Diagnosis and Treatment of Elderly and Senile Chronic Constipation: an Expert Consensus

Aim. An appraisal of practitioners with chronic constipation management details in older and senile adults.
Key points. Chronic constipation is a common issue in geriatrics. Aside to age-related physiological bowel disfunction, a higher constipation incidence is conditioned by declined physical activity and frailty, polypharmacy and a series of secondary constipation-developing chronic states and diseases. Chronic constipation is associated with a higher risk of cardiovascular disease and complications, impaired general perception of health and pain, growing alarm and depression, and reduced quality of life. The treatment tactics in chronic constipation is cause-conditioned and should account for the patient’s history and therapy line, overall clinical condition, cognitive status and functional activity level. An essential baseline aspect of constipation management is apprising the patient and his family of the underlying factors and methods for non-drug and drug correction. An higher-fibre diet is recommended as first measure, with osmotic laxatives added and titrated to clinical response if none observed towards the non-drug and high-fibre regimens. Stimulant laxatives and prokinetics should be recommended in patients reluctant to fibre supplements and osmotic laxatives. Subsidiary correction includes biofeedback, transanal irrigation, acupuncture, foot reflexology and percutaneous tibial nerve stimulation.
Conclusion. Elderly and senile chronic constipation is a prevalent multifactorial state requiring an efficient management via assessment and correction of total risk factors and consistent use of non-medication and drug therapies.

1. Ivashkin V.T., Shelygin Yu.A., Maev I.V., Sheptulin A.A., Aleshin D.V., et al. Clinical Recommendations of the Russian Gastroenterological Association and Association of Coloproctologists of Russia on Diagnosis and Treatment of Constipation in Adults. Rus J Gastroenterol Hepatol Coloproctol. 2020;30(6):69–85. (In Russ.). https://doi.org/10.22416/1382-4376-2020-30-6-69-85

2. Bove A., Pucciani F., Bellini M., Battaglia E., Bocchini R., Altomare D.F., et al. Consensus statement AIGO/SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 2012;18(14):1555–64. DOI: 10.3748/wjg.v18.i14.155

3. Bove A., Bellini M., Battaglia E., Bocchini R., Gambaccini D., Bove V., et al. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol. 2012;18(36):4994–5013. DOI: 10.3748/wjg.v18.i36.4994

4. Drossman D.A., Hasler W.L. Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 2016;150:1257–61.

5. Abdul Wahab P., Mohd Yusoff D., Abdul Kadir A., Ali S.H., Lee Y.Y., Kueh Y.C. Psychometric evaluation of a newly developed Elderly-Constipation Impact Scale. 2020;8:e8581. DOI: 10.7717/peerj.8581

6. Wald A., Scarpignato C., Mueller-Lissner S., Kamm M.A., Hinkel U., Helfrich I., et al. A multinational survey of prevalence and patterns of laxative use among adults with self-defined constipation. Alim Pharmacol Ther. 2008;28(7):917–30.

7. Mari A., Mahamid M., Amara H., Baker F.A., Yaccob A. Chronic Constipation in the Elderly Patient: Updates in Evaluation and Management. Korean J Fam Med. 2020;41(3):139–45. DOI: 10.4082/kjfm.18.0182

8. De Giorgio R., Ruggeri E., Stanghellini V., Eusebi L.H., Bazzoli F., Chiarioni G. Chronic constipation in the elderly: a primer for the gastroenterologist. BMC Gastroenterol. 2015;15:130. DOI: 10.1186/s12876-015-0366-3

9. Norton C. Constipation in older patients: effects on quality of life. Br J Nurs. 2006;15(4):188–92. DOI: 10.12968/bjon.2006.15.4.20542

10. Kinnunen O. Study of constipation in a geriatric hospital, day hospital, old people’s home and at home. Aging (Milano). 1991;3(2):161–70. DOI: 10.1007/BF03323997

11. Dennison C., Prasad M., Lloyd A., Bhattacharyya S.K., Dhawan R., Coyne K. The health-related quality of life and economic burden of constipation. Pharmacoeconomics. 2005;23(5):461–76. DOI: 10.2165/00019053-200523050-00006

12. Sundbøll J., Szépligeti S.K., Adelborg K., Szentkúti P., Gregersen H., Sørensen H.T. Constipation and risk of cardiovascular diseases: a Danish population-based matched cohort study. BMJ Open. 2020;10(9):e037080. DOI: 10.1136/bmjopen-2020-037080

