Abstract
Objectives
This narrative review identifies pitfalls in managing constipation in older adults and provides evidence‐based recommendations to avoid them.
Methods
A selective literature search was conducted across electronic databases (PubMed, MEDLINE, Embase, and Cochrane Library) to identify relevant publications on constipation management in older adults. Randomized controlled trials, meta‐analyses, systematic reviews, evidence‐based clinical practice guidelines, and selected expert consensus statements and narrative reviews were included.
Results
Constipation significantly impacts quality of life and healthcare costs in older adults. It is not a consequence of normal aging but results from decreased mobility, medications, underlying diseases, and pelvic floor dysfunction. A stepwise diagnostic and therapeutic approach is recommended, recognizing that multiple etiologic mechanisms often coexist in elderly patients. Before pharmacological interventions, initial management should include thorough history‐taking, physical examination, medication review, and dietary and lifestyle modifications.
Conclusions
Common management mistakes include inadequate assessment, overlooking underlying conditions, insufficient diagnostic workup, ignoring multifactorial causes, premature medication use, and neglecting patient education. Effective management requires systematic evaluation and personalized interventions.
Clinical Implications
Clinicians should adopt a stepwise approach, from clinical assessment to diagnostic testing or medications. Patient education and individualized treatment based on comorbidities and preferences are essential, with regular efficacy reassessment.
Keywords: colonic transit, constipation, dyssynergic defecation, elderly, pelvic floor dysfunction, slow‐transit constipation
1. INTRODUCTION
Constipation remains a frequently reported bowel symptom in older people aged 65 years or older. 1 Constipation can be associated with fecal incontinence, impaction, urinary retention, hemorrhoids, anal fissures, and cardiovascular complications. 2 Hence, chronic constipation can significantly impact the quality of life of an older individual.
The prevalence of constipation is rising with increasing age. At ages above 65 years, 26% of females and 16% of males were found to have constipation. 3 Although constipation is not a physiologic consequence of aging, many factors, including decreased mobility, medications, numerous age‐specific diseases, and pelvic floor dysfunction, may contribute to its increased prevalence in older persons. Hence, a stepwise diagnostic and therapeutic approach must be adopted to manage constipation in the older person.
Causes of chronic constipation can broadly be categorized into primary and secondary causes. Primary causes include: (1) slow transit constipation (STC), (2) pelvic floor dysfunction (PFD), and (3) normal transit constipation (NTC). 4 STC results in delayed transit of stool through the gut. 4 PFD results from disordered coordination between abdominal, anorectal, and pelvic floor muscles, leading to inadequate rectal propulsive forces and/or increased resistance to defecation. 5 While colonic motility remains unchanged in NTC, patients may complain of significant abdominal pain, discomfort, and increased psychosocial stress. 4 This group of patients with NTC may have a shared pathophysiology with constipation‐predominant irritable bowel syndrome (IBS‐C). 4
Constipation is a prevalent condition, and managing it in older adults is prone to mistakes in primary and secondary care settings. In this review, we highlight common errors in evaluating and managing constipation in the elderly and provide evidence‐based recommendations to avoid them (Figure 1).
FIGURE 1.
Managing chronic constipation in the elderly.
A comprehensive literature review was conducted using multiple online databases, including PubMed, MEDLINE, Embase, and Cochrane Library from January 2000 to February 2025. The search strategy employed combinations of MeSH terms and keywords, including “constipation,” “chronic constipation,” “elderly,” “older adults,” “geriatric,” “management,” “treatment,” “evaluation,” “diagnosis,” “pelvic floor dysfunction,” and “slow transit constipation.” Additional articles were identified through manual searches of reference lists from retrieved publications. Selection criteria prioritized randomized controlled trials, meta‐analyses, systematic reviews, and evidence‐based clinical practice guidelines. Expert consensus statements and narrative reviews were included where experimental evidence was limited. The literature was systematically evaluated, emphasizing diagnostic approaches, management strategies, and common pitfalls in treating constipation in the older population.
