Laxatives And The Elderly: Safe Or Not?

Constipation is a common problem for older people, with about a third of adults over 60 experiencing it and half of nursing home residents. It can have serious consequences, including abdominal pain, haemorrhoids, and faecal impaction. Laxatives are a common treatment, but evidence of their effectiveness and safety for older people is limited.

Laxatives are available without prescription in many countries, and they are widely used by older people. However, older people are more susceptible to adverse effects, such as electrolyte disturbances. Therefore, caution is needed when recommending laxatives to older people, and an assessment of comorbidities, medications, and potential adverse effects is necessary.

Several types of laxatives are available, including bulk-forming agents, softeners, osmotic agents, and stimulants. Osmotic agents, such as polyethylene glycol, are often recommended as they are well-tolerated and can be used daily. Bulk-forming agents, such as psyllium, can also be effective but may cause bloating and abdominal distension. Stimulant laxatives, such as senna, should be used with caution due to potential adverse effects with long-term use.

While laxatives can be beneficial for older people, it is important to address the underlying causes of constipation, such as insufficient fibre or water intake, and to consider non-pharmacological interventions, such as scheduled toileting and increased fluid intake.

What are the risks of laxatives for older people?

Laxatives are the primary treatment for constipation in older people, and they are widely available without a prescription in many countries. However, there is a lack of evidence regarding the safety and effectiveness of most laxatives in older populations. Age-related changes increase the risk of adverse effects associated with laxatives, such as electrolyte disturbances. Therefore, caution must be exercised when recommending laxatives to older individuals, and a careful assessment of their condition, comorbidities, and medications should be conducted.

The risks of laxatives for older people include:

• Magnesium toxicity: Magnesium-based laxatives, such as magnesium citrate and magnesium hydroxide, can lead to magnesium toxicity, especially with long-term use. This is of particular concern in older adults with impaired kidney function.
• Electrolyte disturbances: Age-related changes increase the risk of electrolyte disturbances, such as abnormal levels of blood calcium, potassium, or magnesium.
• Interaction with medications: Older adults often take multiple medications, and laxatives may interact with these drugs. For example, anticholinergics, which include sedating antihistamines and medications for overactive bladder, can worsen constipation.
• Dehydration: Laxatives can lead to dehydration, especially if not taken with adequate fluid intake.
• Dependency: There is a concern that long-term use of laxatives may lead to dependency, with the body becoming reliant on them to produce bowel movements.
• Adverse effects: Laxatives may cause various adverse effects, including abdominal pain, bloating, cramping, nausea, diarrhoea, and lethargy.
• Interaction with diet: The effectiveness of laxatives may be influenced by dietary factors, such as fibre and fluid intake.
• Incorrect choice of laxative: Different types of laxatives are available, including bulk-forming agents, softeners, osmotic agents, and stimulants. Choosing the wrong type of laxative may be ineffective or even harmful.

What are the alternatives to laxatives for older people?

Alternatives to Laxatives for Older People

Laxatives are a common treatment for constipation in older people, but they are not the only option. Here are some alternatives to laxatives that can help manage constipation in older adults:

• Dietary Changes: Increasing the intake of dietary fibre and fluids can help soften stools and improve bowel function. This includes eating more fibre-rich foods, such as prunes, which contain both fibre and sorbitol, a sugar that draws water into the bowel. It is important to increase fibre intake slowly over several weeks to reduce adverse effects.
• Biofeedback: This technique uses anorectal electromyography or a manometry catheter to provide feedback to patients when evacuating a rectal balloon. It can help retrain the defecation muscles and may be effective for treating constipation caused by pelvic floor dysfunction.
• Mineral Oil or Warm Water Enemas: For cases of fecal impaction, mineral oil or warm water enemas can be used to soften and dislodge the impacted stool.
• Glycerin Suppositories: These are safe alternatives to enemas and have been shown to improve rectal emptying in patients with chronic constipation.
• Probiotics: While a systematic review found that probiotics did not improve constipation in adults, this may be an option to consider in conjunction with other treatments.
• Medicine Review: Constipation can be caused or worsened by certain medications, such as anticholinergics, opiate painkillers, and some forms of calcium and iron supplementation. Reviewing and adjusting medications can help reduce constipation.
• Physical Activity: Encouraging older adults to engage in physical activity and establishing a regular toilet routine, such as sitting on the toilet after meals, can help promote bowel movements.
• Scheduled Toileting: Taking advantage of the gastrocolic reflex by scheduling toileting after meals can help improve bowel function.
• Foot Positioning: Placing feet on a small step stool during bowel movements can help straighten the anorectal junction and improve defecation.
• Privacy: Ensuring older adults have adequate time and privacy for bowel movements can reduce feelings of rush or embarrassment, making it easier to pass stools.

What are the best types of laxatives for older people?

