Table 2:

Stepwise approach to the management of constipation in older people

StepDetails
1. Identify the predominant symptom*Frequency, straining, incomplete evacuation
2. Identify possible secondary causes of constipation*

  • Medications (e.g., opioids, nondihydropyridine calcium-channel blockers, iron supplements and antidiarrheal agents)

  • Disease states (e.g., colon cancer, stroke and Parkinson disease)

  • Secondary causes of constipation are treated in the same manner as primary constipation

  • If alarm symptoms or signs are present (see Box 5), local or national guidelines for colon cancer screening should be followed

3. Exclude fecal impaction*

  • In a person who is bedbound or has severe dementia, an abdominal radiograph or a digital rectal examination‡ can be used to diagnose impaction

  • Manual disimpaction is often necessary to treat fecal impaction

4. Optimize behavioural factors†

  • The seated position, with knees at or above the level of hips, is advised

  • If the person has moderate to severe cognitive impairment, allow adequate time to toilet after the morning meal, to take advantage of the gastrocolic reflex

5. Trial of dietary modifications (2–4 wk)

  • Gradually increase fibre intake to 20–30 g/d from dietary (fruits, vegetables, legumes) or supplemental sources (psyllium, methylcellulose, calcium polycarbophil)

  • Not advised in a person who is immobile or bedbound, to avoid impaction or obstruction

6. Trial of a previously preferred laxative agent (2–4 wk)

  • The patient may prefer one agent over another from past experience

7. Trial of a laxative agent supported by evidence from RCTs involving older people (2–4 wk)

  • Polyethylene glycol 17–34 g/d

  • Lactulose 15–30 mL daily to twice daily

8. Trial of another laxative agent or a combination of agents from different classes (2–4 wk)

  • Magnesium hydroxide 15–30 mg daily to twice daily

  • Docusate calcium 240 mg twice daily§

  • Bisacodyl 5–10 mg/d orally or rectally

  • Sennoside, up to 68.8 g/d in divided doses

  • Enema or suppository

9. Referral to a gastroenterologist or geriatrician

  • Note: RCT = randomized controlled trial.

  • ↵* Steps 1 through 3 should be undertaken concurrently.

  • ↵† Step 4 should be undertaken concurrently with each of steps 5 through 8.

  • ↵‡ A negative digital rectal examination does not exclude the possibility of impaction more proximally. If the suspicion is high, an abdominal radiograph should be obtained.

  • ↵§ Docusate calcium and docusate sodium are generally considered to be mild laxatives.