Archive \ Volume.11 2020 Issue 4

An Overview of Constipation Management in the Elderly Population: Systematic Review

 

Khalil Salameh Alneimat1*, Sultan Muteb Sufuq Alshalan2, Sultan Ahmed Naif Almansour3, Saleh Mohammed Saleh Alotaibi3, Abdulaziz Alhumaidi Saleem Alanazi4, Abdulmalek Khaled Suliman Alserhany4, Hamoud Jadan Madhour Alruwaili5, Anwar Mohammed Bakhitan Alazmi4

 

1 Consultant, Internal Medicine Department, Gurayat General Hospital, Gurayat, Saudi Arabia. 2 Medical Service, Medical Ward Mal, Northern Medical Tower, Arar, KSA. 3 Medical Service, Medical Ward, King Abdulaziz Specialist Hospital, Sakaka, KSA. 4 Resedant, Internal Medicine Department, Gurayat General Hospital, Gurayat, Saudi Arabia. 5 Resedant, Internal Medicine Department, Endocrine Unit, Prince Mutaib Hospital, Sakaka, KSA.

Abstract

Background: Constipation is a communal serviceable gastrointestinal (GI) ailment. Prevalence of constipation usually varies according to the used description and reviewed community-based studied. Objective: to assess the management lines of constipation among the population, especially the elderly. Method: This is a systematic review was conducted, including PubMed database searches were performed for the published articles about the prevalence, causes, risk factors, and management lines of constipation among the population, especially the elderly, in Saudi Arabia and worldwide. Results: Afterward functioning the inclusion and exclusion criteria, the 45 identified papers were further reduced to 22 papers for full-text assessment and only 15 papers were included. Conclusion: Extraordinary prevalence of constipation remained observed among the population, especially the elderly, in Saudi Arabia and worldwide. Constipation is a consequence of a group of risk influences, as per reduced physical activity subsequent from long-lasting diseases, reduced fiber, and fluid intake, and multiple medication intakes. Fiber supplementation and laxatives are considered the first line and effective treatment in most patients. Surgical treatment is hardly ever specified for constipation.

Keywords: constipation, prevalence, causes, risk factors, management, Saudi children

INTRODUCTION

Constipation is a communal serviceable gastrointestinal (GI) ailment. Prevalence of constipation usually varies according to the used description and reviewed community-based studied [1]. In many previous studies, it was noted that the elderly are affected by constipation more frequently than younger individuals [2].

Chronic constipation stands a prevalent disorder popular in the elderly population, and symptoms take place in up to 50% of nursing facilities occupants. The incidence of constipation upsurges with age, especially those older than 65 years [3]. Chronic constipation distresses 17-40% of the elderly, which affects their quality of life [4].

In previous studies, it was reported that severe constipation is more common in elderly women, with rates of constipation two to three times higher than that of their male counterparts [5]. Constipation is classified in primary and secondary, primary constipation is stated as practical constipation when secondary constipation is concomitant with chronic illnesses courses, drug usage, and psychosocial problems [1].

According to Rome III principles for adults, constipation is diagnosed as follows: 25% of bowel movements are associated with at least two of the subsequent symptoms (hard or lumpy stools, straining, a sensation of inadequate evacuation, the necessity intended for physical maneuvers, a sensation of anorectal obstruction, and fewer than three defecations per week), arising in the preceding 3 months with the beginning of symptoms of no less than 6 months; non-hard feces are infrequently occurred without consuming laxatives; and at hand, are inadequate standards for irritable bowel syndrome [2].

Like numerous complications that disturb the elderly population, constipation is frequently “multifactorial,” or caused by compound reasons and risk influences [6]. The main cause of constipation in aging individuals is irregular bowel movement which begins as people come older. Constipation is a consequence of several risk factors, as reduced physical activity results from long-lasting diseases, reduced fiber and fluid intake, and multiple medication intakes [7].

The economic affliction of chronic constipation is significant, because of the direct expenses of the healthcare system such as referral, lab investigations, and medications [8-11]. Also, constipation adversely influences the health linked quality of life, besides the psychological and societal concerns [12].

The management lines of constipation come with three manners; by modification of the patient's daily habits, by using natural laxatives, and by using medications. Treatments for constipation require a considerable extent of efficiency. Existing treatment choices are secretagogues lubiprostone and linaclotide [13].

Consequently, it is essential to comprehend the etiology and managing of constipation in this population. Managing constipation in aging people is very important and be contingent chiefly on practice and opinions.

Study objective:

The objective of the present work was to assess the prevalence, causes, risk factors, and management lines of constipation among the population, especially the elderly, in Saudi Arabia and worldwide.

DATA AND METHODS

Study Design: Systematic review.

Study duration:

Data Collected throughout the period from 1- 30 September 2020. Data collection: PubMed database searches were performed for the published articles about the prevalence, causes, risk factors, and management lines of constipation among the population, especially the elderly, in Saudi Arabia and worldwide. This database was selected as it is a high-quality source.

