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
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 appear 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.
- 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 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)
- 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 most informative info
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!
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.
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!
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!
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.