elders, it commonly relates to medical comorbidities and increased defecatory difficulty.
Constipation is a frequently reported bowel symptom in the elderly, with a considerable impact on quality of life and health expenses. The consequences of constipation in elders make it a significant health problem. Chronic constipation impacts functioning in daily living, and elders with these complaints rate their health lower than people without gastrointestinal symptoms.25 These findings were not confounded by the presence of other chronic illnesses or medication use. Health‐related quality of life is reduced in patients with chronic constipation.26 The presence of constipation has also been hypothesized to increase urinary tract symptoms, with the treatment of constipation resulting in reduced urinary frequency, urgency, and dysuria.27 Increased weekly bowel movements due to laxative use also led to patients reporting better sexual function and improved mood and depression.12
Constipation is also associated with bowel incontinence, and treatment of constipation reduces incontinence episodes.28,29 Faecal impaction is a common problem in the elderly; it is estimated that 7% of institutionalized elderly have impacted faeces on rectal examination.30 The first indication of impaction may be overflow diarrhoea and rectal incontinence; if a rectal examination is not performed, there is a risk of impaction being misdiagnosed and treated with antidiarrheal agents.31 Immobile or cognitively impaired individuals with constipation face an increased risk of faecal impaction, stercoral ulceration, and colon perforation.28,32 Constipation reduces quality of life and diminishes self‐perceived health in community‐dwelling elders.25 More effective strategies are needed for reducing the burden of illness and costs associated with constipation.
Aetiology of constipation
Of the multiple causes of constipation in older people, most relate to medication use or coexisting medical illness (Tables 20.2 and 20.3). The most commonly implicated medications are opiates, calcium channel blockers, non‐steroidal anti‐inflammatory drugs (NSAIDs), and medications with anticholinergic effects. Although immobility and reduced fluid and fibre intake are often implicated in the development of constipation, there is little evidence to support this folklore. Increased physical activity does not reliably improve constipation.33 Reduced caloric intake correlates more closely with constipation in elders than do differences in fibre intake.22 Likewise, reduced fluid intake showed no significant association with chronic constipation. Increased psychological distress correlates with reports of constipation by elders, although the mechanism for this association remains unknown.15,22
Table 20.2 Medications commonly associated with constipation.
| Anticonvulsants: gabapentin, phenytoin, pregabalin |
| Antidepressants: SSRIs (selective serotonin reuptake inhibitors), TCAs (tricyclic antidepressants) |
| Antihistamines: hydroxyzine Anticholinergic drugs: antipsychotics, oxybutynin |
| Parkinson’s drugs: bromocriptine, amantadine, pramipexole, levodopa |
| Antihypertensives: calcium channel blockers, beta blockers, diuretics |
| Cation agents: antacids (calcium and aluminium), ferrous gluconate, ferrous sulphate |
| Analgesia: non‐steroidal anti‐inflammatory drugs, opiates |
| Antiemetics: ondansetron, prochlorperazine |
Table 20.3 Medical conditions commonly associated with constipation.
| Mechanical obstruction |
|---|
| Colonic neoplasia |
| Colonic stricture (intrinsic or extrinsic) |
| Anal stenosis |
| Metabolic |
| Amyloidosis |
| Chronic kidney disease |
| Diabetes mellitus |
| Electrolyte disturbance (hypercalcaemia, hypomagnesaemia) |
| Hyperparathyroidism |
| Hypothyroidism |
| Neurological |
| Autonomic neuropathy |
| Cerebrovascular accident |
| Dementia |
| Multiple sclerosis |
| Parkinson’s disease |
| Rheumatological |
| Polymyositis |
| Scleroderma |
| Psychiatric |
| Depression |
Clinical approach
History
The evaluation of constipation begins with understanding the patient’s perspective on their altered bowel function and the time course of constipation development. The acute or subacute onset of constipation requires a more aggressive diagnostic approach to exclude structural lesions, including colon neoplasia, stricture, and volvulus. Likewise, weight loss, rectal bleeding, history of inflammatory bowel disease, family history of colorectal neoplasia, or iron deficiency anaemia requires a structural examination to exclude cancer or other aetiology. Additional helpful details in the patient history include the onset of constipation, frequency of bowel movements, sensation of incomplete evacuation, straining to defecate, consistency of the stool, associated abdominal pain, the need for digitation, perineal splinting or unusual postures for defecation to occur, episodes of bowel incontinence, prior abdominal or pelvic surgery, prior abdominal or pelvic radiation therapy, and prior pregnancies. It is also necessary to review current medications and supplements, current and previously used laxatives with their degree of effectiveness, use of enemas, and use of complementary therapies to treat constipation (e.g. high colonics, herbs, teas). Dietary history includes a general survey of calories ingested, fibre intake, and restricted foods. Given the consistent association of constipation with depression and anxiety, a brief psychological assessment is also warranted. In general, the ideal, evidence‐based approach to the diagnostic evaluation of constipation remains to be identified.
Physical examination
The physical examination is directed to identifying underlying medical causes for constipation, excluding faecal impaction, and providing a preliminary assessment of anorectal function. A faecal mass may be palpable on abdominal palpation.
Rectal examination includes inspection of the perineum at rest and with strain. Normal perineal descent during strain is 1–4 cm. No perineal descent suggests a failure of the pelvic floor to relax and allow the passage of stool. Excessive perineal descent, sometimes characterized as a ballooning of the perineum, indicates excess laxity to the pelvic floor musculature and dyssynergic defecation. This finding is most common in multiparous women. The strength of the anal sphincter muscle at rest and with