Only articles accessible in the English linguistic stayed included. Language restriction was due to unavailable resources for translation. We excluded duplicates and non-obtainable studies. We excluded papers depending on the heading and abstract. All the studies that were not expected to be useful for this review were excluded. The remaining studies using different methodologies were included.

Data management and analysis:

No software has been utilized to analyze the data. The data was extracted based on a specific form that contains (Title of the publication, publication year, study design and setting, author's name, objective, and results). These data were reviewed by the group members to determine its initial findings. A double revision of each member was applied to ensure the validity and minimize the mistakes.

RESULTS

Afterward using the inclusion and exclusion criteria, the 45 identified papers were further reduced to 22 papers for full-text assessment and only 15 papers were included as in table 1.

 

 

Table 1: Author(s), year of publication, study design, study setting, and conclusion of the included studies.

Publication

(Author, Year)

Type of study

Study setting

Conclusion

Roque M and Bouras E, 2015 [14]

Review article

 

It is essential to contemplate that several reasons could be existing in one case, and various issues impact the clinical findings of eldercare. Fiber consumption besides osmotic laxatives is an active first line of treatment for several cases. Surgical treatment is seldom designated in CC.

Alhassan, et al, 2019 [15]

cross-sectional study

Saudi Arabia

The prevalence of constipation is relatively very low among the population of the central region in Saudi Arabia.

Prevalence

Giorgio. et al.,  2015 [16]

Review article

 

Diet and life regime adjustments are frequently unsuccessful in the management of constipation in senior adults and a multifactorial methodology is recommended. Laxatives are still a pillar in treatment; however, safety fears in the fragile elderly must be talked about. In laxative resilient constipation, numerous new drugs that goal dissimilar original pathophysiological processes have been evidenced to be harmless and in effect in adults, but moderately validated in the elderly.

Nour-Eldein H. et al., 2014 May-Aug. [17]

pre-post intervention study

Egypt

An inguinal hernia is a significant public health problem in

Tanzania. If Tanzania continues to address an inguinal hernia

at its current surgical restoration frequency, an excess of nearly 1

a million cases for restoration will progress above the next 10 years

Teaching on life routine adjustment hints to an enhancement in the harshness of the symptoms of constipation and the QOL of the aged in nursing institutions.

Chu H. et al., 2014 [18]

Systematic review

China

In China, the occurrence of constipation was lesser equated with the utmost of other nations. The influences comprising female sex, diagnostic standards, geographic region, age, scholastic class, and race give the impression to have a chief influence on the incidence of constipation.

 Harari D et al., 1994 [19]

Cross‐sectional study.

United States

Our results highlight the necessity for a new systematic methodology to the valuation of constipation in longstanding care situations, chiefly when pharmacologic management is measured.

Cheryl Phillips MD

et al., 2001 [20]

A retrospective multi-center medical record evaluation.

 

This study supports the concern that there is often a gap between the documentation of symptoms and constipation treatment decisions. No association was established between the precise laxative recommended and the occurrence or lack of a familiar diagnosis of constipation. Management choices must be based on thorough examination and individualized patient needs. Furthermore, there is a need to increase monitoring for drug effectiveness.

Werth B. et al., 2015. [21]

cohort study

Australia

The occurrence of constipation and laxative usage upsurges with age in the old, these upsurges are more for males than for females. Inconsistencies between self-described constipation and purgative usage may advocate sub-optimal managing of constipation in the community-residence seniors and advanced work is needed to fully understand this.

Dov Gandell. et al., 2013 [22]

Review article

 

Physicians must inform their patients on ordinary bowel habits and the probable benefits of dietary adjustments to recover symptoms. Studies stated the benefits of osmotic laxatives in the elderly, as lactulose. Studies stated the usage of loose agents, stool softeners, stimulants, and prokinetic agents was lacking, limited, or inconsistent.

Schuster B. et al., 2015 [23]

Case study

 

There is inadequate confirmation about the best-used treatment, but fibers containing supplements would be first, excepting in bedridden cases, are cognitively compromised, or any contraindications, in this case, an osmotic agent such as PEG 3350 or lactulose, is indicated. Patient preferences should be considered. Treating constipation and avoiding fecal impaction must be taken into consideration.

Wald A,  1990 [24]

Cross-sectional study

Pennsylvania

The effective managing of constipation and fecal incontinence in the old people necessitates a considerate of colorectal role, cautious demarcation of the patient's complaint, in some cases, specified studies of the colonic and anorectal role.

Gallagher P. et al.  2012 [25]

Review article

 

There is a defect in studies about the used laxatives in the general or the geriatrics. Modification of lifestyle is beneficial but the evidence is lacking for cases of chronic constipation. So, constipation treatment in the elderly must be adopted according to the individual's desires and prospects.

Bosshard W. et al.  2012 [26]

 

 

Constipation treatment in the elderly must be adopted according to the individual's practice and beliefs. Many agents appear effective but need precisely tried before advised.

