Constipation, both real and perceived, is a common complaint of older adults. Studies show that more than 25% of the elderly experience constipation and that it is more commonly a problem for women. The following changes related to aging or chronic illness increase the risk for constipation: decreased abdominal muscle tone, inactivity, immobility, inadequate fluid intake, inadequate dietary bulk, disease conditions, medications, dependence on laxatives or enemas, and various environmental conditions.

Peristalsis normally slows somewhat with aging. Loss of abdominal muscle tone and inadequate physical activity contribute to even slower peristalsis. Older individuals with weak abdominal muscles and those who are inactive or immobile are highly likely to become constipated.

Water is absorbed as waste products pass through the large intestine. Inadequate fluid intake or excessive fluid loss through perspiration, emesis, or wounds increases the body’s need to recover as much fluid as possible. Because many older adults suffer from some degree of fluid volume deficit, their bodies attempt to reabsorb as much fluid from the stool as possible. The physiologic need to absorb water, combined with a slower rate of peristalsis, results in stools that are drier, harder, and more difficult to pass. Fluid volume deficit also leads to a decrease in urine production.

Dietary fiber plays an important role in promoting normal bowel elimination because this indigestible substance is effective at trapping moisture and providing bulk to the wastes. Foods such as whole grains, fruits, vegetables, and lean meats are high in fiber. Fiber-rich foods are often lacking in the older person’s diet because these foods are more difficult to chew, particularly when teeth are loose or missing. Foods such as dairy products, eggs, refined breads, desserts, and many convenience foods consumed by older adults contain very little fiber. When the diet lacks adequate fiber, less stool is produced. This small amount moves more slowly through the intestine, further contributing to excessive dryness. The small mass of stool produced without fiber is inadequate to stimulate the normal defecation reflex, resulting in infrequent elimination with as many as 4 or more days between bowel movements.

Many older individuals who have had problems with constipation over the years may have developed a habit of taking laxatives or enemas. It is estimated that approximately 30% of healthy older persons take laxatives regularly. Some started taking laxatives when they were quite young because absolute regularity (having a daily bowel movement) was at one time considered important for good health. Thus, some older people have been taking laxatives or enemas daily for 50 to 60 years. We now recognize that this is dangerous because the body can become dependent on laxatives and require this assistance to stimulate elimination. Reestablishing normal bowel elimination in a laxative-dependent older person is almost impossible because the body has forgotten how to work on its own.

Repeatedly ignoring the urge to defecate can lead to suppression or even extinction of the defecation reflex. Changes in neurologic sensitivity or fear of pain may cause older adults to ignore or delay defecation. Those with neurologic disorders may not be aware of the need to defecate because the strength of nerve impulses transmitted to and from the sphincter muscles is decreased. With no urge to defecate, individuals may go for many days unaware of the fact that their bowels have not emptied. Older individuals who encounter pain with defecation are more likely to avoid or deliberately delay what they know will be a painful experience. Pain can originate from the decreased production of mucus in the intestine that is typical with aging. Without the lubrication provided by mucus, the stool becomes excessively dry and irritating to the rectal tissues. The presence of hemorrhoids or anal fissures further contributes to the likelihood of pain. Delaying defecation creates a vicious circle. When defecation is delayed, the stool becomes harder, drier, and more difficult to pass. This, in turn, leads to more painful defecation, which results in further avoidance of defecation. Active interventions are needed to break this cycle. Untreated constipation can result in fecal impaction.

Delays in defecation are not always chosen by the older person. An aging person who requires assistance may need to suppress the defecation reflex while waiting for help getting to the bathroom. If this occurs repeatedly, the individual may lose sensitivity to the urge to defecate and become constipated. If unable to suppress the urge, the person runs the risk of being considered incontinent.

Environmental factors can play a role in constipation, particularly with institutionalized older adults. The aging person may be embarrassed by the sounds or odors involved with bowel elimination. Lack of privacy may cause anxiety or may result in the person’s ignoring or suppressing the urge to defecate.

Difficulty assuming an anatomically suitable or comfortable position can also interfere with effective bowel elimination. Sitting upright or squatting are the preferred positions for defecation because it is easier to bear down in these positions, and gravity assists elimination when the entire body is upright. People confined to bed find that bedpans are particularly uncomfortable and difficult to use. Although they may be necessary, bedpans should be avoided whenever the use of a toilet or commode chair is possible.

Fecal Impaction

Fecal impaction, the presence of a mass of hardened feces that is trapped in the rectum and cannot be expelled, is a result of unrelieved constipation. In severe cases, the fecal mass may extend up into the sigmoid colon. Individuals who have a history of chronic constipation are most at risk for impaction.

Symptoms of impaction include a longer-than-usual delay in defecation. More than 3 days without a bowel movement warrants close attention. Passage of small amounts of liquid stool without any formed fecal material can also indicate impaction. This liquid stool is fecal material from higher in the colon that is able to pass around the hardened mass. It typically oozes from the rectum and differs from a diarrheal stool, which passes with normal force.

Aging persons suffering from fecal impaction are likely to complain of cramping or rectal pain. Abdominal distention and loss of appetite are common. Digital examination of the rectum typically reveals the presence of a hardened mass of feces. This procedure should be done with extreme caution because it is uncomfortable and traumatic to the rectal tissues. Particular caution must be used when examining older persons with a history of cardiac problems because rectal examination can stimulate the vagus nerve and result in a sudden decrease in heart rate, syncope, or even loss of consciousness. Some facilities require physician’s orders before a digital examination of the rectum is performed. Sometimes the impacted mass is higher in the intestinal tract and cannot be detected by digital examination. In these cases, abdominal x-rays may be necessary. Before deciding that an older person has a problem with bowel elimination, nurses should thoroughly assess the total situation, including the frequency, amount, and consistency of stools. Assessment should also include identification of factors that contribute to the development of bowel elimination problems. This enables the development of a plan that promotes sound elimination patterns.