Constipation is a heterogenous disorder with a wide spectrum of symptoms and complaints. Physicians define constipation as less than three bowel movement per week3. Constipation is a condition that is characterized by infrequent bowel movements that are painful or difficult, or stools that are hard in consistency. Infrequent bowel movements alone are not a reliable indicator of constipation because bowel frequency can vary between three times a day to once a week among normal individuals. Therefore, hard stools that are difficult to pass or infrequent stools accompanied by abdominal pain, back pain, and abdominal bloating define importance of constipation12.
Constipation is more common than any other chronic disease including hypertension (48 million), migraine(33 million), obesity(50 ,million) and diabetes mellitus(15 million) 6.
The accurate prevalence of constipation is difficult to calculate due to the increased practice of self medication and laxatives are the common OTC products available all over the world. In U.S, based on an epidemiological analysis of almost 5million people in the National Health Interview Survey, the National Hospital Discharge Survey, and the National Disease and the Therapeutic Index in the United States, and the Morbidity Statistics from General practice in England and Wales, the average prevalence of constipation was 2% and this increases exponentially after the age of 65 years and reaching 10% in those persons older than 75 years6.
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In Canada approximately 10-15% of the general population suffer from constipation and in people aged above 65 years this rate rises to 30-40 %. In 2006, Mehmetoglu reported that the prevalence of constipation in Turkey is 12.8%4 . Another epidemiological survey explored the duration and frequency of constipation in 13,879 participants from four continents and it shows that 12% of people world wide suffers from self-defined constipation and this figures varies among different regions of people. In America and Asia Pacific suffers twice as much as their European counterparts, where the incidence of constipation was lowest and the ratio of Americas and Asia pacific mean is 17.3% versus European is 8.75% 13.
Very few studies regarding constipation and laxative uses have been carried out in Indian population, the spicy food and disorganized style of eating practice in India has become a factor for inducing constipation. Studies reported in India unlike other countries the middle aged are also more prone for gastrointestinal disorders especially irritable bowel syndrome. Indians mostly practice the traditional style of curing this symptoms , preferably the herbal products such as senna and castor oil14.
Constipation affects an average of 14.8% (2-27%) of the North American adult population. Constipation affects more in women than men(2.1:1 ratio)6. This predominance of females has been attributed to hormonal factors, higher risk of constipation during the luteal phase of menstrual cycle, under the effect of progesterone and damage to the pelvic floor muscles, which may occur in women during child birth or gynecological surgery. Constipation is more prevalent in non-whites than whites(1.68:1). In contrast , constipation is less frequent among black Africans than white Africans, the study states that diet and other factors play an important role15. It occurs in all age groups but is more common in those older than 65 years and younger than 4 years6.
Constipation accounts for more than 2.5 million physician visits and more than 500 million dollars spent on laxatives per year, people with constipation may report decreased productivity and increased absenteeism3. The National Health Interview Survey, indicated that 4.5 million people are constipated most of the year. It is considered that most common gastrointestinal disorder in the United States, resulting in about 2 million annual visits to physicians. The prevalence of constipation is between 30-40% in community dwelling older adults and 50% of nursing home residents experience chronic constipation and between 50% and 74% of nursing home residents use laxatives daily16. In general, individual of lower social, economic and educational level have a tendency towards higher constipation rates 17.
Most people resort to over the counter laxatives for relief of constipation , as reflected in annual sales of 725 million dollars of these laxatives. Sales of over-the-counter laxatives total $660 million annually in the United State . These data was based a part of 20-year-old information, suggest that the inclusive economic cost of constipation is about $1 billion annually in the United States, without factoring in inflationary trends. There were an estimated 700 or more commercially available laxatives and enema preparations in U.S.
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Constipation is a symptom, rather than a disease and it's not a physiological consequence of normal aging. Many age related problems such as decreased mobility, comorbid medical conditions, increased use of medications with a side effect profile that induce constipation and change in diet contribute to the increased prevalence of constipation in older adults17. A number of other conditions in the elderly such as anatomical obstruction, slow transit constipation, pelvic floor disorders, irritable bowel syndrome, metabolic disorders, neurological disorders and psychiatric problems remains as the factor for inducing constipation and constipation is classified as structural, mechanical, metabolic and medication related. It's a common misbelief that the physiology of the colon and anorectum changes significantly with ageing, mean anal canal pressure are lower in older persons than in younger individuals and this reduction is more in women, this increase the risk of fecal incontinence10.
Causes of constipation may originate primarily from within the colon and rectum or may originate externally. Causes directly attributable to colon or rectum include left colon motility, slow colonic motility, Hirschusprung disease, Chagas disease and outlet obstruction which can be anatomical or functional. Causes outside the colon includes poor dietary habit, medications such as narcotics, iron supplements, non-magnesium antacids, calcium channel blockers, anti-cholinergic and psychotropic's and also due to certain physiological conditions such as hypo-thyroidism, diabetic neuropathy, hemorrhoids, hepatic porphyria, hypercalcemia, Parkinson disease(nearly 50 -70% patients are sufferers of constipation)18 and ulcerative colitis 19.
