Drugs & Aging

https://doi.org/10.1007/s40266-019-00701-9

THERAPY IN PRACTICE

Appropriate Use of Laxatives in the Older Person

Lisa G. Pont1,2   · Murray Fisher2 · Kylie Williams1

© Springer Nature Switzerland AG 2019

Abstract
Constipation is a common condition, affecting up to half of all older adults during their lifetime. Untreated constipation has
significant impacts, decreasing quality of life and potentially leading to urinary and/or faecal incontinence, faecal impaction
and, in severe cases, hospitalisation. The increased constipation prevalence among older populations is multifactorial, with
a number of age-related factors contributing to the rise in prevalence with aging. Laxatives are the mainstay of constipation
management and are commonly used among older populations for both treatment and prevention of constipation. A range
of laxative types including bulk forming agents, softeners and emollients, osmotic agents, stimulants, and the newer proki-
netic and secretory agents are available. Despite laxatives being freely available without prescription in many countries and
commonly used by older individuals, evidence regarding the effectiveness or safety of most laxatives in older populations is
lacking. Additionally, age-related changes increase the risk of adverse effects associated with laxatives, such as electrolyte
disturbances, among older persons. Caution must be taken when extrapolating recommendations for general adult populations
to older populations. Laxative choice for older individuals should be tailored after careful assessment and consideration of
comorbid conditions, concomitant medications and the potential for adverse effects.

Key Points 
Constipation is a common condition, affecting up to one
third of older adults.
Laxatives are the mainstay of constipation management.
A range of laxative types including bulk forming agents,
softeners and emollients, osmotic agents, stimulants, and
the newer prokinetic and secretory agents are available.
There are limited data in older populations regarding the
safety and efficacy of most laxative agents.
The safety, efficacy and suitability of different laxative
agents should be considered when managing constipa-
tion in older adults.
* Lisa G. Pont
Lisa.Pont@uts.edu.au
1
Discipline of Pharmacy, Graduate School of Health,
University of Technology Sydney (UTS), UTS Building 7,
67 Thomas Street, Ultimo, Sydney, NSW 2006, Australia
2
The University of Sydney, Susan Wakil School of Nursing
and Midwifery, University of Sydney, 88 Mallett St,
Camperdown, NSW 2050, Australia
1 Introduction
Constipation is a commonly occurring condition, with one
in five adults experiencing constipation during their life-
time [1–3]. Older adults are at increased risk of constipa-
tion, with constipation affecting up to 30% of those aged
65 years and older, and up to 50% of individuals aged over
85 years [1]. Constipation has significant impact, both on
the individual and on the health system [4, 5]. Untreated
constipation, especially among older persons, may lead to
urinary and/or faecal incontinence, faecal impaction and,
in severe cases, perforation of the colon or hospitalisation
[5]. In the USA, constipation is estimated to result in 2.5
million physician visits and cost US$6900 million annu-
ally [4].
The increased prevalence of constipation among older
populations is multi-factorial (Table 1). Age-related fac-
tors such as changes in gastrointestinal (GI) physiology,
reduced mobility, decreased liquid and nutritional intake,
as well as increased prevalence of related comorbidities
are all proposed to contribute to the increased constipa-
tion prevalence observed with aging [5]. A wide range of
medications may lead to constipation (Table 1), including
those acting to relax smooth muscle, and those that act at
cholinergic, opioid and serotonergic receptors may slow
GI transit, leading to constipation. Increased medication

Vol.:(0123456789)

