A thorough patient history is critical for a diagnosis of chronic constipation. The type and duration of symptoms can help the clinician determine whether this is an occasional challenge or a more severe chronic condition, as well as whether the patient is suffering from primary or secondary constipation.

A medication review is essential. The clinician should assess the patient’s medication profile to look for highly constipating medications such as verapamil, diltiazem, and ferrous sulfate, and, when possible, recommend either a dose reduction or alternative therapies. The clinician should also look for strong anticholinergic medications that are associated with chronic constipation and, if appropriate, recommend alternatives. Finally, the clinician should inquire about what the patient has done on his or her own to manage the condition, whether those measures have been effective, whether the patient has experienced any adverse effects, and how they would describe their overall satisfaction. Ideally, this information would be documented in a standard fashion to improve the clinician’s ability to observe trends and quickly scan for the effectiveness of any regimen moving forward. In the end, the evaluation should lead to a discussion of patient-specific goals, which the clinician will use to establish a new care plan for the patient.

Whether the patient is a resident of a skilled nursing or assisted living facility or from the community, the first step in treating chronic constipation is determining its cause. For cases in which chronic constipation can be classified as secondary constipation, eliminating or switching a problematic medication when possible or addressing the underlying condition may relieve symptoms. For cases in which no secondary causes can be identified, treatment directed at the primary symptoms should be tried initially. These treatment options range from nonpharmacologic approaches to over-the-counter and prescription medications and, in very rare cases, surgery.

CLINICAL CASE (CONT’D)

Mrs. Smith 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

Non-Pharmacologic Treatment Options

A variety of non-pharmacologic options are available in the management of constipation. Lifestyle measures such as increasing fluids, increasing dietary fiber intake, and initiating an exercise or bowel habit regimen are often recommended as first line therapy in patients with no known secondary causes of constipation, but studies evaluating the effects of these measures have yielded mixed results.²,³ In addition, many patients with chronic constipation will have attempted some version of these practices prior to coming to their clinicians for help.

Although a diet low in fiber can lead to constipation, a high-fiber diet will not necessarily benefit all patients, especially patients with an underlying motility disorder. The American Gastroenterological Association does however recommend a gradual increase in fiber intake in either dietary or supplement form as a first-line approach to management of chronic constipation. Fiber should be introduced gradually to avoid significant bloating and cramps, and patients should be advised that they may experience an increase in gaseousness.⁴

Exercise has not been shown to be an effective stand-alone therapy for chronic constipation, but exercise may help to improve bowel function as part of a broader rehabilitation program.

Other non-pharmacologic therapies include biofeedback therapy, behavior therapy and electrical stimulation; however, these therapies are generally reserved for patients with outlet obstruction and are typically performed at highly specialized centers. The use of biofeedback therapy to teach patients relaxation of the pelvic floor has been shown to be an effective treatment for pelvic floor dysfunction, which is characterized by abnormal contraction or failure to relax the pelvic floor muscles during attempts to defecate. One systematic review of biofeedback studies in patients with pelvic floor dysfunction found an overall success rate of 67%.⁵ Because biofeedback requires good interaction between the therapist and the patient, however, altered mental status or other barriers to communication could reduce the efficacy of this intervention in older patients.

Surgery is rarely used as a therapy for chronic constipation, and very rarely warranted in elderly patients. Patients most likely to benefit from surgery are those with persistent and intractable slow-transit constipation after all other treatment options have been exhausted.⁶

CLINICAL CASE

Mrs. Smith rejected the increased fiber and fluids placed into her diet. The clinician attributes her chronic constipation to slow colonic transit time and reviewed additonial options with her. She opted for a daily regimen of docusate sodium. She returns several weeks later claiming that it did not relieve her symptoms.