Roque M. et al. 2015 [27]

Review article

 

CC in geriatrics is popular; noteworthy disturbs the quality of life and the health care system. An alert history, drug valuation, and bodily examination are supportive in getting significant signs for good management.
  • Alhusainy YA, 2018 [28]

Internet Based Survey

Saudi Arabia

The study reported a high frequency of constipation.  In addition to such high rates, the risk factors related to constipation have been identified in the Saudi community. KSA is highly lacking studies about constipation prevalence and determinants. This may initiate a  call for setting priority as one of the major public health issues and deserves urgent attention both at the clinical and at the community level.

 

DISCUSSION:

According to many previous studies, Constipation is a prevalent disorder and an important cause of morbidity in the elderly. Chronic constipation in the elderly is affected by many factors which make it more prevalent in the elderly more than any other age group especially the people above 65 years old [3]. Yet it has been greatly understudied as a health care issue in the long‐term care setting. Many community‐based studies document the prevalence of constipation in senior adults.

In Roberto De Giorgio's study, the prevalence of constipation in elderly studies reported 26 % in females compared to 16 % in males, while the percentage was 34 % in females and 26 % in males in whom >84 years cases, So, age was associated with leveling between sexes [29, 30].

This may be because frailty in older persons is very common and is associated with immobility, poor food intake, multiple medication usage, and dehydration [31]. An old study reported that constipation is present in 45 % of frail elderly persons [32]. In another community-based study from Minnesota, USA, which included 100 patients aged 65 years old or older, they reported the overall prevalence of constipation to be 40 %, 24.4 % of the patients were affected by functional constipation and 20.5 % by outlet dysfunction [33]. 

Selection of Management line and treatment in constipation depends on the underlying physiologic cause. In the elderly population, it is important to consider other factors that impact constipation such as dehydration, dementia among others before initiating a specific therapy. Management of medication-induced causes, lifestyle modification, and nonpharmacologic therapies should be the first step to avoiding unnecessary drug therapy. Generally, fiber supplementation is a practical original helpful line; conversely, non-responded cases could be advised by osmotic laxatives [31, 32]. 

According to Donini et al., [34] which stated that fiber ingestion was significant mainly in the geriatrics, so, all nationwide dietetic guidelines in addition to the food guide pyramid for aged individuals emphasize the essential to raise the intake of dietary fiber, such as fruits and vegetables. 

In another study done by Roberto De Giorgio [16], they also reported that non-pharmacological treatment, which consists of diet and lifestyle modifications is traditionally considered the first step of a comprehensive treatment program to effectively manage constipation.

Hebatallah Nour-Eldein. Et al. reported a substantial decrease in the contributors who used purgatives from 82.6% - 34.8% consumers in pre-post interference [17]. These results were supported by the results by Sturtzel and Elmadfa [35] that discovered decreased laxative consumption in reply to regular fiber ingestion. While, Park et al., [36] revealed that while exercise and dietary fiber were supportive in selected constipation cases, purgatives were more efficient in releasing symptoms of constipation in other cases.

In a previous study [22], it was reported that using bulk means, stool softeners, stimulants, and prokinetic agents was deficient, limited, or inconsistent, contrary to another preceding study conducted by Paul F. Gallagher. Et al. [25], Whoever, in another study there was a conforming rise in the frequency of laxative usage from 6% - 15% during this time [21].

Stimulant laxatives and prokinetic agents must be earmarked only in cases that are intractable to fiber additions or osmotic purgatives, whoever there is some evidence that laxatives are not effective in some cases. In Danielle Harari's [19], an important potential explanation for the substantial number of laxative users who continue to report constipation symptoms is that current pharmacologic management of this problem is frequently clinically ineffective or becomes ineffective over time. As they reported in their study, in common with 2 others based in US nursing homes, revealed that the stool softener docusate was most commonly prescribed, followed by the laxative magnesium hydroxide [37, 38], whoever, there are only minimal data to support the efficacy of magnesium hydroxide as a laxative in the elderly [39]. Recently published literature [40, 41] and the Physicians Desk Reference clearly describe docusate as a fecal softener without any laxative action, and there are only minimal data to support the efficacy of magnesium hydroxide as a laxative in the elderly [39]. In contrast, the effectiveness of less frequently employed agents such as senna, bulking agents, sorbitol, and lactulose has been demonstrated in elderly subject groups [19]. Also, enemas were reported to be used as a treatment for some cases of constipation, although they are reported to have more associated side effects in the elderly [42, 43]. 

CONCLUSION:

Extraordinary prevalence of constipation remained observed among the population, especially the elderly, in Saudi Arabia and worldwide. Constipation is a consequence of a group of risk influences, as per reduced physical activity subsequent from long-lasting diseases, reduced fiber, and fluid intake, and multiple medication intakes. Fiber supplementation and laxatives are considered the first line and effective treatment in most patients. Surgical treatment is hardly ever specified for constipation.

Limitations:

The used previous studies were constrained to those published in the English linguistic though publication bias possibly will have prejudiced studies having helpful outcomes.

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