2. DIAGNOSTIC EVALUATION MISTAKES
2.1. Mistakes 1
2.1.1. Inadequate initial assessment
Initial assessment of chronic constipation in the elderly includes a thorough history and physical examination.
History‐taking from older patients can be challenging due to memory loss, frailty, and sensory impairments. However, it is imperative that at the initial presentation, a thorough history be taken from both the patient and caregiver to assess the presenting problem, as well as the severity and causation of constipation.
Clinicians must first understand what the patient means by constipation. Most physicians consider constipation a stool frequency of fewer than three defecations per week. 6 However, patients may refer to “constipation” as a broad range of subjective symptoms, including straining, incomplete evacuation and frequency of defecation. The Bristol stool chart, a validated visual tool categorizing stools according to consistency and appearance, helps determine constipation. 7 Bristol stool types 1 and 2 denotes constipated stools.
The ROME IV criteria define constipation as having two or more of the following: (1) less than three bowel movements per week, (2) at least 25% of bowel movements have hard or lumpy stools, (3) straining at stool, (4) use digital maneuvers (vaginal or perianal pressure) to facilitate defecation, (5) a sensation of incomplete evacuation, (6) a sensation of anorectal obstruction. 8 The above criteria should be fulfilled for the last 3 months, with symptom onset starting at least 6 months before diagnosis. 8
Therefore, attention must be paid to stool form, frequency, presence of straining, incontinence, seepage, fecal impaction, and manual maneuvers. Contributory factors include diet, psychological and lifestyle factors of the individuals. Information regarding activities of daily living, living environment, social support and psychosocial stressors should be sought to identify contributory factors.
Since polypharmacy contributes to chronic constipation, an adequate drug history should be obtained. Drug‐induced constipation is one of the most common causes of constipation in the elderly. Anti‐hypertensives (calcium channel blockers, clonidine), anti‐histamines, iron, analgesics (opioids, non‐steroidal anti‐inflammatories (NSAIDs), anabolic steroids), anti‐depressants (tricyclics), anti‐convulsant, and anti‐Parkinson medications have all been linked to constipation. 4 Stopping the offending drug can quickly reverse constipation.
As constipation can be a sign of malignancy, the presence of concurrent “alarm symptoms”, such as loss of appetite, unintentional weight loss, recent onset altered bowel habit, or recurrent rectal bleeding, must be actively explored.
An abdominal examination must be performed to look for palpable masses, distension, and hernias. All patients should undergo a digital rectal examination, with the assessment of resting anal tone, squeezing, and bearing down to assess pelvic floor dyssynergia and to detect perineal descent. 4 Examining the perianal region to check for skin lesions, hemorrhoids, and fissures is essential. The anal sensation should be checked to rule out neuropathy. 4
The patient's general condition, mobility, and functionality must be evaluated during the physical examination. Frailty in the elderly is a common association among patients with chronic constipation. The severity of constipation has been demonstrated to be substantially correlated with an increase in the burden of frailty. 9 Hence, the assessment of frailty by using a validated frailty index such as the FRAIL scale or Clinical Frailty Scale (CFS) will help determine treatment. 10 , 11
2.2. Mistake 2
2.2.1. Overlooking underlying medical conditions
Multiple medical conditions can be related to chronic constipation in the elderly. Such secondary causes include: (1) neurological disorders, (2) myopathic disorders, (3) medications, (4) endocrine and metabolic disorders, and (5) malignancy and paraneoplastic conditions. 4
It is vital to check for underlying disorders linked to chronic constipation in the older person, as many of them have coexisting chronic conditions. Neurological conditions (multiple sclerosis, Parkinson's disease, spinal cord injury, and autonomic neuropathy), as well as myopathies (myotonic dystrophy, dermatomyositis), can be associated with chronic constipation. Metabolic causes such as hypercalcemia, hypokalemia, hyperglycemia and chronic renal disease can also be related to chronic constipation. Chronic constipation can also be seen in patients with endocrine disorders, including diabetes, hypothyroidism, and panhypopituitarism. Therefore, a systematic clinical approach to evaluate for underlying neurological and myopathic conditions, as well as endocrine and metabolic disorders as a contributory factor in chronic constipation in the elderly, should be employed where appropriate.
