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Constipation in older people: A consensus statement

Article in International Journal of Clinical Practice · December 2016

DOI: 10.1111/ijcp.12920

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 Constipation in Older People: A Consensus Statement

Authors: Anton Emmanuel1, Francesco Mattace-Raso2, Maria Cristina Neri3,

Karl-Uwe Petersen4, Enrique Rey5, June Rogers6

Affiliations: 1GI Physiology Unit, University College London, London, United

Kingdom; 2Department of Geriatric Medicine, Erasmus Medical Centre, Rotterdam,

The Netherlands; 3Istituto Geriatrico “Pio Albergo Trivulzio”, Milan, Italy; Faculty of

Medicine, RWTH Aachen, Aachen, Germany; 5Instituo de Investigación Sanitaria San

Carlos, Division of Digestive Diseases, Hospital Clínico San Carlos, Department of

Medicine, Universidad Complutense de Madrid, Madrid, Spain; 6PromoCon, Disabled

Living, Manchester, United Kingdom.

Corresponding Author: TBC

Disclosures: AE has acted on advisory boards for Allergan, Almirall, Astellas,

Coloplast, Hollister, Shire, Sucampo, Takeda and Wellspect

1
ABSTRACT (WORD LIMIT: 250 WORDS; CURRENT WORD COUNT: 250)

Background and Aims: Chronic constipation is a serious medical condition that

affects 30–40% of people over 60 years old. Although not normally life-threatening,

constipation reduces quality of life by the same extent as diabetes and osteoarthritis.

There are currently no Europe-wide guidelines for treating constipation in older

people although there is some country-level guidance for the general population. We

have evaluated the existing guidance and best clinical practice in order to improve the

care of older people with constipation.

Method: European healthcare professionals working in gastroenterology, geriatrics,

nursing and pharmacology discussed the treatment of constipation in older people and

reviewed existing guidance on the treatment of constipation in the general population.

This manuscript represents the consensus of all authors.

Discussion: Most general guidance for constipation treatment recommends increased

dietary fibre, fluid intake and exercise; however, this is not always possible in older

patients. Although a common first-line treatment, bulk-forming laxatives are

unsuitable for older people because of an associated need to increase fluid intake.

Osmotic laxatives are likely to be the most suitable laxative type for older patients.

Treatment is often hampered by reluctance to talk about bowel problems so healthcare

providers should proactively identify older constipated patients who are self-

medicating or not receiving treatment.

Conclusions: With certain modifications, general treatment guidelines can be applied

to older people with constipation although specific guidelines are still required for this

age group. Awareness of constipation, its complications and treatment options needs

to be increased among healthcare providers, patients and carers.

2
What’s Known?

Chronic constipation is a disorder that disproportionately affects older people;

however, no clear pathophysiological reason for this has been identified. Untreated

constipation can eventually lead to inpatient hospitalisation and increases the risk of

impaction and faecal incontinence. Despite its high prevalence in older people, there

are no treatment guidelines specific to this population at a national or European level.

What’s New?

A panel of experienced healthcare professionals used their clinical expertise to

evaluate the existing treatment guidelines for constipation and apply them to the

treatment of constipation in older people. Based on existing guidance and their own

clinical experience, the panel also proposed methods that will allow healthcare

providers to identify patients with untreated constipation and enable treatment before

they require admission to secondary care.

3
INTRODUCTION

Background

The median prevalence of constipation is estimated to be 16% in adults overall and

33.5% in those aged 60–101 years [Bharucha et al., 2013a]. However, despite its high

prevalence, the precise symptoms of constipation are ill-defined [Chatoor et al.,

2009]. In general, patients are reported to associate constipation with both infrequent

bowel movements and stools that are difficult to pass; on the other hand, physicians

have been found to prioritise stool frequency when diagnosing constipation [Herz et

al., 1996]. It was these generally contrasting views that led to the development of the

Rome Diagnostic criteria, which have become the most widely used clinical definition

of constipation [Longsreth et al., 2006; Lacy et al., 2016].

