Constipation is one of the most frequent GIT disorders encountered among older adults in clinical practice. Up to 50% of elderly experiencing constipation at some point in their lives. Elderly women are having 2–3 times more constipation than men. Approximately, 30% of older adults are regular nonprescription laxative users, such as stimulant and bulking laxatives.

1. in
Elderly People
A Case-Based Lecture
Ahmed Khairi Altemimi
Consultant Family Physician

2. 1. Define constipation and describe its prevalence among
elderly populations.
2. Identify the risk factors associated with chronic
constipation in elderly people.
3. Recognize red flags that may indicate a serious
medical condition.
4. Discuss the diagnostic approach for chronic
constipation in elderly patients.
5. Explain the potential complications of chronic
constipation in elderly individuals.
6. Describe the different treatment strategies for chronic
constipation in elderly patients.
7. Discuss methods for preventing chronic constipation in
elderly populations.

3.  It is one of the most frequent GIT disorders
encountered among older adults in clinical
practice.
 Up to 50% of elderly experiencing
constipation at some point in their lives.
 Elderly women are having 2–3 times more
constipation than men.
 Approximately, 30% of older adults are
regular nonprescription laxative users, such
as stimulant and bulking laxatives.

4.  Miss Layla is an 80-year-old woman who has been experiencing
chronic constipation for the past few months.
 She reports having bowel movements once every 3-4 days, and
the bowel movement is often hard and difficult to pass. She also
reports feeling bloated and discomfort.
 Miss Layla has a history of hypertension, osteoporosis, and a
previous stroke. She takes several medications, including a
diuretic, a calcium supplement.
 As a geriatrician, what would be your approach to managing
Miss Layla's chronic constipation?

5.  The definition of constipation in the elderly may involve
infrequent defecation, difficulty in passing stool, or
Sensation of incomplete evacuation of stool.
 Often, there is a significant discrepancy between the
physician’s and the patient's definition of constipation.
 Physicians tend to define constipation as fewer than 3
bowel movements per week.
 For chronic constipation to be diagnosed, symptoms
should be present for at least 12 weeks.
 The elder, on the other hand, often define constipation as
straining to defecate or sensation of incomplete
evacuation.
 So, always ask the elder what he means by constipation.

6. The Rome IV criteria define chronic constipation as symptoms that have
persisted for the past 3 months with an onset at least 6 months prior to
diagnosis, with the following 3 criteria being met:
 Must include 2 or more of the following:
 Hard or lumpy stool in ≥25% of defecations.
 Straining during ≥25% defecations.
 Sensation of incomplete evacuation for at least 25% of defecations.
 Sensation of anorectal obstruction or blockage for ≥25%of defecations.
 Manual maneuvers to facilitate ≥25% of defecations.
 Fewer than 3 defecations per week.
 Loose stools are rarely present without use of laxatives.
 Insufficient criteria for irritable bowel syndrome.

7.  Aging factor, which may lead to slower colonic transit and pelvic floor dysfunction.
 Poor diet (e.g., a diet low in fiber and fluids).
 Lack of physical activity (e.g., sedentary lifestyle).
 Medications (prescription and nonprescription drugs).
 Neurologic disorders (e.g., Parkinson disease, MS, spinal cord injury, CVA, dementia,
diabetic autonomic neuropathy).
 Endocrine disorders (e.g., hypothyroidism, hyperparathyroidism, DM).
 Metabolic disorders (e.g., hypokalemia, hyperkalemia, hypercalcemia).
 Structural disorders (e.g., colonic obstruction, colorectal cancer, rectal prolapse).
 Psychiatric disorders (e.g., depression, anxiety, and cognitive impairment).

