As the body ages, it undergoes a multitude of changes. Some of these changes are visible, whereas others are not and may be elicited during the patient encounter. Some gastrointestinal issues may be more common in the elderly population and possibly in older women. These issues range from motility disorders, such as fecal incontinence and constipation, to changes in neuropeptide function and its effect on the anorexia of aging. This article comprehensively reviews gastrointestinal issues that commonly afflict the elderly female population.
As the body ages, it undergoes a multitude of changes. Some of these changes are visible, whereas others are not and may be elicited during the patient encounter. Some gastrointestinal issues may be more common in the elderly population and possibly in older women. These issues range from motility disorders, such as fecal incontinence (FI) and constipation, to changes in neuropeptide function and its effect on the anorexia of aging. This article comprehensively reviews gastrointestinal issues that commonly afflict the elderly female population.
Anorexia
Enjoying food depends on a combination of factors including taste, olfaction, pain, temperature, sensation, learned responses, cultural beliefs, and prior experiences. This information is gathered, integrated, and processed at the cortical level to yield what we recognize as taste. Alterations of these processes may occur with aging, thereby affecting taste, smell, and ultimately appetite. With aging, many physiologic and pathologic factors may contribute to these alterations and influence both the ability to sense and process information. These factors are examined in this article. It is not clear if gender contributes to anorexia with aging. However, gender may exert an independent influence.
Olfaction has been recognized as the major component involved in tasting food. Over time, olfactory receptors are lost at a rate of approximately 10% per decade. Studies have also shown that olfactory potentials decrease with age. These anatomic and physiologic changes lead to a diminished sense of smell that, in combination with processing and interpretive changes, lead to an altered taste perception, especially in cognitively impaired older patients. No clear gender differences have been observed.
Studies have shown that the threshold for taste declines with age and the male gender, especially with respect to saltiness and unami. Besides salty, sweet, bitter, and sour, unami is the fifth taste sensation and is sensitive to amino acids. The effects of mixtures of food products, solubility properties in water, and olfactory preservation must be considered when interpreting data and reviewing studies. Although some studies suggest that changes in both the sensitivity and the actual number of taste buds are factors in determining taste, it is generally accepted that function, rather than number, is of prime importance. Other factors that contribute to the perception include dental or periodontal disease, medications, tobacco use, and alterations in saliva.
The concept of anorexia of aging can be traced back to Morley and Silver whose 1988 article pointed toward the decline in caloric intake with aging. More recent studies confirm that elderly patients typically experience earlier satiety and have difficulty upregulating caloric intake after a period of abstinence from food when compared with their younger counterparts. Sturm and colleagues found that early satiety in the elderly is secondary to decreased nitric oxide synthase activity in the stomach, causing decreased fundal compliance and a heightened antral stretch response. Therefore, less food triggers antral stretch and thus satiation signals that lead to early satiety. The 2 commonly studied satiety hormones seen with aging are leptin and cholecystokinin (CCK). This section reviews the basic mechanisms of various neuropeptides and their relation to appetite, satiety, and the anorexia of aging in elderly women.
Leptin is a peptide hormone that is produced by white adipose tissue and monitors energy stores. Leptin inhibits the expression of orexigenic neuropeptides, leading to the upregulation of anorexigenic neuropeptides and satiety. This effect is referred to as leptin-induced inhibition of food intake. Studies have reported high fasting concentrations of leptin in the elderly.
Some studies suggest that men experience greater anorexia of aging than women. This trend may be related to a decrease in testosterone levels associated with age, which triggers an increase in levels of circulating leptin. Postmenopausal women experience a decrease in adrenal androgens and testosterone as well, although to a lesser degree than men. This decrease may also lead to an increase in levels of leptin because the 2 hormones are inversely related. Di Francesco and colleagues reported that there were higher serum concentrations of leptin in the elderly (aged 74–82 years) than in the younger patients (aged 25–38 years), that body mass indexes (BMIs, calculated as the weight in kilograms divided by the height in meters squared) were not significantly different in elderly and younger patients, and that satiety was more prolonged in the elderly cohort. This study also suggested that the elderly had less postprandial hunger and higher fasting and postprandial insulin concentrations but these values did not quite attain statistical significance. Elevated plasma insulin levels are thought to amplify the anorexigenic effect of leptin through stimulating central leptin action and sensitivity. This study was limited, however, by the small number (n = 8) of elderly adults studied, all of who were healthy.