Although constipation is not normally life threatening, it is known that its impact on

the quality of life of those suffering with the condition can be as great as the impact of

diabetes and osteoarthritis [Belsey et al., 2010]. Older patients with constipation are

also at risk of psychological and social distress. The seriousness of constipation

combined with its high prevalence has the potential to place a considerable burden on

healthcare infrastructure; for example, in England between April 2013 and April

2014, there were 63,427 patients admitted to hospital with constipation and this

accounted for 159,997 bed days [Health and Social Care Information Centre, 2015a].

Given that the average cost of a single bed day (excluding the cost of treatments and

procedures) is £303 (~€375) to the UK National Health Service [Department of

Health (UK), 2015] there is an undeniable economic case for identifying and treating

constipated patients before they require hospital admission. Unfortunately, equivalent

economic data for other European countries are not publicly available although a

4
recent comparative survey suggests that the prevalence of constipation is similar in

France, Germany, Italy and the UK [Wald et al., 2008].

Chronic constipation is a particular problem in older people. It is estimated to affect

30–40% of older people living at home and over 50% of nursing home residents

[Gallagher et al., 2009]. However, it is believed that the increased prevalence of

constipation in older people is not due to age-related physiological changes; a healthy

older person is as likely to experience constipation as a young person is [Norton,

2006; Gandell et al., 2013]. Reduced physical activity is thought to be a major cause

of constipation in older people with active individuals being less likely to experience

constipation than those who are chair-bound who are themselves less likely to

experience it than the bed-bound [Kinnunen, 1991]. Similarly, constipation is more

common in older people who are resident in long-stay wards than those who live in

the community [Read et al., 1995] and has a prevalence of around 70% in this

population [Rey et al., 2014]. It has been observed that being bedridden for over

15 days is significantly associated with dissatisfaction with bowel emptying

movements [Cardin et al., 2010]. Another key cause of constipation, which is

particularly relevant to older people, is the impact that polypharmacy has on the

function of the gastrointestinal tract [Dennison et al., 2005]. Unfortunately, it may not

be possible to reduce the number of medications an older person receives nor is it

always possible to increase their levels of physical activity; this highlights the

importance of effective pharmaceutical intervention to treat constipation in older

people.

If constipation is not treated effectively, it can develop into faecal impaction

[Gallagher et al., 2008], which can often require emergency hospitalisation. In

England in 2014, 792 patients aged 60 years and over were admitted to hospital for

5
manual evacuation of impacted faeces; this age group represented 68% of all adult

admissions for this procedure [Health and Social Care Information Centre, 2015b].

The average length of hospital stay for a patient with impaction was 7 days – a burden

on healthcare resources that could easily be avoided through better management of

constipation. Furthermore, uncontrolled constipation is the main risk factor associated

with cases of faecal impaction in nursing homes [Rey et al., 2014].

However, appropriate management requires timely recognition of the symptoms and

this can be complicated by the apparently contradictory connection between

impaction and incontinence [Nelson et al., 1998]. For example, it has been shown that

by ensuring complete rectal emptying it was possible to reduce the frequency of

faecal incontinence in a group of elderly nursing home residents [Chassagne et al.,

2000]. These findings appear to demonstrate that effective, early treatment of

constipation can have a beneficial effect on the quality of life of frail patients. Bowel

health is also related to overall health; for example, faecal impaction may be

associated with urinary dysfunction and can lead to stercoral ulceration and bleeding

[Gallagher et al., 2009; Serrano Falcón et al., 2016]. An additional risk of impaction is

that it can cause faecal overflow that can be mistaken for incontinence; if this is

treated with an anti-diarrhoeal it can make the impaction worse [Tracey, 2000; De

Lillo et al., 2000]. Improperly diagnosed ‘overflow’ incontinence resulting from

impaction can also be a key trigger of nursing home admission [Wilson, 2005;

Norton, 2006]. The potential for confounded diagnosis that results in inappropriate

treatment and subsequent failure of the condition to respond (or even get worse) only

serves to underline the importance of identifying and treating chronic constipation in

older people.

