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Constipation and faecal incontinence in older adults
Constipation in older adults mainly results from drugs, immobility, low fluid and fibre intake and diseases (thyroid, calcium, Parkinson disease); exclude alarm features before treating, then start with polyethylene glycol; faecal impaction may present precisely as "diarrhoea", confusion and urinary retention.
Why it matters in the exam
The exam presents a hospitalised older adult with dribbling "diarrhoea", confusion and urinary retention, and the answer is faecal impaction — diagnosed by rectal examination and treated with disimpaction and enemas, not an antidiarrhoeal. Other questions: which laxative fits (polyethylene glycol is the first choice), what to avoid (mineral oil — risk of lipoid aspiration pneumonia; phosphate enemas in kidney disease), and when to perform colonoscopy.
Alarm features that require work-up: bleeding, iron-deficiency anaemia, weight loss, a new change in bowel habit over age 50 and a family history of colorectal cancer. In opioid-induced constipation start with a stimulant or osmotic laxative, and if there is no response — a peripherally acting opioid antagonist (methylnaltrexone, naloxegol). Fibre suits a mobile patient who drinks enough, but may worsen constipation in a bed-bound patient or one taking opioids.
In residents of institutions, constipation and faecal incontinence are very common and affect appetite, mood and the skin. Candidates are also asked about faecal incontinence due to diarrhoea (for example C. difficile infection after antibiotics), in which the cause is investigated before loperamide is given.
Key points
- Causes: drugs, immobility, fluids, thyroid, calcium, neurological disease.
- Alarm features → colonoscopy.
- Polyethylene glycol first; add a stimulant laxative.
- Opioid → a regular laxative; methylnaltrexone or naloxegol if no response.
- Dribbling "diarrhoea", confusion and urinary retention — faecal impaction.
Summary table
| Issue | Key point | Exam point |
|---|---|---|
| Definition (Rome IV) | Two or more: straining, hard stools, incomplete evacuation, sense of blockage, manual help, fewer than 3 bowel movements a week | At least 3 months |
| Causes in older adults | Drugs (opioids, anticholinergics, verapamil, iron, calcium), immobility, hypothyroidism, hypercalcaemia, Parkinson disease | Check TSH and calcium |
| Alarm features | Bleeding, anaemia, weight loss, a new change, family history of cancer | Colonoscopy |
| Treatment | Polyethylene glycol first; stimulant laxative (senna, bisacodyl); fibre for a mobile patient | Avoid mineral oil and phosphate enemas |
| Faecal impaction | Dribbling "diarrhoea", confusion, urinary retention | Rectal examination, disimpaction and enemas |
| Faecal incontinence | Usually impaction, diarrhoea or sphincter weakness | Treat the cause; scheduled toileting |
A free exam question
בן 70 , הופנה למיון לבירור עצירות וכאבי בטן דיפוזיים מזה מספר ימים. בבירור כעת עדות קלינית ומעבדתית לחסימת מעי דק. מה מהבאים הינו הגורם השכיח ביותר לאבחנה זו? (the question as examined, in Hebrew)
- א. הידבקויות
- ב. ממאירות
- ג. מחלת קרוהן
- ד. טיפול קרינתי לבטן בעברו
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Sources
- Rome IV criteria for functional bowel disorders, 2016 — Functional constipation
- American Gastroenterological Association–American College of Gastroenterology guideline on chronic idiopathic constipation, 2023 — Pharmacological treatment
- Geriatrics Review Syllabus (American Geriatrics Society), 11th edition (2022) — Constipation and fecal incontinence
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.