Table 1  Medications associated with constipation [6]
Medication type
Antacids
Iron
Opioid
Anticholinergics
Antihistamines
Antiparkinsonian agents
Antipsychotics
Calcium channel blockers
Calcium supplements
Diuretics
Nonsteroidal anti-inflammatory drugs
Sympathomimetics
Antidiarrhoeal medications
use with increased age further predisposes older individu-
als to constipation [6].
Laxatives are the mainstay in the management of con-
stipation and may be used for prevention of constipation,
such as prevention of constipation associated with opioid
use, or for the treatment of constipation. While there are
a wide range of laxatives available internationally, laxa-
tives can be considered within six main drug groups: the
bulk-forming laxatives; softeners and emollients; stimu-
lant laxatives; osmotically acting laxatives; prokinetic
laxatives; and secretory laxatives. In general, individual
laxatives within each of the six drug groups share similar
mechanisms of action and similar side effect profiles.
2 Laxative Types
2.1 Bulk Forming Laxatives
The bulk forming laxatives include ispaghula husk (psyl-
lium), sterculia, wheat dextran (triticum), polycarbophil
and methylcellulose. Bulk forming laxatives are polysac-
charides and may be either natural (psyllium, triticum),
semi-synthetic (methylcellulose) or synthetic (polycar-
bophil) [5]. The action of the bulk forming laxatives is
to increase the amount of fibre in the colon, increasing
stool bulk, softness and hydration. Within the colon, unfer-
mented fibre increases stool bulk and water content, while
fibre fermented by colonic bacteria increases bacterial
mass and produces short-chain fatty acids, which are pro-
posed to have a prokinetic effect on colonic epithelium [5].
While many treatment algorithms recommend bulk
forming laxatives as first-line management of constipation
following lifestyle changes such as increasing dietary fibre,
hydration and exercise [7–10], there is limited evidence
L. G. Pont et al.
regarding the efficacy of bulk forming laxatives on consti-
pation. The majority of evidence for the benefits of the bulk
forming laxatives is for the use of ispaghula (psyllium). A
US study of 22 participants reported that stool frequency
and stool weight increased significantly with ispaghula
compared with placebo [11]. Given that the mean partici-
pant age in this study was 51 years, the relevance of this
study with regard to supporting the use of ispaghula among
older populations remains questionable. Similar results
were reported in a larger a randomised controlled trial of
201 participants which found that ispaghula husk (3.6 g
three times daily) significantly increased the frequency of
bowel movements and decreased straining associated with
defecation compared with placebo [12]. A single study
examined the effect of wheat dextran with water compared
with water alone [13]. In this study, the age range of par-
ticipants was 21–73 years, with a mean age of 67.4 years,
and while wheat dextran was associated with an increased
frequency of defecation, the small size of the study (n = 40)
and the lack of detail regarding recruitment, randomisation
and outcome measures limits the reliability and generalis-
ability of the results. No robust clinical trials with either
sterculia or methylcellulose have been reported [14].
Unacceptable palatability, bloating, flatulence and
abdominal distension are the main adverse effects reported
with the use of bulking agents, both in general and older
populations [14, 15]. Gradual introduction of bulk forming
laxatives may minimise bloating and abdominal distension
[16]. Furthermore, there is some suggestion that bloating,
flatulence and abdominal pain may be less problematic
with synthetic or semi-synthetic bulk forming agents [17].
One problematic issue with the use of bulk forming laxa-
tives among older populations is the increased fluid intake
required with the use of these agents to avoid exacerbation
of constipation or faecal impaction. Ensuring adequate
fluid intake among older individuals may be difficult, espe-
cially among those with renal or cardiovascular conditions,
who are often advised to limit their fluid intake [3, 18].
2.2 Softeners and Emollients
Stool softeners and emollients aim to facilitate defecations
by changing the consistency of the stool [3]. The two main
softeners used for the management of constipation are docu-
sate sodium and liquid paraffin (mineral oil); however, there
is a lack of evidence regarding the effectiveness of softeners
in both general and older populations [19]. Tarumi et al.
demonstrated in 74 palliative hospice patients that docusate
in combination with a stimulant laxative offered no benefit
over the use of the stimulant laxative alone [20]. While this
study recruited participants over the age of 18 years, the
Appropriate Use of Laxatives in the Older Person