13. Sumida K., Molnar M.Z., Potukuchi P.K., Thomas F., Lu J.L., Yamagata K., et al. Constipation and risk of death and cardiovascular events. Atherosclerosis. 2019;281:114–20. DOI: 10.1016/j.atherosclerosis.2018.12.021

14. Lian W.Q., Li F.J., Huang H.X., Zheng Y.Q., Chen L.H. Constipation and risk of urinary incontinence in women: a meta-analysis. Int Urogynecol J. 2019;30(10):1629–34. DOI: 10.1007/s00192-019-03941-w

15. Zheng S., Yao J. Chinese Geriatric Society, Editorial Board of Chinese Journal of Geriatrics. Expert consensus on the assessment and treatment of chronic constipation in the elderly. Aging Med (Milton). 2018;1(1):8–17. DOI: 10.1002/agm2.12013

16. Glia A., Lindberg G. Quality of life in patients with different types of functional constipation. Scand J Gastroenterol. 1997;32(11):1083–9. DOI: 10.3109/00365529709002985

17. Camilleri M., Lee J.S., Viramontes B., Bharucha A.E., Tangalos E.G. Insights into the pathophysiology and mechanisms of constipation, irritable bowel syndrome, and diverticulosis in older people. J Am Geriatr Soc. 2000;48(9):1142– 50. DOI: 10.1111/j.1532-5415.2000.tb04793.x

18. Yu S.W., Rao S.S. Anorectal physiology and pathophysiology in the elderly. Clin Geriatr Med. 2014;30(1):95–106. DOI: 10.1016/j.cger.2013.10.003

19. Hanani M., Fellig Y., Udassin R., Freund H.R. Agerelated changes in the morphology of the myenteric plexus of the human colon. Auton Neurosci. 2004;113(1–2):71–8. DOI: 10.1016/j.autneu.2004.05.007

20. Koch T.R., Carney J.A., Go V.L., Szurszewski J.H. Inhibitory neuropeptides and intrinsic inhibitory innervation of descending human colon. Dig Dis Sci. 1991;36(6):712–8. doi: 10.1007/BF01311226

21. Bernard C.E., Gibbons S.J., Gomez-Pinilla P.J., Lurken M.S., Schmalz P.F,. Roeder J.L., et al. Effect of age on the enteric nervous system of the human colon. Neurogastroenterol Motil. 2009;21(7):746-e46. DOI: 10.1111/j.1365-2982.2008.01245.x

22. Lagier E., Delvaux M., Vellas B., Fioramonti J., Bueno L., Albarede J.L., Frexinos J. Influence of age on rectal tone and sensitivity to distension in healthy subjects. Neurogastroenterol Motil. 1999;11(2):101–7. DOI: 10.1046/j.1365-2982.1999.00145.x

23. Salles N. Basic mechanisms of the aging gastrointestinal tract. Dig Dis. 2007;25(2):112–7. DOI: 10.1159/000099474

24. Madsen J.L., Graff J. Effects of ageing on gastrointestinal motor function. Age Ageing. 2004;33(2):154–9. DOI: 10.1093/ageing/afh040

25. Wiskur B., Greenwood-Van Meerveld B. The aging colon: the role of enteric neurodegeneration in constipation. Curr Gastroenterol Rep. 2010;12(6):507–12. DOI: 10.1007/s11894-010-0139-7

26. Evans J.M., Fleming K.C., Talley N.J., Schleck C.D., Zinsmeister A.R., Melton L.J. Relation of colonic transit to functional bowel dis- ease in older people: a population-based study. J Am Geriatr Soc. 1998;46(1):83–87. DOI: 10.1111/j.1532-5415.1998.tb01018.x

27. Meier R., Beglinger C., Dederding J.P., Meyer-Wyss B., Fumagalli M., Rowedder A., et al. Influence of age, gender, hormonal status and smoking habits on colonic transit time. Neurogastroenterol Motil. 1995;7(4):235–8. DOI: 10.1111/j.1365-2982.1995.tb00231.x

28. Nullens S., Nelsen T., Camilleri M., Burton D., Eckert D., Iturrino J., et al. Regional colon transit in patients with dys-synergic defaecation or slow transit in patients with constipation. Gut. 2012;61(8):1132–9. DOI: 10.1136/gutjnl-2011-301181

