Constipation is not a glamorous topic, but it’s certainly important, especially in older adults.
As anyone who has experienced occasional — or even chronic — constipation can tell you, it can really put a damper on quality of life and well-being.
Constipation can also cause more substantial problems, such as:
- Severe abdominal pain, which can lead to emergency room visits
- Hemorrhoids, which can bleed or be painful
- Increased irritability, agitation, or even aggression, in people with Alzheimer’s disease or other forms of dementia
- Stress and/or pain that can contribute to delirium (a state of new or worse confusion that often happens when older adults are hospitalized)
- Fecal incontinence, which can be caused or worsened by having a hard lump of stool lodged in the lower bowel
- Avoidance of needed pain medication, due to fear of constipation
Fortunately, it’s usually possible to help older adults effectively manage and prevent constipation. This helps maintain well-being and quality of life, and can also improve difficult behaviors related to dementia.
The trouble is that constipation is often either overlooked or sub-optimally managed by busy healthcare providers who aren’t trained in geriatrics. They are often focused on more “serious” health issues. Also, since many laxatives are available over-the-counter, some providers may assume that people will treat themselves if necessary.
Personally, I don’t like this hands-off approach to constipation. Although several useful laxatives are indeed available over-the-counter (OTC), I’ve found that the average person doesn’t know enough to correctly choose among them.
Also, although in geriatrics we often do end up recommending or prescribing laxatives, it’s vital to start by figuring out what is likely to be causing — or worsening — an older person’s constipation.
For instance, many medications can make constipation worse, so we usually make an attempt to identify and perhaps deprescribe those.
In short, if you’re an older adult, or if you’re helping an older loved one with health issues, it’s worthwhile to learn the basics of how constipation should be evaluated and managed. This way, you’ll be better equipped to get help from your health providers, and if it seems advisable, choose among OTC laxative options.
Here’s what I’ll cover in this article:
- Common signs and symptoms of constipation
- Common causes of constipation in older adults
- Medications that can cause or worsen constipation
- How constipation should be evaluated, and treated
- The laxative myth you shouldn’t believe
- 3 types of over-the-counter laxative that work (and one type that doesn’t)
- My approach to constipation in my older patients
I’ll end with a summary of key take-home points, to summarize what you should know if you’re concerned about constipation for yourself or another older person.
Common signs and symptoms
Constipation can generally be diagnosed when people experience two or more of the following signs, related to at least 25% of their bowel movements:
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straining
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hard or lumpy stools
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a sense of incomplete evacuation
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the need for “manual maneuvers” (some people find they need to help their stools come out)
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fewer than 3 bowel movements per week
People often want to know what is considered “normal” or “ideal,” when it comes to bowel movements. Although it’s probably ideal to have a bowel movement every day, it’s generally considered acceptable to have them every 2-3 days, provided they aren’t hard, painful, or difficult to pass.
The handy Bristol Stool Scale can be used to describe the consistency of a bowel movement, with Type 4 stool often being considered the “ideal” (formed but soft).
Constipation is pretty common in the general population and becomes even more so as people get older. Experts estimate that over 65% of people over age 65 experience constipation, with straining being an especially common symptom.
Other symptoms that may be caused by constipation in older adults
Constipation may be associated with a feeling of fullness, bloating, or even pain in the belly. In some people, this may interfere with appetite.
Although most older adults will admit to symptoms of constipation when asked, a person with Alzheimer’s or a related dementia may be unable to remember or relay these symptoms. Instead, they might just act out or become more irritable when they are constipated.
Prolonged constipation can also lead to a more urgent problem called “fecal impaction.” This means having a hard mass of stool stuck in the rectum or colon. It happens because the longer stool remains in the colon, the dryer it tends to get (which makes it harder to pass).
Impaction tends to be very uncomfortable, and can even provoke a full-on crisis of belly pain. It can also be associated with diarrhea and fecal incontinence.
Clearing out impacted stool can be hard to do with oral laxatives; these can even make things worse by creating more pressure and movement upstream from the blockage.
Fecal impactions are usually dislodged using treatments “from below” to soften and break up the lump, such as suppositories and/or enemas. (I address what type of enema is safest below.) They sometimes require help from clinicians in urgent care or even the emergency room.
Common causes of constipation in older adults
Like many problems that affect older adults, constipation is often “multifactorial,” or due to multiple causes and risk factors.
To have a normal bowel movement, the body needs to do the following:
- Move fecal material through the colon without excess delay (stool gets dryer and harder, the longer it stays in the colon).
- Coordinate a defecation response when stool moves down to the rectum, which requires properly working nerves and pelvic muscles.
As people get older, it becomes increasingly common to develop difficulties with one or both of these physical processes. Such problems can be caused or worsened by:
- Medication side-effects (more on those below)
- Insufficient dietary fiber
- Insufficient water intake
- Electrolyte imbalances, including abnormal levels of blood calcium, potassium, or magnesium
- Endocrine disorders, including hypothyroidism
- Slow transit due to chronic nerve dysfunction, which can be due to neurological conditions (including Parkinson’s disease) or can be caused by long-standing conditions that eventually damage nerves, such as diabetes
- Irritable bowel syndrome
- Pelvic floor dysfunction
- Psychological factors, such as anxiety, depression, or even fear of pain during the bowel movement
- Very low levels of physical activity
- “Mechanical obstruction,” which means that the colon or rectum — or their proper function — is impaired by some kind of mass, lump, narrowing, or another physical factor
- A tumor can cause this problem, but there are also non-cancerous reasons that a person can develop a mechanical obstruction affecting the bowels.
Medications associated with constipation
Several commonly used medications can cause or worsen constipation in older adults. They include:
- Anticholinergics, a broad class which includes sedating antihistamines, medications for overactive bladder, muscle relaxants, anti-nausea medications, and more. (This group of medications is also associated with worse brain function; they block acetylcholine, which is used by brain cells and by the nerves in the gut.)
- Opiate painkillers, such as codeine, morphine, oxycodone
- Diuretics
- Some forms of calcium supplementation
- Some forms of iron supplementation (often prescribed for anemia)
It’s not always possible or desirable to stop every medication associated with constipation. If a medication is otherwise providing an important health benefit and there’s no less constipating alternative, we can continue the medication and look for other ways to improve bowel function.
Still, it’s important to consider whether any current medications can be deprescribed, before deciding to use laxatives and other management approaches.
If opioids are absolutely necessary to manage pain (such as in someone with cancer, for instance), a special type of medication can be used, to counter the constipating effect of opioids in the bowel. This is generally better than depriving a person of much-needed pain medication.
How to evaluate constipation
How to treat constipation basically depends on what appears to be the main causes and contributors to a person’s symptoms.
An evaluation should start with the health provider asking for more information regarding the symptoms, including how long they’ve been going on, as well as the frequency and consistency of stools.
It’s also important for the clinician to ask about “red flags” that might indicate something more serious, such as colon cancer. These include:
- Blood in the stool (which can be red, or black and “tarry” in appearance)
- Weight loss
- New or rapidly worsening symptoms
The next steps of the evaluation will depend on a person’s medical history and symptoms. It’s generally reasonable for a healthcare provider to check for these common causes of constipation:
- Medication side-effects
- Low intake of dietary fiber
- Low fluid intake
- Common causes of painful defecation, such as hemorrhoids or anal fissures
Evaluation for possible mechanical obstruction will depend on what the clinician sees on physical examination, the presence of potential red flags, and other factors. Generally, a rectal exam is a good idea.
In a 2013 review, the American Society for Gastroenterology recommends that clinicians evaluate for possible pelvic floor dysfunction mainly in those people whose constipation doesn’t improve with lifestyle changes and over-the-counter (OTC) laxatives.
They also recommend diagnostic colonoscopy only for people with alarm symptoms, or who are overdue for colorectal cancer screening.
How to treat constipation
In most older adults with constipation, there are no red flags or signs of mechanical obstruction.
To treat these cases of “garden-variety” constipation, geriatricians usually use a step-wise approach:
- Identify and reduce constipating medications if possible.
- This might mean checking to see if iron is really indicated for anemia treatment (it might no longer be needed)
- Increase dietary fiber intake and fluid intake, if indicated.
- Prunes are often effective because they contain fiber and also sorbitol, a non-absorbable type of sugar that draws water into the bowel. A randomized study published in 2011 found that prunes were more effective than psyllium (brand name Metamucil), for the treatment of constipation.
- Other forms of fiber should be slowly increased, to avoid bloating or discomfort. Adequate hydration is essential, because otherwise, fiber can become a hard mass in the colon that is difficult to move out.
- For a detailed technical take on the effect of fiber in the bowel, see Understanding the Physics of Functional Fibers in the Gastrointestinal Tract: An Evidence-Based Approach to Resolving Enduring Misconceptions about Insoluble and Soluble Fiber.
- Encourage a regular toilet routine, with time on the toilet after meals and/or physical activity.
- If necessary — which it often is — use over-the-counter laxatives to establish and maintain regular bowel movements.