6
The Need for a Consensus Statement

Although several organisations have produced treatment guidelines that address

chronic constipation in the general population [Paré et al., 2007; Piche et al., 2007;

Bergert et al., 2010; Nederlands Huisartsen Genootschap, 2010; Bove et al., 2012;

Andresen et al., 2013; Bharucha et al., 2013b; National Institute for Health and

Clinical Excellence, 2015; Serra et al., 2016], there are no guidelines that specifically

describe how to manage the condition in older people [International Longevity

Centre-UK, 2013]. It was recognised by the consensus panel that the lack of clear

advice on the best way to manage constipation in older people is a serious oversight,

particularly in light of how frequently it occurs in this population and its potential to

markedly impact on patient quality of life. To address the lack of guidance, this

consensus statement was developed to evaluate the existing guidelines with respect to

the unique challenges that the older population faces.

It was also recognised that there is an urgent need to increase awareness of

constipation. Patients and health care providers alike need to know the importance of

early treatment and the serious risk of complications; therefore, this consensus

statement considers current approaches towards constipation treatment and proposes

several methods that could be adopted to improve patient quality of life and reduce

the economic burden of constipation.

METHODS

A meeting was arranged to discuss constipation in older people. European healthcare

professionals were invited and a date was chosen such that the greatest number of

responders could attend. A panel of six of these experts met in London in October

2015. The panel represented five European countries (Germany, Italy, the

7
Netherlands, Spain and the United Kingdom) and came from a variety of backgrounds

(gastroenterology, nursing, geriatrics and pharmacology). Each member of the panel

had significant clinical experience of treating older people with constipation. Several

panel members also had a background in clinical research and guidance development.

Before the meeting, attendees voted to determine the priority of discussion topics and

an agenda was created. At the meeting, participants discussed, in structured form,

their understanding of how constipation is addressed in their own country, their own

experience of treating constipation and ways they thought that treatment could be

improved. The day’s discussion was summarised in a comprehensive set of minutes

and these were used to compile a list of consensus points, which were approved by the

meeting participants. The group also provided their most relevant local treatment

guidelines and these were evaluated along with guidelines from countries not

represented in the meeting. This local guidance was supplemented with the group’s

consensus on best practice advice based on literature and experience. The minutes,

consensus points and treatment guidance were then used to prepare this manuscript.

All panel members were involved in the writing, review and approval of the

manuscript.

DISCUSSION

Constipation is a serious problem for older people

There is a widely held belief among the public that constipation is related to lifestyle

factors such as poor diet and lack of exercise [Mihaylov et al., 2008]. As a result, the

majority of people experiencing constipation will respond by changing their lifestyle

as opposed to seeking pharmaceutical treatments [Wald et al., 2008]. However, there

is limited evidence to suggest that lifestyle factors are always the main cause of

constipation and that changing one’s behaviour will alleviate constipation [Müller-
8
Lissner et al., 2004]. Increased fibre consumption is often recommended as a

treatment for constipation and, though it is sometimes effective, there are situations

where it can make constipation worse and/or cause additional discomfort to patients

due to bloating, flatulence and distension [Read et al., 1995; Bosshard et al., 2004;

Müller-Lissner et al., 2005]. Reduced mobility is also implicated as a cause of

constipation although research suggests that it is often only one of several factors and

that increasing mobility alone will not provide relief from constipation [Müller-

Lissner et al., 2005]. Importantly, low mobility in older people may be the result of

frailty and it may not be possible for them to exercise.

Review of Existing Guidance

Although there are no formal European-level guidelines for the treatment of

constipation in older people, several countries have issued guidelines that are intended

to provide advice for healthcare providers treating constipation in the general

population. Much of the information from these guidelines can be applied to older

people; however, it is important to consider the aging population in their own context.

Below, various national guidelines are summarised with a particular emphasis on how

the information pertains to older patients.

United Kingdom

The UK’s National Institute for Health and Clinical Excellence (a public body that

develops clinical guidelines) has issued separate clinical recommendations for the

treatment of constipation in adults and children but no guidelines have yet been issued

for older people [National Institute for Health and Clinical Excellence, 2015]. In the

guidelines addressing constipation in adults, healthcare providers are recommended to

inform patients of the importance or dietary fibre, fluid intake and exercise and to

9
identify any medication that the patient may be taking that could cause constipation.

