|Year : 2017 | Volume
| Issue : 1 | Page : 11-17
Constipation in elderly patients with psychiatric disorders
Naresh Nebhinani, Navratan Suthar
Department of Psychiatry, All India Institute of Medical Science, Jodhpur, Rajasthan, India
|Date of Web Publication||20-Jun-2017|
Department of Psychiatry, All India Institute of Medical Science, Jodhpur - 342 005, Rajasthan
Source of Support: None, Conflict of Interest: None
Constipation is a common complaint among the elderly patients with psychiatric disorders because of age.related physiologic and anatomical changes, lifestyle factors, comorbid physical and surgical disorders, medications, including psychotropics, and polypharmacy. Lack of timely reporting by patients as well as inadequate expertise of physician may contribute to significant delay in treatment and poor quality of life. Primary constipation is amenable to lifestyle modification. (dietary changes, exercise, and physical activity), fiber intake, and laxatives when necessary. Secondary constipation should be treated with managing underlying pathology or predisposing factors, including effective treatment of psychiatric disorders and rationalizing psychotropic prescription. This review article focuses on the definition, etiology, assessment, treatment, and prevention of constipation in elderly population with mental illness.
Keywords: Constipation, elderly, management, prevention, psychiatric disorders
|How to cite this article:|
Nebhinani N, Suthar N. Constipation in elderly patients with psychiatric disorders. J Geriatr Ment Health 2017;4:11-7
|How to cite this URL:|
Nebhinani N, Suthar N. Constipation in elderly patients with psychiatric disorders. J Geriatr Ment Health [serial online] 2017 [cited 2017 Nov 22];4:11-7. Available from: http://www.jgmh.org/text.asp?2017/4/1/11/208610
| Introduction|| |
The prevalence of constipation in general population is ranging from 2% to 27%, depending on its criteria and study population., Constipation is a common complaint in elderly population, more commonly diagnosed in female patients (male/female ratio: 1:2–3), as reported prevalence is 26% for women and 16% for men in individuals 65 years of age or older in the community  and 34% for women and 26% for men in those 84 years of age and older. While in long-term care setting, constipation is reported by around 80% inhabitants. In a recent study, elderly patients (older than 60 years) with psychiatric disorders were significantly associated with constipation (odds ratios 3.38–6.52), in comparison to the patients aged between 18 and 60 years (odds ratios 1.00–2.03).
Aging-related factors such as decreased mobility, improper diet with low fiber and fluid intake, lack of exercise and physical activity, poor toilet habits, decreased awareness and blunted urge to defecate also predispose the risk of constipation in elderly. Brain and bowel functions are interrelated as nervous tension particularly affects the bowel muscles  and on other side loaded bowel can cause distress, psychological problems, and impairs quality of life., Psychotropic medications and other drugs, sedentary lifestyles, unhealthy nutritional habits, relative pain insensitivity as a result of psychiatric disorders, medical and surgical comorbidities also contribute to constipation.
In view of potentially serious consequences of chronic constipation in elderly patients, its prevention, comprehensive assessment, and treatment are important. Although there are several studies on constipation per se and constipation in elderly population, but literature is scarce on “constipation in the elderly patients with psychiatric disorders.” Hence by synthesizing information available from articles on “constipation” in “elderly” with “psychiatric disorders” published in PubMed and Google Scholar, we aimed to provide an overview of definition, etiology, assessment, treatment, and prevention of constipation in elderly population with mental illness.
| Definition of Constipation|| |
Constipation is simply defined as the passage of small hard stool infrequently and with difficulty. Most physicians usually diagnose constipation objectively by measuring the stool frequency. Paradoxically, most of the patients report constipation with subjective measures with predominant focus on their symptoms such as hard stools, infrequent stools, the need for excessive straining, a sense of incomplete evacuation, excessive amount of time spent on the toilet, rather than the stool frequency. Therefore, it is recommended to use the Rome III criteria for defining constipation.