The release of CCK from I cells occurs when nutrients such as fatty acids and aromatic amino acids enter the duodenum. CCK is also present in the hypothalamus, cortex, and midbrain. This neuropeptide acts as a satiety hormone by triggering the contraction of gallbladder, relaxing the sphincter of Oddi, and slowing the rate of gastric emptying. With age, there is an increased basal release of CCK and a heightened release in response to fatty acids in the duodenum. The satiating effects of CCK therefore increase with age. Martinez and colleagues examined elderly patients with idiopathic anorexia and found that they had significantly higher plasma levels of CCK than healthy age-matched controls. Other studies have also shown that the intravenous administration of CCK-8 suppressed food intake twice as much in the elderly as in the young. Understanding the biochemistry of CCK and its role in anorexia of aging have led many to study the effects of CCK antagonists in countering anorexia of aging.
Opioids comprise another class of neuropeptides that are frequently considered in the anorexia of aging. Animal studies have shown that the exogenous administration of opioid agonists causes increased food intake, whereas opioid antagonists inhibit food intake in animals and humans. The role of opioids in the elderly, however, remains unclear. Martinez and colleagues found a correlation between anorexia in the elderly, decreased cerebrospinal fluid (CSF) levels of β-endorphin, and increased plasma concentrations of CCK-8. Silver and Morley studied the effect of intraperitoneal injections of morphine and naloxone in mice and found that morphine increased food intake in younger but not older mice, whereas naloxone led to decreased food intake in the same respective groups of mice. MacIntosh and colleagues evaluated energy intake after naloxone infusions in adults and found that 16% of older adults had suppressed energy intake, whereas only 8% of younger adults were affected, suggesting that aging is not associated with a significant reduction of the endogenous feeding drive. Although this study was double-blinded and randomized, it was limited by a small sample size (N = 24) and did not attain full statistical significance. Multiple studies have revealed conflicting evidence regarding the opioid response to food in aging. However, it remains a critical neuropeptide in understanding the anorexia of aging.
Neuropeptide Y (NPY) is abundant in the central and peripheral nervous systems. NPY is a potent orexigenic molecule that promotes feeding and weight gain. It is released during states of low energy or starvation from the hypothalamus and peripheral nervous system. It was previously thought that NPY activity was reduced in patients with anorexia. Martinez and colleagues reported that elderly patients with senile anorexia actually had increased levels of NPY in both plasma and CSF when compared with age-matched controls. The results from this study challenge the postulated role and mechanism of action of this neuropeptide, and further studies elucidating the definitive role of NPY in the anorexia of aging are needed.
Galanin is yet another neuropeptide that stimulates food intake. A study by Baranowska and colleagues suggests that the mechanism behind galanin’s relationship to anorexia is not from a decrease in secretion but rather from a decrease in sensitivity over time. Previous studies have also shown that growth hormone (GH) secretion is diminished in response to galanin in older women compared with younger women. This effect is thought to be secondary to higher circulating estrogen levels in young women, which has been shown to enhance galanin-induced GH secretion. As estrogen levels drop in postmenopausal women, the ability of galanin to enhance GH secretion is diminished, leading to decreased food intake in elderly women. Further research into the mechanism of action of galanin is warranted to better understand and elucidate its role in the anorexia of aging and its mechanism of action.
Orexins or hypocretins are synthesized in the hypothalamus as either orexin A or orexin B and constitute another group of neuropeptides studied in relation to the anorexia of aging. Orexin A and B secretion help regulate feeding and sleep patterns. Deficiency of these neuropeptides causes narcolepsy and contributes to decreased appetite and subsequent weight loss in animal models. Interestingly, studies have found that orexin levels actually increase rather than decrease with aging. This finding confounds the role of orexins in the anorexia of aging, although their effect on receptor sensitivity over time has yet to be determined.
