Improving Chronic Constipation Management for Older Adults
Through a Comprehensive Approach

Introduction

Chronic constipation in older adults can be complicated by chronic disease burdens, immobility, and/or functional limitations and often presents a number of management challenges for the clinician. Some important complicating factors include:

• Increased risk of chronic constipation associated with medications required to treat other conditions
• Patient reluctance to use laxative agents because of concerns regarding fecal urgency and incontinence
• Challenges in patient treatment compliance because of reduced mobility and cognitive impairment
• Relative scarcity of clinical trial data evaluating the treatment of chronic constipation in older patients

These challenges dictate an approach to care that combines provider and patient education, carefully considered and implemented lifestyle and/or pharmacologic modifications, and the judicious use of pharmacologic and non-pharmacologic therapies. This "comprehensive approach," which encourages the patient (and/or his or her caregiver[s]) and the clinican to commmunicate effectively and work together toward common goals, is the most likely path to an effective treatment plan and a positive outcome for the patient.

CLINICAL CASE

Mrs. Smith is an 81-year-old woman following up with her primary care provider after a short hospitalization for congestive heart failure and pneumonia. In addition to these conditions, she has a history of Type 2 diabetes, hypertension, and GERD. She has limited mobility and her appetite is fair. She complained of frequent constipation prior to her hospitalization and was placed on a regimen of increased fiber and fluids. At this visit she continues to complain of frequent constipation but says she has rejected the increased fiber and fluids citing "too much gas and bloating." She is taking the following medications:

• Furosemide: 20mg daily
• Levothyroxine: 50 micrograms daily
• Sertraline: 25mg daily
• Famotidine: 20mg at bedtime
• Insulin glargine: 20 units at bedtime

Elements of a Comprehensive Management Approach

Because there are many factors that predispose older adults to chronic constipation, a comprehensive approach addressing each individual’s specific symptoms and goals is often the most effective management strategy. This approach should take into consideration each patient’s specific characteristics (eg, physical limitations, comorbid or complicating conditions, medication regimens) and any other factors or secondary etiologies that can potentially contribute to constipation in this group. The care setting should also be considered (eg, Is the patient in a community or institutional setting? Are they independent or do they rely on a caregiver?). In a comprehensive approach to management, lifestyle and diet changes as well as therapeutic options should all be considered when designing a care plan. Regular monitoring of the efficacy and tolerability of any regimen is also essential. The ultimate goal is to return bowel function to a level that is acceptable to the patient and/or caregiver, preventing negative consequences of constipation and adverse effects of medications, and leading to the best possible quality of life.

Evaluation

When investigating a patient’s complaint about constipation, the clinician should first ask the patient to clarify what he or she means by constipation (there is often a significant disconnect between how patients and clinicians define the condition). For example, many patients equate constipation with the passing of hard stools or straining to have a bowel movement, while most clinicians understand it to mean a decrease in stool frequency. It is important to understand the problem as the patient sees it. The clinician should determine the patient’s perception of a “normal” bowel movement by asking the patient about bowel movement frequency, level of straining, and stool consistency. Next, the clinician should conduct a thorough physical examination and obtain a detailed history. The physical exam should include a rectal examination to rule out an obstruction and to evaluate pelvic floor movement and anal sphincter competency. The presence of blood in the stool should be considered a “red flag” and should be evaluated further. In addition, the clinician may consider ordering laboratory tests such as a complete blood count, thyroid-stimulating hormone, serum glucose, creatinine, and electrolytes to further evaluate possible secondary causes of the constipation.