There is no one best evidence-based treatment for chronic constipation in the elderly. While the most common first-line treatments are dietary fiber and exercise, the evidence is insufficient to support this approach in the geriatric population (strength of recommendation [SOR]: for dietary fiber: A, based on a systematic review; for exercise: SOR: B, based on 1 good- and 1 fair-quality randomized controlled trial [RCT]). Herbal supplements (such as aloe), alternative treatments (biofeedback), lubricants (mineral oil), and combination laxatives sold in the US have not been sufficiently studied in controlled trials to make a recommendation (SOR: A, based on systematic review)

Kalish, Virginia B.

Loven, Bridget

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1050	 vol 56, No 12 / December 2007  The Journal of family PracTiceCliniCal INquIrIes From the Family Physicians Inquiries Network		What	is	the	best	treatment		for	chronic	constipation		in	the	elderly?Virginia B. Kalish, MDDewitt Army Community  Hospital-National Capital  Consortium Residency Program, Fort Belvoir, VaBridget loven MliSCarolinas Healthcare System, Charlotte, NCThere is no one best evidence-based treatment for chronic constipation in the elderly. While the most common first-line treatments are dietary fiber and exercise, the evidence is insufficient to support this approach in the geriatric population (strength of recommendation [sor]: for dietary fiber: a, based on a systematic review; for exercise: sor: B, based on 1 good- and 1 fair-quality randomized controlled trial [rcT]).  Herbal supplements (such as aloe), alternative treatments (biofeedback), lubricants (mineral oil), and combination laxatives sold in the us have not been sufficiently studied in controlled trials to make a recommendation (sor: a, based on systematic review).  An abdominal kneading device can be used to treat chronic constipation, but the evidence is limited (sor: B, based on 1 cohort study.) Polyethylene glycol has not been studied in the elderly. A newer agent, lubiprostone (Amitiza), appears to be effective for the treatment of chronic constipation for elderly patients (sor: B, based on subgroup analysis of rcTs.) is the patient truly constipated?many older people feel that if they do not have a bowel movement every day they are constipated. However, constipation is defined as fewer than 3 bowel movements per week. so, the first thing we must do is to confirm that the patient is truly constipated. before I start my patients on any medicine, I suggest a trial of increased daily water and fiber intake along with exercise, followed by a trial of stool softeners and stimulant laxatives, if needed. If all of these methods fail, I consider trying polyethylene glycol, which can be titrated to effect. As with all medication use by the elderly, it is important to titrate cautiously (“start low and go slow”) and add other medications only when necessary.   Mandi Sehgal, MDDepartment of Family medicine/Geriatrics, university of cincinnaticlinical commentaryevidence-based answerfast trackInconsistent  research findings cast doubt on the efficacy of fiber treatment  for constipationz	Evidence	summaryFew well-designed studies have focused on constipation treatment among the elderly. Our search located 1 systematic review of pharmacologic management, a systematic review of fiber management, 2 RCTs on the effect of exercise, and 1 before-after cohort study on abdominal massage. These studies were all conducted among geriatric patients with constipa-tion. Two high-quality systematic reviews regarding chronic constipation manage-fast trackwww.jfponline.com  vol 56, No 12 / December 2007 1051ment for adults of all ages included man-agement options not studied in exclu-sively geriatric populations, such as herbal supplements, biofeedback, tegaserod, and polyethylene glycol.Laxatives,	fiber,	and	exercise:		Studies	are	inconclusiveTwo good-quality systematic reviews looked at 10 RCTs comparing laxatives with placebo, and 10 RCTs comparing 1 laxative with another.1,2 The studies generally had few participants, were of short duration, and were conducted in institutional settings. Most lacked power to make