Peptide YY (PYY) is released from the brain when fats and carbohydrates reach the small intestine. Batterham and colleagues found a 30% reduction in food intake in obese and nonobese patients younger than 50 years on injecting intravenous PYY. The exact role of PYY in anorexia of aging and gender preferences has yet to be defined.
Glucagon-like peptide-1 (GLP-1) is an incretin that is released from the intestinal epithelium in response to nutrient and carbohydrate ingestion. In turn, GLP-1 stimulates insulin secretion, reduces glucagon secretion, slows gastric emptying, and decreases appetite. Flint and colleagues discovered that when GLP-1 was injected into 20 young healthy men, it reduced energy intake and improved satiety. The effects on the elderly, however, have yet to be studied, and there are no clear gender-based observations.
Ghrelin is an endocrine peptide hormone produced primarily by the enteroendocrine cells of the stomach as well as the placenta, pituitary, and hypothalamus. It seems to be an orexigenic regulator of appetite. Levels of ghrelin are highest in fasting states and at nadir during meals. Ghrelin also stimulates the release of GH, and is inhibited by leptin, insulin, GH, a high-fat diet, and insulinlike growth factor-1. Ghrelin is upregulated by fasting, a low protein diet, and a malnourished state. The stomach produces ghrelin in 2 forms: active acylated ghrelin that stimulates food intake and desacyly ghrelin that is thought to have no hormonal action. Research has shown that in animal models, the des-acyl ghrelin released by the stomach actually decreases food intake. This observation begs the question whether ghrelin in the elderly is the primary des-acyl ghrelin with appetite inhibitory properties. Rigamonti and colleagues suggest that there is an age-related decline in plasma ghrelin concentrations. Another theory is that elevated fasting and postprandial insulin levels in elderly patients suppress ghrelin activity and sensitivity. Some studies purport that fasting ghrelin levels are lower in the elderly. However, Di Francesco and colleagues revealed that neither basal nor postprandial ghrelin levels differed significantly between the young and elderly groups. This study also showed that in the elderly patients there was no postprandial increase in the ghrelin concentration. Further studies must be done to better elucidate this relationship.
Interleukin (IL)-1, IL-6, and tumor necrosis factor α are inflammatory cytokines that are present in higher levels in cachectic patients and lead to decreased food intake and body weight. In older cachectic patients, IL-1 and IL-6 levels have been shown to be elevated. Roubenoff and colleagues revealed that plasma IL-6 levels increase with aging and are inversely correlated with functionality in the elderly. Levels of these cytokines also increase with stress, malignancy, and infection and lead to a decrease in appetite, body weight, and functional capacity in the elderly.
The interplay of receptor dysfunction, olfactory and taste decline, gastric motility and compliance, hormonal influence, and centrally mediated mechanisms involving neurotransmitters may contribute to anorexia and weight loss in the older patient. Investigating the individual effects of these mechanisms is difficult because of the multitude of other confounding factors, such as the ability to purchase and prepare food, loss of functional status, and other psychological and socioeconomic issues that may hinder oral intake. Studies at the neuronal and cellular level attempt to more clearly define the approach and management of such issues but are not yet clearly conclusive. Although anorexia of aging may manifest differently in men and women, the aforementioned factors likely play a more substantial role.
Gastroesophageal reflux disease
The prevalence of gastroesophageal reflux disease (GERD) does not seem to demonstrate an age-related gender preference. Although overt symptoms may be less common or less frequently reported in the older population, complications related to GERD such as peptic stricture, esophagitis, and Barrett esophagus do seem to worsen with age. A true understanding of the prevalence is difficult because of conflicts in the definition of GERD (esophagitis vs no esophagitis), as well as the relatively sparse number of international studies when compared with the magnitude of the problem. Differences in race, BMI, diet, central adiposity, acid production, and presence of Helicobacter pylori may be confounding factors in determining the presence of GERD. Current literature, however, cites an overall prevalence of about 20% for weekly symptoms and 40% to 45% for monthly symptoms. It is to be noted that there is significant worldwide variation.
