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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #75

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LEARNING OBJECTIVES

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Learning Objectives

  • Describe the definition and prevalence of constipation in the older adult.

  • Understand the pathophysiology of constipation in the older adult.

  • Identify diagnoses associated with and classification of constipation in the older adult.

  • Summarize the assessment and management of constipation in the older adult.

  • List the complications of constipation in the older adult.

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Key Clinical Points

  1. Constipation is a common problem in older adults.

  2. Constipation is an expensive condition, with high costs ranging from laxative expenditure to nursing time.

  3. Health care providers should routinely inquire about constipation symptoms in older people, and be alert to the possible presence of constipation in individuals unable to communicate.

  4. In many older people with constipation symptoms, lifestyle advice (diet, fluids, exercise, toileting habits) will preempt the need for laxative therapy.

  5. In higher risk patients, a stepwise approach to prescribing laxatives, suppositories, or enemas should be used, with the goal of achieving comfortable and regular evacuation.

  6. Rectal evacuation difficulties should be specifically addressed in order to identify conditions that may require additional interventions.

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INTRODUCTION

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Constipation is a frequent health concern for older people in every health care setting. Primary care visits for constipation increase markedly in people older than 60 years, as does regular use of laxatives. Self-reported constipation in older people is associated with anxiety, depression, and poor health perception, while clinical constipation in vulnerable individuals may lead to complications such as fecal impaction, overflow incontinence, sigmoid volvulus, and urinary retention. Constipation is an expensive condition, with high costs ranging from laxative expenditure to nursing time. For instance, it is estimated that 80% of community nurses working with older people in the United Kingdom are managing constipation (particularly fecal impaction) as part of their case-load. An Australian study used in-depth, semistructured interviews to explore older individuals’ experiences with constipation, and their findings largely summed up feelings and problems, no doubt, shared by many older people across the developed world:

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  • They feel “not right” in themselves when they are constipated.

  • Physicians can have a dismissive attitude about constipation and do not consider the problem seriously.

  • Patients are keen to find a solution, but feel useful and empathic advice and information are generally unavailable.

  • At the same time, patients have a strong imperative for self-management including use of over-the-counter laxatives.

  • There are some barriers to lifestyle approaches, for example, expense of fruit and vegetables, fear of urinary incontinence with increased fluid intake, reluctance to walk out alone.

  • One-quarter still need to do self-manual removal despite measures taken.

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This chapter will describe the definition, epidemiology, risk factors, clinical presentation, assessment, and treatment of constipation in older adults. Data sources were searched of the English language literature (1966–2014), systematic review including the Cochrane database, reference lists from recent systematic reviews and book chapters, and expert committee reports, society guidelines, ...

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