8.  Antacids (e.g., aluminum hydroxide
and calcium carbonate).
 Anticholinergic agents (e.g.,
trihexyphenidyl, diphenhydramine,
oxybutynin).
 Antidepressants (e.g., tricyclic
antidepressants).
 Antihypertensive (e.g., diuretics,
Verapamil, CCBs).
 Opioid pain killers.
 Sympathomimetics (e.g.,
pseudoephedrine).
 Antipsychotics (e.g., haloperidol,
risperidone, and olanzapine).
 Metals (e.g., bismuth and Iron
supplements).

9.  Blood in the stool.
 Severe abdominal pain or
cramping.
 Nausea and/or vomiting.
 Family history of colon cancer or
inflammatory bowel disease.
 Anemia.
 Positive fecal occult blood test.
 Unexplained weight loss (≥10
pounds).
 Constipation that is refractory to
treatment.

10. 1. Medical history: A detailed history should be
obtained, including the duration and nature of the
constipation, associated symptoms, medication
history, diet, lifestyle, and past medical history.
2. Physical examination: to assess for any signs of
structural abnormalities, such as an abdominal mass,
rectal prolapse, hemorrhoids, or anal fissures.
 Digital Rectal Examination to assess the tone
and strength of the anal sphincter, as well as to
detect any masses or fecal impaction.

11. 3. Laboratory tests: Blood and stool tests may
be done to evaluate for any underlying
conditions that may be contributing to the
constipation, such as CBC, ESR, TFT, S. Ca.
4. Imaging studies: Depending on the findings
of the physical examination and the laboratory
tests, imaging studies such as X-rays, CT scans,
or MRI scans may be recommended to assess for
any structural abnormalities in the colon or
rectum.

12. 5. Functional testing: These may be
recommended to evaluate for any
underlying problems with bowel motility,
such as colonic transit studies, anorectal
manometry, or defecography.
6. Colonoscopy: This may be
recommended in some cases, such as
rectal bleeding, weight loss, or a family
history of colon cancer.

13.  Fecal impaction.
 Anal fissures, Hemorrhoids, and
Rectal prolapse.
 Diverticular disease.
 Megacolon.
 Volvulus, especially of the sigmoid
colon.
 Fecal incontinence.
 UTI and Urinary incontinence.
 Malnutrition.
 Decreased quality of life.

14.  There are several treatment strategies for
management, including Pharmacologic and
Nonpharmacologic treatment and Surgical
interventions.
 Management should be individualized based
on the patient’s presentation, severity of
symptoms, and comorbidities.
 Treatment should also aim to improve quality
of life, prevent complications, and minimize
adverse effects from medications.

15.  The treatment of constipation is
primarily non-pharmacologic.
 It involves inducing the patient to
adopt a healthier lifestyle, such as
Dietary changes, Regular exercise,
and Bowel training.
 It's important to note that these
non-pharmacologic treatments
may take time to have an effect.

16.  Increasing fiber intake (20 to 25
g/day), and increase consumption
of liquids, particularly water (2
L/day.
 Foods high in fiber include fruits,
vegetables, whole grains, and
beans.
 Avoid foods that are low in fiber,
such as processed foods, meats,
and dairy products.

17.  Exercise can help stimulate
bowel movements.
 Even light activity such as
walking or stretching can be
beneficial.
 Bedridden patients are at great
risk of constipation and often
respond poorly to treatment.
 Establishing a regular time for
bowel movements can help
regulate bowel function and
reduce constipation.
 This includes taking time to sit
on the toilet for a few minutes
each day, preferably after
meals.

18.  It is strengthening the muscles of the pelvic
floor to improve bowel control and reduce
constipation.
 Biofeedback is a mind-body technique that
involves using visual or auditory feedback to
gain control over involuntary bodily functions.
 It involves using sensors to monitor muscle
activity in the pelvic floor and provide feedback
to help individuals learn how to relax and
contract these muscles.

19. 1.Bulk-forming laxatives.
2.Stool softeners.
3.Osmotic laxatives.
4.Stimulant laxatives.
5.Prokinetic agents.
6.Enemas.

