36: Constipation

Essentials of Diagnosis

General Principles in Older Adults

Chronic constipation is one of the most frequent gastrointestinal disorders encountered among older adults in clinical practice. Constipation is often associated with other abdominal complaints (pain, bloating, and gas), as well as decreased overall well-being. It may involve infrequent defecation, difficulty in passing stool, or incomplete evacuation of stool. Physicians often define constipation as infrequent passage of stool; however, patients often define it as straining to defecate or sensation of incomplete evacuation. For chronic constipation to be diagnosed, symptoms should be present for at least 12 weeks.

Chronic constipation disproportionately affects older individuals with an estimated prevalence of 40% among people older than age 65 years. Women are also at increased risk, having 2–3 times more constipation 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 $820 million are spent per year on nonprescription agents. Few resources are available to health care providers to guide them in an evidence-based approach to this common problem.

Clinical Findings

Symptoms & Signs

Symptoms of constipation reported by patients often differ from definitions and classification from clinical criteria. Patients often report symptoms related to bloating, fullness, and incomplete evacuation. However, clinicians often focus on stool frequency and consistency to define constipation. The Rome III criteria, published in 2006, 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:

1. Must include 2 or more of the following:

   1. Hard or lumpy stool in ≥25% of defecations

   2. Straining during ≥25% defecations

   3. Sensation of incomplete evacuation for at least 25% of defecations

   4. Sensation of anorectal obstruction or blockage for ≥25% of defecations

   5. Manual maneuvers to facilitate ≥25% of defecations (eg, digital evacuation, support of the pelvic floor)

   6. Fewer than 3 defecations per week

2. Loose stools are rarely present without use of laxatives

3. Insufficient criteria for irritable bowel syndrome (IBS)

Differentiating symptoms of chronic constipation from IBS with constipation (IBS-C) may not be as important in older adults, as age ≥50 years is associated with lower rates of IBS. However, management can differ between the 2 diagnoses. IBS-C is defined by recurrent abdominal pain or discomfort for at least 3 days per month in the previous 3 months (onset ≥6 months prior to the ...