Nonetheless, cancer remains the most concerning cause of constipation. It is estimated that constipation occurs in over 60% of patients with cancer. 12 In addition to the tumor‐related factors, other factors, including diet, medication, electrolyte imbalances, dehydration, anorexia, and reduced mobility, can contribute to chronic constipation among patients with malignancy. Therefore, a careful evaluation of cancer‐related symptoms and physical signs should be part of the evaluation of chronic constipation in the elderly.
Psychological factors like depression, anxiety, and cognitive impairment cannot be ignored when considering constipation in older adults. These conditions not only worsen the symptoms but also make it harder for patients to follow up and adhere to their treatments, especially for those with dementia. Additionally, social isolation is a major contributor to the worsening of the condition and leads to significant debilitation.
2.3. Mistake 3
2.3.1. Insufficient diagnostic workup, including neglecting PFD
Diagnostic workup of chronic constipation in the elderly must be systematic to cover probable primary and secondary causes. Serum investigations must include a complete blood count for anemia, a metabolic profile for elevated serum calcium levels, and abnormal thyroid function tests. An abdominal X‐ray can be used to identify fecal impaction or to rule out an acute bowel obstruction. Non‐invasive imaging techniques such as ultrasound or computer tomography (CT) of the abdomen and pelvis can aid in detecting underlying malignancy. A colonoscopy allows one to visualize the bowel mucosa and acquire biopsies to rule out inflammatory bowel diseases, especially proctitis. Colonic diverticular disease can be associated with chronic constipation in the elderly. In the presence of alarm symptoms in a patient with constipation, such as loss of appetite, unintentional weight loss, per rectal bleeding, or new onset iron deficiency anemia, a colonoscopy is mandatory to rule out the presence of colonic malignancy.
STC may be due to a defect in either enteric nerve innervation or smooth muscles of the colon. 4 It results in delayed transit of stool through the gut. PFD results from the anal sphincters, pelvic floor muscles, and abdominal muscles contracting paradoxically or failing to release to defecate. 5 There can be concomitant STC in some patients with PFD. While colonic motility remains unchanged in NTC, patients may complain of significant abdominal pain, discomfort, and increased psychosocial stress. 4
Physiological tests are encouraged as they help diagnose PFD and STC. 4 Anorectal manometry, the primary test to evaluate the pelvic floor, comprehensively assesses the pressure activity, strength, tone, and sensation in the anorectum. 13 A balloon expulsion test involving the insertion of a warm water‐filled balloon or a silicone‐filled device into the rectum, which is then expelled by the patient in a sitting position, can be used to determine PFD or dyssynergic defecation. Additionally, defecography, either barium or dynamic pelvic magnetic resonance imaging (MRI), can assess pelvic floor function and structure. While barium defecography provides a good assessment of functionality, it is inferior to dynamic pelvic MRI, which provides direct visualization of structural abnormalities such as rectocele and prolapses. 14
The Sitzmark capsule study helps assess transit through the colon. 15 Recently, a wireless motility capsule system has been developed, a safe, well‐tolerated, and radiation‐free assessment of colonic transit time. 16 While it allows gut transit assessment, it remains an expensive modality. 16 Although wireless motility capsules give comprehensive information, they should not be considered first‐line diagnostic tools. Sitz marker studies remain the current standard.
Colonic transit studies will be normal in patients with NTC, and they will fulfill the diagnostic criteria for IBS‐C. 8
In medical practice, especially within the resource‐limited setting, the cost, accessibility, and clinical necessity of these novel advanced investigation modalities like wireless motility capsule and dynamic MRI defecography demand careful consideration. Rushing to expensive investigations without comprehensive clinical evaluation undermines good medical practice.
Table 1 outlines the stepwise evolution of an older patient with chronic constipation.
TABLE 1.
