Chronic constipation in the elderly 1 Dec,2011 R 2 Natta Asanaleykha
Epidemiology Definition Scope The impact of chronic constipation in the elderly Pathophysiology Evaluation the elderly patient with constipation Prevention and management
Introduction Constipation is a common problem in elderly persons Constipation is NOT a normal part of aging Constipation results from a combination of risk factors Aliment Pharmacol Ther 2010 ; 31 : 938 49
Epidemiology The prevalence increases with age and is more frequent in females Prevalence : 26% of men Age 65 34% of women Am J Gastroenterol 2004 ; 99 : 750 9 Manag Care Interface 2005 ; 18 : 23 30
Definition of chronic stipation Unsatisfactory defecation due to Infrequent stools(< 3 evacuations/wk) Difficult stool passage - symptoms of straining - difficulty expelling stool - sense of incomplete evacuation - hard or lumpy stools - prolonged time to stool - Need for manual maneuvers to pass stool At least 3 months
Definition of chronic constipation
Why does constipation become a problem in the elderly? Increased prevalence of Secondary Causes.. Immobility Improper Diet Endocrine & Metabolic Disorders Neurological Disorders Psychological Conditions Structural Abnormalities Medications
What are some of the consequences of constipation in the elderly? Nausea and reduced appetite weight loss Impaired quality of life Significant individual healthcare costs Complication - Fecal impactation overflow diarrhea - Stercoral ulcer - Volvulus
Causes of chronic constipation Primary type Slow-transit constipation Defecation disorder Constipation-predominant irritable bowel syndrome Secondary type
Slow-transit constipation Delay of stool transit through colon due to - Myopathy - neuropathy - secondary to evacuation disorder Can also occur in the setting of a generalized intestinal motility disorder colonic inertia Infrequency Bloating
Defecation disorder Characterized by difficult or unsatisfactory expulsion of stool from the rectum Can result from dyssynergic defecation and impaired perineal descent Excessive straining Incomplete evacuation Use of fingers to facilitate defecation Anal/perineal pain
Constipation-predominant IBS Abdominal discomfort or pain relieved by defecation is the predominant symptom
WHAT ARE THE COMMON MECHANISMS INVOLVED IN CONSTIPATION IN THE ELDERLY POPULATION? Change of colonic physiology - neuron in myenteric plexus - collagen deposition of colon - amplitude of inhibitory n. input to circular m. layer of colon Change in anorectal function - resting and max. anal sphincter pressure - max. squeeze pressure and loss of rectal wall elasticity - Fibro-fatty degeneration and thickness of internal anal sphincter with aging Brocklehurst s Textbook of Geriatric Medicine and Gerontology
APPROACH TO THE ELDERLY WITH CONSTIPATION
History Nature and onset of symptom - Stool frequency,consistency, size - Degree of straining during defecation - History of ignoring a call to defecate - Dietary history - Laxative used - Fecal incontinence Inquiry into underlying cause Alarm feature colonoscopy/ct scan Patient s activity and psychosocial stressor
Physical examination Anorectal and digital rectal exam - Skin erosion - Skin tag - Anal fissure - Hemorrhoid Perianal sensation and reflex
Metabolic and structural evaluation Constipation may be caused by an underlying metabolic and pathologic disorder Routine blood tests ; CBC,biochemical profile, calcium level and TFT Structural tests ; flexible sigmoidoscopy or colonoscopy negative Functional disorder
Physiological test Colonic transit study Anorectal manometry Balloon expulsion test
Prevention and management Non pharmacologic management 1 st line Rx education on the importance of diet, exercise, and toilet training can lead to improved symptoms Pharmacologic management
Fluid therapy Fluid intake is important for maintaining intestinal motility Few studies have correlated poor hydration with constipation Unless dehydrated, increasing fluid does not relieve chronic constipation and may increase the risk of fluid overload J Gerontol A Biol Sci Med Sci 2000; 55: M361-5 Sing Fam Phys. 2009;35(3):84-92
Dietary therapy Recommended daily intake of fiber 20 35 g/day Decreased colonic transit times and increased stool bulk Fiber-rich foods;bran, fruits, vegetables and nuts In elderly with constipation, adding bran 10 g twice daily resulted in significantly shorter colonic transit times (89 vs. 126 h) compared with psyllium 6 g twice daily Scand J Gastroenterol 1979 ; 14 : 821 6
Dietary therapy RCT showed that prunes or prune juice were more effective than psyllium in mild to moderate constipation Subgroup respond poorly to a high-fiber diet osmotic agents or stimulant laxatives RCT suggested that Rx with Bifidobacterium lactis, Lactobacillus casei Shirota, and E.coli Nissle resulted in favorable effects on stool frequency and consistency Aliment Pharmacol Ther 2011 ; 34:.397-8 World J Gastroenterol 2008 ; 14 : 6237 43