valid conclusions. These studies varied in the reported outcome measures, including stool frequency, stool con-sistency, straining, decrease in laxative use, and symptom scores. The reviews concluded that the best pharmacologic treatment for chronic constipation in the elderly has not been established. Five of the higher-quality studies attained statistical significance. They showed a small but significant improve-ment in bowel movement frequency with a laxative when compared with placebo or another laxative (TabLE). The authors noted that multiple poor-quality stud-ies have shown nonsignificant trends for improved constipation symptoms with laxatives compared with placebo. inconsistent findings on fiber. A good-quality systematic review3 of dietary fiber in the treatment of constipation for older patients located 8 moderate- to high-quality studies (6 RCTs and 2 blinded before-after studies), with 269 study par-ticipants in institutional settings. Results among studies were inconsistent, casting doubt on the efficacy of fiber treatment for constipation in the institutionalized elder. Two RCTs4,5 investigating the effect of exercise on 246 institutionalized older patients showed no improvement in con-stipation. One study was of good qual-ity, reporting adequate power and used an intention-to-treat analysis. The other was of fair quality.alternative	TXs	not	well	studiedA high-quality systematic review6 of con-stipation management among adults of all ages in North America found a lack of quality RCTs examining herbal supple-ment treatment. Biofeedback has been studied in adult populations, but no RCTs with placebo or sham-controls have been published. One before-after cohort study7 inves-tigated an external kneading mechanical device (Free-Lax) that was applied to the abdomen for 20 minutes once daily in 30 randomly selected chronically constipated nursing home residents. Researchers found significant improvements in bowel move-ment frequency, stool consistency and vol-ume, and colonic transit time without side effects (TabLE). a	look	beyond	geriatric	patients	Polyethylene glycol, tegaserod, and lu-biprostone have not been studied in tri-als of exclusively geriatric populations. Two high-quality systematic reviews,6,8 including medium- to high-quality RCTs of pharmacologic management of chron-ic constipation, found good evidence to support treatment with polyethylene gly-col and tegaserod in adults of all ages. Of the 8 RCTs looking at polyethylene glycol, only 1 of the studies—a high- How	well	do	these	interventions	work		for	older	patients	with	chronic	constipation?inTervenTion  STool frequency vS comPariSon (SToolS Per week) nnT‡agiolax* vs lactulose 4.5 vs 2.2 43agiolax* vs lactulose 5.6 vs 4.2 71lactitol† vs  placebo 4.9 vs 3.6 77lactitol† vs lactulose 5.5 vs 4.9 160lactulose vs sorbitol† 7.0 vs 6.7 330external abdominal  3.9 vs 1.4 40 kneading (before-after)*  Agiolax is a combination bulk and stimulant laxative not readily found in the  united states.†  lactitol and sorbitol are sugar alcohols used as replacement sweeteners and  approved by the FDA as food additives.‡ Number needed to treat (NNT) for 1 person to have 1 more stool per week. taBle 2 RCTs showed no improvement of constipation from exercise in older patientsfast track1052	 vol 56, No 12 / December 2007  The Journal of family PracTiceCliniCal INquIrIesquality crossover comparison of poly-ethylene glycol vs placebo with 37 out-patient subjects—included a population with a mean age >60 years (mean age 62, range 42–89 years). A subgroup analysis9 of 331 elderly patients enrolled in 2 RCTs of tegaserod found no difference in outcomes between treatment with tegaserod and placebo, al-though this analysis was limited by inad-equate power. Tegaserod linked to ischemic events. A recent analysis of clinical trials found a statistically significant increase in cardio-vascular ischemic events associated with tegaserod. The manufacturer took the product off the market in compliance with an FDA request in March 2007. lubiprostone offers promise. Lubipro-stone, a chloride channel activator ap-proved by the FDA for the treatment of chronic idiopathic constipation, has been studied