Patients should be reminded that defecation should be unhurried and that they should

attempt to defecate soon after waking or within 30 minutes of a meal. Particularly

relevant to older patients is the recommendation that people with limited mobility

should have sufficient access to carers such that they can quickly respond to the urge

to defecate.

Once it is established that lifestyle factors are not responsible for a patient’s

constipation, the recommended first-choice laxative is a bulk-forming laxative;

however, the guideline specifically notes that the necessary increase in fluid intake

might make this unsuitable for older people. Osmotic laxatives are the recommended

alternative to bulk-forming laxative with macrogol preferred over lactulose. In the

event that stools continue to be difficult to pass despite being soft, the guidelines

advise that a stimulant laxative should be administered with the osmotic laxative.

During the discussions that took place as part of the development of this consensus

statement, it was noted that clinical experience in the UK suggests that sodium

docusate is a good first-choice laxative for initial treatment of older people. In the

event that sodium docusate is ineffective, an osmotic laxative should be used with

macrogol as the first choice. It was also proposed that if stools are softened by

laxative treatment but are still difficult to pass, a glycerine suppository, stimulant

laxative or a microlax enema should be considered in that order of preference unless

rectal administration is not acceptable for the patient or carer.

The guidelines also describe a detailed approach for the treatment of impaction. In the

event that the impacted stool is hard, a high, escalating dose of oral macrogol should

be used. An oral stimulant laxative is recommended when this approach is found to be

ineffective, or if stools were soft to begin with. If oral laxative treatment fails to
10
resolve impaction, suppositories (bisacodyl for soft stools and glycerol with or

without bisacodyl for hard stools) or a docusate or sodium citrate enema should be

considered. If these first-choice enemas do not succeed, sodium phosphate or arachis

oil enemas should be used. Clinical experience in the UK has found this approach to

be suitable for older people.

Germany

In Germany, a guideline on pathophysiology, diagnosis and treatment of chronic

constipation in the general population was written based on a systematic literature

search [Andresen et al., 2013]. Participating experts were selected by the German

Society of Neurogastroenterology and Motility and the German Society for Digestive

and Metabolic Diseases in cooperation with four further medical societies.

The guideline suggests that frequently cited pathophysiological factors such as a low-

fibre diet, insufficient fluid intake and lack of mobility may aggravate existing

constipation, but have not been proven to cause constipation; therefore, measures to

correct such deficiencies are of unclear benefit. Nonetheless, patients should be

advised to increase dietary fibre, aim to drink 1.5–2 L of fluid per day, maintain a

level of exercise appropriate for their age and avoid habitual voluntary stool restraint.

If lifestyle changes and bulk-forming laxatives like psyllium prove insufficient or

intolerable, further medical therapy should be considered.

The guideline recommends macrogol, bisacodyl and sodium picosulfate as first-

choice treatments. The recommended second-line treatments are anthrachinones and

sugars/sugar alcohols (lactulose, lactitol, sorbitol and, depending on the individual

disposition, lactose). Further possibilities are combinations of the aforementioned

measures, suppositories (e.g., bisacodyl) and, as a temporary measure only, enemas.

11
Salinic laxatives such as magnesium hydroxide, are not recommended for chronic

constipation due to possible adverse effects. Paraffin oil is not recommended due to

the risk of lipid pneumonia secondary to microaspiration and disturbed absorption of

lipid-soluble vitamins. Prucalopride is recommended for use only where lifestyle

changes and conventional therapy have been unsatisfactory or intolerable. Where

available, lubiprostone and linaclotide can be used to treat prucalopride-resistant

constipation; the development of patient-specific treatment regimes is encouraged.

Opioid-induced constipation can treated using opioid antagonists. Methylnaltrexone is

mentioned but it has the disadvantage of requiring subcutaneous administration.

Further antagonists are alvimopan and oral naloxone. It should be noted that since the

guideline was published, Naloxegol, a pegylated naloxone derivative, has been

approved.

