Anita's Topic: Physiological Changes Related To Constipation ✓ Solved

Anita's Topic: Physiological changes related to constipation

Anita's Topic: Physiological changes related to constipation in the elderly, including how digestive system and nutrition impact constipation; provide guidance on assessment and management of constipation in this patient population.

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Introduction

Constipation is a common, multifactorial problem in older adults that results from age-related physiologic changes, comorbid conditions, medications, and lifestyle factors (Rao, 2020). Effective assessment and management require understanding how digestive physiology and nutrition interact with aging, plus a pragmatic, patient-centered approach that minimizes risk and improves quality of life (Wald, 2020; Hubert & VanMeter, 2018).

Age-related physiological contributors

Colonic motility and transit

Colonic motor activity tends to decline with age due to changes in smooth muscle, enteric neurons, and neuromodulation, producing slower transit and more fecal stasis (Camilleri, 2018; Rao, 2020). Slow-transit constipation (STC) can be driven by neuropathic or myopathic alterations and is more common in older adults with multimorbidity (Bharucha et al., 2013).

Anorectal function and dyssynergia

Defecatory disorders such as dyssynergic defecation arise from impaired coordination of pelvic floor and anal sphincter muscles, impaired rectal sensation, and decreased rectal compliance with age (Lacy et al., 2016; Wald, 2020). These mechanisms reduce evacuation efficiency even when stool consistency is normal.

Neurologic and systemic influences

Neurologic diseases (e.g., Parkinson’s disease, stroke, diabetic neuropathy) and systemic disorders (hypothyroidism, hypercalcemia) that are more prevalent in older populations commonly contribute to secondary constipation (Rao, 2020). Enteric nervous system degeneration and altered autonomic function are important mechanisms (Camilleri, 2018).

Nutrition, hydration, dentition, and muscle mass

Poor dentition, reduced salivation, and food preferences may reduce fiber and fluid intake, aggravating constipation (Hubert & VanMeter, 2018). Sarcopenia and reduced abdominal wall and pelvic floor muscle strength impair effective straining and evacuation (Morley et al., 2014). Dehydration secondary to reduced thirst perception and diuretic use further thickens stools (NIDDK, 2019).

Medications and polypharmacy

Many agents commonly used by older adults—opioids, anticholinergics, calcium channel blockers, iron supplements, tricyclic antidepressants—cause or worsen constipation (Rao, 2020). Polypharmacy increases cumulative risk and complicates management.

Assessment

A structured assessment includes a focused history, medication review, dietary and mobility evaluation, and targeted physical exam. Use Rome IV criteria to characterize functional constipation and document duration and severity (Lacy et al., 2016).

History

Ask about bowel frequency, stool form (e.g., Bristol Stool Scale), straining, incomplete evacuation, need for manual maneuvers, red flags (unintended weight loss, hematochezia, anemia), onset relative to medications, and impact on activities of daily living (Wald, 2020).

Examination and basic investigations

Perform abdominal and focused rectal examination to assess fecal impaction, sphincter tone, masses, or occult blood. Basic labs (CBC, electrolytes, TSH, metabolic panel) help identify secondary causes (Wald, 2020). When indicated, consider colonoscopy for alarm features or inadequate prior colorectal cancer screening (Rao, 2020).

Physiologic testing

For refractory cases or suspected anorectal dysfunction, anorectal manometry, balloon expulsion testing, and colonic transit studies can distinguish STC, dyssynergia, and mixed patterns and guide targeted therapy (Bharucha et al., 2013).

Management strategies

Non-pharmacologic interventions

First-line management emphasizes dietary fiber (gradual increase to 20–30 g/day if tolerated), adequate fluid intake, and regular physical activity tailored to capacity (NICE, 2019; NIDDK, 2019). Address dentition and swallowing problems by recommending easily chewed high-fiber foods and collaboration with dental services or dietitians (Hubert & VanMeter, 2018).

Medication review and deprescribing

Systematically review medications and minimize or substitute constipating agents when possible (e.g., opioid-sparing strategies, alternative antidepressants) while balancing clinical risks (Rao, 2020).

Laxative therapy

When lifestyle measures are inadequate, select laxatives according to mechanism and patient factors. Bulk-forming agents (psyllium) suit many but require adequate fluid intake; osmotic laxatives (polyethylene glycol) are effective and well-tolerated in older adults; stimulant laxatives (bisacodyl, senna) can be used short-term or intermittently; stool softeners (docusate) have limited evidence as monotherapy (Camilleri, 2018; Nelson, 2015).

Targeted and advanced therapies

For slow-transit constipation or refractory cases, secretagogues (linaclotide, lubiprostone), prokinetics (prucalopride), or neuromodulatory approaches may be appropriate after specialist consultation (Bharucha et al., 2013). For dyssynergic defecation, pelvic floor retraining with biofeedback is highly effective and preferred over surgery in older adults (Lacy et al., 2016).

Special considerations for frail older adults

Tailor treatment to comorbidity, renal function, swallowing ability, and goals of care. Avoid aggressive regimens that risk dehydration, electrolyte disturbance, or falls. Monitor response and adverse effects closely and prioritize noninvasive, low-risk options (Hubert & VanMeter, 2018; Rao, 2020).

Clinical pathway and follow-up

Begin with education, dietary and activity optimization, and medication review. If no improvement in 2–4 weeks, initiate or escalate pharmacologic therapy while considering referral for physiologic testing or gastroenterology consultation for refractory or complex cases. Reassess for red flags continuously and adjust for evolving frailty or changing goals of care (NICE, 2019; Wald, 2020).

Conclusion

Constipation in the elderly is typically multifactorial and driven by physiologic aging changes, comorbidities, medications, and nutritional factors. A systematic approach—comprehensive assessment, addressing reversible contributors (hydration, diet, mobility, medications), and escalating to targeted therapies including biofeedback or specialist pharmacotherapy—optimizes outcomes while minimizing harm in this vulnerable population (Rao, 2020; Lacy et al., 2016).

References

• Rao, S. S. C. (2020). Constipation in the older adult. UpToDate.
• Wald, A. (2020). Etiology and evaluation of chronic constipation in adults. UpToDate.
• Hubert, R. J., & VanMeter, K. C. (2018). Gould's Pathophysiology for the Health Professions (6th ed.). Elsevier.
• Lacy, B. E., Mearin, F., Chang, L., Chey, W. D., Lembo, A. J., Simrén, M., & Spiller, R. (2016). Bowel disorders. Gastroenterology, 150(6), 1393–1407. (Rome IV)
• Camilleri, M. (2018). Chronic constipation. New England Journal of Medicine, 378(5), 427–436.
• Bharucha, A. E., Pemberton, J. H., & Locke, G. R. (2013). American Gastroenterological Association technical review on constipation. Gastroenterology.
• NIDDK. (2019). Constipation—National Institute of Diabetes and Digestive and Kidney Diseases. U.S. Department of Health and Human Services.
• NICE. (2019). Constipation: assessment and management. National Institute for Health and Care Excellence.
• Nelson, R. (2015). Osmotic and stimulant laxatives for chronic constipation in adults. Cochrane Database of Systematic Reviews.
• Morley, J. E., Vellas, B., van Kan, G. A., Anker, S. D., Bauer, J. M., et al. (2014). Sarcopenia with limited mobility: consensus report. Journal of the American Medical Directors Association.