Management of Chronic Diarrhea in Elderly Patients

Diagnostic Evaluation

The American Geriatrics Society recommends sending repeat stool specimen for C. difficile toxin testing if the patient received antibiotics within the past 60 days, as toxin assays are only 60-90% sensitive on a single specimen 2
Consider C. difficile even without recent antibiotic use if severe leukocytosis is present, as this indicates severe disease even without typical symptoms 2
Check for antibiotic or chemotherapy exposure in the previous 4-6 weeks, as one-third of colonized elderly patients will develop symptomatic diarrhea within 2 weeks of antibiotic therapy 2
Send stool for culture, ova and parasites, and Shiga toxin/E. coli O157:H7 testing, particularly if there is fever, bloody stool, or prominent inflammatory signs 2

The American College of Physicians recommends administering oral rehydration solution for mild to moderate dehydration, continuing until clinical dehydration corrects 1
Administer intravenous isotonic fluids for severe dehydration or inability to tolerate oral intake 1
Eliminate all lactose-containing products and high-osmolar dietary supplements 4

Loperamide 4 mg initially, then 2 mg every 4 hours or after each unformed stool is appropriate ONLY for uncomplicated diarrhea once infectious causes are excluded 4, 1
Do NOT use loperamide if there is any suspicion of C. difficile, bloody diarrhea, fever, or severe abdominal pain, as antimotility agents can precipitate toxic megacolon and mask worsening disease 1, 5

Do not start antimotility agents before excluding infectious causes, particularly C. difficile, as this can lead to catastrophic complications including toxic megacolon and perforation 1, 5
Avoid unnecessary antibiotic use during workup, as this can precipitate C. difficile infection in colonized elderly patients 1, 3