The American Society of Gastroenterology recommends more in-depth constipation evaluation for older adults who fail to improve from this type of first-round treatment. Some older adults do have pelvic floor disorders, which can be effectively treated through biofeedback.
The laxative myth you shouldn’t believe
People often have concerns about using laxatives more than occasionally, because they’ve heard this can be dangerous, or risky.
This is a myth that really should be dispelled. Although medical experts used to worry that chronic use of laxatives would result in a “lazy” bowel, there is no scientific evidence to support this concern.
In fact, in their technical review covering constipation, the American Society of Gastroenterology notes that “Contrary to earlier studies, stimulant laxatives (senna, bisacodyl) do not appear to damage the enteric nervous system.”
(FYI: the “enteric nervous system” means the system of nerves controlling the digestive tract.)
Lifestyle changes and over-the-counter oral laxatives are the approaches endorsed as the first-line of constipation therapy, by the American Gastroenterology Society and others. There are no evidence-based guidelines that caution clinicians to only use laxatives for a limited time period.
The four types of OTC laxatives that I’ll cover in the next section have been used by clinicians and older adults for decades, and when used correctly, are considered safe and do not seem to cause any long-term problems.
That’s not to say that they should be used willy-nilly, or in any which way. You absolutely should understand the basics of how each type works, so let’s cover that now.
Three types of laxative that work (and one that doesn’t)
There are basically four categories of oral over-the-counter (OTC) laxative available. Three of them are proven to work. A fourth type is commonly used but actually does not appear to be very effective. Each has a different main mechanism of action.
The three types of OTC laxative that work are:
- Osmotic agents: These include polyethylene glycol (brand name Miralax), sorbitol, and lactulose. Magnesium-based laxatives also mostly work through this mechanism.
- These work by drawing extra water into the stool, which keeps it softer and easier to move through the bowel.
- Studies have shown osmotic agents to be effective, even for 6-24 months. Research suggests that polyethylene glycol tends to be better tolerated than the other agents.
- Magnesium-based agents should be used with caution in older adults, mainly because it’s possible to build up risky levels of magnesium if one has decreased kidney function, and mild-to-moderately decreased kidney function is quite common in older adults.
- Stimulant agents: These include senna (brand name Senakot) and bisacodyl (brand name Dulcolax).
- These work by stimulating the colon to squeeze and move things along more quickly.
- Studies have shown stimulant laxatives to be effective. They can be used as “rescue agents” (e.g. to prompt a bowel movement if there has been none for two days) or daily, if needed.
- Bisacodyl is also available in suppository form, and can be used this way as a “rescue agent.”
- Bulking agents: These include soluble fiber supplements such as psyllium (brand name Metamucil) and methylcellulose (brand name Citrucel).
- These work by making the stool bigger. Provided the stool doesn’t get too dried out and stiff, a bulkier stool is easier for the colon to move along.
- Bulking agents have been shown to improve constipation symptoms, but they must be taken with lots of water. Older adults who take bulking agents without enough hydration — or who otherwise have very slow bowels — can become impacted by the extra fiber.
- People with drug-induced constipation or slow transit are not likely to benefit from bulking agents.
(For more details regarding the scientific evidence on these laxatives, see this 2013 technical review.)
And now, let’s address the type of OTC laxative that is least likely to work.
The type of OTC laxative that isn’t really effective is a “stool softener”, such as docusate sodium (brand name Colace).
These create some extra lubrication and slipperiness around the stool. They actually have often been prescribed by doctors; when I was a medical student, almost all of our hospitalized patients were put on some Colace.
But, the scientific evidence just isn’t there! Because this type of laxative is so commonly prescribed, despite a weak evidence base, the Canadian Agency for Drugs and Technologies in Health completed a comprehensive review in 2014. Their conclusion was:
“Docusate appears to be no more effective than placebo for increasing stool frequency or softening stool consistency.”
So, save your money and your time. Don’t bother buying docusate or taking it. And if a clinician suggests it or prescribes it, politely speak up and say you’ve heard that the scientific evidence indicates this type of laxative is less effective than other types.
Laxatives do work and are often appropriate to use, but you need to use one of the ones that has been shown to work.
About prescription laxatives
Newer prescription laxatives are also available, and may be an option for those who remain constipated despite implementing lifestyle changes and correctly used over-the-counter laxatives. These include lubiprostone (brand name Amitiza) and linaclotide (brand name Linzess).
But, it’s not clear, from the scientific research, that they are more effective than older over-the-counter laxatives. In its technical review, the American Society of Gastroenterology noted that “meta-analyses, systematic reviews, and the only head-to-head comparative study suggested that some traditional approaches are as effective as newer agents for treating patients with chronic constipation.”
Since these newer medications have a more limited safety record and are also expensive, they probably should only be used after an older person has undergone careful evaluation, including evaluation for possible pelvic floor disorders.
About enemas
Enemas are another form of “constipation treatment” available over-the-counter in the U.S.
The main thing to know is that the most commonly available form, saline enemas (Fleet is a common brand name), have been associated with serious electrolyte disturbances and even kidney damage. Because of this, the FDA issued a warning in 2014, urging caution when saline enemas are used in older adults.
Enemas certainly can be helpful as “rescue therapy,” to prevent a painful fecal impaction if an older person hasn’t had a bowel movement for a few days. But they should not be used every day.
Frequent use of enemas is really a sign that a person needs a better bowel maintenance regimen. This often means some form of regular laxative use, plus a plan to use a little extra oral laxative as needed, before things reach the point of requiring an enema.
If an enema appears necessary, experts recommend that older adults avoid saline enemas, and instead use a warm tap water enema, or a mineral oil enema.
My approach to constipation in my older patients
Generally, to help my older patients with garden-variety constipation, I start by checking for medications that are constipating, and then recommending prunes and encouraging more fiber-rich foods. As noted above, a randomized trial found that 50 grams of prunes twice daily (about 12 prunes) was more effective in treating constipation than psyllium (brand name Metamucil).
Then we usually add a daily osmotic laxative, such as polyethylene glycol (Miralax). If needed, we might then add a stimulant agent, such as senna.
We do sometimes try a bulking agent, but I find that many frailer older adults tend to get stoppered up by the extra bulk. Again, if you use a supplement (such as Metamucil) to put extra fiber in the colon but can’t keep things moving along fast enough, that extra fiber might dry out and become very difficult to pass as a bowel movement.
It usually takes a little trial and error to figure out the right approach for each person, so it’s essential for an older person — or their family — to keep a log of the bowel movements and the laxatives that are taken. If a person has loose stools or too many bowel movements, in response to a given laxative regimen, we dial back the laxatives a bit.
It’s also important to have a plan for “rescue,” which means adding some extra “as-needed” laxative (usually either senna or a suppository), if a person hasn’t had a bowel movement for 2-3 days. The goal of rescue is to avoid the beginnings of fecal impaction.
Last but not least, we also try to make sure an older person is getting enough physical activity, and to establish a routine of having the person sit on the toilet after meals.
With a little time and effort, we usually find a way to help an older person have a comfortable bowel movement every 1-2 days. This does often require taking a daily oral laxative indefinitely, but this is quite common in geriatrics. And as best we can tell, daily laxatives are unlikely to cause harm, provided one doesn’t use a magnesium laxative daily.
The most important take-home points on constipation in older adults
Here’s what I hope you’ll take away from this article:
1.Know that constipation is common but shouldn’t be considered a “normal” part of aging. It deserves to be evaluated and managed by your healthcare providers.
- Be sure to ask for help, if you’ve noticed any difficulties having a comfortable bowel movement every 1-2 days.
- A log of bowel movements and related symptoms will be very helpful to your health providers.
2. If an older person with Alzheimer’s or another dementia is acting out, consider the possibility of constipation.
3. Be sure to speak up if you’ve noticed any “alarm symptoms.”
- The main ones to look for are red blood in the stool, black or tarry stools, unintended weight loss, and new or worsening symptoms.
4. An initial evaluation of constipation should include the following:
- A review of concerning symptoms
- A review of diet, fiber, and fluid intake
- Checking for medications that cause or aggravate constipation (especially anticholinergics) and making sure that any prescribed iron is really necessary
- A rectal exam
5. Most garden-variety constipation can be effectively managed through a combination of lifestyle changes, deprescribing constipating medications, and using over-the-counter (OTC) laxatives.
- Lifestyle changes to consider include avoiding mild dehydration, eating fiber-rich foods, getting enough physical activity, and encouraging a regular toilet routine (e.g. sitting on the toilet after meals).
- Anticholinergics and other constipating medications should be deprescribed whenever possible.
- Daily prunes are especially effective as a “natural” laxative, since they contain soluble fiber and exert an “osmotic laxative” effect.
6. It is often ok to use OTC oral laxatives daily or regularly.
- Many older adults will need to use OTC laxatives to maintain regular bowel movements.
- There is no credible evidence that it’s harmful to use OTC oral laxatives long-term.
7. Three types of OTC laxative have proven efficacy: bulk-forming fiber supplements, osmotic laxatives, and stimulant laxatives. It often takes some trial and error to find the right regimen for a person.