29. Shin A., Camilleri M., Nadeau A., Nullens S., Rhee J.C., Jeong I.D., Burton D.D. Interpretation of overall colonic transit in defecation disorders in males and females. Neurogastroenterol Motil. 2013;25(6):502–8. DOI: 10.1111/nmo.12095

30. Bannister J.J., Abouzekry L., Read N.W. Effect of aging on anorectal function. Gut. 1987;28(3):353–7. DOI: 10.1136/gut.28.3.353

31. Laurberg S., Swash M. Effects of aging on the anorectal sphincters and their innervation. Dis Colon Rectum. 1989;32(9):737–42. DOI: 10.1007/BF02562120

32. McHugh S.M., Diamant N.E. Effect of age, gender, and parity on anal canal pressures. Contribution of impaired anal sphincter function to fecal incontinence. Dig Dis Sci. 1987;32(7):726–36. DOI: 10.1007/BF01296139

33. Orr W.C., Chen C.L. Aging and neural control of the GI tract: IV. Clinical and physiological aspects of gastrointestinal motility and aging. Am J Physiol Gastrointest Liver Physiol. 2002;283(6):G1226–31. DOI: 10.1152/ajpgi.00276.2002

34. Suares N.C., Ford A.C. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol. 2011;106(9):1582–91; quiz 1581, 1592. DOI: 10.1038/ajg.2011.164

35. Bharucha A.E. Constipation. Best Pract Res Clin Gastroenterol. 2007;21(4):709–31. DOI: 10.1016/j.bpg.2007.07.001

36. Locke G.R. 3rd, Pemberton J.H., Phillips S.F. AGA technical review on constipation. American Gastroenterological Association. Gastroenterology. 2000;119(6):1766–78. DOI: 10.1053/gast.2000.20392

37. Talley N.J., Fleming K.C., Evans J.M., O’Keefe E.A., Weaver A.L., Zinsmeister A.R., Melton L.J. 3rd. Constipation in an elderly community: a study of prevalence and potential risk factors. Am J Gastroenterol. 1996;91(1):19–25.

38. Talley N.J., Jones M., Nuyts G., Dubois D. Risk factors for chronic constipation based on a general practice sample. Am J Gastroenterol. 2003;98(5):1107–11. DOI: 10.1111/j.1572-0241.2003.07465.x

39. Bouras E.P., Tangalos E.G. Chronic constipation in the elderly. Gastroenterol Clin North Am. 2009;38(3):463–80. doi: 10.1016/j.gtc.2009.06.001

40. O’Mahony D., O’Sullivan D., Byrne S., O’Connor M.N., Ryan C., Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–8. DOI: 10.1093/ageing/afu145

41. Kyle G. A guide to managing constipation: Part two. Nurs Times. 2007;103(19):42–3.

42. Gallegos-Orozco J.F., Foxx-Orenstein A.E,. Sterler S.M., Stoa J.M. Chronic constipation in the elderly. Am J Gastroenterol. 2012;107(1):18–25; quiz 26. DOI: 10.1038/ajg.2011.349

43. American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol. 2005;100 (Suppl 1):S1–4. DOI: 10.1111/j.1572-0241.2005.50613_1.x

44. Chen C.L., Liang T.M., Chen H.H., Lee Y.Y., Chuang Y.C., Chen N.C. Constipation and Its Associated Factors among Patients with Dementia. Int J Environ Res Public Health. 2020;17(23):9006. DOI: 10.3390/ijerph17239006

45. McCrea G.L., Miaskowski C., Stotts N.A., Macera L,. Varma M.G. A review of the literature on gender and age differences in the prevalence and characteristics of constipation in North America. J Pain Symptom Manage. 2009;37(4):737–45. DOI: 10.1016/j.jpainsymman.2008.04.016

46. Talley N.J., Jones M., Nuyts G., Dubois D. Risk factors for chronic constipation based on a general practice sample. Am J Gastroenterol. 2003;98(5):1107–11. DOI: 10.1111/j.1572-0241.2003.07465.x

47. Zhu L.M., Fang X.C., Liu S., Zhang J., Li Z.S., Hu P.J., Gao J., Xin H.W., Ke MY. Multi-centered stratified clinical studies for psychological and sleeping status in patients with chronic constipation in China. Zhonghua Yi Xue Za Zhi. 2012;92(32):2243–6.

