ESSENTIALS OF DIAGNOSIS
Constipation is common in older adults and requires careful assessment to rule out mechanical causes.
May present with other abdominal complaints, such as pain, bloating, and/or gas.
May involve infrequent defecation, difficulty passing stool, or incomplete evacuation of stool.
A diagnosis of chronic constipation requires the presence of symptoms for at least 12 weeks.
Chronic constipation is one of the most frequent gastrointestinal disorders encountered among older adults in clinical practice. Constipation may be caused by medications, as a manifestation of systemic disease, or due to psychosocial factors. It may involve difficulty in passing stool, infrequent stool passage, or incomplete evacuation of stool. Infrequent passage of stool is not a requirement to meet the diagnosis of constipation if difficulty with or incomplete evacuation of stool is present. For chronic constipation to be diagnosed, symptoms should be present for at least 12 weeks.
Chronic constipation is common in older adults. About one-third of adults age 60 years or older report at least occasional constipation, and more than half of nursing home residents experience constipation. Women are at increased risk, experiencing constipation two to three times more often than men. African Americans also exhibit increased risk. Many community-dwelling older adults commonly use nonprescription preparations, such as stimulant and bulking laxatives. Nearly 85% of physician visits for constipation result in a prescription for laxatives, and more than $1.6 billion dollars are spent on constipation-related emergency department visits.
Health care providers often regard constipation to mean infrequent bowel movements, but patient-reported symptoms of constipation are often more varied and associated with other abdominal complaints, including pain, bloating, fullness, gas, and incomplete evacuation. Straining is often the predominant symptom in older adults and occurs in up to 65% of community-based individuals older than 65 years of age. Hard stools are reported in approximately 40%.
In most cases, patients with chronic constipation do not warrant extensive diagnostic evaluation. Historical features are key, and specific questions should be asked, including what symptom the patient finds most distressing—infrequency, straining, hard stools, incomplete defecation, or symptoms unrelated to bowel habits (eg, bloating, pain, or malaise). The presence of bloating or abdominal pain may suggest underlying irritable bowel syndrome.
Additional questions should assess for “alarm symptoms,” including symptoms of hematochezia, 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, and new-onset constipation without evidence of potential primary cause. Older patients who have “alarm” symptoms should consider the benefits and risks of doing further evaluation with colonoscopy or other invasive testing.
The clinical evaluation should consist of a thorough history containing the above ...