Last Updated on 8 January 2022 by Ray Plumlee
Constipation may not always refer to the changes in the bowel movement, but it may also be defined by the stool concentration. It may be too hard, too small, difficulty in defecating, or infrequent (less than three in a week). The patient might also experience an urge to strain and a feeling that bowels don’t evacuate completely. Constipation is now becoming a very common problem, especially for older adults due to sedentary behavior. Several factors are contributing to this issue and can lead to serious complications if left untreated.
Constipation can be a side effect of many diseases, so it is necessary to check the patient’s medication history. The diagnosis of constipation is done both by physical examination and a rectal examination. Rectal examination is a procedure of inserting gloved fingers inside the rectum to check if there is any lump or abnormality, in case the patient complains of blood in the stool.
Also, after certain conditions, the testing may proceed further. Such conditions include changes in bowel habits, bloody stool, weight loss, colon cancer in the family. Testing procedures include blood tests, x-rays, sigmoidoscopy, colonoscopy, and many other specialized techniques.
The treatment for constipation comprises of behavioral changes, fiber-rich foods, laxatives, and enemas.
People may need to pay attention when nature calls; usually, the bowel movement is active soon after having a meal. So, if a person doesn’t bother about the body’s signal, it will get weaker soon. So, it’s better to avoid controlling the urge to defecate. Intake of caffeine beverages in the morning can be a remedy.
A fiber-rich diet is another way of overcoming constipation. The intake of dietary fiber should be 20 to 35 grams per day. Many vegetables and fruits are an excellent source of fiber. It includes citrus fruits, prunes, prune juice, breakfast cereals, artichokes, broccoli, and green leafy vegetables.
Beware of the side effect as overuse of fiber causes bloating or gas. So, the best way is to start with a small amount and then gradually increase the intake until the stool softens up and becomes more frequent.
If the above treatment approaches fail to provide relief from constipation, your clinician may put you on laxatives. Laxatives have different classes, each possessing different modes of action. Your healthcare provider chooses the best one for you after reviewing the working and safety of all the laxatives.
Laxatives are categorized into the following groups:
1. Bulk Forming Laxatives:
Bulk-forming laxatives help by absorbing liquid in the intestine. It then swells up and makes the stool soft, bulky, and easy to pass. These are prepared either by natural fiber or commercial fiber. Examples are:
- Psyllium (Konsyl; Metamucil; Perdiem)
- Methylcellulose (Citrucel)
- Calcium polycarbophil (FiberCon; Fiber-Lax; Mitrolan)
- Wheat dextrin (Benefiber)
The patient must be advised to gradually increase the dose, otherwise gas and cramping would result. Also, increase fluid intake when on these supplements.
2. Hyperosmolar Laxatives:
Hyperosmolar laxatives work by absorbing water into the bowel from the surrounding tissue, thereby softening the stool and enhance bowel evacuation. These include:
- Polyethylene glycol (MiraLAX, GlycoLax)
Polyethylene glycol is the preferred one among the three as there is no bloating or gas issue stick to it as compared to lactulose and sorbitol. Sorbitol and lactulose have the same working, but sorbitol is not very expensive.
3. Saline Laxatives:
They have the same mode of action as the hyperosmolar laxatives. Saline laxatives are:
- Magnesium hydroxide (Milk of Magnesia)
- Magnesium citrate (Evac-Q-Mag)
4. Stimulant Laxatives:
Stimulant laxatives increase the intestinal motility and water content of the stool. Some stimulant laxatives are:
- Senna (e.g., Black Draught, Ex-Lax, Fletcher’s, Castoria, Senokot)
- Bisacodyl (e.g., Correctol, Doxidan, Dulcolax)
Stimulant laxatives have side effects upon large amounts like diarrhea, low level of potassium, and cramping. So, avoid its overuse or monitor the dose carefully if regular intake is required.
Apart from that, it is a myth as there is no supporting evidence that the use of stimulant laxatives has a damaging effect on the colon or causes an increased risk of colorectal cancer or other tumors.
When constipation becomes severe or if a patient fails to respond to any previous medication, the following medications can be given, though they are expensive.
- Lubiprostone (Amitiza)
- Linaclotide (Linzess)
- Plecanatide (Trulance)
- Plecanatide (Motegrity)
- Tenapanor (Ibsrela)
Types of Dosage Forms Available for Laxatives:
Laxatives can be designed as pills (taken by mouth) or suppositories and enemas (inserted in the rectum). Suppositories and enemas have a quick onset of action as compared to pills, but people don’t like it because of its unaesthetic use. These are not recommended for patients with heart and kidney problems, and they shouldn’t get more than one. Enema containing sodium phosphate/biphosphate (Fleet) is mostly used.
What to Avoid?
- Emollient laxatives that contain mineral oil and help in stool softening. Heavy use may cause mineral oil to get absorbed more.
- Natural products; as one cannot claim the correct dose and purity of these substances, so it’s better to avoid using them. However, these products are a part of commercially available laxatives.
- Homemade products like soapsuds, hydrogen peroxide, and household detergents should strictly be avoided as they irritate the intestinal lining.
Another way for those with severe constipation is to make behavioral changes – involuntary squeezing of the muscles than relaxing during defecation.
This is how constipation can be treated in older adults. Ask your physician before starting any treatment.
I am chief medical resident doctor in Internal Medicine at a tertiary care hospital. I am also an author and editor at StatPearls publishing, a medical website with thousands of PubMed indexed articles and MCQs.