Factors that contribute to the development and expression of GERD, such as antireflux barriers, lower esophageal sphincter (LES) pressure, esophageal clearance, acid production, gastric emptying, duodenogastric reflux, and esophageal resistance, may be influenced by age. Medications commonly used in the elderly may alter these factors and exacerbate reflux. There is a paucity of long-term studies that examine the effects of medications and other contributing factors within the elderly population. The pathogenesis of GERD is multifactorial and, as noted earlier, involves both anatomic and physiologic factors, which may be influenced by both age and gender.
Salivary secretion and bicarbonate concentration are decreased in the older population when compared with their younger counterparts. Saliva and bicarbonate production is also affected by medications, tobacco usage, and the presence of GERD itself but has not been shown to be gender specific. Some medications, such as anticholinergics, may affect esophageal clearance of saliva in the older patient. This is especially true with regard to nocturnal acid exposure, a time when basal salivary output is at its lowest point, which may partly help to explain the higher rates of esophagitis in the elderly as well as the higher rate of GERD-related complications.
The role of hiatal hernia in GERD has evolved. Although the presence of a hernia is often associated with more severe GERD, erosive esophagitis, and esophageal injury, as well as reflux-associated complications, its presence alone is not always a cause. Despite a higher incidence of hiatal hernia with aging and the female gender, the clinical correlation with respect to GERD and its complications is not clearly evident.
Acid clearance is paramount in preventing reflux damage through both volume clearance and restoration of a normal esophageal pH. These actions do not prevent reflux but rather attempt to prevent damage and restore basal homeostasis; they depend on both effective peristalsis and action of saliva. The amplitude and effectiveness of peristalsis may also be decreased in some older individuals, leading to more prolonged acid exposure and, potentially, to more subsequent esophagitis.
LES plays the most important role in the generation of reflux in many individuals. Transient lower esophageal sphincter relaxation (tLESR) accounts for reflux in most patients. Gastric distention is the major stimulus for this event, although medications such as cholinergic drugs, stress, and certain foods such as fats may contribute to tLESRs. Hypotensive LES pressures are less common causes of GERD. There are no studies to date that document alterations in tLESRs or basal LES pressures with either aging or gender. Such studies are needed to help clarify the importance of these factors in GERD in the older individual.
Acid and pepsin are 2 components of gastric refluxate that cause esophagitis. Although gastric emptying may be altered in the older individual, it is not clear whether this delay is clinically relevant. Acid production in the older individual may also be decreased but seems to be a consequence of atrophic gastritis and H pylori infections rather than a function of aging per se. These mitigating factors may contribute to symptoms in some patients, but the effects on any particular individual may be too variable to predict a defined and reproducible clinical response and effect.
Clinical Presentation
Older patients are often less symptomatic with GERD. This may be associated with less acid production, decreased pain perception or esophageal sensitivity, or failure to report symptoms altogether. It is, in part, a consequence of this lack of recognition or underreporting of symptoms that complications such as Barrett esophagitis and peptic strictures occur more commonly in the elderly. There are no clear gender-based differences in the clinical presentation of GERD. Extraintestinal symptoms such as atypical chest pain and pulmonary issues are seen equally in the older population with GERD without any gender preference or difference.
Management
Treatment strategies and management do not significantly differ in the older patient when compared with the younger patient with GERD. Acid suppression remains the cornerstone of therapy. When placing an older female patient on acid-suppressing medications, concerns for malabsorption of calcium and vitamins, as well as bacterial overgrowth, arise. Clinicians must be cognizant of the potential risk of osteopenia, osteoporosis, and resultant fractures associated with decreased calcium absorption. Also, when the gastric pH is increased via acid suppressants, patients are more susceptible to bacterial overgrowth, which can be complicated by vitamin B 12 deficiency and subsequent anemia and neuropathy. Although endoscopic treatment modalities have been largely abandoned because of safety and efficacy concerns, surgical approaches remain plausible for managing GERD in the older patient. Functional status and comorbidities are more important risk stratifiers than age in determining appropriateness for antireflux surgery. There do not seem to be gender differences with regard to efficacy of treatment modalities, outcomes, mortality, and morbidity.