48. Van Oudenhove L., Vandenberghe J., Demyttenaere K., Tack J. Psychosocial factors, psychiatric illness and functional gastrointestinal disorders: a historical perspective. Digestion. 2010;82(4):201–10. DOI: 10.1159/000269822

49. Bharucha A.E. Update of tests of colon and rectal structure and function. J Clin Gastroenterol. 2006;40(2):96– 103. DOI: 10.1097/01.mcg.0000196190.42296.a9

50. Metcalf A.M., Phillips S.F., Zinsmeister A.R., MacCarty R.L., Beart R.W., Wolff B.G. Simplified assessment of segmental colonic transit. Gastroenterology. 1987;92(1):40–7. DOI: 10.1016/0016-5085(87)90837-7

51. Gandell D., Straus S.E., Bundookwala M., Tsui V., Alibhai S.M. Treatment of constipation in older people. CMAJ. 2013;185(8):663–70. DOI: 10.1503/cmaj.120819

52. Ford A.C., Moayyedi P., Lacy B.E., Lembo A.J., Saito Y.A., Schiller L.R., et al.; Task Force on the Management of Functional Bowel Disorders. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol. 2014;109 (Suppl 1):S2–26; quiz S27. DOI: 10.1038/ajg.2014.187

53. Fleming V., Wade W.E. A review of laxative therapies for treatment of chronic constipation in older adults. Am J Geriatr Pharmacother. 2010;8(6):514–50. DOI: 10.1016/S1543-5946(10)80003-0

54. Xu L., Yu W., Jiang J., Li N. Clinical benefits after soluble dietary fiber supplementation: a randomized clinical trial in adults with slow-transit constipation. Zhonghua Yi Xue Za Zhi. 2014;94(48):3813–6.

55. Gao R., Tao Y., Zhou C., Li J., Wang X., Chen L., et al. Exercise therapy in patients with constipation: a systematic review and meta-analysis of randomized controlled trials. Scand J Gastroenterol. 2019;54(2):169–77. DOI: 10.1080/00365521.2019.1568544

56. Spinzi G.C. Bowel Care in the Elderly. Dig Dis. 2007;25:160–5.

57. Gwee K.A., Ghoshal U.C., Gonlachanvit S., Chua A.S., Myung S.J., Rajindrajith S., et al. Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool. J Neurogastroenterol Motil. 2013;19(2):149–60. DOI: 10.5056/jnm.2013.19.2.149

58. Lee-Robichaud H., Thomas K., Morgan J., Nelson R.L. Lactulose versus Polyethylene Glycol for Chronic Constipation. Cochrane Database Syst Rev. 2010;(7):CD007570. DOI: 10.1002/14651858.CD007570.pub2. PMID: 20614462

59. De Giorgio R., Cestari R., Corinaldesi R., Stanghellini V., Barbara G., Felicani C., et al. Use of macrogol 4000 in chronic constipation. Eur Rev Med Pharmacol Sci. 2011;15(8):960–6.

60. Culbert P., Gillett H., Ferguson A. Highly effective new oral therapy for faecal impaction. Br J Gen Pract. 1998;48(434):1599–600.

61. Chen C.C., Su M.Y., Tung S.Y., Chang F.Y., Wong J.M., Geraint M. Evaluation of polyethylene glycol plus electrolytes in the treatment of severe constipation and faecal impaction in adults. Curr Med Res Opin. 2005;21(10):1595–602. DOI: 10.1185/030079905X65385

62. Dipalma J.A., Cleveland M.V., McGowan J., Herrera J.L. A randomized, multicenter, placebo-controlled trial of polyethylene glycol laxative for chronic treatment of chronic constipation. Am J Gastroenterol. 2007;102(7):1436–41. DOI: 10.1111/j.1572-0241.2007.01199.x

63. Sobrado C. W., Corrêa Neto I.J.F., Pinto R.A., Sobrado L.F., Nahas S. C., Cecconello I. Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria. J. Coloproctol. (Rio J.). 2018; 38(2):137–44. DOI: 10.1016/j.jcol.2018.02.003

64. Сhaussade S., Minic M. Comparison of efficacy and safety of two doses of two different polyethylene glycolbased laxatives in the treatment of constipation. Aliment Pharmacol Ther. 2003;17:165–72. DOI: 10.1046/j.1365-2036.2003.01390.x