The stepwise evaluation of a patient with chronic constipation.
| History |
|
Stool form, frequency, straining, manual evacuation, fecal impaction, seepage, fecal incontinence |
|
Psychiatric, Metabolic and endocrine causes of constipation | |
|
Check for polypharmacy, constipation‐prone medication | |
|
Diet, living conditions, social support, activities of daily living, stressors | |
|
Loss of appetite, weight loss, altered bowel habit, per rectal bleeding | |
| Examination |
|
Presence of palpable masses or stool, abdominal distension, hernias (inguinal/femoral/abdominal) |
|
Skin lesions, hemorrhoids, fissures, anal tone, perineal sensation | |
| Investigations |
|
Anemia, Hypercalcemia, Hypothyroidism |
|
To rule out malignancy, inflammatory bowel disease, solitary rectal ulcer syndrome | |
|
To rule out acute bowel obstruction, intra‐abdominal lymphadenopathy, malignancy | |
|
Used for pelvic floor evaluation: Assess strength, tone, and sensation in the anus and rectum Helps to rule out defecatory disorder especially dyssynergic defecation |
|
|
Pelvic floor function: rectocele, enterocele, pelvic organ prolapses | |
|
To assess transit through colon: (Slow/normal transit constipation) |
3. THERAPEUTIC MISTAKES
3.1. Mistake 4
3.1.1. Ignoring multifactorial nature
Constipation in the older person is usually multifactorial, so a comprehensive management plan is warranted. Changes in diet, lifestyle, and bowel control strategies should be the first step in the management process. A review of medications and issues affecting compliance must be undertaken. Additionally, it is advised that patients maintain a journal to document their bowel movements, stool consistency, form (using the Bristol stool chart), need to strain, and manual techniques and drugs used to ease constipation. 4 Setting up a schedule for defecation, especially in the morning, is encouraged as stronger physiological contractions occur in the early morning and after meals.
If not recognized early, fecal impaction can be a significant problem in the elderly. It can lead to increased morbidity and impair the quality of life of the patient. 17 Notably, it is common among those on frequent opioid use who remain in institutionalized care or have neuropsychiatric disorders. 18 , 19 In these instances, lifestyle modifications and routine laxatives are not helpful. The mainstay of treatment includes digital evacuation of the impacted fecal mass or the rectal administration of stool softening agents (enemas or suppositories). If peritonitis is suspected, early surgical evaluation is crucial, as stercoral perforation has a high mortality rate of up to 55%. 20
Despite the diverse nature of the condition, implementing a more personalized and stratified approach remains essential for optimal management. Considering all physical and psychological factors, a shared care approach with a multidisciplinary team is beneficial. Among all these factors, patient preferences are the most important for adherence. For example, some adults may prefer non‐invasive approaches; thus, shared decision‐making should be emphasized.
3.2. Mistake 5
3.2.1. Neglecting patient education
Education and reassurance of patients with general bowel management tips are recommended. These tips include: (1) the ideal toileting time between 3 and 5 min (never more than 10 min), (2) sitting tall on the toilet using a small stool under the feet, (3) diaphragmatic breathing techniques, and (4) avoidance of straining. Patient education on bowel management techniques should be routine in all elderly patients with chronic constipation.
Dietary advice should not be overlooked. A high‐fiber diet (containing nuts, vegetables, and fruits) and daily exercise can intensify the gastrocolic reflex. 4 Fiber, both insoluble and soluble, help relieve constipation. While soluble fiber traps water and softens the stools, insoluble fiber increases stool bulk. Hence, a dietary history focusing specifically on fiber intake must be established. A gradual increase in fiber is recommended, starting at 5 g/week and increasing as tolerated, considering that fiber can further exacerbate symptoms of bloating and distension. 4 Alternative diets, such as a low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) diet, may benefit those with excessive bloating and IBS‐C. 4 Adequate fluid intake should be advised when increasing fiber content in the diet. Fruits such as prunes and kiwi fruit are known to improve gut motility. However, this dietary advice does not apply to all causes of constipation.