- Osmotic laxatives such as polyethylene glycol (brand name Miralax) are well-tolerated by most older adults, and can be used daily.
- Fiber supplements such as psyllium (brand name Metamucil) are usually effective, provided an older adult drinks enough fluid and doesn’t suffer from a condition causing slow colonic transit. Fiber supplements that get dried out in a slow colon can worsen blockage.
- Stimulant laxatives such as senna are often helpful, and can be used in combination with an osmotic laxative. They can be used daily or as needed, for “rescue therapy.”
8. “Stool softeners” such as docusate sodium (brand name Colace) do not appear to be effective. Don’t bother taking them.
9. It’s best to have a bowel maintenance plan and also a “rescue plan.”
- Your health providers can help you determine which additional laxatives to use “as-needed,” if a person hasn’t had a bowel movement for a few days.
- Frequent use of “rescue” laxatives usually means the regular regimen should be adjusted.
10. Be prepared to do some trial and error, to figure out the best way to manage chronic constipation in any particular person.
- Be sure to keep track of bowel movements and what laxatives you — or your older relative — are taking.
- Your clinicians will need this information in order to advise you on how to further adjust your laxative use.
I hope you now feel better equipped to address this important issue for yourself, or on behalf of an older loved one. Please post any questions or comments below!
My gastroenterologist (who is affiliated with a major academic medical center) recently recommended Align probiotic and Colace for constipation. With respect to the Colace, I have trouble believing that this gastroenterologist doesn’t know what she’s talking about.
Hm, I’m not sure what to say regarding your gastroenterologist. You could bring up the scientific evidence, including the Canadian review that I link to in the article, and ask her for more information on why she thinks Colace is likely to benefit you. She may have particular reasons for recommending it. Just because the evidence suggests it’s no better than placebo in studies doesn’t mean a doctor might not have good reasons to recommend it to a particular person.
The other thing to consider is, how well is it working for YOU? If your symptoms have improved, then that is what is most important.
Thank you for this excellent article. Do you have a discussion on prevention of recurring Diverticulitis? I am 92 years old and have had one episode, but mixed advise on prevention.
Great question! A diverticula is an outpouching in the lining of the colon (but can happen in other parts of the GI tract) and when there are many it’s called diverticulosis, which is more common as we age. These little pockets can become inflamed, and that is called diverticulitis.
Diverticulitis is painful, and its complications include bowel obstruction or infection, sometimes leading to surgery.
I found this article: Mayo Clinic Patient Care and Health Information: Diverticulitis..
Prevention of diverticulitis includes:
1. Exercise promotes normal bowel function and can help with weight management. Obesity is a risk factor for diverticulosis as well.
2. Eat more fiber. A high-fiber diet decreases the risk of diverticulitis, and some will need to take a fibre supplement, like psyllium.
3. Drink plenty of fluids, which helps the fibre to work effectively.
4. Avoid smoking.
5. There’s no need to avoid nuts, seeds or popcorn. It seems that these foods do not affect the risk of diverticulitis.
Brilliant article. Thorough, science-based yet easily intelligible. Extremely helpful.
I’m so glad you enjoyed it!
I concur…very few medical articles these days are reliable and based on EBM! Thank you for an excellent overview on this subject.
I’m so happy you liked the article! Please let us know if there are other topics we should cover.
Is prune juice just as good as eating prunes to relieve constipation?
Prunes and prune juice are both likely to be helpful to promote regular bowel movements, but whole prunes are higher in fibre and sorbitol than prune juice.
Sorbitol passes through the digestive tract without being digested and also absorbs water as it moves through the bowel, which makes bowel movements softer and easier to pass.
So enjoy prunes if you’re prone to constipation!
I loved the article. I am 78 and have had surgery for anal stenosis and mineral oil is the main thing that has helped me. That and a colace was recommended by the gastroenterology surgeon.
Thank you for this most informative info
My personal experience as a 77 year old with constipation problems is that Colace is useless. It hasn’t helped me at all and I drink 60 ounces of water or more each day as well as take a fiber supplement.. I’m going to give the prunes a shot and cut back a little on my psyllium fiber as see if that’s a moving experience.
Best of luck with the prunes! Most Geriatricians would agree that docusate is not very effective, yet it is widely used. Fibre seems to be much more effective, and this article is an oldie but a goodie. Here’s to a happy bathroom visit!
Dr. Didyk — At the age of 72, I have apparently developed chronic constipation, despite daily brisk walks, a healthy high-fiber diet, polyethylene glycol 2x/day, Citrucel 2x/day, 10-12 prunes/day, and a probiotic. I would like to add senna as part of my regimen. How do I add it so that it doesn’t cause too much diarrhea? This has all been very challenging…and aggravating. I’m so grateful to have found this website!
I’m glad you found this website as well!
The only thing you don’t mention that helps with constipation is fluid intake. When taking fibre especially, it’s vital to ensure there is enough fluid to keep it moving in the colon.
I would also advise making sure there isn’t some other cause of constipation, especially if you notice a change in the size or colour of your stools, or any bleeding. If those symptoms occur, see a doctor right away.
When it comes to adding senna, as with all medication changes in older adults, we recommend starting slowly. Even one tablet (8.6 mg) every other day might be a way to start. When senna is added, one might need to adjust one of the other laxatives, such as reducing the PEG to once a day. It does take some experimentation and of course bowel movements can vary from day to day with different dietary, emotional, and other factors.
Thanks for reading and I hope you get the results you’re looking for!
Same here but is taking Miralax daily okay as an addition?
PEG (Polyetylene glycol or PEG 3350) is also called Miralax and it sounds like Sheridan was already taking it.
By the way, very useful article!
Comment #1 – A tablet form of calcium supplement will cause me serious constipation. When I stop, I am quickly back to my normal daily morning stool. I understand it is the binding agent in the pill.
So now I get my calcium through foods. Targeting the recommended 1200 mg or so, I have 2 glasses skim milk, a large glass of orange juice with calcium, a fortified container of low fat cottage cheese after dinner. I have frequent small portions of cheese and other calcium goodies here and there.
My doctor said she did not care which type of calcium I supplemented with. I read that calcium citrate is easier to digest and can be taken without food, so I buy a brand of orange juice with that.
As my cup is really measures a cup and a half, that gets me to my goal. I spread things out during the day so not “all at once”.
Because my vitamin D level in the lab test is on the low threshold of 30, I supplement vitamin D with 2 capsules with 1000 units each, plus what is in the foods. We’ll see what the new lab test is in the future. I understand to aim for 50 I am age 70.
Generally, it’s a good idea to get as much of one’s calcium as possible through diet rather than supplements, so sounds like you are on the right track.
Re vitamin D, it’s debatable whether a level of 30 is too low or not. I address some of the debate in this article: Vitamin D: the Healthy Aging Dose(Plus Answers to 7 FAQs)
Thank you for the link! Excellent article, I made some comments.
Comment #2 – When I took an opioid, the problem wasn’t constipation. It was actually a stopping of peristalsis. My bowels simply did not move. I kept eating normally, then got so bloated as nothing moved. After a few days, maybe on day 4, I stopped the opioid and in another day, maybe 24 to 48 hours, the train started up again. The stool was perfectly normal, it was not hard and dry like in what I think of as constipation.
So, constipation doesn’t require hard/dry stools per se. I would describe a “stopping of peristalsis” as a form of constipation, if it causes bowel movements to decrease in frequency, especially if a person experiences other symptoms such as bloating.
Opioid-induced constipation is a very well-known phenomenon in medicine and in palliative care.
I’m glad it was an option for you to stop the opioid painkiller, and that your bowel movements resumed without too much difficulty.
Do you have thoughts about glycerin suppositories? When I can’t get things moving . . . and it’s been more than a few days, I will use a glycerin suppository and have always then had a bowel movement within the hour. I have not experienced some of the negative effects I’ve read about – such as pain, cramping, etc.
Glcyerin suppositories are very briefly mentioned in the American Gastroenterology Society’s technical review, it says they “seem safe.”
They haven’t been rigorously studied in adults, as best I can tell, but there’s no reason to think they aren’t reasonable to use as you are doing, which sounds like “rescue” therapy.
Informative, comprehensive and very practical advice for a problem that can creep up on anyone.
thank you!
My PCP recommended Miralax and possibly Senna daily but the gastrointestinal doc wants a colonoscopy. Confusing. Age 75 and healthy except for constipation.
Very informative article. Thank you.
Miranda Wolhuter
glad you found it informative. Hope it will be helpful to you or someone you know.
Dear Dr. K,
Once again, you boldly and cheerfully go where few will venture, and you tell us what we need to know!
Thank you for this thorough, clear information on a topic for all ages at one time or another!
You are that rare combination of high intelligence and generosity.
Pam
Thank you for this feedback, I appreciate it!
Would a laxative such as Milk of Magnesia be safe to use on a regular (once weekly) basis?
A magnesium-based laxative is generally safe if one has normal kidney function, however many older adults don’t. Older adults can also experience the fairly quick onset of decreased kidney function due to dehydration, illness, or medication side-effects.