Gastroesophageal reflux disease
The prevalence of gastroesophageal reflux disease (GERD) does not seem to demonstrate an age-related gender preference. Although overt symptoms may be less common or less frequently reported in the older population, complications related to GERD such as peptic stricture, esophagitis, and Barrett esophagus do seem to worsen with age. A true understanding of the prevalence is difficult because of conflicts in the definition of GERD (esophagitis vs no esophagitis), as well as the relatively sparse number of international studies when compared with the magnitude of the problem. Differences in race, BMI, diet, central adiposity, acid production, and presence of Helicobacter pylori may be confounding factors in determining the presence of GERD. Current literature, however, cites an overall prevalence of about 20% for weekly symptoms and 40% to 45% for monthly symptoms. It is to be noted that there is significant worldwide variation.
Factors that contribute to the development and expression of GERD, such as antireflux barriers, lower esophageal sphincter (LES) pressure, esophageal clearance, acid production, gastric emptying, duodenogastric reflux, and esophageal resistance, may be influenced by age. Medications commonly used in the elderly may alter these factors and exacerbate reflux. There is a paucity of long-term studies that examine the effects of medications and other contributing factors within the elderly population. The pathogenesis of GERD is multifactorial and, as noted earlier, involves both anatomic and physiologic factors, which may be influenced by both age and gender.
Salivary secretion and bicarbonate concentration are decreased in the older population when compared with their younger counterparts. Saliva and bicarbonate production is also affected by medications, tobacco usage, and the presence of GERD itself but has not been shown to be gender specific. Some medications, such as anticholinergics, may affect esophageal clearance of saliva in the older patient. This is especially true with regard to nocturnal acid exposure, a time when basal salivary output is at its lowest point, which may partly help to explain the higher rates of esophagitis in the elderly as well as the higher rate of GERD-related complications.
The role of hiatal hernia in GERD has evolved. Although the presence of a hernia is often associated with more severe GERD, erosive esophagitis, and esophageal injury, as well as reflux-associated complications, its presence alone is not always a cause. Despite a higher incidence of hiatal hernia with aging and the female gender, the clinical correlation with respect to GERD and its complications is not clearly evident.
Acid clearance is paramount in preventing reflux damage through both volume clearance and restoration of a normal esophageal pH. These actions do not prevent reflux but rather attempt to prevent damage and restore basal homeostasis; they depend on both effective peristalsis and action of saliva. The amplitude and effectiveness of peristalsis may also be decreased in some older individuals, leading to more prolonged acid exposure and, potentially, to more subsequent esophagitis.
LES plays the most important role in the generation of reflux in many individuals. Transient lower esophageal sphincter relaxation (tLESR) accounts for reflux in most patients. Gastric distention is the major stimulus for this event, although medications such as cholinergic drugs, stress, and certain foods such as fats may contribute to tLESRs. Hypotensive LES pressures are less common causes of GERD. There are no studies to date that document alterations in tLESRs or basal LES pressures with either aging or gender. Such studies are needed to help clarify the importance of these factors in GERD in the older individual.
Acid and pepsin are 2 components of gastric refluxate that cause esophagitis. Although gastric emptying may be altered in the older individual, it is not clear whether this delay is clinically relevant. Acid production in the older individual may also be decreased but seems to be a consequence of atrophic gastritis and H pylori infections rather than a function of aging per se. These mitigating factors may contribute to symptoms in some patients, but the effects on any particular individual may be too variable to predict a defined and reproducible clinical response and effect.
Clinical Presentation
Older patients are often less symptomatic with GERD. This may be associated with less acid production, decreased pain perception or esophageal sensitivity, or failure to report symptoms altogether. It is, in part, a consequence of this lack of recognition or underreporting of symptoms that complications such as Barrett esophagitis and peptic strictures occur more commonly in the elderly. There are no clear gender-based differences in the clinical presentation of GERD. Extraintestinal symptoms such as atypical chest pain and pulmonary issues are seen equally in the older population with GERD without any gender preference or difference.