Rome III criteria (2006) diagnose constipation in the presence of at least 2 of the following criterion in at least 25% time during defecation: Straining; lumpy or hard stools; sensation of incomplete evacuation; sensation of anorectal obstruction/blockage; need for manual maneuvers to facilitate defecation; and fewer than 3 defecations per week., Constipation is considered chronic if such symptoms persist for 6 months or more., In the absence of medical or surgical cause, constipation is considered idiopathic or simple.
| Pathophysiology|| |
Normal defecation requires several gastrointestinal actions in following sequence: Relaxation of the puborectalis muscles, descent of the pelvic floor with straightening of the anorectal angle, inhibition of segmental colonic peristalsis, contraction of the abdominal wall muscles, and subsequently, relaxation of the external anal sphincter with expulsion of feces.
Following anatomical and physiological changes may produce constipation in elderly.
Motor changes may directly affect smooth muscle function or through visceral innervation.
Anatomic changes may lead to thickening of internal anal sphincter and thinning of external anal sphincter.
Neurologic changes may decrease mucosal electrosensitivity, sensation of rectal distention, and functioning of somatic motor nerves
As detailed in [Table 1], various intrinsic and extrinsic factors including psychosocial and behavioral factors play key role in the development of constipation.
| Intrinsic Factors|| |
These can be broadly classified into two categories - pelvic floor dysfunction and slow colon transit time.
Pelvic floor dysfunction involves laxity of the pelvic floor muscles with impaired rectal sensation and decreased luminal pressure in the anal canal, which leads to chronic constipation, more commonly in elderly women.,,
Slow colon transit time is presentence with reduced high-amplitude propagated contractions in the colon, which further leads to slow transit of feces, abdominal discomfort, bloating, and renders the feces hard and fails to produce adequate rectal pressure for defecation reflex.
Normal transit constipation is a functional gastrointestinal disorder, with normal colon transit time and stool frequency. Such patients perceive constipation due to difficulty in defecation with the presence of hard stools. This presentation is similar to irritable bowel syndrome (IBS) with constipation, except the presence of abdominal pain or discomfort in patients with IBS.
| Extrinsic Factors|| |
Medications and aging-related changes
High rates of polypharmacy, pharmacodynamics and pharmacokinetics changes, reduction in glomerular filtration rate, chronic physical disorders, lowered hepatic blood flow, and metabolism in older people contributes to constipation. Some commonly implicated agents are following:
Medication-induced gastrointestinal hypomotility is primarily mediated through antagonism of muscarinic anticholinergic activity., Besides this, many patients with schizophrenia also receive anticholinergic medications for the treatment of extrapyramidal side effects  and sedation due to histamine H1 receptor antagonism also results in inactivity, and further leads to constipation.
As detailed in [Table 2], certain medications with a markedly anticholinergic effect such as antipsychotics,, central anticholinergic drugs, benzodiazepine derivatives, tricyclic antidepressants (TCAs) develop constipation more commonly.,
Talley et al. reported 1.9 times greater risk for developing constipation with antipsychotic use. 14%–60% clozapine users report constipation, which may rarely lead to bowel obstruction and paralytic ileus.,,
High-potency typical antipsychotic agents and clozapine have greater risk for constipation due to high anticholinergic activity while aripiprazole and ziprasidone have lower risk for constipation. Both anticholinergic drugs and antipsychotics with anticholinergic properties are significantly associated with risk of ileus. Despite the widespread use of atypical antipsychotics, anticholinergic co-prescription is still in vogue, which needs serious relook in prescribing practice.
TCAs have greater propensity anticholinergic side effects, such as dry mouth and constipation. Tertiary amines TCAs (e.g., imipramine, amitriptyline, clomipramine) have the greatest anticholinergic effects.
Opioids cause constipation by binding to specific receptors in the gastrointestinal tract and central nervous system, resulting in reduced bowel motility through direct action and indirectly with anticholinergic mechanisms. The delayed colonic transit time causes excessive water and electrolyte reabsorption from feces, which further dehydrates stool and increases constipation.,
Elderly patients with chronic pain are less active and often treated with opioid analgesics, or on other side, elderly may be already dependent on opium or other opioid preparations or receiving opioid substitution therapy (like methadone). Majority of such patients report constipation., Therefore, they should be routinely advised for drinking adequate amounts of fluids, eating fiber-rich foods, increasing physical activity, and exercising regularly, etc.
