Introduction
Constipation is a delay in bowel emptying for more than 48 hours, accompanied by incomplete emptying with the discharge of a small number of feces of increased hardness. Chronic constipation (CC) is diagnosed when bowel movements occur less than 3 times a week over the last 3 months, with a total duration of constipation of at least 6 months (Bharucha & Wald, 2019). Additional criteria for CC are the need for straining and/or manual assistance.
It is necessary to differentiate constipation as a disease symptom from functional constipation, which develops primarily in the absence of other pathology. Left untreated and self-medicating for constipation can be dangerous. In this regard, the question arises: Among elderly patients, is medical treatment of constipation, compared with alternative methods, more effective at preventing its spread?
The extremely high prevalence determines the relevance of chronic diseases. The background question was, what is the prevalence of constipation in people over 65? It is important to determine how relevant the topic is. According to epidemiological studies, 3-27% of the adult population suffers from chronic constipation in Europe and North America (Serra et al., 2019).
Using the population, intervention, comparison, and outcome (PICO) format, the population is older adults, the intervention is medical treatment for constipation, the comparison is alternative therapies, and the outcome is a reduction in the prevalence of chronic constipation among older adults. In addition, constipation can be a symptom and cause of other serious diseases, such as dementia or Parkinson’s disease. Thus, it is necessary to study the processes of treating constipation and preventing its complications among the elderly.
Methods
A systematic electronic search of articles across various scientific databases was conducted. The search strategy focused on therapeutic interventions to reduce the risk of complications of chronic constipation, including medication and alternative therapies. The main databases used for searching articles are the National Library of Medicine, PubMed, ScienceDirect, and Google Scholar. Search terms include constipation, chronic constipation, therapy of constipation among the elderly, elderly, prevention of constipation, clinical interventions, and constipation therapy. Truncation has also broadened the search for medical or alternative interventions. In addition, the search was limited to articles from 2018 to the present and in English.
Based on the given parameters, about 10 articles on the topic were selected that met the limiting criteria. At the first stage of selection, the literature review was limited to the title, abstract, design, and methodology of the studies, after which the number of articles was reduced to five. Subsequently, most non-experimental studies were excluded, leaving only theoretical and practical evidence.
After a closer review of the articles, the top three were selected for analysis based on the PICOT question. The first article studied was Wang et al. (2022), which examined the prevalence of constipation among the elderly. Further analysis of the article by Kang et al. (2021) focused on medical interventions for treating constipation in the elderly. As a third article, Mari et al. (2020) present new approaches to managing constipation in the elderly.
Prevalence of Constipation in the Elderly
A cross-sectional survey was conducted in China from May to December 2019 among 29 communities and 45 villages. The data for the analysis were collected using a multi-stage stratified cluster sampling design. Wang et al. (2022) considered various factors, including the area’s geographic location, level of economic development, and population size, to obtain a diverse sample.
Ultimately, the researchers recruited more than 11,000 individuals with an average age of 73, of whom 1,785 had constipation (Wang et al., 2022). The article also tried to collect representatives of both economic regions and to align the sample by gender. As a result, 56.0% of women (6576) participated in the survey, and 61.9% of all participants were from rural areas (7272).
To calculate the prevalence of constipation across potentially different groups of the elderly, scientists also considered socio-demographic characteristics, medical history, and lifestyle. The researchers paid special attention to diseases such as diabetes mellitus, heart disease, arterial hypertension, stroke, and a history of headaches. Lifestyle included drinking, smoking, marital status, and general social activity.
On average, interviews lasted about 2 hours and were recorded. In the second stage, Wang et al. (2022) performed a defecation test and a neurological examination according to standard protocols. The authors used the activity of daily living (ADL) as a measure of social functioning. A questionnaire was developed to assess constipation using the Rome VI criteria and the Bristol Stool Scale. The Mini-Mental State Examination (MMSE) served as the basis for cognitive assessment.
In analyzing survey data, the scientists examined the overall prevalence of constipation among the elderly. In addition, they identified the most common diseases that could cause them. According to the article’s authors, the overall prevalence of constipation was 15.2%, with the highest prevalence among people aged 65 years and over at 14.8% (Wang et al., 2022).
The researchers also examined constipation prevalence across populations and found higher rates among women and the rural population: 16.0% and 16.7%, respectively (Wang et al., 2022). Thus, the authors noted that the likelihood of having constipation increases with age, especially among those aged 65 to 79 years (Wang et al., 2022). They also concluded that a higher prevalence of constipation was associated with dementia and non-amnestic mild cognitive impairment (na-MCI) (Wang et al., 2022). Regarding demographic differences, the proportion of older women who live in rural areas and have conditions such as diabetes, heart disease, or headache is higher for constipation.
Medical Management of Constipation in Elderly Patients
Kang et al. (2021) reviewed 23 randomized controlled trials to investigate the safety and efficacy of various laxatives. They looked at the effects of different drugs for treating constipation in older people over 65. The review included randomized controlled trials (RCTs) and their retrospective analyses to examine the effects of medical treatment for chronic constipation. In addition, researchers compared drug treatment overall with a placebo or other non-reviewed laxatives. Kang et al. (2021) analyzed 10 crossover and 13 parallel studies in the literature.