Constipation is classified in to Primary and Secondary. Primary can be classified in to three namely Normal transit constipation, Slow transit constipation and Anorectal dysfunction. Normal transit is also known as functional constipation and in that the stool passes through the colon at a normal rate. In slow transit there occur prolonged delay of stool to pass through the colon and the patients experience abdominal bloating, infrequent bowel movements and the contributing factor includes abnormalities of mycenteric plexus, defective cholinergic innervations and anomalies of noradrenergic neuromascular transmission system. Anorectal dysfunction may be an acquired behavioral disorder.
Secondary constipation means the constipation occurring due to any other particular causes such as endocrine and metabolic diseases, myopathic conditions, neurological diseases and certain medications such as antidepressants, anti-cholinergics, etc 17.
Diagnosis of constipation in older adult should begin with a good history, the first step is to carefully review the patient's diet emphasizing on fiber content, caloric and fluid intake. The patient should be questioned about the level of physical activity as immobile patients are more prone to constipation and their drug profile has to be carefully reviewed in order to list out any constipation inducing medications.
Initial evaluation begins with simple laboratory tests including blood count, thyroid stimulating hormones and electrolytes and an abnormal x-ray can be used to look for evidence of impactation or severe obstipation. Most importantly the patient should be asked what they mean when they say they are constipated, Stool frequency, stool consistency, straining, ease of evacuation, pain with defecation and the need for manual maneuvers should be assessed, though stool frequency is not a good indicator, stool consistency can be used to asses the condition. Examination should be performed to check for systemic diseases such as hypothyroidism or scleroderma or the presence of neurological disorders 10.
If the cause of the constipation is not secondary and not subsiding with laxatives more specialized tests should be considered. Test of colonic transit or pelvic floor should only be considered for older people with severe, intractable constipation. In older patients with symptoms and signs suggestive of defecatory disorders, anorectal manometry and ballon expulsion should be considered 16.
Anorectal manometry is performed by inserting a pressure-sensitive catheter through the anal canal to measure rectal sensation, anorectal reflexes and sphincter pressure. In balloon expulsion a latex ballon is inserted in to the rectum filled with air or water, failure to expel the balloon within 1 min is suggestive of defecatory disorder. In the case of structural rectal abnormality that hinder defecation, defecatory or pelvic magnetic imaging is being used, in older patients who don't have the symptoms of defecatory disorders in such cases colonic transit time should be checked and this can be done by ingesting a capsule of radio-opaque marker followed by abdominal radiograph 5 days later and if more than 20% remain then colonic transit is being delayed 16.
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The treatment includes both pharmacological and non-pharmacological methods, when no secondary cause is found with the patient then empiric treatment should be tried initially for functional constipation and the management should begin with non-pharmacological methods to improve bowel regularity. Then if the constipation is refractory to medical treatment the patient should be referred to a specialist for further diagnostic evaluation.
Non-pharmacological treatment should begin with patient education and training them to recognize and respond to the urge to defecate and the methods listed under non-pharmacological includes bowel training, dietary fiber intake, fluid intake and regular exercise. In bowel training the patients are made to understand the optimal times to have bowel movements that is especially after walking and meals when the colonic activity is more, inadequate fiber intake is one of the main reason for constipation in western countries. Increased fiber intake leads to decreased colonic transit time and bulkier stools, daily recommended fiber intake is 20 to 35 grams daily and if fiber content is low it should be added in to the patient's diet that is 5 grams per day. Sudden rise in the fiber content may lead to bloating and excessive gas. Like fiber, fluid also has a role in normal bowel motility though much evidences are not there certain studies states that decreased fluid intake play a major role in the development of fecal impactation. The National Health and Nutrition Examination survey found that low physical activity is associated with two fold increased risk of constipation, patients with prolonged immobility and bed rest are often associated with constipation hence the patients should be taught with certain physical activities which can improve their bowel motility17 and it was found in a health study including 62,036 women that physical activity two to six times a week were associated with 35 percent of lower risk of constipation. Abdominal massaging is yet another method which is rarely being practiced, application of castor oil pack to the abdomen has increased the intestinal motility in elderly women in U.S, the method doesn't cause any side effects4.
Pharmacological methods should be adopted when non-pharmacological methods fail to respond to the symptom and the use of laxatives are considered to be the prime method of treatment. Laxatives are classified in to four types based on their mechanism of action and there are no evidence -based guidelines on the preferred order of using different types of laxatives. Bulk-forming laxative contain soluble psyllium or pectin or insoluble cellulose products, they are hydrophilic in nature, absorbing water from the intestinal lumen to increase the stool mass and soften the stool consistency, these are common recommendation in the initial treatment for elderly and helpful in IBS, diverticulosis and colostomies. The drugs under bulk laxatives include methylcellulose, polycarbophil , guargum and these drugs should be taken with full glass of water so it is contra-indicated in patients who need to restrict their oral fluid intake 17,19.