3.3. Mistake 6
3.3.1. Premature pharmacological intervention and inappropriate laxative use
There are limited studies on the efficacy and safety of many of the common pharmacological agents used in treating constipation in older persons. Most trials contain only a small number of study participants over the age of 65 years. Hence, pharmacological treatment should be individualized, considering the patient's background, functionality, comorbidities, social support, and financial status. Consideration of pharmacological therapies should be done if there is no improvement in symptoms despite lifestyle modifications and adequate adherence to bowel management techniques.
Bulk‐forming laxatives are considered the first line in treating chronic constipation. They increase stool weight and water‐absorbent properties, thus increasing bowel movements by an average of 1.4 per week. 21 While the onset is delayed, bulk‐forming laxatives are usually well‐tolerated, decrease abdominal pain, and improve stool consistency. 21 Psyllium, a soluble intermediate fermentable fiber, is the only bulk‐forming laxative with sufficient clinical evidence for effectiveness in chronic constipation. 22 Other options include calcium polycarbophil, wheat dextrin, and methylcellulose, but they have insufficient evidence of effectiveness. 22
Osmotic laxatives include polyethylene glycol (PEG), poorly absorbed sugars (lactulose, sorbitol) and magnesium hydroxide. They retain water in the intestinal lumen, resulting in a softer stool and effective evacuation. Additionally, osmotic laxatives improve stool form, consistency, frequency, and need to strain. 23 PEG is generally considered safe and effective. Lactulose is a non‐absorbable carbohydrate that alters intestinal osmolality. 4 While lactulose can provide relief, side effects such as bloating, nausea, cramping, flatulence, and diarrhea are reported. 24 Magnesium hydroxide increases stool frequency but can result in renal insufficiency and, therefore, must be used with caution in older persons. 21 , 23
Stimulant laxatives enhance colonic motility by stimulating the colonic myenteric plexus and altering the intestinal mucosa's electrolyte transportation. Although some patients respond well to stimulant laxatives like bisacodyl and senna, they do not appear to be more effective than other laxatives. 24 They are generally used as short‐term rescue therapy (<4 weeks) because their long‐term safety remains unconfirmed. 24 Glycerin suppositories can aid in stool evacuation in patients with defecation disorders (DD), especially when taken 30 min after breakfast, thus taking advantage of the gastrocolic reflex. 25 There appears to be insufficient research regarding the effectiveness of stool softeners such as liquid paraffin, but they may help improve symptoms.
Intestinal secretagogues, such as Linaclotide and Lubiprostone, are used in difficult‐to‐treat chronic constipation. Linaclotide, minimally absorbed peptide agonists of the guanylate cyclase‐C receptor, stimulates intestinal fluid secretion and transit. 26 Common side effects include diarrhea, headache, and arthralgia. Studies have shown that a low dose of linaclotide is more effective and safer for older persons. 5 Lubiprostone is currently approved for use in chronic constipation, IBS‐C, as well as opioid‐induced constipation. 27 Nausea is the predominant side effect.
Prucalopride is a highly selective serotonin 5‐hydroxytryptamine 4 (5‐HT4) receptor agonist approved for chronic constipation treatment. 5 It increases serotonin release by the enterochromaffin cells in the small bowel. In addition to improving intestinal motility, it has an added prokinetic effect. 5 Prucalopride is currently recommended in older patients who have not responded satisfactorily to either fiber, osmotic, or stimulant laxatives. 28 Common adverse effects experienced on treatment include abdominal pain, nausea, diarrhea, headache, dizziness, and fatigue. There are also reports of worsening depression and suicidality. 5 Hence, caution must be exercised in at‐risk patients.
Tepanor is a selective sodium‐hydrogen exchanger inhibitor approved for use in IBS‐C. It reduces sodium absorption from the intestine, resulting in water secretion in the lumen. This further increases intestinal transit, resulting in softer stool. 29 Tepanor also relieves abdominal pain and increases complete spontaneous bowel movement. 29 The main adverse effects of Tepanor are reported as abdominal distention and diarrhea.