Before using a magnesium-based laxative regularly, it would be best to check with one’s healthcare provider and perhaps also a pharmacist.
Thank you!
I really thought this article was very interesting.
I commented earlier about how I really enjoyed reading the article you posted. I also wanted to add that I found it very interesting how the use of docusate sodium is really not all that effective for constipation. Yet I find a lot of doctors prescribe it for patients with their maintenance medications at the pharmacy where I work. I enjoy reading all the articles you post because with each one I learn something new.
thank you!
A gastroenterologist recommended solace (docusate sodium) for me. It simply seems to make mucus lubrication for stool. Not much help, though.
Yes, although plenty of health providers prescribe or recommend docusate sodium (brand name Colace), the scientific evidence — and the experience of many individuals — suggests it’s minimally effective. It’s generally not harmful to try it, but no reason to keep taking it unless you are in the minority that seem to be results from it.
Most Doctors know a lot about how our bodies function and don’t function, but very few are educated in pharmaceuticals. Ask your Doctor how many hours of study are dedicated to pharmaceuticals. They will tell you 0. Thats education for pharmacist. Ask your pharmacist about colace.
I agree that pharmacists are an excellent resource to tap into.
What about drinking Smooth Move Tea instead of a laxative?
According to the manufacturer’s website, Smooth Move Tea contains senna, so this is just a different form of a stimulant-type laxative.
Thank you so much Dr Kernisan! This is the most educational article I have come across in my search for elderly constipation management.
What’s your best advice managing for elderly with dementia who has chronic constipation and fecal incontinence ?
I’m so glad you enjoyed the article!
When fecal incontinence is associated with chronic constipation, it’s often a case of “overflow diarrhea”. The bowel is blocked by a large, hard stool (fecal impaction), and watery stool leaks out around it. So the answer might be to press on with trying to clear the constipation, including a suppository or enema if needed.
To determine if the issue is fecal impaction with overflow, a rectal examination by a doctor or nurse may be needed, or an x-ray to see if the bowel is full of stool. If there’s no impaction, then the laxatives might have overdone their job, and backing off or adding a bulking agent (fibre) might help.
Breath of fresh air: all the information you need in one place. I’m the ‘older adult’ (68), and I’m a bit confused by all the talk about ‘taking care of your loved one,’ but those of us who are perfectly competent to make these decisions for ourselves often have a hard time getting the information from our doctors (those pesky 15 min. appointments Medicare pays for).
I don’t like prunes, but the rest was spot on. Many thanks.
The audience for this site is almost evenly split between people who are concerned about an older parent or other relative, versus people learning about their own health. Glad you found the article helpful.
I really appreciate your advice about laxatives. I have had problems with constipation from early on by sitting facing a glass of milk magnesia not wanting to drink it. I grew up after time with the mm believing laxatives were not to be used unless absolutely necessary. Thank you for your helpful advice and allowing me to be more comfort and not be tied to old wives tales!!!
Glad you found the article helpful. Well, one shouldn’t rush to use laxatives before trying non-drug approaches, but yes, in most cases it’s ok to use them indefinitely if it seems necessary. Good luck!
Have you heard of a product called Swiss Kriss? It is a herbal laxitive.
I haven’t but taking a quick look, it appears to have senna as its main ingredient.
I care for my 92-year-old mother who has moderate dementia of the Alzheimer’s type. She can’t ‘read’ her body well, but she still does (most of) her own toileting fairly well. I intervene when help is needed.
Last year she had a severe blockage (or maybe two, back to back) that required two ER visits eight days apart. Not pretty, and VERY painful for her. Extreme, over-the-top pain. Ater taking antibiotics for a dental procedure, less movement due to wildfire smoke near us so we didn’t go out, and a change to soft foods for a week ’cause her dental partial was out being worked on, things came to a halt internally. Before this, and during this time, I gave her small doses of powered Miralax in her drinks – not daily, but a few times a week. However, whenever I did, she had bouts of shuddering, shaking, chills, and poor balance. When I stopped the Miralax, it all stopped, expect for the balance issues, but they lessened. I think that’s vision-related though, as she has almost no sight in one eye beginning around this time due. Her doctor said she’d never heard of Miralax causing such a reaction, yet my mom has never taken it again, and she’s never had that severe shuddering since. Do you have any thoughts on that Miralax reaction?
Finally, someone (non-medical) suggested slippery elm supplement to help. My mom has always had a tendency toward hemorrhoids. As she’s also on blood thinners, this is not a good thing. It’s weird to put this in writing, but not only is my goal for her to have regular bowel movements, but that they be ‘formed’ (if too messy, she doesn’t clean well, and I need to help out a lot more, which she doesn’t love), but still soft enough that her hemorrhoids are not bothered as much, if that makes sense. Any thoughts on slippery elm?
Kind regards.
Your mother’s reaction to Miralax sounds unusual, I haven’t had that issue when my patients use it. However, if it seems she didn’t react well to that, there should be other laxatives you can try, either within that same osmotic category or within a different category (e.g. senna, which is a stimulant).
Many people her age DO need to take some type of laxative regularly to keep from getting constipated.
I can’t really comment on an herbal or other supplement, such as the slippery elm you are mentioning. You could try searching Pubmed for “slippery elm” and “constipation” to see if it’s been studied. But in general, I don’t recommend or use supplements because the quality of the active ingredients is very variable in the US. Good luck!
I have the same goal for my Mom, since I have to clean her. We’re trying prunes. Miralax makes everything too messy.
Thanks doc. From India and here very less doctors talk in depth about faecel incontinence and constipation in elderly. My dad is 62 yrs and irritated and doesn’t able to move out of house due to constipation.this article would be great help for him. Thanks again.
Glad you found this helpful. Your father’s doctors may be able to help if you or your father bring up the constipation and explicitly ask for their help with this issue.
This was just what I needed! Have had two impactions, which both finally resolved, but not without a lot of prayer, singing, sitting on the toilet doing crossed puzzle, and more prayer! DON’T want to go through that again. I’m 82, eat very healthy diet, walk and am otherwise active. Was taking calcium tablets, citrucel, and stool softener. Now will DC the calcium, try to add it into diet, stop stool softener, get metamucil and Senna, and suppositories for v rescue, AND cut back on citrucel and drink more water. Feeling hopeful!
I’m so glad if the article is helpful to you. Calcium supplements are indeed constipating, so hopefully stopping them will help you.
As I note in the article, a bulking agent such as Metamucil can stopper up some people. I especially recommend prunes, and for some people, an osmotic agent such as Miralax is helpful.
With a little trial and error, you should be able to find a regimen that keeps your regular and free of impactions. Good luck!
I put plain milk kiefer from Trader Joe’s in my smoothie and it keeps me quite regular.
Thank you for sharing this tip! Yes, this can work for some people. It can be a good idea to do a little experimenting and learn what works for one’s own body.
Very Interesting …thank you . In NZ we have a natural product in a capsule called Phloe which is made from NZ Kiwifruit . It says “Clinically ” proven and I find it works really well. I am 70+
Interesting! thank you for sharing this.
Dear Dr Kernisan
I really appreciate your posting of this article and many others. I suffer of constipation for most of my life but now in my 70’s is getting worse…It seems that my intestines refuse to move even with laxatives such as Linzess 145mg dosage/day. However when I go in vacation, hiking for 5-7 hours a day, everything comes back to normal without any laxative…Back at home, although I walk 5-6 miles/day, eat lots of fiber nothing moves without medications.
I will try Prunes, 12/day, and lots of water…
Thank You very much for sharing your knowledge so generously with us.
Edith Z.
As I mention in the article, linaclotide (brand name Linzess) is a newer anti-constipation agent and it’s not clear that it works better (or is safer) than our old stand-bys. I would recommend asking your health provider to assist you and experimenting with the over-the-counter options that I describe. If someone tries prunes and water but still isn’t getting enough results, we would often add a little senna next. Good luck!
12 prunes twice daily alters blood sugar levels in diabetic elderly pts?
which is best time to consume?
For people with diabetes, it may be better to try an osmotic OTC laxative such as polyethylene glycol (brand name Miralax) as this should not affect blood sugar. A pharmacist or your usual health provider should be able to advise to what would be a good choice given an older person’s diabetes.
I find the information very useful because it has made me aware that laxatives have their value for constipation . It is also good to know that prunes are a good choice when we have problem in constipation. I intend to relay what I have learned from this article to a family member who had a problem of constipation after a surgical procedure. Thanks!
As an RN Patient Advocate I’ve had many “opportunities” to deal with a patient-client’s constipation. Warm prune juice with a pat of butter has helped about 98% of the time. I appreciate your knowledgeable, well-documented post!
Thank you for adding this terrific practical tip to the post! I appreciate your commenting, thanks!
I’ve been constipated my whole life. It seems to run in the family. A couple comments that might be helpful to people:
– My young-adult son has also been constipated, but has found that bran flakes with almond milk keeps him regular. (Incidentally, almond milk has more calcium but not as much protein as cow’s milk.)
– I saw a colo-rectal specialist who advised avoiding milk products, and I think that has helped some.
