Makindo Medical Notes

Constipation = infrequent, hard or difficult stool passage, often <3 bowel motions per week or requiring straining/manual assistance. Prevalence in older adults: up to 30% in community;>50% in institutional care. Causes are usually multifactorial.

⚙️ Pathophysiology in Ageing

• 🧠 ↓ Autonomic function and slowed colonic transit.
• 🦴 ↓ Mobility & muscle tone.
• 🧬 Pelvic floor dysfunction & weak abdominal muscles.
• 🛏️ Institutionalisation and dependence on carers.
• 💊 Polypharmacy: anticholinergics, opioids, calcium channel blockers, iron, diuretics, TCAs.

🔎 Common Causes (Mnemonic: “DOPED”)

• Drugs – opioids, anticholinergics, calcium supplements, iron, antidepressants.
• Obstipation – bowel obstruction, cancer, strictures.
• Painful conditions – fissures, haemorrhoids, immobility.
• Endocrine/metabolic – hypothyroidism, diabetes, hypercalcaemia, hypokalaemia.
• Dehydration/diet – low fibre, low fluid intake, malnutrition.

🚨 Red Flags (need urgent investigation)

• 💔 Unintentional weight loss.
• 💉 Anaemia (iron deficiency).
• 🩸 Rectal bleeding or melaena.
• 🧠 Family history of bowel cancer.
• ⚡ New-onset constipation in >50 years.
• ⛔ Abdominal distension + vomiting (obstruction).

🧑‍⚕️ Assessment

• 📋 History: bowel frequency, stool type (Bristol Stool Chart), diet, mobility, drugs, pain, red flags.
• 👩‍⚕️ Exam: abdominal exam, PR exam (faecal loading, masses, rectal tone, prostate in men).
• 🧪 Investigations: U&E (dehydration), Ca (hypercalcaemia), TFTs, glucose. Consider colonoscopy if red flags.

🛠️ Management – Stepwise

1️⃣ General Measures

• 💧 Adequate hydration (≥1.5 L/day if safe).
• 🥗 High-fibre diet (fruits, vegetables, wholegrains).
• 🚶 Encourage mobility & exercise.
• 🪑 Regular toileting routine, optimise privacy & dignity.
• 👓 Ensure sensory aids (glasses, hearing aids) for toileting independence.

2️⃣ Medication Review

• 🔍 Stop or switch constipating drugs if possible (opioids, anticholinergics, iron, CCBs).
• 💊 Consider opioid antagonists (e.g. naloxegol) for refractory opioid-induced constipation.

3️⃣ Laxatives (NICE CG99, BGS guidance)

• 💦 Osmotic: First-line for chronic constipation (e.g. macrogol [Movicol], lactulose). Draws water into bowel.
• 🌱 Bulk-forming: (e.g. ispaghula husk/Fybogel) if adequate hydration & no obstruction.
• ⚡ Stimulant: (e.g. senna, bisacodyl) if inadequate response. Stimulates peristalsis.
• 🛑 Stool softeners: (e.g. docusate sodium) useful if hard stool.
• 💉 Suppositories/enemas: (glycerol, phosphate enema) for impaction or rapid relief.

4️⃣ Faecal Impaction Management

• Step 1: High-dose oral macrogol (up to 8 sachets/day, taper when disimpacted).
• Step 2: Add stimulant laxative (senna/bisacodyl).
• Step 3: Suppositories (glycerol, bisacodyl) or phosphate enema if refractory.
• Step 4: Manual evacuation in resistant cases (specialist care).

🛡️ Special Considerations in Elderly

• 🧠 Dementia/delirium: constipation may present as agitation or confusion.
• 🛏️ Immobility: regular bowel charts and proactive laxatives often required.
• 🧾 Polypharmacy: always review meds — opioids, anticholinergics, calcium, iron.
• ⚖️ Dignity: private toileting, avoid unnecessary catheterisation or diapers if constipation-related incontinence is reversible.
• 🏥 Care homes: bowel charts, PR exams often neglected — must be routine.

📝 OSCE / Exam Pearls

• ❓ "Elderly with acute confusion" → always consider constipation.
• 📋 Always mention hydration, mobility, fibre, medication review before laxatives.
• ⚡ For opioid-induced constipation: use stimulant ± osmotic from the outset (don’t wait for constipation to develop).
• 🚨 Never prescribe bulk-forming laxatives if bowel obstruction suspected.
• 🧠 In OSCE: demonstrate Bristol Stool Chart knowledge.

🧑‍⚕️ Case Examples — Constipation in the Elderly

• Case 1 (Medication-induced): 💊 An 82-year-old woman with osteoarthritis and atrial fibrillation presents with infrequent, hard stools and straining. She is on codeine for chronic pain and verapamil for rate control. Examination is unremarkable. Diagnosis: Opioid and calcium channel blocker–induced constipation. Managed by reviewing analgesia (consider stopping codeine), introducing a stimulant laxative (senna) plus a stool softener, and encouraging hydration and mobility.
• Case 2 (Slow transit + immobility): 🪑 A 90-year-old man in a nursing home has constipation, bloating, and decreased appetite. He is largely chair-bound after a hip fracture. Abdominal exam shows mild distension but no masses. Diagnosis: Slow transit constipation due to reduced mobility and frailty. Managed with regular osmotic laxatives (lactulose or macrogol), mobilisation support with physiotherapy, and ensuring adequate dietary fibre and fluids.
• Case 3 (Secondary to obstruction): 🚨 A 77-year-old woman presents with progressive constipation, weight loss, and iron-deficiency anaemia. On exam, she has a palpable left iliac fossa mass. Colonoscopy confirms an obstructing sigmoid carcinoma. Diagnosis: Constipation secondary to colorectal cancer. Managed with surgical resection after staging and optimisation, alongside palliative laxatives for symptomatic relief.