Senior man exercising next to a lake

Introduction

Constipation is a common problem in the elderly population. Epidemiological studies show that the incidence of constipation increases from the age of 65 by 25-50%. The frequency of constipation may be as high as 75% of patients who are in senior care facilities, hospitals or other institutions and in particular if they suffer from dementia, stroke, Parkinson’s disease or other degenerative neurological conditions. Constipation is also more common in patients taking medications that may affect bowel motility as discussed below.

Constipation is a problem that affects the quality of life, causes discomfort and many times significant concern that often results in several office visits, specialty referrals, hospital admissions, and surgical procedures. Constipation has therefore, a major impact on healthcare costs in the United States.

What is constipation?

The term constipation for everyone means different things. In general, it can mean a change in bowel habits, the production of hard stools, the production of small stools, difficulty in defecation, straining, reduced stool frequency, the feeling of incomplete evacuation, and so on. It is therefore very important to understand exactly what the patient is complaining about when he says that he suffers from constipation. Taking a detailed medical history is perhaps the most important factor in understanding and addressing the patient’s problem.

Medical history

As we explained earlier it is important to figure out what the term constipation means for the patient, to look for possible accompanying symptoms such as abdominal pain, bleeding, weight loss, discuss the patient’s diet, his medical treatment, his previous medical history, possible abdominal surgery in the past, etc.

The duration of the symptoms, any accompanying symptoms and other evidence from the medical history and physical examination will determine whether or not there is a need for laboratory, imaging examinations (e.g. CT scan) or endoscopic examinations (e.g. colonoscopy).

Causes of constipation

The causes of constipation are several and relate to problems of the bowel, but also other systems of the body, which can indirectly affect the intestine. In older people the causes of constipation are usually multifactorial. Trying to classify the causes of constipation, we can distinguish the following categories:

  • Obstructive causes: Colorectal cancer, narrowing of the bowel due to ischemia (poor blood circulation), inflammation of the bowel or external pressure from tumours and growths from neighbouring organs, etc.
  • Endocrine and Metabolic Causes: Diabetes, hypothyroidism (hypoactive thyroid), hypercalcaemia (high calcium in the blood), chronic kidney failure, etc.
  • Neuromuscular causes: Spinal cord injuries, Parkinson’s disease, multiple sclerosis, amyloidosis, scleroderma, myotonic dystrophy, etc.
  • Medicines: Opioids, antihypertensives, antidepressants, antiparkinsonian, antipsychotics, etc.
  • Other causes: diet low in fiber, dehydration, sedentary life, being bedridden, etc.

Management

The ways we deal with constipation depend on the severity of the symptoms, the causes, the accompanying diseases, and so on. Generally high fiber diet, hydration, daily regular toilet visit and exercise help the patient suffering from constipation. Many times, however, especially in the elderly, the above tactics do not help effectively or are not very practical. We therefore need to resort to some kind of pharmaceutical intervention for these patients. It is important to stress that the use of pharmaceuticals should be done with care and should be under medical supervision.

Categories of laxatives we use:

Stool bulking agents: The substances used contain natural or synthetic fiber in various forms. They are the first line of treatment for constipation and they work by increasing the volume of stools. Insoluble fiber has the tendency to cause gas and it is advisable to increase the dose gradually.

Osmotic laxatives: Osmotic laxatives consist of substances that are not absorbed by the digestive tract and thus remaining in the intestine retain a greater amount of water and as a result they soften the faeces.

Stimulant laxatives: These laxatives are based on senna or other synthetic substances and cause an increase in intestinal peristalsis (movement).

Fecal emollients / suppositories and enemas: This category is useful in cases where we suspect fecal impaction. They are usually combined with some oral laxatives for best results. Fecal impaction is more common in bedridden patients, neurological patients, people in nursing homes, and so on. These patients have a low sensitivity in the rectum, so they do not perceive the presence of stools. As stools accumulate in the rectum, they are dehydrated and cause paradoxical diarrea. This is confusing many times and delays the diagnosis which is established only with a rectal digital examination.

Summary

Patients aged over 65 often experience constipation, especially if they are suffering from neurological, metabolic or other systemic conditions, if they are taking certain medicines, are not being properly fed, or have reduced mobility. Good history and physical examination are often enough to assess the possible cause of constipation, but may sometimes require laboratory or other examinations to rule-out more serious conditions. Diet adaptation or simple pharmaceutical approaches are often enough to address the symptoms of constipation. However, there are cases where the severity or chronicity of constipation requires the help of a specialist.

Senior couple walking in the park

Depression is considered among the most disabling conditions affecting the quality of life of millions and contributing to increased mortality rate, especially in the elderly population where depression accounts for over 80% of deaths by suicide. Self-harm in adults over the age of 60 is found to be 67 times greater than the general population. Depression can lead to profound loss of function, mood changes, physical symptoms, altered thoughts and perception. Depression is considered an heterogenous group of disorders with overlapping core features including low mood, lack of interest and pleasure (anhedonia), fatigue and physical symptoms such as lack of appetite, sleeping disorders, hallucinations, motor symptoms etc.

Depression especially in the elderly can complicate other chronic organic disorders such as coronary artery disease, diabetes, kidney failure affecting their treatment by virtue of apathy, lack of engagement and compliance with the medications. It is also considered a risk factor for the development of coronary artery disease, stroke, colorectal cancer, irritable bowel syndrome and others. Depression in the elderly does not always manifest the same way as younger adults. The symptoms many times tend to be more severe and more physical as compared to the younger patients. 

Depression in the elderly many times is under-detected by their primary physician. Depression in later life is also far less likely to be treated than in younger adults. And even in cases where it is recognized, it is less likely to be referred to the psychiatric service. It is estimated that around one in six older depressed people in the UK receive treatment of any sort and only 6% is referred to the psychiatrist compared to 50% of young adults.

Studies vary regarding the real prevalence of depression in the elderly with reports varying from 0.4 to 35% with an average of 13.5% in ages over 55. There is a broader agreement regarding factors contributing to increased prevalence of depression. The important factors are being widowed and divorced, living in communities with poor social networks and low socioeconomic conditions. Interestingly enough, protective factors are having a religious faith, excercise, good physical health, being married and living within a strong social network. 

In terms of treating depression in the elderly we have to consider that it is a condition that can be self-limiting in a percentage of patients that can reach 30-40%. The principles of treatment in the elderly are the same as for young people. Treatment with antidepressants can reach a 60% response rate. The choise of the antidepressant medication has to be tailored to each individual taking into consideration the side effect profile of the drugs and co-morbidities of the elderly patient. Best outcomes are achieved when combining drugs with psychological therapies.

As depression tends to be so heterogenous, old and new therapies show varied results. It seems that an early response to therapy predicts better outcome. Following recovery it is important to carry on the therapy in the elderly as this strategy seems to lower the relapse rate. Approaches that minimize disability, promote independence, supportive therapies, and social networks play an important part of a treatment plan.