Therapist may consider a combined stimulant laxative with a stool softener when initiating opioids. In general, bulking agents are not recommended for patients with opioid-induced constipation, especially if the patient has poor fluid intake or immobility, as they increase the risk of bowel obstruction. Oral naloxone (an opioid antagonist) alleviates opioid-induced constipation without loss of analgesic effects. PAMORA (subcutaneous or oral) and an oral chloride channel activator have received Food and Drug Administration approval for opioid-induced constipation. Lubiprostone is a promising and well-tolerated agent for this indication.
Nicotine increases intestinal peristalsis by acting on the parasympathomimetic system, therefore, constipation is reported as a possible tobacco withdrawal symptom, usually presents within the first few days, and relieves in 2–3 weeks. It can also present as side effect of medications used (bupropion and varenicline) for quitting tobacco.
To manage tobacco-related constipation, lifestyle modification and magnesium salts are advised. If constipation persists then, neostigmine is prescribed, which has parasympathomimetic activity.
Depression, dementia, and delirium are important causes of constipation in elderly psychiatric patients. Contributing factors might be lifestyle related (e.g., loss of appetite, low fiber diets, decreased physical activity), psychotropic-related (anticholinergic properties of certain medications), difficulty in finding the toilet, especially in unfamiliar surroundings (in dementia and delirium), relative pain insensitivity and decrease awareness of somatic symptoms associated with defecation reflex, etc.,,
| Clinical Presentation|| |
The clinical presentation of elderly patient suffering from constipation is heterogeneous and different from adult populations., Straining and hard stools are the predominant complaints nearly half of the elderly population in community.,
Many elderly patients experience fecal seepage and usually misdiagnosed with fecal incontinence. Severe constipation may alter gastric motility and result in delayed gastric emptying, concomitant dyspepsia, abdominal cramping, bloating, flatulence, heartburn, nausea, and vomiting.,, Sometimes, elderly patients with impaired cognitive abilities may also present with nonspecific symptoms such as agitation, anorexia, or decline in overall functioning.
Following complications may occur in elderly patients with chronic constipation: Fecal incontinence, hemorrhoids, anal fissure, organ prolapse, fecal impaction and bowel obstruction, bowel perforation, peritonitis, etc.
| Diagnostic Assessment|| |
Diagnostic assessment is to be done as per an evidence-based approach given by American College of Gastroenterology Chronic Constipation Task Force.
- Obtain detailed history to determine whether symptoms are secondary to any diseases or medications. Medical history should include the use of medications, including psychotropic medication, anticholinergic drugs, opioid analgesics, substance abuse including opium and tobacco, coexisting medical and surgical disorders, dietary habits, physical activities, and general psychosocial situation
- Physical examination includes general physical examination, perianal and digital rectal examination. This examination assess for mass lesions, anal strictures, fissures, stool impaction and the mechanism of defecation
- Laboratory tests (e.g., complete blood count, thyroid function tests, serum calcium) and structural tests of the colon (e.g., colonoscopy, flexible sigmoidoscopy, barium enema) may aid in diagnostic work-up
- Colonoscopy is recommended for elderly patients with family history of inflammatory bowel disease or colon cancer, or alarm symptoms, including rectal bleeding, heme-positive stool, weight loss, and iron-deficient anemia, etc., [Table 3].
| Management|| |
Proper management of constipation should be aimed to relieve associated symptoms, along with restoring normal bowel habit (i.e., passage of a soft, formed stool at least three times a week, without straining), and quality of life. Treatment algorithm is similar for elderly and adult population.
Following stepwise approach is recommended for managing constipation in elderly population 
- Step 1: Establish the diagnosis of constipation
- Define constipation as per Rome III criteria and enumerate the presenting symptoms.