Management
Treatment strategies and management do not significantly differ in the older patient when compared with the younger patient with GERD. Acid suppression remains the cornerstone of therapy. When placing an older female patient on acid-suppressing medications, concerns for malabsorption of calcium and vitamins, as well as bacterial overgrowth, arise. Clinicians must be cognizant of the potential risk of osteopenia, osteoporosis, and resultant fractures associated with decreased calcium absorption. Also, when the gastric pH is increased via acid suppressants, patients are more susceptible to bacterial overgrowth, which can be complicated by vitamin B 12 deficiency and subsequent anemia and neuropathy. Although endoscopic treatment modalities have been largely abandoned because of safety and efficacy concerns, surgical approaches remain plausible for managing GERD in the older patient. Functional status and comorbidities are more important risk stratifiers than age in determining appropriateness for antireflux surgery. There do not seem to be gender differences with regard to efficacy of treatment modalities, outcomes, mortality, and morbidity.
Motility
Aging has been associated with alteration in motility of the gastrointestinal tract. Changes in esophageal peristalsis, gastric emptying, colonic transit, and sphincter pressure and function may contribute to symptoms in the older patient. However, there is no clear evidence of alteration in small intestinal motility with either age or gender. Colonic transit time and FI in the elderly are discussed in the subsequent sections.
Esophageal motility is clearly affected by aging. Many individuals older than 80 years have a decline in the amplitude of peristaltic waves, as well as an increased frequency of nonpropulsive contractions. There may also be less secondary peristalsis. Many studies cite these findings in patients older than 80 years, although a clear correlation with gastrointestinal symptoms is lacking. This findings may be secondary to diminished pain perception and an overall failure to report symptoms in this cohort, as previously mentioned. Ren and colleagues recognized an inverse relationship between age and both upper and lower esophageal sphincter pressures, lengths, and peristaltic wave amplitudes and velocities. This relationship may contribute to lengthier reflux episodes in older patients. No gender difference was noted.
Gastric emptying times may be delayed in older individuals. Although initial studies did not clearly demonstrate age- or gender-related differences, later studies demonstrated a delay in gastric emptying of solid food in older patients. Electromyographic studies have shown a decrease in contractile force and peristalsis in the stomach. In addition, the lipid component of the meal may independently exert a profound effect on gastric emptying in the older individual. Methodology and clinical relevance are 2 factors that are important and germane to the interpretation of these studies. At present, it does not seem that aging or gender plays a significant role in gastric emptying and its relationship with GERD.
Changes in esophageal and gastric motility may certainly contribute to symptoms such as GERD, dyspepsia, and anorexia in the elderly. Motility abnormalities, if present, in the small intestine and colon may also contribute to these symptoms. Definitive studies that account for underreporting and confounding factors are needed to ascertain whether these changes can predict clinical symptoms.
Constipation
Background
Constipation is one of the most common gastroenterological complaints. The prevalence of constipation in elderly patients is 50% in the general community and up to 74% in nursing home residents, which may be due, in part, to insufficient caloric intake or several other comorbidities in this population. The Rome III criteria for functional constipation were developed to more clearly define this disorder. Older patients, however, may commonly present with symptoms of constipation that may not fit the Rome III criteria. Despite this presentation, clinicians must be able to recognize and treat such symptoms.
Self-reported constipation in the United States is more common among women, non-Caucasians, and those older than 65 years. Studies have also shown a positive correlation with minimal physical activity, poor diet, low income, limited education, polypharmacy, history of sexual abuse, and depression. Furthermore, severe constipation, defined as bowel movements occurring twice per month, is almost exclusively seen in women.