20.  Bulking agents are first-line agents for constipation,
and the safest laxatives.
 These are fiber-containing preparations which absorbs
water and helps to increase the stool mass and soften
the stool consistency.
 Adequate hydration with bulking agents is necessary
for the desired outcome and to avoid dehydration,
worsening of constipation, or impaction.
 Bulking agents may Interfere with the absorption of
other drugs and should be taken 1 hour before or 2
hours after other medications.
 Bulking agents should also be increased slowly over
weekly periods to avoid side effects, such as
abdominal bloating and discomfort.
 These may include Methylcellulose (Citrucel), Psyllium
(Metamucil), and Polycarbophil (FiberCon).

21.  Stool softeners work by increasing the amount of
water in bowel motion.
 These are often used when bulking agents do
not work or are not preferred.
 Stool softeners can also be used in combination
with bulking agents.
 These include Mineral Oil and docusate salts,
such as docusate sodium (Colace) and docusate
calcium (Surfak).
 Aspiration pneumonia is known risks of using
Mineral Oil in older adults.
 Mineral Oil is generally not recommended
because safer, more effective agents are
available.

22.  These work by drawing water into the
intestines by osmotic activity.
 They include Magnesium hydroxide (Milk
of Magnesia), Polyethylene glycol
(Miralax), Lactulose (Duphalac), and
Sorbitol 70%.
 Polyethylene glycol has the best evidence
of use and may be better than lactulose.
 Osmotic laxatives are useful when first-
line bulking agents and/or stool
softeners are not effective.

23.  Stimulants increase intestinal motility by
increasing peristaltic contractions.
 They also decrease water absorption from
the lumen.
 Examples include Senna (Senokot) and
Bisacodyl (Dulcolax).
 They cause unfavorable side effects:
abdominal discomfort, cramping,
diarrhea, and electrolyte imbalance.
 Chronic stimulant laxatives use has been
associated with Melanosis Coli.

24.  These medications enhance GIT motility
by increasing intestinal contractions.
 Examples include Metoclopramide
(Reglan), Tegaserod (Zelnorm), and
Prucalopride (Resolor).
 These drugs are no longer used to treat
constipation in older adults.
 The use of Tegaserod and Prucalopride
has cardiovascular adverse effects.
 Metoclopramide should be avoided
because of the side-effect profile in
older adults.

25.  These work by stimulating the bowel
movement.
 Enemas can be uncomfortable and may cause
side effects such as abdominal cramping and
diarrhea.
 Enemas can also be difficult to administer,
particularly for elderly individuals.
 Enemas may recommended in certain
situations, such as when other treatments
have been ineffective or when constipation is
severe and causing fecal impaction.
 Examples: Saline enemas, Mineral oil enemas,
and Phosphate enemas.

26.  GIT problems (bloating,
cramping, and diarrhea)
 Dehydration.
 Electrolyte imbalances.
 Malabsorption.
 Dependence.

27. Surgical interventions are reserved
for refractory cases to restore
quality of life.
It should be considered only after
careful evaluation by a
gastroenterologist.
Examples: Colectomy and
Ileorectal anastomosis.

28.  Monitoring is an essential
components of managing chronic
constipation in elderly patients.
 In follow-up visits, we should inquire
about changes in bowel habits and
assess for any new or worsening
symptoms.
 Follow-up is also important to assess
the effectiveness of the treatment
plan and adjust it as necessary.
 We should also monitor for medication-
related adverse effects that may occur
with long-term use of certain laxatives.
 Close monitoring is critical to identify
and manage complications promptly.
 The frequency of follow-up visits will
depend on the severity of the
constipation and the patient's response
to treatment.
 Patients should also be encouraged to
report any new symptoms or concerns
between follow-up visits.

29.  We should focus on early identification of risk factors and
early intervention to prevent the onset of constipation.
 Regular exercise, adequate fluid intake, and a high-fiber diet
are key components of prevention.
 We should be aware of the medications that can cause
constipation and attempt to minimize their use.
 Identify and treat underlying medical conditions that may
contribute to constipation.