3.4. Mistake 7
3.4.1. Not considering additional treatment modalities
Patients who do not respond to a non‐pharmacological lifestyle and pharmacological intervention should be considered for additional treatment modalities.
Biofeedback is a behavioral approach that can be used to treat chronic constipation. A trained and skilled therapist should perform it. Patient education on underlying conditions, coping strategies, urge suppression techniques, skin care, stress reduction, and pelvic floor muscle training are included. It appears effective in DD without structural abnormalities such as a rectocele, enterocele, or prolapse. 30 In one study, biofeedback therapy helped to eliminate DD in 91% of patients, and 85% confirmed improvement in the balloon expulsion test. 31 However, there remains a lack of high‐quality biofeedback therapy in practice. In those who fail biofeedback therapy, visceral manipulation can be used, though there remains little evidence for its efficacy. 32
Given the older patient's many comorbidities and weaknesses, surgery for chronic constipation should be undertaken with caution. Patients with severe STC without global gastrointestinal hypomotility and/or defecation problems who have not responded to pharmacological therapy may be candidates for surgical treatment. Before surgery, however, it is essential to rule out other concomitant conditions such as IBS‐C or PFD/DD.
Studies have shown that aroma therapy may have a place in treating chronic constipation. Aroma massage practice has been found to enhance defecation frequency and feces' volume and consistency. 33 Additionally, it was noted to decrease straining during defecation and a feeling of incomplete evacuation of feces. 33
The emerging studies evaluating the efficacy of microecological therapies such as probiotics, prebiotics, and fecal microbiota transplantation (FMT) for functional constipation have shown encouraging results that suggest potential for clinical practice. 34 However, there is a research gap that exists regarding the management of functional constipation and IBS‐C, especially in elderly populations.
4. CONCLUSIONS
Chronic constipation has an increased prevalence in older persons due to polypharmacy, immobility, physiologic changes in the intestinal tract and pelvic floor function caused by aging. Hence, it is a considerable burden to any healthcare system. Common errors occur in primary and secondary care when treating constipation in older adults. Therefore, healthcare providers should systematically evaluate and treat elderly patients with long‐term constipation (Table 2).
TABLE 2.
The stepwise therapeutic management of a patient with chronic constipation.
| General management | Pharmacological therapy | Additional treatment modalities |
|---|---|---|
Changes in diet
|
Bulk‐forming laxatives
|
Biofeedback |
Lifestyle modification
|
Stimulant laxatives
|
Surgical interventions |
Bowel control strategies
|
Osmotic laxatives
|
Aroma therapy |
Stool softeners
|
||
Intestinal secretagogues
|
||
|
5‐HT4 receptor agonist
|
A thorough history and physical examination are necessary to assess the cause and severity of constipation. Initial management includes medication review, diet, and lifestyle changes. Pharmacologic treatments should be individualized considering the patient's comorbidities, functionality, social support, and financial status. Education and reassurance play a significant role in managing chronic constipation in the older person. Judicious use of pharmacological therapies is advised. Further research is warranted to define the efficacy and safety of newer treatments. Refractory patients may benefit from biofeedback therapy and even surgery.
AUTHOR CONTRIBUTIONS
Madunil Niriella: Conceptualization; writing – review and editing; supervision. Hiruni Jayasena: Writing – original draft; data curation; writing – review and editing. Prathibha Wijesingha: Writing – original draft; writing – review and editing; data curation. Janaka de Silva: Writing – review and editing.
FUNDING INFORMATION
This paper was not funded.
CONFLICT OF INTEREST STATEMENT
The authors have stated explicitly that there are no conflicts of interest in connection with this article.
ETHICS STATEMENT
Ethics approval statement: None.
Patient consent statement: None.
Clinical trial registration: None.
ACKNOWLEDGMENTS
The authors have nothing to report.
Niriella M, Jayasena H, Wijesingha P, de Silva J. Critical mistakes in managing chronic constipation in the older person and how to avoid them: A narrative review. J Gen Fam Med. 2025;26:394–401. 10.1002/jgf2.70033
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
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Associated Data
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Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.