Constipation can be primary or secondary. Symptoms of constipation can be secondary to underlying disorders such as primary diseases of the colon (strictures, cancer, anal fissure, proctitis), metabolic disturbances (hypercalcemia, hypothyroidism, diabetes mellitus), and neurologic disorders (parkinsonism, spinal cord lesions/injury, multiple sclerosis). Some of these issues may be more common in the aging individual without clear gender difference, and treatment should be targeted at the primary disorder. There are 3 known subtypes of constipation: normal transit, dyssynergic defecation (DD), and slow transit. The first subtype, normal transit constipation, is the most common form of constipation treated by physicians. These patients have normal stool transit times and pelvic floor function; however, they often feel constipated. This feeling may be because of the perceived presence of hard stools and difficulty with subsequent evacuation. These patients may complain of bloating and abdominal pain and many may also have irritable bowel syndrome. The second subtype of constipation, DD, is described as difficulty expelling stool from the anorectum. DD results from the failure to relax the puborectalis muscle or inappropriate contraction of the puborectalis and external anal sphincter muscles. This behavior is acquired in two-thirds of patients. The final subtype, slow transit constipation, is defined as the delay of stool transit from the proximal to distal colon. This delay may be caused by colonic myopathy or neuropathy. Within this category, patients can either have (1) colonic inertia, associated with decreased frequency of high-amplitude colonic contractions, accounting for impaired propulsion of colonic contents especially after meals or (2) increased, uncoordinated motor activity of the distal colon, causing retropulsion of colonic contents. Frequently, patients may also have a combination of both. The relationship between colonic transit and aging is somewhat controversial because some studies have found a slowing in the elderly, whereas others have found no difference.
Studies that delineate which type of constipation is more common in the elderly are lacking. However, it is known that constipation in the elderly is multifactorial, including polypharmacy, endocrine and metabolic disorders, neurologic disorders, myopathic disorders, depression, disability, and limited mobility. In elderly patients with multiple illnesses, cancer, and chronic pain, opioid-induced constipation is the most common. A study by Towers and colleagues revealed that elderly patients who consume fewer meals and calories are more inclined to have constipation. These patients can also develop fecal impaction with overflow incontinence. Slow transit constipation can result from a myopathy, neuropathy, or DD in the elderly population. With aging, the enteric nervous system undergoes age-related neurodegenerative changes. In patients older than 65 years, there is a 37% loss of enteric neurons when compared with people aged 20 to 35 years. This loss is associated with an increase in the elastic and collagen fibers in the myenteric ganglia of older subjects. Although enteric neuron loss has been documented in the elderly, cases of Hirschsprung disease in this population are rarely reported.
Diagnostic Approach
Regardless of the cause, a thorough history and physical examination is of paramount importance in the diagnosis of constipation. Discussion should focus on the nature and duration of constipation, medication history, surgical history, systemic and neurologic disorders, and history of malignancy. A psychosocial history should also be assessed. This multifaceted approach is especially important in the elderly because of the multiple factors that predispose to constipation, such as decreased mobility, poor nutrition, lack of independence, and social isolation. Elderly patients may ignore the urge to defecate, for example, because they are unable to mobilize for toileting. This process may lead to the suppression of fecal rectal sensation and a decreased desire to defecate. In turn, this can exacerbate constipation because fecal retention can lead to large volume hard stools, which are difficult to evacuate.
Colonic transit time is commonly assessed with the Hinton (sitz marker) test, which delineates colonic inertia from outlet delay and normal transit. Gastroenterologists may also use a wireless motility capsule, a viable and safe option for the elderly population that does not use radiation or require radiographs. Anorectal manometry is another diagnostic test used in the setting of DD. It provides a method to determine pressures in both the rectum and the anal sphincters, allows assessment of rectal sensation and rectoanal reflexes, and evaluates rectal compliance as well. The balloon expulsion test is another useful study to assess rectal sensation and the ability to relax the pelvic floor in defecation. Care must be taken in choosing the least embarrassing and least uncomfortable diagnostic tool for the older female patient. These studies are not mutually exclusive and a combination may be most helpful in the delineation of the cause for constipation in a specific individual.
Treatment
Patients with constipation can face 3 inextricable problems: significant financial burden, diminished quality of life, and negative self-perception. For an older woman, these factors may lead to unnecessary stress, psychological burden, and awkward social encounters. These factors have also been associated with significant psychological distress. Multiple studies show a higher prevalence of depression, anxiety, obsessive compulsiveness, paranoia, and somatization in the constipated population. Studies in adults with constipation have also elucidated sexual abuse in 22% to 48% of subjects and physical abuse in 31% to 74%. Multiple studies also demonstrate a positive correlation between bowel function and quality of life. Constipation can also be a social handicap, causing some patients to never leave their homes for fear of unpredictable bowel movements or urges.