– The specialist also pointed out the importance of getting enough of both soluable and insoluable fiber in balance.
Question: For various reasons I think I have a motility problem, rather than lack of fiber, for example. Is there a way to determine the root cause of one’s constipation other than trial and error with potential remedies?
Yes, there are more in-depth evaluations that can be done and that might help determine the cause. As I mention in the article, the American Gastroenterological Association recommends further evaluation if people don’t improve with lifestyle changes and OTC laxatives. (This is assuming there are no red flags to begin with and that the person seems to be experiencing chronic constipation.) You can read this section of their guidelines here: https://www.gastrojournal.org/article/S0016-5085(12)01545-4/fulltext#sec4
Good luck!
I need advice for the management of MiraLax use and flip flopping between having constipation then diarrhea. Trying to find that happy medium. When needing to scale back is it best to skip days or decrease the amount and give everyday? I don’t see an information on trying to regulate this and what’s best practice.
MiraLax, aka PEG 33550 is commonly used in constipation management. This podcast covers some of the common meds used to treat this condition and may be helpful. A pharmacist is often a good resource as well, as they can review all of your other meds and medical conditions when advising about how to use this laxative. Some trial and error may be involved but most epople can find that happy medium eventually. Good luck!
I am the caregiver for my 88 year old father, but constipation isn’t our problem. He has advanced dementia and no control over his bowels, and his stools are routinely unformed and loose. I deal with the mess of regular leakage from his pull-ups. This is honestly my biggest challenge as his caregiver. Do you have equivalent information for this type of problem? I give him one Imodium each morning, as well as generic Benefiber to make his stools more solid, but I can’t tell that either has much effect. The generic Benefiber is dextrin, which wasn’t mentioned as a bulking agent. Is dextrin an effective bulking agent? Any suggestions for very unformed and loose stools?
When you mention “leakage” that makes me wonder about a type of diarrhea that is actually due to constipation. It’s called “overflow” diarrhea and can occur if a person actually has a hard, impacted stool in the colon, and then watery stool leaks out around it. A doctor or nurse can do an examination called a rectal exam (inserting a gloved finger into the anus to feel for any masses or stool) to rule this out. If this is the case, something like Imodium might make it worse.
Another approach when a person is having loose stools is to review the diet. Lactose can be a common culprit.
Finally, there are numerous medications that can contribute to diarrhea, including the dementia drugs: cholinesterase inhibitors (like donepezil, rivastigmine or galanthamine), and others like metformin (for diabetes) and the SSRI antidepressants.
Wheat dextrin is a type of soluble fibre which can add bulk to stool by forming a sort of slippery liquid in the colon. It’s usually used for constipation.
Excellent & informative article. My father is suffering from this illness. I got few tips on the management. Thanks.
I’m so glad you found the article helpful.
Thank you for this article. I am 76 and recently started being constipated. Over 5 days I tried OTC products. Milk of magnesia was the only one that worked. Not wanting to rely on it I started adding more fiber to my diet. Three sources have been very helpful when used every day – split pea soup made with lots of carrots and potatoes, pears, and All-bran Buds. Prunes were just OK and produced extremely malodorous flatulence. Now I’m experimenting to find the right amount of fibrous foods. On occasion I have ingested too much and my stools were very sof
Good for you for turning to lifestyle changes to manage your health! As pointed out in the article, most of the time there is no medical danger in using laxatives regularly, but I can understand not wanting to need to use them all the time.
It’s worth repeating that exercise and fluid intake can help with bowel regularity, as well as a review of medications, to see if any are constipating. Here’s a video I made about bowel changes that might be of interest! It demystifies the Bristol stool chart that Dr. Kernisan mentions in the article.
Great article! Just to be clear, when you say “50 grams of prunes twice daily (about 12 prunes)”, is that 12 prunes a day or 24 prunes a day? If you mean 50 grams twice daily, I guess that’s 100 grams per day. So, I don’t really know how much a normal prune should weigh. Please clarify.
Thank you.
That’s a good question! Fifty grams of prunes is about 5 – 7 prunes, so 12 prunes a day is enough for most people to manage their constipation.
Love the article! I am caring for my 95-year-old mother who has dementia. Her stool consistency is not described in any of the categories. It is mushy but it won’t come out. All the doctors don’t help me. One said to give her a warm water enema daily. I did it once and it did not work at all. Not sure how to help her!Your article gives great suggestions about prunes, liquid, and exercise. I think I will try MiraLAX daily? Should I do the daily enigmas?
Hi Kris and thanks for sharing your story. Here’s a link to little video about the Bristol stool scale that has some visual aids that you might find interesting.
In my clinic, when I hear that the stool is soft but won’t pass easily, I always want to do a rectal examination to make sure that there are no signs of nerve damage or obstruction that could be getting in the way of passing a bowel movement. If this has been done and those conditions have been ruled out, then turning to lifestyle changes and medications is reasonable.
I would hope that your grandmother could be spared daily enemas, unless that is her preference. I have had many patients get good outcomes with the use of MiraLAX as often as daily. It pulls fluid into the bowel and makes the stools easier to pass, and the side effects are few. Best of luck.
A very close friend of my family is 89 and normally she has loose stools. She complained of feeling constipated recently and used a stool softener, which didn’t do much. She said her stomach hurt and was very tired. I suggested seeing a doctor. Another family member worked with the elderly as a nurse’s aide and gave her a soap enema and encouraged her to drink pedialyte. The family states that she is the “nurse” and knows best. However, by the time she gave her the enema, this woman had been in bed for 2 days and only had 2 cups of liquid total. She said that she would be back in the morning to do it again and try to get her to eat and drink. She did and made her an appointment an Urgent Care to be checked for Covid-19. When Covid was ruled out they said it was pneumonia, since laying for so long created mucus in her lungs. The consultation was done at the car. They then made a follow up appointment the next day. She continued to complain of pain in her stomach and wasn’t getting better. At the follow up appointment they sent her to the ER. I felt like due to the dehydration alone she should have been taken to the ER well before the soap enema. At the hospital they found a mass on her bowel and liver. I also saw that she takes iron in the evening every day. So two questions: 1. Was giving the soap enema rather than seeking emergency medical treatment the right route? 2. In a normal case of constipation, would iron be limited until the passing of severe constipation? When I was pregnant with constipation the doctor had me cut the iron for awhile; but I don’t know what’s normal for an elderly person. Thank you in advance. Maybe I was reading into things…I’m not a nurse or nurse’s aid, it just all seemed off to me
Thanks for sharing your story. I’m sorry to hear about the trouble that your friend has been having.
I don’t have enough information to really say whether giving the enema was the right call, but your tale emphasizes how difficult it is with COVID in the mix. Many are trying everything they can to “cure” themselves before going to a hospital ER, and sometimes, it leads to delays in treatment and diagnosis. I think that everyone should trust their instincts and seek help when they feel they need it, as waiting can make things worse.
In terms of iron, it can definitely cause constipation, so if someone on iron is constipated, and it’s safe for them to do so, holding the iron for a while may help to get things moving again.
Leslie,
What I wouldn’t give to have you take a look at my mom. She is 4’5, 83 years old and 4 years into dementia which developed quickly after back to back xrays (which used iodine). She already had “redmans disease” a rash covering her whole body when the ER doc decided to do another xray, (against our warning that she was probably allergic). We suspected this because every time she had this xray in the past,, she ended up with a horrible rash. Well, following the 2nd xray, she went into anaphylactic shock in the ER and stopped breathing. We could not get a doctor or a nurse to help us. She has never been the same. Delerium and dementia were launched! Fast Forward…She now has constant bowel issues, moderate dementia which clearly gets worse when her bowels are troubling her. She also has had many bouts of Urinary Retention which has landed us in the ER many nights. I am a full-time teacher and care for her many times throughout the day even though she lives with my dad. I spend so much time trying to calm her, clean her, feed her the right things and I am at the end of my rope. She also has an Innguinal hernia which I wonder if that contributes to constipation. I loved reading your article. You sound so compassionate and knowledgeable. I wish you were my mom’s doctor.
Thanks for sharing your experience, Leanna. It sounds like your mom has had a difficult journey and that you’ve done a great job advocating for help.
Constipation can contribute to urinary retention and incontinence, and if a hernia gets incarcerated or strangulated (usually this causes quite a bit of pain), that could interfere with bowel function too. I hope you found the information in Dr Kernisan’s article to be helpful. I have a short video about bowel movements, here.
It sounds like you’re balancing being a care partner and also working full time, and that is hard to do without lots of support. You might be interested in the Helping Older Parents Membership. The membership provides ongoing guidance from Dr. Kernisan and her team of professional geriatric care managers, to help you more easily get through your journey helping your aging parents. It also includes access to her popular Helping Older Parents Course and live QA calls with her. You can join the waitlist here if you’re interested.
