Seasoned caregivers are no strangers to age-related digestive issues like diarrhea, constipation, C. difficile and IBS. Our metabolisms slow naturally as we age, but when things come to a screeching halt, it can cause a great deal of discomfort and anxiety. Although most people prefer not to talk about their bowels, untreated constipation can result in serious health problems, such as fecal impaction, anal fissures and bowel incontinence.
According to a medical position statement published by the American Gastroenterological Association, constipation affects approximately 16 percent of adults overall and 33 percent of adults over age 60. Family caregivers should be knowledgeable about this seemingly small problem since it can easily turn into a major health event, especially for seniors.
When Is Constipation Serious in Elderly Individuals?
“Constipation is a very common health concern affecting people of all ages, but particularly the elderly,” explains Kim English, RN, BScN, MN, professor at the Trent/Fleming School of Nursing in Peterborough, Ontario, Canada. “There is a stereotype of older people focusing on the function of their bowels. That may not be a bad thing, but the reality is that we all experience episodes of constipation at some point of our lives.”
The medical definition of constipation is when a person has less than 3 bowel movements (BMs) a week, consisting of hard, dry stools that are difficult to pass. Frequent straining during BMs is a symptom as well. A person experiencing constipation will often complain of abdominal discomfort, bloating and a feeling of fullness or incomplete evacuation of the bowel.
Read more: Occasional Constipation in the Elderly
According to an article published in American Family Physician, “Chronic constipation is characterized by the presence of these symptoms for at least three months out of the preceding 12 months.”
A common question from family caregivers is “how long can an elderly person go without a bowel movement?” Unfortunately, there is no one-size-fits all answer since each person’s metabolism, diet, health status, medication regimen and other influential factors are unique. It’s best to err on the side of caution if an aging loved one deviates from their usual frequency or complains of discomfort. This is particularly important for dementia patients who may not be able to articulate that they are feeling constipated or remember when their last BM was. Discuss this question with your loved one’s physician to get personalized recommendations for dealing with instances of worsened constipation.
English emphasizes that constipation is considered a symptom of another problem. Be proactive about seeking out the underlying cause and addressing it, especially if symptoms are recurrent or long lasting. Possible causes include bowel diseases, such as diverticulitis, irritable bowel syndrome (IBS), or lack of fiber and water in the diet.
What Causes Chronic Constipation in Elderly Individuals?
Lifestyle choices like diet and exercise play a huge role in sluggish digestion. Unfortunately for older adults, many of these contributing factors are the norm. For example, limited physical activity is common in seniors with mobility issues and those who are bedridden or require prolonged bed rest. English also points out that elders experience a weaker “thirst mechanism” and often suffer from dehydration without even knowing it. This is a serious concern for dementia patients who typically do not consume enough fluids.
Many chronic medical conditions and the prescription medications used to treat them contribute to constipation as well. For instance, conditions that affect hormone levels or nerves and muscles around the colon can interfere with the ability to have regular bowel movements. “Infrequent elimination can be caused by hormone imbalances due to diabetes and thyroid issues, neurological problems associated with Parkinson’s disease, stroke, and multiple sclerosis (MS), and issues with pelvic floor muscles,” English warns.
Countless medications used to treat these and other health issues list constipation as a side effect. “Ironically, this also includes an overuse of laxatives,” English notes. Antidepressants, anticonvulsants, antihistamines, antacids, diuretics, calcium channel blockers and iron supplements are a few of the most common offenders, but one class of medication has an especially bad reputation for its effects on the digestive system.
“Narcotic pain medications (opioids) are notorious for interfering with digestion but are often prescribed to seniors with conditions like arthritis, cancer, neuropathy and fibromyalgia as well as following an injury, surgery or infection,” English says.
Any one of these factors can contribute to irregularity, but constipation is inevitable when several are present at once.
Can Chronic Constipation Be Cured?
Most health care practitioners prefer to treat constipation more conservatively at first in the hopes the issue will resolve on its own. An initial first step would be encouraging a person to incorporate more fiber in their diet, exercise more and increase their fluid intake—especially plain water. While these measures might bring relief for some people, they may not be effective or realistic for older adults with multiple comorbidities who have been struggling with difficult and/or infrequent BMs for some time.
Although it may be counterintuitive, keep in mind that laxative use can exacerbate symptoms in some cases. These over-the-counter medications are intended to help the bowel move stool along and are typically the go-to remedy for constipated individuals. However, stool softeners are often preferred over stimulant laxatives and osmotic laxatives, which can cause adverse effects like electrolyte imbalances and lazy bowel syndrome.