In addition, relevant guidelines for the treatment of constipation in a palliative care

setting have been published by the Leitliniengruppe Hessen (Hesse Guidelines Group)

under the auspices of Kassenärztliche Vereinigung Hessen (Hesse Association of

Statutory Health Insurance Physicians) [Bergert et al., 2010]. Patients in palliative

care often experience frailty, immobility, polypharmacy and decreased fibre and fluid

intake. In many ways, this makes them comparable with older people from the point

of view of constipation and its treatment. The guidelines recommend that the first

stage of treatment should involve an increase in fibre, fluids and exercise. However, if

these lifestyle changes are difficult to make because of a patient’s condition,

therapeutic intervention is recommended. In the first instance, therapies based on

macrogol with electrolytes are advised because they rarely cause bloating and they

maintain electrolyte balance. In the event of a hardened stool, stimulant laxatives with

the possible addition of lubricants should be used with manual removal considered a

12
last resort. For patients who cannot swallow, rectal administration of bisacodyl or

glycerol is recommended.

Italy

The Italian Association of Hospital Gastroenterologists and the Italian Society of

Colo-Rectal Surgery published an evidence-based consensus statement on the

diagnosis and treatment of chronic constipation and obstructed defecation in adults

[Bove et al., 2012]. The authors found no evidence that constipation can be effectively

treated by increasing physical exercise and improving defecation habits; increased

fluid intake is recommended only if a patient is dehydrated. The guideline awards the

highest grade of recommendation (grade A) to macrogol, tegaserod and prucalopride.

Psyllium, lactulose, lubiprostone and linaclotide receive a Grade B recommendation.

Experience from Italy suggests that treatment of older people with constipation should

begin with a thorough review of the patient’s medications. If any constipation-causing

medications are identified, the aim is to replace them with alternate therapies where

possible. If this is not possible or fails to resolve the constipation, patients who are

consuming less than 30 g of soluble fibre per day should aim to increase their intake

to this level gradually. In addition, patients should be educated on recognising and

responding to the urge to defecate and, in order to benefit most from the gastrocolic

reflex, visits to the toilet should be routinely scheduled soon after waking and after

meals. Elevating the feet with a foot stool and, if possible, abdominal and pelvic floor

muscle-strengthening exercises may provide additional help with defecation [Lacy et

al., 2016].

It is generally considered that when patients fail to respond to fibre supplementation,

osmotic laxatives such as macrogol should be used, with the dose titrated until a

13
clinical response is achieved. Syrup-based formulations are particularly well tolerated

by dysphagic patients. In patients with more refractory constipation, stimulant

laxatives (bisacodyl, senna) and prokinetic agents (prucalopride 1 mg/day) or

secretagogue drugs (such as linaclotide, which improves intestinal transit and

abdominal pain) should be used, if necessary in conjunction with osmotic laxatives. In

patients with pelvic floor dysfunction, periodic hydrocolontherapy or once- or twice-

weekly enemas are considered effective. Where patients have no cognitive

impairment and demonstrate ano-rectal muscular integrity, biofeedback therapy can

be effective in patients with pelvic floor dysfunction or faecal incontinence.

For residents of nursing homes, a daily stool diary should be maintained with a record

of stool profile as described by the Bristol stool scale. It is important for the nurses

who have daily contact with patients to coordinate their activities with attending

physicians, especially in residents who are not able to report symptoms. Attention

from a dietician may also be beneficial. Macrogol should be used as the first-line

therapeutic intervention with dose titrated according to patient response. After three

days without a bowel movement, a rectal exam should be conducted followed by a tap

water enema. A combination of osmotic laxatives with stimulant or prokinetic

laxatives (bisacodyl/senna or prucalopride) is also considered to be effective in

nursing home residents suffering with constipation. A technical aid in the

management of constipation that has been shown to have some effect in older people

is an abdominal massage, which can increase the frequency of bowel movements and

decrease discomfort in patients with constipation (Sinclair, 2011).

The Netherlands

Dutch guidelines have been issued by the Nederlands Huisartsen Genootschap (Dutch

College of General Practioners) for the treatment of constipation in the general

14
population [Nederlands Huisartsen Genootschap, 2010]. The guidelines recommend

lactulose or macrogol as first-line treatments and note that macrogol with electrolytes

is as effective as macrogol without electrolytes. Macrogol with electrolytes is

recommended for treating faecal impaction. If a patient does not tolerate a treatment –

for example, they experience bloating or dislike the taste – the health care

professional should select another treatment.