Thank you so much for your article. It helped me feel more relaxed about my chronic constipation which first came to light when I was in ER for urinary retention. I am 89 and now self catheter which usually works well, except when constipated. From ER (5 years ago) I was prescribed Laxol (docusate+8 mg senna),and lactulose syrup. I have been warned by both GP and Pharmacist that continuing and increasing medication will eventually increase my problem. … dead nerves/muscles in the bowel etc… ( I asked my pharmacist re extra senna and he was horrified and gave me dire warnings and recommended a natural supplement – not a good experience) So your article did reassure me (re the myth). But sadly it seems to be true for me. Despite adding more prunes to my routine I added another Laxol yesterday. I care for my 93 old husband (not a chore but attention-consuming) so perhaps perhaps being more intentional and staying on the toilet longer might help Do you think that kind intentional care of myself is what is missing?
Thanks for sharing your experience and I’m sorry to hear that it seems you are getting some mixed messages.
Making sure you have enough time to fully evacuate your bowel is part of managing constipation, and exercise and diet are critical pieces too. I hope you can find a balance in your roles as a care partner, and in looking after yourself!
Recently acquired constipation on a low calorie high fiber diet for diabetes while taking prostate medication. Alfuzosin. Gastro has put me on daily Miralax and I am also taking a 125 mg of magnesium citrate supplement tablet, the lowest I can get. I have no kidney issues. Was told by Gastro that both of these drugs are safe for long term constipation. Take these drugs each morning with breakfast and coffee. Keep getting loose stools but really works for constipation symptoms. Is this a safe regimen and how long should this last? Male 68. Thanks.
Thanks for sharing your experience. Changes in diet can be a common cause of changes in bowel function. The laxatives that you describe are osmotic agents that encourage water absorption in the stool. With normal kidney and cardiac function they are very safe and can be used regularly over the long-term quite safely.
Constipation that’s related to a lifestyle change may be short-lived or more chronic depending on other medications taken and other health issues. Remember that fluid intake and exercise are part of a comprehensive plan to tackle constipation. I’m glad this regimen works for you!
In your opinion, how effective would you rate exlax for use with chronic constipation?
“Ex lax” is a brand name for senna, which is a stimulant laxative. As, Dr. K says in the article, “studies have shown stimulant laxatives to be effective. They can be used as “rescue agents” (e.g. to prompt a bowel movement if there has been none for two days) or daily, if needed.” It can also be used on a chronic basis, for example in a person who takes narcotics regularly.
Thank you for your reply.
Dear Doctor,
I am 75, always been and still am athletic and get in daily brisk walking, golf and light weight training. In late November, I noticed that my daily BM had dramatically decreased and a week later I saw my internist. He recommended fiber supplementation but no other treatment. Consequently I became impacted in my lower colon and was ordered to relieve it by using a combination of Ducolax and Miralax. Within 6 hours or so, following very painful cramping, the impaction was dislodged. But this exact same impacted colon repeated itself two more times, and under my PCP’s direction I was able to clear them in the same manner as the initial event.
My PCP then placed me on a once-daily Miralax packet along with Colace stool softener twice daily. It’s been three days now following this regimen and I’ve been gradually adding back in fiber-laden foods to my diet, plus taking Benefiber twice a day. I still haven’t had anything resembling a normal BM, but at least it seems I’m no longer impacted. I sense though that without the OTC meds, I’d quickly become impacted again. It seems my digestive tract was stopped working effectively and I need some sage advice on what else I should be taking…such as a senna-based OTC medication.
My real concern though becomes: how long does a lazy bowel like mine take to respond? Will I need to continue using a laxative ad infinitem? I do have CKD, stage 3, but with a careful diet it occasionally moves into stage 2.
Thank you so much!
It sounds like you’re on a regimen that we use a lot with older adults, and some individual do need to take bowel medications or supplements on a daily basis.
Senna is a stimulant of the bowel, so it might be worth trying if your medical team feels it is appropriate. It’s safe to take in the short term, and can be safe to use regularly for some, but it can affect potassium levels so a person living with renal disease may need to be cautious.
If there is a problem with “transit time” in your GI tract, a gastroenterologist might be able to help. Some conditions, like diabetes can cause nerve issues that decrease digestion speed. I found this article about electrical colon stimulation, but this hasn’t really caught on.
It sounds like your medical team has had some good suggestions and I would advise someone in your situation to continue to work with them.
I am a 91 year old with a 92 year old wife. W e take only one med, for low thyroid (88mcg for her and 50 mcg for me)_ I read Dr. Russell Blaylock’s Health Report My wife and I apparently had Covid19 and survived by having taken 5000 IUs of Vit D and Beta Glucan and Sambucol daily.
I research as much as possible for supplements that will keep us healthy but I am concerned that there is little information regarding supplements proper for nonagerians. For example, I have read that men should have about 420 mg and women about 320 each day. My wife takes 144 mg of magnesium (from 2000 mg Magtein magnesium L-threonate and I take 300 mg from 2000 mg magnesium lysinate glycinate chelate.
I would truly appreciate your commentary and any suggestion you may have about finding geriatric information about supplements tat we should or should not be taking. I have discovered through bad experiences that some medicines regularly prescribed for patients younger than I can cause me serious problems.
My wife and I will celebrate our 70th anniversary in June; 3 children; 6 grandchildren; 6 great grandchildren.
Thanks for sharing your experience and I wish you a happy anniversary!
Most older adults don’t need any supplements as long as they have a varied diet and don’t have medical conditions or dietary restrictions that can cause malabsorption or vitamin or mineral deficiencies. Many older adults take Vitamin D and Vitamin B12, but unless you’re deficient, they’re not necessary for all of us to take.
Thank you, Doctor. Your advice is very appreciated. After reading your excellent information section on treating constipation, I experimented by taking a senna supplement I found at Whole Foods. I began seeing a big change after taking these caplets for two days, whereas Miralax and Colace alone had little effect. I understand I need to be wary in continuing to use senna due to its potassium content. I’m hopeful that in a few days I can wean off of senna, use Mirallax as needed and increase good fiber intake in my diet. I’ve already added a small quantity of prunes (also high in K though), more veggies, hydrated chia seeds, and more fibrous berries. I’m supposedly being referred to see a gastroenterologist and by the time this happens maybe his expertise will no longer be necessary. Thanks again!
You’re very welcome and I’m happy to hear that this regimen is working for you! Don’t forget that fluids and exercise are important in bowel regularity too.
Thank you for sharing these knowledge to us. This has been very helpful in a way that I can now easily deal with these things while I take care of my elderly love ones. I am relieved after reading about the myths about the OTC laxatives. Thank you!
I’m so glad you found the article helpful and bless you for caring for the older adults in your life!
Hello! I was wondering about the possible impact of fibre supplements on my 97 year old mum whose BMs seem less regular, due I think to her decreased muscular performance down there. I use Lactulose daily and this works for her. I’ve scaled back her fibre supplement, which is organic ACACIA powder, which also works well.
I’ve been primary carer for mum for 10 years. She has Alzheimer’s so I need to be clued in to what she cannot tell me verbally. This was a Very helpful article. Thank you so much.
Hello. Great that you allow for comments! 🙂
Bristol Stool scale: very helpful reference. I would add though that its not only about consistency, shape and form, but frequency. My 97 year old mum has 2 or 3 BMs throughout the day that would fall into the Type 1, and then one of Type 4. I don’t think that her Type 1 means she is severely constipated though, just that the whole process is taking longer resulting in Type variation. Would you agree? There is no agitation or telltale signs of severe constipation.
Thank you.
Jac
I’m so glad you enjoyed the article and thanks for taking the time to comment!
If someone is having a constipated seeming stool followed by other, more sausage-like stools later on, it could indicate a degree of constipation. Increasing fibre and fluid might promote less frequent but softer stools. Lactulose is usually effective and is safe to use longer term for most people, even in an older age group. As mentioned in the article, senna could be added occasionally as a “rescue” if there seems to be a slow down in bowel movement frequency or if the type starts to be consistently in the 1-2 range.
The key with fibre is to ensure adequate fluid intake as well. Without enough fluid, the fibre can stay in a sludgy state in the colon and that wouldn’t help the situation!
It sounds like you’re doing a good job of caring for your mother, and keeping track of her health.
I need to find out more about polyethylene glycol. PEG. I think I’m allergic to it, as I’ve had bad reactions to medications that have it listed. Most recently I had the Moderna Covid vaccination. My arm turned red and swollen, and glands under arm and that side of my neck were swollen. The itching and burning and redness on my arm continued on for three full weeks. I found out the the Moderna contains PEG. In the past, I’ve had scary skin reactions when I’ve taken Colace and Miralax. Swelling and pain in rectal area and vaginal area, lasting a couple of days. Also I cannot use medications for vaginal yeast infections. Same reaction with terrible stomach cramps and breaking out in hot rash in vaginal and anus. Doctors were all puzzled, but I did research and found out that all of those meds contain PEG. I’m not getting my second Moderna shot, but will wait, and get the J&J when it’s available. It does not contain PEG. Does any of this sound familiar or make sense? Have you heard of anyone being allergic to PEG? I’m 86 years old.