One of the first steps in treating constipation in the elderly is to increase fiber intake. Daily fiber intake should optimally range between 20 and 35 g, ideally in the form of fruits, vegetables, and whole grains. If increased ingestion of dietary fiber is unsuccessful, fiber supplements may be added. Side effects may limit usage, and supplements are better tolerated when starting with smaller amounts with subsequent gradual increments. It is important to educate older patients about dose adjustments to help enhance compliance. Excessive intake may exacerbate constipation. A written outline or plan for management of the older individual with constipation may also be helpful.
Laxatives can also be used in the elderly population. Bulk-forming laxatives are natural or synthetic polysaccharides or cellulose derivatives that lead to water absorption, increased fecal mass, and increased stool frequency. Although the efficacy of bulk laxatives has not been well studied, there is considerable clinical experience with these agents. Osmotic laxatives, such as polyethylene glycol, lactulose, and magnesium citrate, are available for patients who do not respond to increased fiber intake. These laxatives are poorly absorbed agents that act as hyperosmolar solutions and increase secretion of water into the gut lumen. In the elderly patient with underlying renal or cardiac dysfunction, these agents must be used with caution because of disturbances in the absorption of magnesium. Osmotic laxatives can also cause dehydration, making them a less-attractive option for the elderly. Stimulant laxatives, such as bisacodyl and senna, produce an increase in intestinal motility and secretions via alteration of electrolyte transport by the intestinal mucosa. Stimulant laxatives are commonly used in patients who are unresponsive or intolerant of osmotic laxatives or those with specific issues or needs requiring an increase in motility and secretions.
Other agents are available and may be efficacious in the older individual with constipation. Lubiprostone is an oral bicyclic fatty acid that activates type 2 chloride channels on intestinal epithelial cells, leading to secretion of chloride and water into the gut lumen. Several randomized controlled trials have shown that lubiprostone when compared with placebo leads to increased spontaneous bowel movements per week, improved consistency and patient-perceived treatment efficacy, and decreased straining and severity. In the study by Johanson and Ueno 10% of the participants were elderly. Alvimopan and methylnaltrexone are newer medications used for the treatment of opioid-induced constipation. These agents work peripherally as μ-opioid receptor antagonists, inhibiting opioid-induced gastrointestinal hypomotility without crossing the blood-brain barrier. This class of medication allows elderly patients with chronic pain the benefit of pain control without the debilitating effects of constipation.
The treatment of choice for pelvic floor dysfunction is biofeedback, a conditioning treatment that helps patients learn how to control pelvic floor movements. There are different therapeutic approaches to biofeedback, including anorectal electromyography, manometry, and balloon expulsion. These modalities are commonly used to highlight normal coordination for successful defecation. This therapy does require compliance and active participation in the therapeutic process, which may be challenging for some older individuals. The efficacy of biofeedback in the elderly is thus contingent on an initial assessment of both the physical and mental aptitudes of the patient and must be individualized.
Surgery is an option in patients with refractory constipation. In patients with slow transit constipation refractory to medical management, a subtotal colectomy with ileorectal anastomosis may be considered. As with any surgical procedure, there are side effects, including diarrhea, incontinence, bowel obstruction, and prolonged ileus.
Summary
Constipation is a widespread disorder, affecting nearly one-fifth of people worldwide. If left untreated, it can have a deleterious effect on functionality and quality of life, especially in the elderly female population. Obtaining a thorough patient history is paramount in distinguishing between slow and normal transit constipation, and can be confirmed using the Hinton test and anal manometry for DD. Therapy is individualized and may start with dietary fiber intake and can be supplemented with physical activity, adequate fluid intake, laxatives, opioid antagonists, biofeedback, and, for refractory cases, surgery (depending on the cause of the constipation). Through recognition of symptoms, goal-directed therapy can be initiated and implemented early and efficaciously.
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