A Rational Approach to Constipation

Hershl Berman, MD, FRCPC; Laura Brooks, RegN, MscN, APN; Shawna Silver, MD, PEng


Geriatrics and Aging. 2007;10(10):654-660. 

In This Article

Abstract and Introduction


Constipation is a common complaint, especially in older adults. It results in millions of physician visits per year, with hundreds of millions of dollars spent on laxatives. Untreated it can lead to serious morbidity and can be a contributing factor in mortality. A rational approach to the patient presenting with constipation includes a detailed history, general and focused physical examination, specific investigations, and appropriate therapy. Treatment should aim to address the underlying cause, as should the choice of laxative. In general, it is best to clear out hard stool in the distal bowel before using an aggressive oral regimen.


Constipation is a very common finding, particularly in older adults. The prevalence in North America in individuals over 18 years of age has been estimated to be as high as 27%,[1] with up to 26% of men and 34% of women over the age of 65 reporting symptoms.[2] In the United States alone, over two and a half million physician visits per year are devoted to constipation[1] with more than $800 million spent on laxatives annually.[3]

Constipation is not a benign condition. Case reports of deaths due to bowel perforation attributed to constipation have been published.[4] Other complications including hemorrhoids, anal fissures, rectal prolapse, fecal impaction, perforation, and overflow diarrhea have also been reported.[5] In long-term and acute care health centres, constipation is often overlooked or treated less aggressively than it should be, contributing to morbidity and mortality.[4]

Among older adults, many factors can contribute to the problem. Inappropriate use of medications increases the risk of constipation. Multiple medical problems may contribute to it as well. Social isolation and impaired cognitive ability may result in behaviours, such as poor adherence with medications or poor diet, that exacerbate the situation.[6]

This article describes criteria for diagnosis and a rational approach to assess the patient complaining of constipation and guides the clinician to initiate appropriate therapies based on the underlying cause and the mechanism of actions of various laxatives.


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