Hello Marilyn and I ‘m sorry to hear about your reactions. A person can definitely have an allergic reaction to PEG (polyethylene glycol), which is in a lot of cosmetic and hygiene products, as well as medications. We’re hearing more about PEG reactions since it’s an ingredient on the Pfizer and Modena vaccines as you point out.
I would let your doctor and pharmacist know about your reaction to PEG and read the labels of your soaps and hygiene products carefully! This article might be helpful: https://accp1.onlinelibrary.wiley.com/doi/10.1002/jcph.1824
Thank you for the link explaining PEG allergy. I hope to see an allergist, in hopes of being tested. In the meantime, I’ll do my best to read labels for ingredients, and avoid taking medications or injections of all kinds. I am allergic to most antibiotics, and never knew why. Now I suspect it’s related to PEG.
Thank you, this information is timely and helpful. I didn’t know that stool softeners haven’t been shown to work, and I feel more comfortable now about taking polyethylene glycol and dulcolax.
I’m 66, and my doctor recently recommended I take an iron supplement for mild anemia. I’ve been using Feosol Bifera, which apparently does not need to be taken with extra Vitamin C. It’s hard to pin down, but I suspect the iron is making my constipation worse. I’ve also been taking the recommended dose of polyethylene glycol daily for several weeks now. Is it safe to use more daily, or should I stick with the recommended dosage?
Are there other iron supplements that have a reduced incidence of constipation?
Gastrointestinal side effects like constipation, diarrhea, nausea and stomach upset are common with all oral iron supplements. There’s not much difference between the different formulations, but ferrous sulphate may be a bit more tolerable. There are intravenous forms of iron which cause fewer stomach issues but that form of supplement is not feasible for many.
To reduce the effects of the iron on your stomach, you could try (after talking to your doctor):
-Take the iron every other day
-Take it with food
-Lower the dose
-Try a liquid
I have patients who take PEG daily and have no problems, but if a person has low potassium or other issues, it may not be right for them.
Bowel movements are doing well with 4 prunes in the AM. However, hemorrhoids are there. At times there is pain, possible fissures. ( No bleeding). I use Prep. H suppositories at bedtime to shrink the hemorrhoids. Seems to be working. The instructions say not to use for very long. Is it safe to continue using them? Have been using them for weeks. I have regular, daily movements, slight pain at the beginning but nicely moving stools. I’m 70. We eats lots of fruit and veggies. Thanks much!
I’m glad you’re getting results with the prunes.
It’s true that the over-the-counter remedies, like Preparation H can provide a lot of relief, but they aren’t meant for long-term use.
If someone still has painful hemorrhoids after a few weeks of treatment, I would encourage them to see their doctor to make sure that a consultation with a surgeon isn’t in order. Here’s a little video I made about hemorrhoids that might be of interest: https://youtu.be/zYjQxGDGKBQ
Have you researched the problems of an over-active digestive system that causes loose bowel movements?
I’m not sure what you mean by “overactive” digestive system, and I confess to not having done research in this area. As far as I know, the closest thing to what you’re describing is Irritable Bowel Syndrome which can cause over activity or underactivity (or both) of the colon.
IBS affects about 10-15% of the population and is more common in younger adults, compared to those over 50. Treatment usually involves dietary changes, exercise, and sometimes a mediation or supplement.
I find eating a fresh peeled green kiwi fruit daily to work very well or sometimes 2. gives me my Vit c as well as being delicious.
I’ve had constipation for years and have tried almost everything that you have mentioned. For the last several years, I’ve been using 50 mg of Senna daily with my dinner. It produces a bowel movement or more than one bowel movement almost every morning. If I skip a night, I usually do not have a bowel movement the following day. Am I using too much? When I cut it back to 25 mg I usually do not have a bowel movement the next day. Even with the 50 mg. sometimes I struggle with getting it to come out. I’m on a high soluble diet now because my cholesterol level is high. I have used prunes before, but never 12 of them a day. What are your thoughts, or suggestions?
Hi Norma. Senna can be taken up to 100 mg a day, and it’s probably safe from a bowel perspective to take it daily, but it can have side effects that include low potassium levels and dehydration for some people.
If prunes fit with your dietary plan, then adding them in might allow you to reduce your senna dose. Remember that exercise and adequate water intake is important to bowel regularity as well.
Thank you for this info. Truly. After prunes and Miralax when can I take the Senna if I’m still not going?
Sincerely,
Sherry
I’m so glad you liked the article and thanks for taking the time t leave a comment!
Many people have to take prunes, miralax and senna to keep things moving, and that’s considered safe. In my practice, if a person is still constipated with more than one agent, I review physical activity, fluid intake and any other meds that might be slowing down the bowel.
Good luck!
I find that eating dried prunes or drinking prune juice can cause painful cramping. I soak my prunes in warm water at a level just to cover them and eat several of them soggy in the morning and evening. I keep them in a small covered container on my counter and they last without refrigeration for the days that I use them until I soak another batch.
The other gentle laxative I use is canned spinach. Magic!
I’m so glad to hear that you’ve found some foods that work for your bowels! Spinach is pretty high in fibre, and 100g of canned spinach has 1.6 g of fibre (about the same as 3 prunes) and over 2 g of protein.
A primary doc recommended Senokot be limited and not to give it to the very elderly daily. She had my Mom, 93, taking Senokot for 7 days and Cholace the rest of the month. So 1 week Senokot, 3 weeks Cholace. I don’t see that you mention a concern about daily Senna.
Sadly my Mother passed away in December but I am asking for my own edification as I am helping a friend navigate assisting her own elderly Mom. I also see now you say Cholace doesn’t work … I certainly would’ve brought that up to Mom’s doc if I saw this then. It seems to help when taking in conjunction with pain meds … but I guess that’s a different situation … not when referring specifically to constipation in the very elderly.
PS. I wanted to thank you so very much. Your advice, information, etc., was so incredibly helpful when I was caring for my Mom. I miss her dearly and would take all the struggles back in a heartbeat for a bit more time with her. _/\_
Thank you for your kind words, I know it means the world to Dr. K. I’m sorry that you lost your mom and I’m so glad Better Health While aging was helpful to you.
Like many over-the-counter medications, senokot is marketed and intended to be used on a temporary basis (several weeks), but for most older adults, it’s perfectly safe to be used for a longer period of time, as long as the dose is not escalating and the person is under health care provider’s supervision.
Colace does continue to be prescribed widely, but unfortunately, it doesn’t have any efficacy in the scientific studies that we have in older adults.
That’s so kind of you to help your friend, and they might be interested in Dr. K’s new book : When Your Aging Parent Starts Needing Help: a geriatrician’s step by step guide. You can find out more about it here:https://betterhealthwhileaging.net/education-and-support/when-your-aging-parent-needs-help/
Dr.K. wrote a really good book and the online group has been a godsend to me my sister and my mom who has lewy body dementia.Dr. Didyk…you have been helpful as well…the article on constipation was a godsend my mother called today about constipation and dehydration…we are going to use prunes and metamucil for mom and I will ask the nurse about blood tests for mom to see if she is dehydrated
Thanks for taking the time to let us know that our answers have been helpful!
The book you mention is Dr. K’s new one: “When Your Aging Parent Needs Help: a geriatrician’s step-by-step guide to memory loss, resistance, safety worries, and more. It’s a practical book, co-authored by Paula Spencer Scott, with easy to follow advice for children caring for their aging parents. I know I’ve used it in caring for my own family members!
Readers can find out more about the book here, and about the Helping Older Parents Membership that you mention here.
good luck with the constipation and keep up the proactive approach to helping your mom!
My mom has constipation due to taking pain relievers, inactive do to poor health. She has been using stimulants laxative for so long i believe she has a lazy colon. I want to start her on more natural approach with Chia seed, fiber power, prunes and Senna. What is the best plan to do this and what brand of senna. is the best to use? There are just so many and most use fillers.
I’m glad you’re able to help your mom with her constipation and adding more dietary fibre is a great way to go. Remember that fluid intake is vital when upping fibre as well.
We’re learning more about long-term use of stimulant laxatives like bisacodyl and sodium picosulfate (dulcolax), but there continue to be gaps in the scientific knowledge. It’s not clear that they cause a “lazy colon” but they might not be effective if used over the very long term.
I can’t give a specific regimen, but a pharmacist might be able to steer you towards a brand of senna that’s reliable.
My dad’s care facility has been giving him Senokot but he’s been having 2-3 bowel movements a day and has been worrying about having “accidents”. I’ve asked the nurses to ease up on the laxatives but the excessive (especially considering how little he eats) bowel movements are still happening. How long does Senokot stay in the system. Sorry . . . this is just the opposite of constipation so a bit off topic!
Well, there can be a type of diarrhea that is caused by constipation: overflow diarrhea. This happens when a person is constipated and has a hard lump of stool in the lower rectum, and liquid stool leaks out around it which can be confused with diarrhea. A health care provider could do a rectal examination to investigate this, or an x-ray of the abdomen to check if the colon is full of stool or is empty. If that’s the case, sometimes the stool has to be removed by hand, or with an enema, to get things moving again.
Senokot lasts about 40 hours in the system after that last dose is taken so it’s probably not hanging around much longer than that.