Physical activity Constipation commonly occurs low physical activity, such as immobile or bedridden No evidence that increased exercise is beneficial in severe constipation J Nutr Health Aging 2004; 8 (2):116-2 BMC Geriatr 2006;6:1-9
Bowel training Daily routine with an evening dose of fiber supplement (bulk and soften) Begins with mild physical activity, a hot beverage, and a fiber within an hour of arising Visit to the toilet when the 1 st urge is perceived Biofeedback training is an important treatment in dyssynergic defecation J Fam Pract 2007 ; 56 : S13 9
Fiber and bulking agents Organic polymers that increase water-absorbency properties of stool - increasing stool bulk, consistency, and weight Ensure good fluid intake to prevent fecal impaction Onset of action 2-3 days e.g. psyllium (Metamucil ), sterculia (Normacol ), ispaghula (Fybogel ) S/E : bloating, flatulence, distension bowel obstruction(rare)
Stimulant laxatives Direct stimulatory effects of the myenteric plexus and inhibiting water absorption intestinal motility e.g.senna (Senokot ), bisacodyl (Durolax,Bisalax ) Contraindication : suspected intestinal obstruction S/E : abdominal cramping,discomfort electrolyte imbalance,melanosis coli
Osmotic laxatives Contain poorly absorbed ions or molecules -- > osmotic gradient in intestinal lumen -- > water retention --> softer stool e.g. PEG,lactulose, sorbitol, MOM, and Mg citrate Good quality evidence supports the use both PEG and lactulose in constipation Safe for longterm use, and routine use in practice S/E : abdominal cramping,bloating,flatulence
Weekly treatment success (response) No use of rescue laxative Satisfactory stool greater than or equal to 3 per Primary week efficacy variable was seen in 52% of PEG One or fewer of the remaining three 11% of ROMEbased symptom criteria (P < placebo 0.001). a. Straining in more than 25% of defecations b. Lumpy or hard stools in more than 25% of defecations c. Sensation of incomplete evacuation in more than 25%of defecations. Am J Gastroenterol.2007;102(7):1436 1441
PEG Am J Gastroenterol.2007;102(7):1436 1441
Laxative vs Placebo Osmotic laxative NNT of 3(95 % CI: 2 4) Stimulant laxative NNT of 3(95 % CI: 2 3.5)
Agiolax A senna fiber combination Improve stool consistency,frequency and ease of passage in nursing home residents Cheaper than lactulose Pharmacology.1993;47 Suppl 1:249 252
Chloride-channel activator (Lubiprostone) Selectively activates type 2 chloride channels (ClC-2) in apical membrane of the Gl tract Increased fluid secretion into lumen No significant electrolyte change Approved by the FDA in January 2006 Rx of chronic idiopathic constipation in adults Am J Gastroenterol 2008 ; 103 : 170 7
Lubiprostone vs Placebo NNT of 4 (95 % CI: 3 7)
GC activators(linaclotide) Activates the GC-C receptor on the apical surface of intestinal epithelial cells Increase secretion of Cl and HCO3 into the intestinal lumen Increased the number of weekly spontaneous bowel movement Improved stool consistency, straining and severity of constipation S/E : dose-dependent diarrhea Curr Opin Mol Ther2007 ; 9 : 403 10
Linaclotide vs Placebo NNT of 6 (95 % CI: 5-8)
Serotonergic enterokinetic agents highly selective 5-HT 4 receptor agonist e.g. Prucalopride, Velusetrag and norcisapride Recent RCT study the use of prucalopride in age 65 - Benefit on bowel movements - Benefit on constipation-related symptoms - Improve QOL - Safe and well tolerate S/E : headache,nausea,diarrhea Neurogastroenterol Motil 2010 ; 22 : 991 8, e255
Prucalopride vs Placebo number needed to treat (NNT) of 6 (95 % CI: 5-9)
Novel 5-HT 4 receptor agonist Velusetrag and Norcisapride Recent RCT, 4-Wk trial of velusetrag (15, 30, or 50 mg daily) with placebo found that it was efficacious and well tolerated in patients with chronic idiopathic constipation Norcisapride : recent early phase 2 trials Expert Opin Investig Drugs 2010 ; 19 : 765 75 Aliment Pharmacol Ther 2010 ; 32 : 1102-12
Enemas and Suppositories Used when rapid relief from fecal loading is required Induce bowel movements by distension of the rectum and colon Frequent use may cause poor rectal tone and may exacerbate incontinence Tap water enemas are safest for regular use Phosphate enemas (Fleet ) increase the risk of hyperphosphataemia in renal impairment Glycerine suppositories stimulate rectal secretion by osmotic action
Thank you
Correlates with symptoms of straining and difficult evacuation slow colonic transit time Faster colonic transit time University of Bristol, Scand J Gastroenterol, 1997
Alarm feature Involuntary weight loss of > 10 lb hematochezia FHx of colorectal cancer or IBD Positive fecal occult blood testing Iron deficiency anemia Acute onset of constipation Am J Gastroenterol 2005 ; 100