Spain

Spanish guidelines for the treatment of constipation in the general population were

developed using an evidence-based approach and released in 2016 [Serra et al., 2016].

The guideline recommends that after drug-related or medical causes of constipation

have been ruled out, patients should be encouraged to increase consumption of

soluble fibre and fluids and take regular exercise. If this is not possible or is

ineffective, osmotic laxatives are recommended as the first line treatment with the

guidelines noting the stronger evidence base for the use of macrogol over lactulose.

Stimulant laxatives should be used as a recue medication for non responders. When

laxatives fail to produce a satisfactory relief of symptoms, prucalopride is

recommended as an alternative. A functional study by a gastroenterologist should take

place if none of these treatments is effective. Clinical experience in Spain indicates

that these general guidelines would be suitable for the treatment of older patients.

France

In France, general treatment guidelines have been issued by the Société Française de

Gastroentérologie (French Society of Gastroenterology) [Piche et al., 2007]. The

authors took a systematic, evidence-based approach, which considered 722 different

articles. The guidelines recommend that the first step of any treatment should be for

15
healthcare professionals to remind patients of the importance of maintaining regular

toilet habits and to establish that patients are allowing sufficient time for bowel

movements and that they have enough privacy. The guidelines also cite a study in

older people reporting that the use of a footstool while on the toilet improves stool

movement of through the anal canal. The guidelines do not find sufficient supporting

evidence for them to recommend increased hydration and increased physical activity.

A gradual increase of dietary fibre intake is suggested although the guidelines

mention that it may only have a modest impact.

The first-line therapeutic interventions recommended by the guidelines are osmotic

laxatives (macrogol, lactulose or milk of magnesia) and bulk-forming laxatives

(psyllium, ispaghula, sterculia gum and bran). No single laxative is identified as a

first-choice treatment. Stool softeners are recommended as a second-line treatment

although the guidelines note the propensity of mineral oils to increase the risk of

faecal incontinence and anal seepage, and the possibility that they may leech lipid-

soluble vitamins A, D, E and K. The guidelines also mention that elderly patients may

be at risk of complications caused by choking on orally administered oils. Stimulant

laxatives are recommended for use only when other treatment options have failed;

however, their usefulness in especially frail elderly patients is noted. For certain older

patients or patients with neurological diseases suppositories and enemas are proposed.

Canada

A Canadian consensus group was assembled to evaluate the literature and produced a

statement on the treatment of constipation in a general population [Paré et al., 2007].

The group concluded that there was insufficient evidence to support increased fluid

intake and increased exercise to relieve constipation although they supported the use

of increased fibre intake. It is noted, however, that older patients may already have
16
especially low fluid intake and that this should be increased. Unsurprisingly, given

that both guidelines were based on a comprehensive review of clinical trial data, the

conclusions of the panel were similar to those of the Société Française de

Gastroentérologie [Piche et al., 2007]. Initially, it is recommended that patients are

educated on bowel function followed by a gradual increase in dietary fibre. Should

this be ineffective, osmotic laxatives are recommended followed by glycerine-based

suppositories if necessary. A specific osmotic laxative is not recommended although

the guidelines note that milk of magnesia is cheaper than macrogol. However, the

guidelines also highlight the gas-producing effect of lactulose and the fact that there

have been no long-term studies of the effectiveness of lactulose or milk of magnesia.

USA

The American Gastroenterological Association has also published a set of guidelines

for the treatment of constipation in the general population [Bharucha et al., 2013b]. In

common with several other guidelines, they recommend increased fibre as the initial

treatment. As a first line treatment, they recommend an inexpensive osmotic agent

with milk of magnesia and macrogols given as examples.

Summary of local guidance

Figure 1 shows a simple treatment flowchart based on the local guidelines discussed

above.