When I see an older adult with a change in bowel routine, I also review medications to make sure there isn’t anything there that could be the culprit. Good luck!
Thankyou for this article. My mum in law who is in a nursing home has this problem and to know that it should be investigated and that it may take trial and error is good to know. She has currently stopped eating,drinking and taking her meds in an effort to “go” she can’t walk as she used to and we are trying to get her to use a walker with a seat (her current one doesn’t have a seat) so that she can walk and rest but she has lung issues from smoking so it really us a challenge for her to move around. We can now speak to her Drs and care givers to hopefully get them to fully assess her situation with a bit mire knowledge under our belts.
I’m so happy that the article was helpful. It makes my job as a Geriatrician easier when I am working with a family with some accurate information about their family member’s health conditions.
I agree with the strategy of promoting mobility in someone like your mom. This will help the bowels as well as prevent falls and improve mood. I also do a careful medication review to make sure that there aren’t any emds that could be a cause of constipation, so if your mom starts taking her pills again, she can avoid those.
Dear Dr. Kernisan,
Thank you for all the very useful information on a subject that does not get enough attention. I have a specific question:
I am a 69 year old Male
Is it Ok to take two does of Miralax in one day? ….say one in the morning after breakfast and one after dinner
I’m so glad that you enjoyed the article!
Some people with constipation may need to take 2 doses a day of Polyethylene glycol 3350 (aka Miralax), but in that case, there’s a higher risk of side effects such as diarrhea, flatulence, nausea, abdominal pain, loose stools, and bloating. A little trial and error may be needed to find the right dosing regimen.
Thank You Dr. Didyk …… will experiment to see what works
Sincerely,
Alan H. Van Reed
Thank you for this article. It has helped me learn about different options in dealing with occasional constipation. I was wondering what your opinion is of mineral oil as a laxative? I have only used it as makeup remover but the label says for laxative use. Thank you!
Mineral oil is a lubricant laxative, and used to be the mainstay of treatment for constipation in kids. It’s not very appetizing, so most of the time we use PEG3350 instead.
The potential risks of using mineral oil is that it can cause pneumonia if inhaled into the lungs (very unlikely unless a person has swallowing problems to begin with) and may interfere with the absorption of fat-soluble vitamins, like Vitamin A, K E and D.
I think it’s reasonable and safe to use mineral oil occasionally if that’s what a person prefers. It’s also good for softening ear wax!
Thank you for your reply. I didn’t know that it helps soften ear wax too!
You’re most welcome. Olive oil works too!
Hello,
I’ve been having constipation on and off I’m 64. . “Just when I think I’m out it pulls me back in!” I looked at your list of meds you should no take. I’ve been taking a calcium supplement. Could this be the culprit?
I love your sense of humour, but constipation can be no joke. Lower doses of calcium, such as 500 mg per day, may not be enough to cause constipation, as was found in this study of healthy females.
Nonetheless, for some, calcium supplementation could affect bowel movements. Alternatives include increasing the intake of calcium in the diet. This list of calcium-rich foods includes cheese and milk, but also almonds and white beans (the beans could help add fibre to the diet too).
If a person can get adequate dietary calcium, then it might be reasonable to try stopping the supplement and monitoring bowel movements. Best of luck.
I found online that only calcium carbonate supplements were suspected of causing constipation. Other forms are not a concern? And taking magnesium along with calcium (ratio of 2:1, calcium:magnesium) can help mitigate any possible constipating effects. Personally I can’t eat dairy products so must take a calcium supplement.
A higher calcium intake, whether by diet or supplement, can lead to constipation. I’m not sure that calcium carbonate is less likely to produce that side effect.
Magnesium can help with constipation, by drawing more fluid into the bowel, helping stool to pass more easily. Here’s an article that explains: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911806/ For most, it’s safe and effective to take a magnesium supplement, and there are many formulations with magnesium and calcium in the same tablet.
My doctor lauded Aloe Vera juice. It turned out to be the best thing I’ve ever taken, better than prune juice or magnesium citrate. And I’ve I suffered a lifetime of stubborn bowels.
I’ve heard of aloe vera being used by some as a dietary supplement, mostly to help with skin and hair, but I’m not aware that it can be useful for treatment of constipation. I’m glad it works for you!
Thank you for this article! My sister is in a long term care facility, She is 67 yrs old, in a wheelchair (so no activity), with dementia and brain injury. All of her food is pureed, getting her to eat anything is hit and miss, and it’s been much worse the past year. On a good day she will have maybe 20 oz of fluid. She’s down to about 60 lbs. Her dr is prescribing one packet of Lax-a-day every 2nd day. It’s hit and miss how often she actually takes it, as she often refuses anything to drink. She often goes 3 to 5 days without a BM, and then explodes with large BM every day for 3 or 4 days. I’m worried this is so hard on her body, and wondering if 1 packet of Lax-a-day is too much for her tiny body and lack of intake. Would it be better to have 50% packet every day (knowing that it’s hit and miss so she won’t really have it every day)? Thank you!
It would certainly be reasonable to try a lower dose of Lax-a-day (also called polyethylene glycol) more frequently. Dosing of this laxative can be weight dependent, for example the pediatric doses are calculated by weight.
It sounds like it’s difficult to get your sister to drink the medication, so switching to or adding a pill form of laxative might be helpful as well. Many older adults use senna, which is a small pill that’s fairly easy to swallow.
Thank you. Some days it’s hard to get her to eat or drink, so either way it’s a challenge. If there is a day when she is eating but not drinking, is it ok to just mix into her yogourt or sprinkle on whatever she might be eating, without dissolving it first?
From what I understand, the powder needs to be dissolved before being ingested. It only needs about 4 ounces of liquid, which can be any liquid, hot or cold.
I hunted and hunted for a logical article about elderly bowel habits. I knew there was a norm. Although changing. Thank you for your clear and concise article.
I’m so happy that you found the article and it was helpful! Thanks for taking the time to leave a comment.
Good afternoon Doctor
This is a bit of a late reply but I have a question about Miralax.
It sounds promising but I have been diagnosed with stage III mild kidney disease. It has been stable for a number of years. There are a lot of comments about using Miralax with this issue. The directions on the box say not to use it with “kidney disease”. There is a lot of chatter on the Internet on both sides.
Do you have any thoughts that you could share about it?
Thanks for the article and for useful flow of information on aging.
Miralax is also known as PEG 3350, or polyethylene glycol 3350. As Dr. K mentions, it’s an osmotic agent that draws water into the bowel and promotes more freqent bowel movements.
Occasional use is no problem for the kidneys, but using PEG3350 every day for more than a few weeks, or more than once a day, could upset the balance of fluid and electrolyes (sodium and potassium levels in the blood) in people with kidney problems. I have patients with kidney impairment who use PEG 3350 occasionally, but if the kidney failure is severe (e.g. on dialysis or pre-dialysis), I would talk to their nephrologist first.
It’s ideal if people can use laxatives once in a while and work on lifestyle changes to bring about sustainable and natural regulation of bowel movements, but of course that’s not always possible.
Am 78 and severely constipated. Using prunes and lactulose plus fybogel. This regim causes lots of wind. Would movicol be better than lactulose or are they the same? Your articles are the only that explain this problem. Many thanks.
Movicol is the same as polyethylene glycol or PEG 3350. It doesn’t tend to produce as much flatulence as lactuolse, and they do act differently. Both draw water into the stool, but lactulose does this by interacting with the bowel bacteria, which can cause gas. The PEG (movicol) uses electrolytes and osmosis to move water.
Appreciate your comments. Found this site very very helpful. Many thanks.
Very informative article. I am 75 now pushing 76 and was regular until the last year or so. I have not been taking any laxatives until recently and try to manage by taking more fiber foods. It is mostly working. You take on some of the safe laxatives was good to read. My gastroenterologist has me on Miralax, and also on senna, but so far I have not been taking them daily as I read that was not good for you. I have upped my water and prune intake.
Thank You for the info.
Thanks for sharing your experience and emphasizing that dietary fibre and fluid intake can make a big difference. I’m so glad you found the article informative!
Thank you for the informative article on constipation.
I am 72 years of age and have constipation due to redundant sigmoid colon. I am taking ducolax and detox every two or three days to have bowel movements. I sometimes supplement with enema when I can feel the urge but cannot poop.
It sounds like you have a routine that works for you. A warm water enema is what we recommend for older adults, rather than a phosphate enema, which can cause electrolyte changes.
Would appreciate alternative options to having bowel movements with constipation due to redundant sigmoid colon. I have been advised to reduce intake of fiber intake which can result in blockage.
It seems like redundant sigmoid colon is sometimes managed with surgery, and I’m not sure if that’s an option for you. Usually dietary fibre is safe to take as long as fluid intake is adequate.
Resection surgery is a last resort due to my age.
Can I take two tablet ducolax daily after dinner?
Maybe with 10 prunes? Doctor has advised me to reduce fibre intake due to redundant sigmoid colon.
Any advice would be appreciated as now I am encountering hit and miss bowel movement which is stressing me in daily activities