Background: Despite its prevalence, constipation is frequently under-recognized and treated with ineffective agents in hospitalized older adults.
Methods: An anonymous survey was distributed to physicians regarding constipation management in hospitalized older adults. Chi-square or Fisher’s exact, as appropriate, were used to explore associations between demographics and survey answers. T-test was used to compare groups on continuous measures, and Spearman’s correlation was used to measure the relationship between ordinal variables.
Results: Of 104 responders, 75% had practiced ≤10 years, 53% were female, 40% were hospitalists, and 21% had geriatrics or palliative care training. Nearly all (92%) responded that treating constipation was extremely or very important, and 71% reported that they were extremely or very comfortable treating constipation. Over half (52%) reported >60% of their hospitalized older patients (age >65) experience symptomatic constipation. The vast majority of respondents were correctly able to identify risk factors predisposing elderly patients to developing symptoms of constipation during hospitalization such as age (87%), immobility (92%), institutionalization (86%), and concurrent use of opioids (99%). 69% reported assessing patient bowel movements daily. Diagnostic tests utilized included physical exam (41%) and abdominal X-ray (28%), although 20% selected none. Preferred initial treatment agents were sennosides (33%), docusate sodium (31%), and polyethylene glycol (28%).
For cases of fecal impaction, 61% selected manual disimpaction as the initial treatment of choice, with 56% identifying that physicians are responsible for performing disimpaction. Yet, 64% had treated patients in the last year who should have been previously disimpacted but were not. Furthermore, 48% noted not having disimpacted a patient in the past year with 63% feeling that disimpaction training was needed despite prior experience. There was a significant positive correlation between performing disimpaction and the proportion of older hospitalized patient that were assessed for symptomatic constipation; number of enemas ordered; and whether physicians had encountered patients who should have been previously disimpacted (n=95, r=0.22, p=0.0324; n=98, r=0.42, p<0.0001; n=97, r=0.68, p<0.0001, respectively).
Conclusions: Although the majority of physicians surveyed endorse that constipation is common in hospitalized older patients, almost half admit to not personally utilizing disimpaction in the past year. Furthermore, about one third rely on diagnostic tests such as X-rays and treatments such as docusate sodium which are not supported in the literature. Educational efforts around the utility of evidence-based pharmacologic treatments as well as disimpaction can improve the management of constipation in the hospital setting in an effort to reduce patient morbidity and costs.