65. Mueller-Lissner S., Kamm M.A., Wald A., Hinkel U., Koehler U., Richter E., et al. Multicenter, 4-week, doubleblind, randomized, placebo-controlled trial of sodium picosulfate in patients with chronic constipation. Am J Gastroenterol 2010;105:897–903. DOI: 10.1038/ajg.2010.41

66. Kamm M.A., Mueller-Lissner S., Wald A., Richter E., Swallow R., Gessner U. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol. 2011;9:577–83. DOI: 10.1016/j.cgh.2011.03.026

67. Bouras E.P., Tangalos E.G. Chronic constipation in the elderly. Gastroenterol Clin North Am. 2009;38:463–80. DOI: 10.1016/j.gtc.2009.06.001

68. Rao S.S., Go J.T. Update on the management of constipation in the elderly: new treatment options. Clin Interv Aging. 2010;5:163–71. DOI: 10.2147/cia.s8100

69. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674–94. DOI: 10.1111/jgs.15767

70. Muller-Lissner S., Rykx A., Kerstens R., Vandeplassche L. A doubleblind, placebo-controlled study of prucalopride in elderly patients with chronic constipation. Neurogastroenterol Motil. 2010;22:991–8. DOI: 10.1111/j.1365-2982.2010.01533.x

71. Camilleri M., Piessevaux H., Yiannakou Y., Tack J., Kerstens R., Quigley E.M.M., et al. Efficacy and safety of prucalopride in chronic constipation: an integrated analysis of six randomized, controlled clinical trials. Dig Dis Sci. 2016;61:2357–72. DOI: 10.1007/s10620-016-4147-9

72. Maev I.V., Samsonov A.A., Andreev D.N. Modern algorithm of patient management in chronic constipation syndrome, a pharmacological outlook. Farmateka. 2012;13:37–43

73. Quigley E.M. Prucalopride: safety, efficacy and potential applications. Therap Adv Gastroenterol 2012;5(1):23-30; DOI: 10.1177/1756283X11423706

74. Camilleri M., Deiteren A. Invited Review. Prucalopride for constipation. Exp Opin Pharmacother 2010;11:451–61. DOI: 10.1517/14656560903567057

75. Camilleri M., Beyens G., Kerstens R., Robinson P., Vandeplassche L. Safety assessment of prucalopride in elderly patients with constipation: a double-blind, placebo-controlled study. Neurogastroenterol Motil. 2009;21(12):1256-e117. DOI: 10.1111/j.1365-2982.2009.01398

76. Nee J., Zakari M., Sugarman M.A., Whelan J., Hirsch W., Sultan S., et al. Efficacy of Treatments for Opioid-Induced Constipation: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol. 2018;16(10):1569–84.e2. DOI: 10.1016/j.cgh.2018.01.021

77. Roerig J.L., Steffen K.J., Mitchell J.E., Zunker C. Laxative abuse: epidemiology, diagnosis and management. Drugs. 2010;70(12):1487–503. DOI: 10.2165/11898640-000000000-00000

78. Dale M., Morgan H., Carter K., White J., CarolanRees G. Peristeen Transanal Irrigation System to Manage Bowel Dysfunction: A NICE Medical Technology Guidance. Appl Health Econ Health Policy. 2019;17(1):25–34. DOI: 10.1007/s40258-018-0447-x

79. Juul T., Christensen P. Prospective evaluation of transanal irrigation for fecal incontinence and constipation. Tech Coloproctol. 2017;21(5):363–371 DOI: 10.1007/s10151-017-2035-7

80. Muchtar N.J., Helianthi D.R., Nareswari I. Effectiveness of Acupuncture for Management in a Hospitalized Geriatric Patient with Constipation. Med Acupunct. 2020;32(2):116–20. DOI: 10.1089/acu.2019.1401

81. Inkaya B., Tuzer H. Effect of Reflexology on the Constipation Status of Elderly People. Yonago Acta Med. 2020;63(2):115–21. DOI: 10.33160/yam.2020.05.007

82. Gokce A.H., Gokce F.S. Effects of bilateral transcutaneous tibial nerve stimulation on constipation severity in geriatric patients: A prospective clinical study. Geriatric gerontology internatonal. 2020;20(2):101–5. DOI: 10.1111/ggi.13822

83. Knowles C.H., Grossi U., Chapman M., Mason J. Surgery for constipation: Systematic review and practice recommendations. Colorectal Dis. 2017;19 Suppl 3:17–36. DOI: 10.1111/codi.13779