Constipation is a common gastrointestinal problem which is often misdiagnosed and under-treated. It affects up to 50% of older adults in the community and 74% of nursing home residents.
By definition, two or more of the following symptoms must be experienced for at least three months: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of ano-rectal obstruction, manual maneuvers to facilitate evacuation, and less than 3 bowel movements per week.
Clarification of what the patient means by ‘constipation’ is important, as many feel constipated even if they are passing stools regularly with no apparent problem. Assessment of dietary fiber intake, level of physical activity, and use of medications, including over-the-counter laxatives, is required. The patient’s perspective and concerns should be elicited, and a careful psychosocial history should be obtained; signs of depression or anxiety should be noted as these are known contributory factors.
Diet and lifestyle advice is the first-line option, including use of probiotics. Patients should be advised not to ignore any spontaneous urge to defecate and to adopt the correct toilet position with the knees slightly higher than the hips, with feet supported on a step if necessary. For those with a very sedentary lifestyle, particularly the elderly, increasing physical activity may be helpful in stimulating bowel movements.
An increased fluid intake may be of benefit. A recommended dose of 20-30g per day of fiber increases stool weight and shortens gut transit time. However, increased fiber is not always helpful, particularly for those individuals who have abdominal distension and pain. It is important therefore that any increase in fiber intake be initiated slowly. For individuals whose constipation remains unresolved despite these measures, consideration should be given to the use of laxatives or a specialist referral.