Osmotic laxatives are considered to be the most effective treatment in the general

population [Gandell et al., 2013] and this is reflected by their recommendation as a

first-choice laxative in general treatment guidelines in Germany [Bergert et al., 2010;

Andresen et al., 2013], Netherlands [Nederlands Huisartsen Genootschap, 2010],

Spain [Serra et al., 2016], France [Piche et al., 2007], Canada [Paré et al., 2007] and

17
the USA [Bharucha et al., 2013b]. In contrast, the UK’s National Institute of Clinical

Excellence guidelines recommend bulk-forming laxatives over osmotic laxatives

although they note that the increased fluid intake required by patients receiving bulk-

forming laxatives may make them unsuitable for older people [National Institute for

Health and Clinical Excellence, 2015]. Several clinical trials have demonstrated the

effectiveness of osmotic laxatives in this population. For example, lactulose has been

shown to reduce constipation-associated symptoms in older people [Wesselius-De

Casparis et al., 1968; Sanders, 1978] and the clinical effectiveness of macrogol with

electrolytes has been demonstrated in older people with Parkinson’s disease

[Zangaglia et al., 2007].

The relative effectiveness of lactulose and macrogol in the general population was

recently evaluated in a Cochrane review [Lee-Robichaud et al., 2010]. The review

considered data from 10 clinical trials and concluded that, overall, macrogol increased

stool frequency and improved stool form. As well as the clearer efficacy of macrogol

over lactulose, there are also reports of bloating and flatulence when lactulose is

metabolised by gut flora – something that impacts on treatment tolerability and patient

quality of life [Attar et al., 1999].

Awareness of constipation

The perception that chronic constipation is not in itself a treatable medical condition

leads to under-reporting and this is compounded by the fact that many older people

consider bowel health a private matter and find it difficult to discuss [Norton, 2006].

Consequently, many patients resort to self-medication [De Lillo et al., 2000; Dennison

et al., 2005] and therefore do not benefit from the expertise of healthcare

professionals.

18
In order to circumvent the self-imposed social stigma associated with constipation, the

authors recommend that healthcare providers should proactively identify patients with

constipation who are not receiving appropriate treatment. In older patients, this could

be addressed by asking few short questions at routine health visits that would allow

healthcare providers to determine if any treatment is required. The questions could be

as simple as “are you happy with your bowels?”, “how long do you spend on the

toilet?”, “do you ever need to strain on the toilet?”, “how frequent are your bowel

movements?”, “do you use any medication for your bowel?”. Alternatively, questions

that are more general could be asked such as “do you have any problems with your

bowels?” or “do bowel symptoms prevent your enjoyment of any part of life?”.

Introducing patients to the Bristol stool scale may also assist in the discovery of

undiagnosed constipation. Where a healthcare provider thinks that a patient might be

constipated, they can ask further questions and decide on an appropriate intervention.

To encourage patients who self-medicate to seek professional advice, a partnership

with pharmacists would be useful. For example, when a patient buys an over-the-

counter constipation treatment, the pharmacist should ask a simple question such as

“how long have you been using this?”. If the answer is longer than 3 months, the

pharmacist should recommend an alternative treatment or encourage the patient to

seek further advice from a healthcare provider.

One final group of older people with constipation who may prove difficult to identify

are older people with communication difficulties [Tracey, 2000]. In the opinion of the

authors, stool diaries and digital rectal examination could be used with the goal of

identifying constipation before patients require treatment for impaction. As discussed

above, preventing impaction is likely to reduce the occurrence of faecal incontinence;

this is important on many levels because it can have a substantial negative impact on

the dignity of patients and increases the workload of nursing home staff.
19
To better emphasise the need for proactive identification of patients suffering with

constipation, the economic aspects of constipation need to be thoroughly considered.

Only through the collection and reporting of robust patient outcome data will it be

possible to encourage general practitioners to think in terms of long-term secondary

care costs instead of short-term prescribing costs. To date, there has been almost no

research into the secondary care costs of untreated constipation although a report by

the company Coloplast determined that constipation cost UK hospitals £145 million

(€179 million) in 2014/15 [Coloplast, 2016]. Some research has reported on the

estimated economic value of macrogol over lactulose [Christie et al., 2002; Guest et

al., 2008] but the research only considers the basic cost of the treatments and does not

evaluate the cost of secondary care that can arise from complications.

