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pain, and reducing the sensation of an incomplete bowel movement.⁷⁸ The results of a systematic review strongly suggest that abdominal massage can be effective in reducing the incidence and severity of constipation after stroke; however, further high‐quality studies need to be conducted to establish a definitive conclusion.⁷⁹

      The use of combinations of laxatives has rarely been addressed in the literature but is commonly encountered in practice when a single agent is ineffective. The most common combination is an osmotic laxative with a stimulant laxative. In patients with continued complaints of constipation despite the use of a single laxative, obtaining a plain abdominal radiograph to assess the degree of stool retention may be helpful. Patients with a large amount of stool (and no evidence of faecal impaction) may be treated with a colon preparation such as balanced electrolytes plus PEG (e.g. NuLYTELY) to cleanse the colon. The patient may be then started on an osmotic laxative with a stimulant laxative available on an as‐needed basis every two to three days if a satisfactory bowel movement does not occur.

      Patients with refractory constipation and slow‐transit constipation may benefit from subtotal colectomy and ileorectostomy.⁸⁰ Fortunately, this is rarely required as nearly 90% of patients with slow‐transit constipation respond to laxatives.⁸¹ When dyssynergic defecation is present, biofeedback improves defecatory function in around 70% of patients.⁸² Patients with both slow‐transit constipation and dyssynergic defecation should first be treated with biofeedback. When slow‐transit constipation persists after successful treatment of dyssynergic defecation, subtotal colectomy may be considered. Surgical therapy is most successful in patients without upper gut motility disorders or significant psychological symptoms.⁸³ In patients with very refractory constipation, the use of antegrade enemas has been described.^84,85 Antegrade enemas involve creating a caecostomy placed surgically or endoscopically. Water or PEG is flushed through the tube periodically to facilitate colonic emptying. No high‐quality, controlled trials have assessed any of these enema therapies, and the evidence of the risks and benefits remains limited.

      The optimal treatment for faecal impaction is not clear. Patients able to tolerate oral therapy may benefit from PEG or other osmotic laxatives with or without the use of enemas.⁸⁶ Patients with a hard or very large faecal bolus in the rectum may require manual removal of the faeces. Hyperosmotic, water‐soluble contrast enemas have also been used with success in relieving faecal impaction.⁸⁷ Bulking agents should be avoided in this patient group.

Conclusion

      Complaints of constipation and the use of laxatives remain common in older people. When controlling for comorbidities, constipation is no more common in elderly than in younger people. Stool frequency remains unchanged with ageing. Elders more commonly complain of straining and hard stools. Risk factors for constipation include medication use, chronic medical illness, and psychological distress. Healthy elders are no more likely to develop constipation than younger people. Constipation adversely affects elders’ sense of well‐being and quality of life. The economic impact is also significant due to the cost of laxatives alone. In patients with up‐to‐date colorectal cancer screening who lack worrisome symptoms such as bleeding or weight loss, empirical treatment is appropriate.

      A step‐wise approach should be taken in the management of constipation. First, review medications causing constipation, and increase dietary fibre and fluid intake. There is limited evidence that making lifestyle changes resolves constipation, but it is universally accepted as an initial approach. Bulking agents can be added first‐line, then an osmotic laxative, and then a stimulant laxative if required. The safest, best‐tolerated and, least expensive laxatives should be implemented before prescribing the more expensive second‐line laxatives. Avoid bulking agents in the context of faecal impaction. A paucity of evidence is available to support the use of stool softeners. Patients who fail to respond require a more detailed evaluation.

Identifying the most effective treatment strategy for constipation in elders, whether in the community or long‐term care setting, remains unclear due to the lack of high‐quality therapeutic trials for most laxatives. Improved research in this area is needed to identify the most effective, economically viable therapeutic agents.

      Key points

       Reports of constipation and the use of laxatives are very common in older people.

       Stool frequency is no different in elders than younger people, with elders complaining most of straining and hard stools.

       The use of medications and chronic medical illness correlate most closely with the development of constipation in elders.

       Patients lacking worrisome symptoms may undergo an empirical therapeutic trial, with diagnostic testing reserved for those who fail to respond.

       The best available evidence supports the use of psyllium, osmotic laxatives (especially PEG), and lubiprostone to treat constipation in elders.

       Methylnaltrexone, available as an injection, is an important advance in the treatment of refractory opiate‐induced constipation.

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