- Step 2: Physical examination
- Thorough inspection and digital anal-rectal examination are recommended for identifying local anorectal disease. Alarming features, for example, weight loss, blood in stool, fever, felt mass, vomiting, abdominal pain and abnormal laboratory results, etc., should be explored to rule out structural disorders.
- Step 3: Assessment and treatment of reversible causes
- To reduce or resolve constipation, reversible causes should be treated first.
- Step 4: Medication history
- As mentioned earlier, numerous drugs may cause or contribute to constipation, therefore detailed medication history is very important. If feasible, therapist should decrease the dose, discontinue the medication, or switch to another drug with a lesser propensity of constipation.
- Step 5: Lifestyle modification
- A regular toilet routine with toileting in the morning, even without urge, is recommended for elderly. Adequate hydration is recommended for patients with low intake or who are taking bulk-forming agents, and who are not advised fluid restrictions (e.g., heart or kidney failure). Soluble fibers (e.g., psyllium) are preferred and have better evidence than insoluble fibers (e.g., bran). To minimize gastrointestinal side effects (e.g. flatulence, bloating), fiber should be titrated gradually (e.g., increased by 5 g/week) up to the dose of 20–30 g/day. Patients with slow-transit constipation or pelvic floor dyssynergia poorly respond to fiber supplementation.
- Step 6: Laxative therapy [Table 1]
- Recommended therapy begins with a bulk-forming agent, then an osmotic laxative followed by a stimulant laxative, if need arises., Fecal impaction is treated with manual disimpaction, lubrication of rectum and anus, and enema.
- Following laxatives should be avoided or used with caution in elderly patients: Docusate, magnesium, mineral oil, soapsuds enema, sodium phosphate enema, picosulfate, magnesium oxide, and citric acid, polyethylene glycol 3350 with electrolytes, etc.
- Step 7: Other modalities.
Biofeedback therapy is indicated for pelvic floor dysfunction or dyssynergic defecation type of chronic constipation. It enables the patient to relax the pelvic floor muscles by retraining of the sensation and control of the anorectum and pelvic floor and eliminates paradoxical contractions during the process of defecation. It has been found efficacious in several controlled trials , and recommended for adults and elderly patients.
Lactobacillus and Bifidobacterium are symbiotic floras in the large intestine that protect from the harmful pathogens and maintain mucosal health. Both floras are reportedly low in patients with chronic constipation. Prospective trials have shown improvement in constipation with Lactobacillus and Bifidobacterium supplementation. However, it is not recommended in routine practice due to lack of high-quality evidence [Table 4] and [Table 5].,
|Table 4: How to manage constipation related to psychiatric disorder or psychotropics|
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Chronic constipation may cause abdominal pain and distension, fecal impaction, in some serious situations, rectal tearing, bleeding, bowel obstruction, and colonic perforation.,
Preventive strategies such as high fiber diet, adequate hydration, regular exercise, and physical activity should be promoted. Psychotropic drugs should be appropriately selected and started with low dose and slowly titrated in elderly patients and polypharmacy should be avoided. To obviate severe consequences of constipation early detection, monitoring over the course of treatment, routine prophylaxis, and early treatment are important.
| Conclusion|| |
Elderly patients with psychiatric disorders often have low health expectations and are less likely to complain for constipation. Sometimes, they have problem in communication due to cognitive impairment while other side, this all is considered part and parcel of aging by health professionals. Therefore, assessment of constipation in patients with severe mental illness must be included in the comprehensive management by mental health professionals. In view of multiple risk factors, physical comorbidities, and medication, stepwise approach is advised for treating constipation [Figure 1].
|Figure 1: Algorithm for management of constipation in elderly patients with psychiatric disorders|
Click here to view
At the first step of management, therapist should look and correct the underlying causes of constipation. Instead of starting further treatment for constipation in the first instance, dose adjustment of concomitant psychotropics and treatment rationalization should be considered. Treatment should be started with nonpharmacological approaches, including patient and caregiver education, toileting habits, abdominal massage, high-fiber diet, regular physical activity, and exercise (e.g., prompting to walk to the toilet, exercise for chair-bound patients). In pharmacological approaches, fiber supplements, stool softeners, osmotic, and stimulant laxatives, and the secretagogues are available. However, fiber and laxatives are commonly advised as initial treatment in constipation. Biofeedback should be considered for the patients with pelvic dyssynergia or pelvic floor dysfunction. This review highlights the vital need for better knowledge base, assessment, management, and prevention of constipation in elder patients with psychiatric disorders.