in 6 placebo-controlled, double-blind, randomized Phase II and III clinical trials. In 2 unpublished pooled analyses of 3 of the trials, lubiprostone was found to be effective in a total of 220 elderly pa-tients 65 years of age and older.10,11 Recommendations	from	othersThe American College of Gastroenterology Chronic Constipation Task Force evi-dence-based guidelines make no refer-ence to age, but state that evidence is best for treatment with psyllium, tegaserod, polyethylene glycol, and lactulose.12 They found insufficient evidence to support  use of stimulants, stool softeners, lubricants, herbal supplements, biofeedback, and al-ternative treatments. The American Gastroenterological Association guidelines on constipation are primarily based on expert opinion.13 Age is not specified in their recommendations. Dietary and exercise modifications are recommended as first-line treatments, fol-lowed by laxatives. Laxatives are recom-mended based on cost, in order from the least to most expensive agents. Supposito-ries, enemas, biofeedback, and (in refrac-tory cases) surgery are recommended for patients with pelvic floor dysfunction. The Registered Nurses Association of Ontario guidelines for constipation pre-vention in the older adult population rec-ommend fluid and dietary fiber, regular exercise, and consistent toileting.14   n references 1.  Petticrew m, Watt I, brand m. What’s the “best buy” for treatment of constipation? results of a systematic review of the efficacy and comparative efficacy of laxa-tives in the elderly. Br J Gen Pract 1999; 49:387–393.  2.  Petticrew m, Watt I, sheldon T. systematic review of the effectiveness of laxatives in the elderly. Health Technol Assess 1997; 1:i–iv,1–52. 3.  Kenny KA, skelly Jm. Dietary fiber for constipation in older adults: a systematic review. Clinical Effective-ness in Nursing 2001; 5:120–128.  4.  chin APmJ, van Poppel mN, van mechelen W. effects of resistance and functional-skills training on habitual activity and constipation among older adults living in long-term care facilities: a randomized controlled trial. BMC Geriatr 2006; 6:9.  5.  simmons sF, schnelle JF. effects of an exercise and scheduled-toileting intervention on appetite and con-stipation in nursing home residents. J Nutr Health Ag-ing 2004; 8:116–121. 6.  brandt lJ, Prather cm, quigley em, schiller lr, schoenfeld P, Talley NJ. systematic review on the management of chronic constipation in North Amer-ica. Am J Gastroenterol 2005; 100 suppl 1:s5–s21. 7.  mimidis K, Galinsky D, rimon e, Papadopoulos v, Zicherman Y, oreopoulos D. use of a device that ap-plies external kneading-like force on the abdomen for treatment of constipation. World J Gastroenterol 2005; 11:1971–1975. 8.  ramkumar D, rao ss. efficacy and safety of tradition-al medical therapies for chronic constipation: system-atic review. Am J Gastroenterol 2005; 100:936–971. 9.  baun rF, levy Hb. Tegaserod for treating chronic con-stipation in elderly patients. Ann Pharmacother 2007; 41:309–313.  10.  ueno r, Joswick Tr, Wahle A, et al. efficacy and safety of lubiprostone for the treatment of chronic constipation in elderly vs non-elderly subjects. Gas-troenterology 2006; 130(suppl 2):A189. 11.  ueno r, Panas r, Wahle A, et al. long-term safety and efficacy of lubiprostone for the treatment of chronic constipation in elderly subjects. Gastroenter-ology 2006; 130(suppl 2):A188. 12.  American college of Gastroenterology chronic consti-pation Task Force.An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005; 100 suppl 1:s1–s4.13.  locke Gr, 3rd, Pemberton JH, Phillips sF. American Gastroenterological Association medical Position statement: guidelines on constipation. Gastroenterol-ogy 2000; 119:1761–1766. 14.  registered Nurses Association of ontario (rNAo). Prevention of constipation in the older adult popula-tion. Toronto, ontario: rNAo; 2005. Available at: www.guideline.gov/summary/summary.aspx?ss=15&doc_id=7004&nbr=4213. Accessed on November 8, 2007.There was good evidence  to support the use of polyethylene glycol in adults  of all ages

What is the best treatment for chronic constipation in the elderly?

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