problem; symptoms of a chronic problem wax and wane for months or years and are often compounded by habitual laxative use.
  • Inquire about constipation at every visit if the patient is on any medication(s) that warn of constipation as a possible adverse effect. Try to anticipate and mitigate this effect in advance when prescribing such medications.
  • Be aware of alarm signs associated with chronic constipation that may indicate a larger problem or may require referral to a gastroenterologist, such as unintentional weight loss, rectal bleeding, decreased hemoglobin, increased white blood cell count, etc.

Editorial by:
David R. Thomas, MD, FACP, AGSF, GSAF, CMD
Professor of Internal Medicine
Division of Geriatrics/Gerontology
St. Louis University
St. Louis, MO

References
(1) Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004;99(4):750-759.
(2) Harari D, Gurwitz JH, Minaker KL. Constipation in the elderly. J Am Geriatr Soc. 1993;41:1130-1140.
(3) Sonnenberg A, Koch TR. Epidemiology of constipation in the US. Dis Colon Rectum. 1989;32:1-8.
(4) Whitehead WE, Drinkwater D, Cheskin LJ, et al. Constipation in the elderly living  at home: Definition, prevalence and relationship to lifestyle and health status. J Am Geriatr Soc. 1989;37(5):423-429.
(5) Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006;130:480-491.

 

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The E-IMPACCT (Elderly IMProvements & Advances in Chronic Constipation Treatment) educational initiative is sponsored through a collaboration of ASCP, AKH Inc., and Medical Communications Media, Inc.

Supported by an educational grant from Sucampo Pharmaceuticals, Inc. and Takeda Pharmaceuticals North America, Inc.

 

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