“Using too many stimulant laxatives too often actually slows natural movements down, making the bowel ‘lazy,’ ” English explains. “When this happens, the bowel is no longer able to pass stool without the use of laxative medications. More and more of the medication will be necessary for spurring any sort of movement, which can be difficult to reverse. The bowel consists of many muscles that play a role in evacuation, but these cannot be strengthened in the same manner as other muscles in the body.”
Despite the three-month definition of chronic constipation, it’s important to seek medical attention as soon as symptoms begin interfering with one’s daily activities and quality of life. There are different causes and types of constipation (many of which can and do co-occur, particularly in older adults) and there is no silver bullet that addresses all of these. It may sound odd, but keeping a food diary and tracking BMs (frequency, timing, symptoms and description using the Bristol Stool Form Scale) can help a doctor get an accurate picture of one’s diet and symptoms. A complete medication list and medical history also factor into ruling out underlying causes and deciding if diagnostic testing is necessary to gather more information.
Possible treatments might include a change in laxative program, prescription medication and/or biofeedback sessions for pelvic floor retraining. In some cases, surgery may be needed to correct some underlying defecatory disorders (e.g., rectocele, prolapse, blockage), but surgical intervention is only rarely recommended for severe and intractable chronic constipation that does not respond to other less invasive treatments.
Complications of Chronic Constipation
When a person is chronically constipated, muscles and nerves in the bowel are affected, making it harder for them to do their job. According to English, it is very difficult to then restore normal function. If left untreated, constipation can lead to painful and sometimes embarrassing medical situations, some of which can be very serious.
“The intense straining that often accompanies constipation can cause damage to vascular structures or skin in the anal canal,” English says. “These can be internal or external and typically present with light bleeding during BMs, itching, swelling and pain.”
Hemorrhoids and anal fissures can become serious but often heal within a few days. On the other hand, the most concerning complication of untreated chronic constipation is fecal impaction. Impaction can become a medical emergency when the bowel becomes completely blocked with a solid, immobile mass of feces.
“Not only can this can be a medical emergency, but it is also painful and uncomfortable for the person experiencing it,” warns English. “The large intestine becomes blocked, and the problem just keeps getting worse.”
The first sign of fecal impaction may be the lack of a bowel movement for an extended period of time. Keep an eye out for these symptoms of severe constipation that can become serious very quickly:
- Abdominal discomfort and bloating
- Loss of appetite
- Weight loss
Some people may also experience leakage of liquid stool (referred to as paradoxical diarrhea or overflow incontinence) that manages to move past the area of blockage. Dementia patients who are experiencing fecal impaction may exhibit a sudden worsening of behavioral symptoms and/or cognitive decline. This phenomenon is similar to the changes in mental status that present with urinary tract infection (UTI) in the elderly.
Diagnosing and Treating Fecal Impaction in Elderly Individuals
Anyone who has persistent constipation is at risk of bowel impaction, so it is important to seek medical attention for chronic symptoms.
“A health care provider will perform an abdominal assessment and will likely be able to feel the mass,” English explains. “A digital rectal examination may also be performed to determine the presence of stool and/or a blockage in the lower part of the colon. They may then perform other diagnostic tests, such as x-rays, to confirm the nature of the blockage.”
Laxatives are frequently one of the first choices for treatment of fecal impaction. However, English advises these must be administered very carefully under the direction and supervision of health care providers, otherwise they may cause more problems. Enemas and water irrigation enemas may also be used, again with caution. However, if none of these treatments works, then manual removal may be an option.
“Manual disimpaction of stool involves a health care provider removing the fecal matter using lubricant and a gloved finger,” English describes.
This procedure can be quite uncomfortable and is usually done without any anesthesia, although a mild sedative may be used. English reminds family caregivers that manual disimpaction should only be done by trained medical professionals due to the risk of perforation, vasovagal response (a sudden drop in heart rate and blood pressure also known as fainting) and bleeding.
In very severe cases where the above options are not successful, surgical removal may be necessary to treat megacolon or a complete blockage. If fecal impaction is not diagnosed and addressed quickly, there is a risk of serious complications, such colon perforation, peritonitis and sepsis, which can be deadly.
“It is much easier to prevent digestive issues than treat them after the fact,” English urges. “In this case, prevention comes in the form of proper diet (including lots of fiber and water), regular exercise, paying attention to personal ‘normal’ bowel functions, and seeking prompt medical advice.”