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| References|| |
Higgins PD, Johanson JF. Epidemiology of constipation in North America: A systematic review. Am J Gastroenterol 2004;99:750-9.
Bharucha AE, Pemberton JH, Locke GR. American Gastroenterological Association technical review on constipation. Gastroenterology 2013;144:218-38.
Gallegos-Orozco JF, Foxx-Orenstein AE, Sterler SM, Stoa JM. Chronic constipation in the elderly. Am J Gastroenterol 2012;107:18-25.
Fleming V, Wade WE. A review of laxative therapies for treatment of chronic constipation in older adults. Am J Geriatr Pharmacother 2010;8:514-50.
Jessurun JG, van Harten PN, Egberts TC, Pijl YJ, Wilting I, Tenback DE. The relation between psychiatric diagnoses and constipation in hospitalized patients: A Cross-sectional study. Psychiatry J 2016;2016:2459693.
Talley NJ, O'Keefe EA, Zinsmeister AR, Melton LJ 3rd
. Prevalence of gastrointestinal symptoms in the elderly: A population-based study. Gastroenterology 1992;102:895-901.
Alvarez WC. An Introduction to Gastro-Enterology. 4th
ed. London: Hoeber; 1948 p. 617.
Bongers ME, Benninga MA, Maurice-Stam H, Grootenhuis MA. Health-related quality of life in young adults with symptoms of constipation continuing from childhood into adulthood. Health Qual Life Outcomes 2009;7:20.
Wang JP, Duan LP, Ye HJ, Wu ZG, Zou B. Assessment of psychological status and quality of life in patients with functional constipation. Zhonghua Nei Ke Za Zhi 2008;47:460-3.
Lacy BE, Cole MS. Constipation in the elder adult. Clin Geriatr 2004;12:44-54.
Drossman DA. Rome III: The new criteria. Chin J Dig Dis 2006;7:181-5.
Longstreth GF. Functional bowel disorders: Functional constipation. In: Drossman DA, editor. The Functional Gastrointestinal Disorders. 3rd
ed. Lawrence, KS: Allen Press; 2006. p. 515-23.
Pare P, Ferrazzi S, Thompson WG, Irvine EJ, Rance L. An epidemiological survey of constipation in Canada: Definitions, rates, demographics, and predictors of health care seeking. Am J Gastroenterol 2001;96:3130-7.
Brown WJ, Mishra G, Lee C, Bauman A. Leisure time physical activity in Australian women: Relationship with well being and symptoms. Res Q Exerc Sport 2000;71:206-16.
Schiller LR. Constipation and fecal incontinence in the elderly. Gastroenterol Clin North Am 2001;30:497-515.
Bannister JJ, Abouzekry L, Read NW. Effect of aging on anorectal function. Gut 1987;28:353-7.
Laurberg S, Swash M. Effects of aging on the anorectal sphincters and their innervation. Dis Colon Rectum 1989;32:737-42.
Akervall S, Nordgren S, Fasth S, Oresland T, Pettersson K, Hultén L. The effects of age, gender, and parity on rectoanal functions in adults. Scand J Gastroenterol 1990;25:1247-56.
Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003;349:1360-8.
Lavan AH, O'Grady J, Gallagher PF. Appropriate prescribing in the elderly: Current perspectives. World J Pharmacol 2015;4:193-209.
Talley NJ, Jones M, Nuyts G, Dubois D. Risk factors for chronic constipation based on a general practice sample. Am J Gastroenterol 2003;98:1107-11.
Dome P, Teleki Z, Kotanyi R. Paralytic ileus associated with combined atypical antipsychotic therapy. Prog Neuropsychopharmacol Biol Psychiatry 2007;31:557-60.