Potential benefits of the consensus statement

The principle aim of this consensus statement was to evaluate the current guidance on

the treatment of constipation and assess its applicability to an older population. This

combined advice is intended to improve patient care and reduce the likelihood of

complications such as faecal impaction. It can also be anticipated that patients who

are successfully treated will be encouraged to seek treatment for similar problems in

the future and will therefore have improved bowel health for their entire lives.

The authors seek to reemphasise the serious nature of constipation and address the

reasons it continues to go undetected and untreated. It needs to be emphasised that

patients can be reluctant to discuss bowel problems and that it is up to healthcare

professionals to identify proactively those patients who are unsuccessfully self-

medicating or who do not realise they have a problem. By increasing awareness of the

personal, social and economic costs of constipation, it is envisaged that a greater

number of constipated patients will receive the attention they need and be treated

20
appropriately. It is likely that this will reduce the number of patients requiring

expensive secondary care. Public awareness of bowel issues needs to be increased; in

short, people need to know that they can be happy with their bowels. They also need

to know that acute episodes of constipation can be addressed with the help of

healthcare professionals before the secondary consequences of untreated constipation

impact on health and well-being. By raising these issues in this consensus statement,

it is hoped that the relevant authorities will be encouraged to reach out to older

patients suffering with constipation and let them know that support is available.

CONCLUSIONS

The bowel health of older people has the potential to have a marked impact on their

overall quality of life; unfortunately, it is something that many people are

uncomfortable discussing. For this reason, constipation often goes untreated, which

increases the risk of impaction and incontinence. This consensus statement provides

treatment guidance for older people, which is itself derived from general evidence-

based treatment guidelines that have been produced by respected national authorities.

Furthermore, it draws attention to the social and economic importance of effective

constipation treatment and includes suggestions for healthcare providers to identify

patients who are unsuccessfully self-medicating or not seeking treatment. It is hoped

that this consensus statement will serve to focus attention on the opportunity to

improve the quality of life of patients and reduce the economic burden of constipation

across Europe. The present document underlines the current issues and how the

healthcare community is failing older people. The authors hope that this work will

serve as a ‘call to arms’ to those working with older people to develop guidelines,

especially where they do not already exist, that address the challenges posed by the

condition.

21
AUTHOR CONTRIBUTIONS

AE, FMR, MCN, KUP, ER and JR attended the consensus meeting and contributed to

writing and critical review of the manuscript. JR chaired the meeting.

ACKNOWLEDGEMENTS

Funding for this project was provided by an unrestricted educational grant from

Norgine Pharmaceuticals Limited. Medical writing assistance was provided by

Dr James Serginson of Niche Science & Technology Limited and was paid for by

Norgine Pharmaceuticals Limited.

22
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 Figure 1 Treatment of Constipation
If an effective treatment is found, adjust dose as necessary and repeat
treatment as required. Consider withdrawal if patients regularly produce
soft, formed stools. Withdrawal should take place after 2–4 weeks of
START Stop/replace medication
normal passage of stool. Withdrawl should not be sudden and may take
several months. For drug-induced constipation, continue for as long as
constipating drug is used.
YES Specific treatment scenarios
Is the patient receiving medication YES Can the medication be
that is known to cause constipation? stopped/replaced? Patient unable to swallow Opioid-induced constipation

NO NO
Stop/replace medication
Osmotic laxative administered orally
as syrup
Advise patient on lifestyle
measures:
Increase patient’s fluid and fibre
- Increase dietary fibre
Osmotic laxative intake and use an osmotic laxative
- Eat regular meals
and a stimulant laxative
- Drink sufficient fluids
- Increase mobility Administration of osmotic laxative
- Toileting advice (including via gastrostomy tube (if present)
correct position on toilet) Enema
Stimulant laxative (if continuous treatment not
required)
Rectal administration of stimulant
laxative
If two laxatives from different Opioid antagonist (Naloxegol
classes have been tried at the preferred if available)
highest dose without success for at Suppositories/enema
least six months, consider
prucalopride or lubiprostone Rectal administration of stimulant
laxative with stool softener Trans-anal irrigation

29

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