The authors limited their study to not looking at the effects of dietary supplements, prebiotics, or probiotics. In addition, Kang et al. (2021) excluded from their review articles those that examined the role of restricted drugs, such as herbs, which are not used as the primary treatment for constipation in the elderly. Thus, the authors considered only pharmacological interventions, including stimulant laxatives, bulk laxatives, osmotic laxatives, and novel drugs such as elobixibate, lubiprostone, prucalopride, velusetrag, and linaclotide. It is also important to note that Kang et al. (2021) did not study the effects of drugs on acute or opioid-induced constipation or irritable bowel syndrome; that is, they only looked at chronic constipation and its treatment.
As a result of a comprehensive review of the literature, analysis, and comparison, the authors selected drugs based on their safety and effectiveness for use in the elderly. First of all, they noted drugs for short-term use, that is, within 3 months. These include stimulant laxatives, bulk laxatives, osmotic laxatives with or without fiber, and other drugs. According to Kang et al. (2021), the most effective and safe long-term treatment is polyethylene glycol, which can be used for about 6 months. Thus, drug intervention has its strengths and weaknesses: some drugs cannot be used for long-term treatment, which may be ineffective for patients with chronic constipation.
Chronic Constipation in the Elderly Patient: Updates in Evaluation and Management
Mari et al. (2020) reviewed new treatments for constipation in people over 65 that have developed in recent decades as alternatives to traditional medical intervention. Patient evaluation is a crucial step in selecting an appropriate treatment, as it involves determining the cause of constipation and, based on this, choosing the most suitable treatment (Mari et al., 2020). The authors state that obtaining a detailed medical and social history is an important first step in managing elderly patients with constipation (Mari et al., 2020). The article then discusses possible approaches to assessing and treating patients.
The first alternative method, especially effective in the early stages of chronic constipation, involves lifestyle changes, particularly dietary adjustments. They state that moderate physical activity in patients with mild constipation improves symptoms (Mari et al., 2020). However, the authors note that this may not significantly affect the elderly with severe, chronic constipation.
Furthermore, Mari et al. (2020) emphasize the importance of reviewing the list of medications that can cause constipation and, if possible, discontinuing their use or finding a suitable alternative (Mari et al., 2020). As a new and effective alternative treatment, the authors discuss biofeedback. It is a practice that aims to teach patients to relax rather than contract the abdominal and pelvic floor muscles (Mari et al., 2020). This approach yields effective results, with a 70-80% increase in outcomes after one year, and is considered the safest method (Mari et al., 2020).
While the researchers are considering new methods for assessing and treating constipation in the elderly, they also note the possibility of turning to laxatives if other methods fail to achieve results. However, they emphasize that the choice of drug should consider the patient’s medical history and the compatibility with the drugs they are already taking; that is, it should be completely personalized.
Conclusion
All three reviewed articles are particularly important for medical practice. They provide a comprehensive picture that allows one to understand the overall prevalence of constipation among older adults aged 65 and older. In the first article, it is also important that the authors identify potential causes of constipation, such as diabetes, heart disease, and dementia, among others. The article by Kang et al. (2021) identifies the most effective drugs for medical intervention, while Mari et al. (2020) offer various alternative treatments, with biofeedback as the most effective. However, drug treatment is most effective in preventing the spread of constipation among the elderly, since if alternative treatment fails, it is necessary to use drugs.
References
Bharucha, A. E., & Wald, A. (2019). Chronic constipation. Mayo Clinic Proceedings, 94(11), 2340–2357.
Kang, S. J., Cho, Y. S., Lee, T. H., Kim, S.-E., Ryu, H. S., Kim, J.-W., Park, S.-Y., Lee, Y. J., & Shin, J. E. (2021). Medical management of constipation in elderly patients: Systematic review. Journal of Neurogastroenterology and Motility, 27(4), 495–512.
Mari, A., Mahamid, M., Amara, H., Baker, F. A., & Yaccob, A. (2020). Chronic constipation in the elderly patient: Updates in evaluation and Management. Korean Journal of Family Medicine, 41(3), 139–145.
Serra, J., Pohl, D., Azpiroz, F., Chiarioni, G., Ducrotté, P., Gourcerol, G., Hungin, A. P., Layer, P., Mendive, J. M., Pfeifer, J., Rogler, G., Scott, S. M., Simrén, M., Whorwell, P., Aguilar, A., Caballero, N., Schindler, V., Popa, S. L., Malagelada, C., … SS, H. (2019). European Society of neurogastroenterology and Motility Guidelines on functional constipation in adults. Neurogastroenterology & Motility, 32(2).
Wang, F., Fei, M., Hu, W.-Z., Wang, X.-D., Liu, S., Zeng, Y., Zhang, J.-H., Lv, Y., Niu, J.-ping, Meng, X.-ling, Cai, P., Li, Y., Gang, B.-zhi, You, Y., Lv, Y., & Ji, Y. (2022). Prevalence of constipation in elderly and its association with dementia and mild cognitive impairment: A cross-sectional study. Frontiers in Neuroscience, 15.