A Review of Treatment Guidelines for Constipation in the PACE Population

Constipation is a common complaint in the PACE population, and understandably so. The incidence of constipation is higher in older populations when compared to younger populations. And it’s even more common in older women.
While constipation is not considered a natural consequence of aging, the PACE population is affected by age-related physiologic changes that may contribute to constipation.
Some of these changes include:

  • decreased mobility
  • comorbid conditions
  • side effects of medications—such as opioids, anticholinergic medications, and antidepressants, among others

The good news, though, is that through both non-pharmacological and pharmacological treatments, PACE pharmacy providers can help older adults belonging to the PACE population get a handle on constipation.

Non-Pharmacological Options for Treating Constipation in the PACE Population

While there are various prescription and over-the-counter medications that are effective in relieving constipation symptoms, there are also a number of non-medication options that can help.

Many of these options can be used with medications to improve constipation symptoms in PACE participants. However, before employing a pharmacological treatment option, it’s worth trying the following non-pharmacologic ones:

  • Keeping a stool diary—While it may seem rudimentary, it can be helpful for both the PACE participant and his or her healthcare provider if the participant keeps a log of bowel movements, noting things like stool frequency, size, and degree of straining.
  • Being informed about regular vs. irregular bowel habits—There’s a common misconception that people need to have at least one bowel movement a day. However, that simply isn’t true—especially for older adults. If a PACE participant is experiencing infrequency but not experiencing symptoms of constipation, therapy may not be necessary.
  • Increasing fiber intake—The daily recommended fiber intake for seniors is 20 to 30 grams. The addition of fiber-rich foods—such as bran, fruits, nuts, and/or prune juice—can help alleviate constipation symptoms. We recommend increasing fiber intake by five grams each week until the PACE participant reaches the recommended intake. If fiber intake is added too quickly, though, increased bloating and excessive gas may occur.
  • Exercising more often—Though this may be more challenging for PACE participants to achieve, they can promote bowel movements by increasing their mobility, as able to do so.

Pharmacological Options for Treating Constipation in the PACE Population

Of course, there are pharmacologic options available to help manage constipation. Various laxatives and prokinetic agents are often used to treat constipation, including in the PACE population.

Bulk laxatives, which includes Methylcellulose, Polycarbophil, and Psyllium, work by absorbing water from the intestinal lumen to increase stool mass and soften stool consistency.
Because it can take anywhere from 12 hours to three days for bulk-forming laxatives to work, they are not recommended for the immediate relief of constipation.

Emollient laxatives or stool softeners, such as Docusate, work by allowing water to enter the bowel more readily.
These laxatives are generally well-tolerated, but are not as effective as psyllium in the treatment of constipation.
It’s important to note that in chronically ill older adults, stool softeners are not considered effective, as they generally take between 12 and 72 hours to work.

And finally, though mineral oil is a common go-to for chronic constipation, it’s not a recommended treatment. Experts have noted a severe complication of this medication—the risk of aspiration—and emphasize the importance of heightened awareness among caregivers and post-acute pharmacy providers regarding the potential dangers of inappropriate mineral oil use.

Osmotic laxatives, such as Lactulose, Magnesium Citrate, and Sorbitol, help alleviate constipation by causing water to secrete into the intestinal lumen via osmotic activity.

This class of laxatives tends to show effectiveness roughly one to two days following administration.

It’s important to note that these laxatives should be used carefully among adults in the PACE population who have congestive heart failure and chronic renal insufficiency.

Stimulant laxatives, like Senna and Bisacodyl, work by boosting intestinal motility and water secretion into the bowel.

This class of laxatives generally produces bowel movements within hours, but may cause abdominal cramping because of the increased peristalsis. Typically, stimulant laxatives take between six and 12 hours to work.
In adults belonging to the PACE population, a combination of senna and bulk laxative has shown to be more effective than lactulose in improving stool frequency and consistency. In addition, stimulant laxatives can be used on an as-needed basis, so long as participants carefully follow the manufacturer’s instructions.

Prokinetic agents, which include medications like Tegaserod and Misoprostol, have been studied for the treatment of slow transit constipation—though they haven’t been approved by the U.S. Food and Drug Administration for this indication.

Larger trials are needed to confirm the efficacy and safety of the long-term use for chronic constipation. To date, Tegaserod, in particular, has shown to not improve older adults’ symptoms of abdominal pain/discomfort, even though it increases bowel movements.

Evaluating Pharmacological Options for the Treatment of Constipation in the PACE Population

If a PACE participant is started on one of medications discussed in this article, it is extremely important to continually monitor him or her for the continuation or relief of symptoms.

Additionally, it is recommended to monitor for diarrhea and/or increased bowel movements, which may lead to needing to discontinue medication use.

Though helpful in alleviating constipation symptoms in older adults, laxatives are a drug class that may be potentially unnecessary after period of time. These agents tend to stay on participants’ medication lists for longer periods of time than may be clinically necessary, and there are potential harms associated with long-term laxative use, including:

  • rebound constipation
  • diarrhea
  • dehydration
  • electrolyte abnormalities
  • bloody stool
  • impaired intestinal function
  • rectal prolapse

Because of the risk of long-term harm, it’s essential to reassess the need for laxatives once the participant’s symptoms of constipation are alleviated.
By properly following treatment guidelines, together we can work to minimize the recurrence and symptoms of constipation in PACE participants.

Those in the PACE population have unique medical needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504 or emailing paceteam@granerx.com.

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