Constipation is a common condition among older people, affecting their quality of life and potentially leading to more severe health issues. Laxatives are the primary treatment option, but choosing the right type is essential to ensure effectiveness and avoid adverse effects. Here are some of the best types of laxatives for older adults:

• Osmotic agents: Osmotic laxatives, such as polyethylene glycol (brand name Miralax), sorbitol, and lactulose, are often well-tolerated and effective. They work by drawing water into the stool, making it softer and easier to pass. Polyethylene glycol is particularly well-tolerated and can be used daily.
• Stimulant agents: Stimulant laxatives like senna (Senokot) and bisacodyl (Dulcolax) stimulate the colon to contract and move stool more quickly. They can be used as "rescue agents" or daily if needed. Bisacodyl is also available as a suppository.
• Bulk-forming agents or bulking agents: These include fibre supplements like psyllium (Metamucil) and methylcellulose (Citrucel). They increase stool bulk by absorbing water, making it easier for the colon to move the stool. However, they must be taken with plenty of water, or they may worsen constipation.
• Prescription laxatives: For older adults who don't respond to over-the-counter options, prescription laxatives like lubiprostone (Amitiza) and linaclotide (Linzess) may be an option. However, they are more expensive and have a more limited safety record.
• Enemas and suppositories: For fecal impaction or those who can't take oral laxatives, enemas and suppositories can be used. Warm water enemas or mineral oil enemas are recommended over saline enemas, which carry a risk of electrolyte disturbances. Glycerin suppositories are a safe and effective alternative.

It's important to note that not all laxatives are suitable for everyone, and some may have potential side effects. Therefore, it's always best to consult a healthcare professional before starting any new treatment, especially for older adults who may have multiple health considerations.

What are the causes of constipation in older people?

Constipation is a common condition among older people, affecting up to half of all older adults during their lifetime. It is characterised by having fewer than three bowel movements a week, having a difficult time passing stools, experiencing lumpy or hard stools, and feeling blocked or unable to fully empty one's bowels.

There are two main types of constipation: primary and secondary. Primary constipation, or functional constipation, occurs when the problem is related to bowel function and is not caused by another medical condition or medication. It is further divided into three subgroups: normal transit constipation, slow transit constipation, and disorders of defecation. Secondary constipation, on the other hand, is when bowel problems develop as a result of some other medical, physical, or structural problem, or due to medication or treatment.

The causes of constipation in older adults can be multifactorial, with a range of age-related factors contributing to the condition. Here are some of the common causes:

• Multiple chronic illnesses
• Insufficient food and water intake
• Stenosis of the anus
• Rectocele, where the rectum bulges into the vagina
• Loss of abdominal strength
• Bowel obstructions and perforations
• Medication side effects
• Insufficient dietary fibre
• 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 caused by neurological conditions such as Parkinson's disease or long-standing conditions like diabetes
• Irritable bowel syndrome
• Pelvic floor dysfunction
• Psychological factors such as anxiety, depression, or fear of pain during bowel movements
• Very low levels of physical activity
• Mechanical obstruction, where the colon or rectum is impaired by a mass, lump, narrowing, or another physical factor

It is important to note that constipation can also be caused or worsened by certain medications, including anticholinergics, opiate painkillers, some forms of calcium and iron supplementation, and antidepressants.

What are the best treatments for constipation in older people?

Best treatments for constipation in older people

Constipation is a common problem, affecting up to half of all older adults during their lifetime. It can cause severe abdominal pain, haemorrhoids, irritability, and even faecal incontinence. While laxatives are the mainstay of constipation management, they should be used with caution in older people due to the risk of adverse effects such as electrolyte disturbances. It is important to tailor the treatment to the individual, considering their comorbid conditions and medications. Here are some recommended treatments for constipation in older people:

• Lifestyle modifications: This includes scheduled toileting after meals, increased fluid intake, and increased dietary fibre intake. Fibre intake should be increased slowly over several weeks to reduce adverse effects such as flatulence and bloating. Prunes are particularly effective as they contain fibre and sorbitol, which draws water into the bowel.
• Osmotic laxatives: Osmotic laxatives, such as polyethylene glycol (Miralax), lactulose, and sorbitol, are often recommended as the next step in treatment. They work by drawing water into the stool, making it softer and easier to pass.
• Stool softeners: Stool softeners, such as docusate sodium (Colace), can be used after osmotic laxatives. However, there is limited evidence for their effectiveness.
• Stimulant laxatives: Stimulant laxatives, such as senna (Senakot) and bisacodyl (Dulcolax), can be used if other treatments are ineffective. They stimulate the colon to move things along more quickly.
• Bulking agents: Bulking agents, such as psyllium (Metamucil) and methylcellulose (Citrucel), can be used but may cause bloating and abdominal discomfort. They should be avoided if fecal impaction is present.
• Mineral oil or warm water enemas: These can be used to treat fecal impaction, which is a more urgent problem caused by a hard mass of stool stuck in the rectum or colon.
• Biofeedback: Biofeedback to retrain the defecation muscles may be effective, particularly for constipation caused by pelvic floor dysfunction. However, there is limited evidence for its effectiveness.
• Newer prescription laxatives: Lubiprostone (Amitiza) and linaclotide (Linzess) are prescription laxatives that may be effective for those who do not respond to other treatments. However, they are expensive and have a more limited safety record.

In summary, the treatment of constipation in older people should start with lifestyle modifications and progress to the use of laxatives if necessary. It is important to be cautious when using laxatives in older people due to the risk of adverse effects, and to tailor the treatment to the individual's specific needs and circumstances.

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