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:
- 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, they 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.
This chapter will describe the epidemiology, risk factors, clinical presentation, assessment, and treatment of constipation in older adults. Data sources were a computer search of the English language literature (1966 to 2006), systematic review Web sites including the Cochrane database, reference lists from recent systematic reviews and book chapters, and expert committee reports and opinion. Levels of evidence are as used by the U.S. Preventive Task Force:
- Good evidence Level : consistent results from well-designed, well-conducted studies
- Fair evidence Level : results show benefit, but strength limited by number, quality, or consistency of studies
- Poor evidence Level : insufficient because of limited number, power, or quality of studies
Definitions of constipation in older people in medical and nursing literature have been inconsistent. Studies of older people have tended to define constipation
- subjectively by self-report,
- according to specific bowel-related symptoms, or
- by daily laxative usage.
Few use objective assessment–based definitions (e.g., fecal loading). The feeling of being constipated frequently means different things to different individuals. While the nonspecific self-reporting of constipation (“I suffer from constipation”) provides insight into how individuals perceive their bowel habit, standardized definitions based on specific symptoms (Rome II criteria) are now widely used in both clinical practice and research (Table 93-1). A recent systematic review reported that approximately 63 million people in North America meet the Rome II criteria for constipation with a disproportionate number being older than 65. An important subtype ...