Bolden C, Cusack B, Richelson E. Antagonism by antimuscarinic and neuroleptic compounds at five cloned human muscarinic cholinergic receptors in Chinese hamster ovary cells. J Pharmacol Exp Ther 1992;260:576-80.
Kroeze WK, Hufeisen SJ, Popadak BA, Renock SM, Steinberg S, Ernsberger P, et al.
H1-histamine receptor affinity predicts short-term weight gain for typical and atypical antipsychotic drugs. Neuropsychopharmacology 2003;28:519-26.
Peyriere H, Roux C, Ferard C, Deleau N, Kreft-Jais C, Hillaire-Buys D, et al
. Antipsychotics-induced ischaemic colitis and gastrointestinal necrosis: A review of the French pharmacovigilance database. Pharmacoepidemiol Drug Saf 2009;18:948-55.
De Hert M, Hudyana H, Dockx L, Bernagie C, Sweers K, Tack J, et al.
Second-generation antipsychotics and constipation: A review of the literature. Eur Psychiatry 2011;26:34-44.
McMahon AJ. Amitriptyline overdose complicated by intestinal pseudo-obstruction and caecal perforation. Postgrad Med J 1989;65:948-9.
Trindade E, Menon D, Topfer LA, Coloma C. Adverse effects associated with selective serotonin reuptake inhibitors and tricyclic antidepressants: A meta-analysis. CMAJ 1998;159:1245-52.
Palmer SE, McLean RM, Ellis PM, Harrison-Woolrych M. Life-threatening clozapine-induced gastrointestinal hypomotility: An analysis of 102 cases. J Clin Psychiatry 2008;69:759-68.
Hibbard KR, Propst A, Frank DE, Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: A literature review and two case reports. Psychosomatics 2009;50:416-9.
Rege S, Lafferty T. Life-threatening constipation associated with clozapine. Australas Psychiatry 2008;16:216-9.
Nielsen J, Meyer JM. Risk factors for ileus in patients with schizophrenia. Schizophr Bull 2012;38:592-8.
Bell TJ, Panchal SJ, Miaskowski C, Bolge SC, Milanova T, Williamson R. The prevalence, severity, and impact of opioid-induced bowel dysfunction: Results of a US and European patient survey (PROBE 1). Pain Med 2009;10:35-42.
Chou R, Fanciullo GL, Fine PG, Adler JA, Ballantyne JC, Davies P, et al
. Opioid treatment guidelines: Clinical guidelines for the use of chronic opioid therapy. J Pain 2009;10:113-30.
McNicol ED, Boyce D, Schumann R, Carr DB. Mu-opioid antagonists for opioid-induced bowel dysfunction. Cochrane Database Syst Rev 2008;(2):CD006332. DOI: 10.1002/14651858.
Culpepper-Morgan JA, Inturrisi CE, Portenoy RK, Foley K, Houde RW, Marsh F, et al.
Treatment of opioid-induced constipation with oral naloxone: A pilot study. Clin Pharmacol Ther 1992;52:90-5.
Jamal MM, Adams AB, Jansen JP, Webster LR. A randomized, placebo-controlled trial of lubiprostone for opioid-induced constipation in chronic noncancer pain. Am J Gastroenterol 2015;110:725-32.
Hajek P, Gillison F, McRobbie H. Stopping smoking can cause constipation. Addiction 2003;98:1563-7.
Lagrue G, Cormier S, Mautrait C, Diviné C. Stopping smoking and constipation. Presse Med 2006;35(2 Pt 1):246-8.
Dworkin RH. Pain insensitivity in schizophrenia: A neglected phenomenon and some implications. Schizophr Bull 1994;20:235-48.
Guieu R, Samuélian JC, Coulouvrat H. Objective evaluation of pain perception in patients with schizophrenia. Br J Psychiatry 1994;164:253-5.
Moore AR, O'Keeffe ST. Drug-induced cognitive impairment in the elderly. Drugs Aging 1999;15:15-28.
