Fecal Impaction Management in Elderly Patients

Diagnosis and Contributing Factors

The American Geriatrics Society suggests that elderly patients have a 24-50% prevalence of constipation, which is a contributing factor to fecal impaction 2
The presence of multiple constipating medications, such as chlorthalidone, timolol, and lovastatin, can increase the risk of fecal impaction 1, 3, 4
Hypothyroidism, even if treated, may contribute to decreased bowel motility and increase the risk of fecal impaction 5
Decreased mobility, given age and multiple comorbidities, can also contribute to fecal impaction 1

Manual digital disimpaction should be performed first, with premedication using an analgesic ± anxiolytic for patient comfort, as recommended by the National Comprehensive Cancer Network 6, 2
Following partial manual disimpaction, administer a water or oil retention enema to facilitate passage of remaining stool through the anal canal 7, 2
Glycerine suppository can be used as an alternative or adjunct to enemas 6
Isotonic saline enemas are preferable in elderly patients due to lower risk of adverse effects compared to sodium phosphate enemas 4, 8

The American Gastroenterological Association recommends continuing PEG 17g daily as the safest option for maintenance bowel regimen in elderly patients with multiple ongoing risk factors 1, 8
Avoid magnesium-based laxatives due to risk of hypermagnesemia, especially with potential renal impairment from diuretic use 1, 5, 8
Stimulant laxatives, such as senna or bisacodyl, can be used as alternative or additional options if PEG is insufficient 1, 5

Ensure toilet access and privacy, especially important if mobility is limited, as recommended by the American Geriatrics Society 1
Optimize toileting schedule by attempting defecation twice daily, 30 minutes after meals, and straining no more than 5 minutes 1, 5
Increase fluid intake within limits of cardiac status, and maximize mobility even if just bed-to-chair transfers 1
Use a small footstool to assist with positioning and gravity during defecation 1, 5

Review necessity of chlorthalidone and monitor for electrolyte imbalances given combination of diuretic therapy and laxative use, as recommended by the National Comprehensive Cancer Network 1, 8
Ensure adequate levothyroxine dosing, as hypothyroidism contributes to constipation 5
Regularly assess kidney and heart function when using diuretics with laxatives, with a goal of 1 non-forced bowel movement every 1-2 days 6, 3