30.  Miss Layla is an 80-year-old woman who has been experiencing
chronic constipation for the past few months.
 She reports having bowel movements once every 3-4 days, and
the bowel movement is often hard and difficult to pass. She also
reports feeling bloated and discomfort.
 Miss Layla has a history of hypertension, osteoporosis, and a
previous stroke. She takes several medications, including a
diuretic, a calcium supplement.
 As a geriatrician, what would be your approach to managing
Miss Layla's chronic constipation?

31.  The first step in management would be to take a thorough
Medical History, including her diet and exercise habits,
medication use, and any previous bowel or digestive
issues. This would help identify any underlying medical
conditions that may be contributing to her constipation.
 Then, we would perform a Physical Examination to assess
for any signs of structural abnormalities, such as an
abdominal mass, rectal prolapse, hemorrhoids, or anal
fissures.
 Digital Rectal Exam must performed to detect any masses
or fecal impaction.

32.  Based on medical history and physical exam, we
may recommend lifestyle changes.
 Advise her to increase her intake of fiber-rich
foods.
 She should also increase her fluid intake and
engage in regular exercise.
 We would also advise her to establish a regular
bowel routine.

33.  If lifestyle modifications do not improve the
condition, Then:
 We may recommend bulk-forming laxative.
 If a bulk-forming laxative is not effective, a stool
softener, then osmotic laxative can be used.
 Stimulant laxatives and enema should be
reserved for severe cases and used only on a
short-term basis.

34.  Given Miss Layla's age and medical history, it is
important to be followed up in 2-4 weeks to assess
the effectiveness of the management plan.
 We would also advise her to report any new or
worsening symptoms, such as rectal bleeding or
severe abdominal pain.
 If her symptoms persist, further evaluation with a
colonoscopy may be warranted.

35.  Brandt LJ, Prather CM, Quigley EM, Schiller LR,
Schoenfeld P, Talley NJ. Systematic review on
the management of chronic constipation in
North America. Am J Gastroenterol. 2005;100
Suppl 1:S5-S21.
 Gallegos-Orozco JF, Foxx-Orenstein AE, Sterler
SM, Stoa JM. Chronic constipation in the elderly.
Am J Gastroenterol. 2012;107(1):18-25.
 Higgins PDR, Johanson JF. Epidemiology of
constipation in North America: a systematic
review. Am J Gastroenterol. 2004;99(4):750-
759.
 Lee-Robichaud H, Thomas K, Morgan J, Nelson
RL. Lactulose versus polyethylene glycol for
chronic constipation. Cochrane Database Syst
Rev. 2010;(7):CD007570.
 Lembo A, Camilleri M. Chronic constipation. N
Engl J Med. 2003;349(14):1360-1368.
 Leung L, Riutta T, Lotecha J, Rosser W.
Chronic constipation: an evidence-based
review. J Am Board Fam Med.
2011;24(4):436-451.
 Longstreth GF, Thompson WG, Chey WD,
Houghton LA, Mearin F, Spiller RC.
Functional bowel disorders.
Gastroenterology. 2006;130(5):1480-1491.
 Rao SS, Go JT. Update on the management of
constipation in the elderly: new treatment
options. Clin Interv Aging. 2010;5:163-171.
 Wald A. Constipation in the primary care
setting: current concepts and
misconceptions. Am J Med.
2006;119(9):736-739.

36.  Alsalimy N, Madi L, Awaisu A. Efficacy and
safety of laxatives for chronic constipation
in long-term care settings: a systematic
review. J Clin Pharm Ther. 2018;43:595–
605.
 Mounsey A, Raleigh M, Wilson A.
Management of constipation in older
adults. Am Fam Physician. 2015;92(6):500–
504.
 Reuben DB, Herr KA, Pacala JT, et al.
Constipation. In: Geriatrics at Your
Fingertips. 21st ed. American Geriatrics
Society; 2019:137–138.