Harari D, Gurwitz JH, Avorn J, Bohn R, Minaker KL. How do older persons define constipation? Implications for therapeutic management. J Gen Intern Med 1997;12:63-6.
Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ. Functional constipation and outlet delay: A population-based study. Gastroenterology 1993;105:781-90.
Gandell D, Straus SE, Bundookwala M, Tsui V, Alibhai SM. Treatment of constipation in older people. CMAJ 2013;185:663-70.
Rao SS, Ozturk R, Stessman M. Investigation of the pathophysiology of fecal seepage. Am J Gastroenterol 2004;99:2204-9.
Wald A, Scarpignato C, Mueller-Lissner S, Kamm MA, Hinkel U, Helfrich I, et al.
A multinational survey of prevalence and patterns of laxative use among adults with self-defined constipation. Aliment Pharmacol Ther 2008;28:917-30.
Locke GR 3rd
, Zinsmeister AR, Fett SL, Melton LJ 3rd
, Talley NJ. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil 2005;17:29-34.
Bharucha AE, Pemberton JH, Locke GR 3rd
. American Gastroenterological Association technical review on constipation. Gastroenterology 2013;144:218-38.
Jamshed N, Lee ZE, Olden KW. Diagnostic approach to chronic constipation in adults. Am Fam Physician 2011;84:299-306.
Leung FW, Rao SS. Approach to fecal incontinence and constipation in older hospitalized patients. Hosp Pract 2011;39:97-104.
American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005;100 Suppl 1:S1-4.
Vasanwala FF. Management of chronic constipation in the elderly. Singapore Fam Physician 2009;35:84-92.
Schuster BG, Kosar L, Kamrul R. Constipation in older adults: Stepwise approach to keep things moving. Can Fam Physician 2015;61:152-8.
Pare P. The approach to diagnosis and treatment of chronic constipation: Suggestions for a general practitioner. Can J Gastroenterol 2011;25 Suppl B: 36B-40B.
Liu LW. Chronic constipation: Current treatment options. Can J Gastroenterol 2011;25 Suppl B: 22B-8B.
Simón MA, Bueno AM. Behavioural treatment of the dyssynergic defecation in chronically constipated elderly patients: A randomized controlled trial. Appl Psychophysiol Biofeedback 2009;34:273-7.
Rao SS, Singh S. Clinical utility of colonic and anorectal manometry in chronic constipation. J Clin Gastroenterol 2010;44:597-609.
Khalif IL, Quigley EM, Konovitch EA, Maximova ID. Alterations in the colonic flora and intestinal permeability and evidence of immune activation in chronic constipation. Dig Liver Dis 2005;37:838-49.
An HM, Baek EH, Jang S, Lee DK, Kim MJ, Kim JR, et al.
Efficacy of lactic acid bacteria (LAB) supplement in management of constipation among nursing home residents. Nutr J 2010 5;9:5.
Amenta M, Cascio MT, Di Fiore P, Venturini I. Diet and chronic constipation. Benefits of oral supplementation with symbiotic zir fos (Bifidobacterium longum
W11 + FOS Actilight). Acta Biomed 2006;77:157-62.
Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, et al.
Opioid complications and side effects. Pain Physician 2008;11 2 Suppl: S105-20.
Larkin PJ, Sykes NP, Centeno C, Ellershaw JE, Elsner F, Eugene B, et al.
The management of constipation in palliative care: Clinical practice recommendations. Palliat Med 2008;22:796-807.
Suzuki T, Uchida H, Watanabe K, Kashima H. Minimizing antipsychotic medication obviated the need for enema against severe constipation leading to paralytic ileus: A case report. J Clin Pharm Ther 2007;32:525-7.
Koizumi T, Uchida H, Suzuki T, Sakurai H, Tsunoda K, Nishimoto M, et al
. Oversight of constipation in inpatients with schizophrenia: A cross-sectional study. Gen Hosp Psychiatry 2013;35:649-52.
Parrish CR. Nutrients and constipation: Cause or cure? Pract Gastroenterol 2008;61:43-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]