Stool softeners also called as emollient laxatives act by lowering surface tension and allowing water to enter the bowel more readily thus preventing the hardening of feces, the active ingredient in most of the stool softeners is a drug named docsate. It doesn't stimulate or increase the bowel movements they are used more to prevent constipation than to treat it. It is more useful for patients with anal fissures or hemorrhoids that causes painful defecation. Precaution should be taken not to be combined with mineral oil as it may increase the absorption and toxicity of mineral oil thereby causes it's accumulation in the body leading to inflammation of lymph nodes, liver and spleen 17,19.
Osmotic laxatives or saline laxatives are hyper-osmolar agents that causes secretion of water into intestinal lumen by osmotic activity, the water softens the stool and increases the pressure within the intestine and increases the intestinal contraction resulting in the discharge of softer stool. The most commonly used osmotic laxatives are oral magnesium hydroxide, magnesium citrate and sodium bi-phosphate. These agents are considered safe as they work inside lumen and do not have systemic effect and the onset of bowel movement starts within half an hour to three hour. This should be given with care to the patients suffering from congestive heart failure and chronic renal insufficiency because magnesium and phosphate in the blood can lead to toxicity .
Stimulant laxative increases the intestinal motility and secretion of water in to the bowel and increasing the muscle contraction of the intestine. This includes senna, bisacodyl and castor oil. These agents produce bowel movements within 6 to 8 hours but may cause abdominal cramping because of increased peristalsis. It should not be given to the patients with intestinal obstruction and the chronic use of stimulant laxative containing anthraquinones may cause a brown-black pigmentation of the colonic mucosa known as melanosis coli and colonic inertia is seen in some chronic users of stimulant laxative. Castor oil is a liquid stimulant that works in the small intestine and causes the evacuation of the bowel and should not be given along with food. This laxative works quickly usually within 2 to 6 hours and this is usually used to cleanse the colon for surgery or colonoscopy.
Prokinetic agents are also now recommended for the treatment of slow transit constipation, colchicines and misoprostol are the successful among this groups, these agents accelerate colonic transit time and increases stool frequency. In women with irritable bowel syndrome , tegaserod is effective as it improves stool consistency and frequency 17,19.
ENEMAS AND SUPPOSITORIES
Rectally administered enemas and suppositories are commonly used to cleanse the rectum and the sigmoid colon prior to surgery. Enemas are also used when the laxatives fails to give adequate bowel movement and in the case of rectal impactation and it is used in conjugation with oral laxatives. Enemas and suppositories include docusate, bisacodyl, and sodium phosphate which are intended for occasional use and not recommended for chronic laxative regimen unless directed by a physician. Soapsuds enemas can cause rectal irritation and sometimes rectal gangrene therefore it is not recommended and it can also cause fluid and electrolyte disturbance in the blood if used on chronic basis 19.
Surgery is the last choice, the patients who is being evaluated by physiological testing and proven to have slow transit constipation benefit from surgery, a subtotal colectomy with ileorectostomy is the procedure of choice for patients with slow transit constipation that is persistant and intractable. There can occur certain complications after surgery which include small bowel obstruction, recurrent or persistent constipation, diarrhea and incontinence. Surgery is not recommended for anorectal dysfunction and surgical correction is reserved for patients with large rectoceles that alter bowel function 17.
SIDE EFFECTS OF TREATMENT
Laxatives containing psyllium have been associated with anaphylaxis, asthma and other allergic conditions. Other potential adverse effect includes gas and bloating sensation and bowel obstruction if stricture present17.
Liquid paraffin is associated with lipoid pneumonia as a result of aspiration. Docusate have been implicated in hepatotoxicity, they act on gut mucosa wall affecting the gastrointestinal and hepatic uptake of other drugs such as erythromycin19.
Castor oil is often associated with cramping, abdominal pain and is associated with anal seepage of oily material. Sodium salts including phosphor-soda and fleet enema can cause dehydration and hyperphosphatemia in chronic renal failure. The classical adverse effect of laxative is diarrhea, which may result in severe metabolic disturbances caused by depletion of electrolytes, dicotyl sodium has the potential to result in electrolyte imbalance and which is reversible on stopping the drug.
COMPLICATIONS OF CONSTIPATION
The major complication of constipation in older people are faecal impactation and faecal incontinence. Faecal impactation means accumulation of hardened faeces in the rectum and colon and this hardened mass can cause diminished rectal sensation and resultant faecal incontinence. Faecal impactation can further lead to delirium, urinary tract infection and the risk also extends to prolonged immobility, cognitive impairment, spinal cord disorders and colonic neuromuscular disorders. Excessive straining during constipation may cause haemorrhoids, anal fissures and rectal prolapsed and it can also affect cerebral and coronary circulation with resultant syncope or cardiac ischaemia16. There are some evidences that chronic constipation may also be a risk factor for carcinoma of the colon and rectum particularly in women and this is linked to increased exposure time of susceptible mucosa to carcinogenic substances20. For most patients constipation remains a chronic problem thus leading to high expense as well as reduction in their quality of life3.