38. Question 1
What is the first-line pharmacologic treatment for
chronic constipation in the elderly population?
Bulk-forming
laxatives
Osmotic laxatives
Lubricant laxatives Stimulant laxatives

39. Question 1
What is the first-line pharmacologic treatment for
chronic constipation in the elderly population?
Bulk-forming
laxatives
Osmotic laxatives
Lubricant laxatives Stimulant laxatives
Bulk-forming
laxatives

40. Question 2
What is the gold standard for the diagnosis of
constipation in older adults?
Colonoscopy Rome IV criteria
Sigmoidoscopy
Anorectal
manometry

41. Question 2
What is the gold standard for the diagnosis of
constipation in older adults?
Colonoscopy Rome IV criteria
Sigmoidoscopy
Anorectal
manometry
Rome IV criteria

42. Question 3
Which of the following is an appropriate goal for the
management of constipation in older adults?
Complete resolution
of symptoms
Maintenance of regular
bowel movements
Reversal of
underlying causes
All of the above

43. Question 3
Which of the following is an appropriate goal for the
management of constipation in older adults?
Complete resolution
of symptoms
Maintenance of regular
bowel movements
Reversal of
underlying causes
All of the above
All of the above

44. Question 4
Which of the following is a red flag symptom that
warrants further evaluation in older adults with
constipation?
Abdominal bloating
Infrequent bowel
movements
Rectal bleeding
Difficulty passing
stools

45. Question 4
Which of the following is a red flag symptom that
warrants further evaluation in older adults with
constipation?
Abdominal bloating
Infrequent bowel
movements
Rectal bleeding
Difficulty passing
stools
Rectal bleeding

46. Question 5
Which of the following is NOT a potential
consequence of untreated chronic constipation in
older adults?
Fecal impaction
Increased risk of
colorectal cancer
Rectal prolapse Bowel obstruction

47. Question 5
Which of the following is NOT a potential
consequence of untreated chronic constipation in
older adults?
Fecal impaction
Increased risk of
colorectal cancer
Rectal prolapse Bowel obstruction
Increased risk of
colorectal cancer

48. Question 6
Which of the following medications may contribute
to constipation in elderly patients?
Tricyclic
antidepressants
CCBs
Oxybutynin All of the above

49. Question 6
Which of the following medications may contribute
to constipation in elderly patients?
CCBs
Oxybutynin All of the above
All of the above
Tricyclic
antidepressants

50. Question 7
Which of the following laxatives is NOT
recommended for long-term use in elderly patients?
Bulk-forming
laxatives
Stimulant laxatives
Osmotic laxatives Stool softeners

51. Question 7
Which of the following laxatives is NOT
recommended for long-term use in elderly patients?
Bulk-forming
laxatives
Stimulant laxatives
Osmotic laxatives Stool softeners
Stimulant laxatives

52. Question 8
Which of the following is NOT a common cause of
chronic constipation in the elderly?
Slow colonic transit
Pelvic floor
dysfunction
Hyperthyroidism Opioid use

53. Question 8
Which of the following is NOT a common cause of
chronic constipation in the elderly?
Slow colonic transit
Pelvic floor
dysfunction
Hyperthyroidism Opioid use
Hyperthyroidism

54. Question 9
What is the recommended daily fiber intake for
elderly individuals to prevent chronic constipation?
Less than 5 grams 5-10 grams
10-15 grams More than 15 grams

55. More than 15 grams
What is the recommended daily fiber intake for
elderly individuals to prevent chronic constipation?
Less than 5 grams 5-10 grams
10-15 grams More than 15 grams
Question 9

56. Question 10
Which of the following is a potential complication of
treatment with Stool Softeners?
Diarrhea Nausea
Abdominal cramps All of the above

57. Question 10
Which of the following is a potential complication of
treatment with Stool Softeners?
Diarrhea Nausea
Abdominal cramps All of the above
All of the above