majority of participants (86%) were aged over 60 years, and bisoxatin. Stimulant laxatives act via a number of proposed
thus the results are highly relevant for older populations. mechanisms. They modify electrolyte transport and increase
The use of liquid paraffin among older populations is not intraluminal fluid secretion as well as stimulating propulsion
recommended due to an increased risk of aspiration pneu- by indirectly stimulating sensory nerve endings [31].
monia and disturbances in the absorption of fat-soluble vita- Stimulant laxatives are commonly used by older popu-
mins. In light of these risks, mineral oil has been included lations, with senna and bisacodyl the most frequently
in the Beers criteria as a potentially inappropriate medicine reported agents [32, 33]. While these agents are often used
which should be avoided in older persons since 2003 [21, for the management of constipation among older persons,
22]. robust, well conducted trials of their safety and efficacy in
the elderly are limited. There is no evidence that stimulant
laxatives are more efficacious than other laxatives among
2.3 Osmotic Laxatives
older populations and little evidence of differences between
stimulant laxatives in terms of efficacy [34].
Osmotic laxatives are hyperosmolar, and as such result in
Bloating and cramping are commonly associated with
secretion of water across the gut membrane into the intes-
the use of stimulant laxatives and may limit their accept-
tinal lumen, increasing stool consistency and decreasing
ability to older populations [5]. While there is no evidence
bowel transit times [5]. A number of osmotic laxatives are
that stimulant laxatives are associated with dependence or
available, including lactulose, lactitol, polyethylene glycol
changes in bowel muscle function over time [35], electro-
and sorbitol. There is a relatively wide body of evidence sup-
lyte disturbances have been associated with long-term use of
porting the use of osmotic agents; however, similar to other
stimulant laxatives, which should be taken into consideration
laxative classes, evidence specifically among older popula-
when they are used for the management of constipation in
tions is lacking [23, 24].
older individuals [10].
Like with stimulant laxatives, abdominal bloating, cramp-
ing and flatulence are common adverse effects associated
2.5 Prokinetic Agents
with the use of osmotic laxatives, especially among older
populations [25]. Additionally, electrolyte disturbances,
Prokinetic agents have serotonergic actions, acting at the
common to many laxative classes, have also been reported
5-hydroxytryptamine type 4 (5-HT4) receptors in the GI
for some osmotic laxatives [5]. Clinical trial results suggest
tract to stimulate secretion and increase GI tract motility
that polyethylene glycol–electrolyte combinations have no
[3]. Cisapride, a previously available prokinetic agent, was
effect on serum electrolytes [26, 27]; however, these stud-
removed from the market in 2000 due to cardiovascular tox-
ies included small patient numbers (approximately 200 per
icity associated with prolongation of the QT interval [36].
study) and were conducted in general adult populations with
Tegaserod, not marketed in Europe, is a partial 5-HT4 ago-
a mean age < 50 years [26, 27]; further research in older
nist and has been shown to be effective for the management
populations, who are at increased risk of adverse effects,
of chronic constipation in younger adult populations [37,
is needed.
38]. Despite demonstrated efficacy, concerns around car-
Magnesium-containing preparations, primarily as magne-
diovascular safety saw tegaserod removed from the market
sium citrate, hydroxide or oxide, are used as osmotic agents
in North America, Europe and Australia [10].
in a number of countries. Declining renal function, common
A number of new serotonergic laxatives are in develop-
among older populations, has been identified as a risk factor
ment, and of these, prucalopride is the first to be marketed.
for hypermagnesaemia [28], and current recommendations
The efficacy of prucalopride in older populations was exam-
are that magnesium-containing laxatives should be avoided
ined in a trial of 300 chronically constipated patients aged
among older populations [29]. Similarly, sodium phosphate
over 65 years who were randomised to receive prucalopride
preparations, also available in many countries as osmotic
or placebo for 4 weeks. In this population, prucalopride was
laxatives, have been associated with severe dehydration and
shown to be effective in improving constipation symptoms
electrolyte disturbances, with a US Food and Drug Admin-
and quality of life [39]. A small randomised controlled
istration (FDA) warning issued in 2014 indicating that these
trial examining the use of prucalopride in 84 nursing home
agents should not be used in individuals aged over 55 years
residents with resistant constipation over a 4-week period
[30].
reported that the agent was well tolerated and that no adverse
cardiac events or QT prolongation were observed [40].
2.4 Stimulant Laxatives
Given their activity at the 5-HT4 receptor, all of the proki-
netic laxatives have the potential to interact with other drugs
The stimulant laxatives, also known as contact laxatives,
acting at the same receptor or metabolised by the same meta-
include bisacodyl, senna, cascara, sodium picosulfate and
bolic pathways. Prucalopride has a relatively low potential

for interactions with other drugs as it is not metabolised via
the cytochrome P450 pathway [41]. Potential for interac-
tions with other medications is an important consideration
with any agent used in older populations, given that medi-
cine use and polypharmacy increase with age. Future 5-HT4
agents include velusetrag, a highly selective 5-HT4 agonist.
A small-scale study in 60 healthy volunteers reported that
velusetrag increased gastric emptying and colonic transit
compared with placebo, while a larger study found that
velusetrag improved stool frequency, stool consistency and
decreased straining compared with placebo [42, 43]. The
role of velusetrag in the management of constipation in older
individuals remains to be defined. Initial trial populations
were relatively young, with the larger study having a mean
participant age of 45 years. Velusetrag is currently under
development and not yet commercially available.
2.6 Secretory Laxatives
The secretory laxatives comprise a new laxative class, with
the two agents currently marketed, lubiprostone and linaclo-
tide, differing significantly in their mechanisms of action.
For both agents, the mean age of participants in the clinical
trial populations was below 50 years, and the extrapolation
of the clinical trial findings to older populations should be
viewed with caution.
Lubiprostone is a fatty acid derived from a metabolite
of prostaglandin E1. Lubiprostone increases intestinal and
colonic transit by activating type 2 chloride channels on the
apical membrane of epithelial cells [10]. Activation of the
chloride channels results in efflux of chloride and sodium
into the GI tract lumen, which is followed by secretion of
water into the GI lumen to maintain the isotonic equilibrium.
Additional to chloride channel activation, lubiprostone is
proposed to impact smooth muscle contraction in the GI
tract [10]. As is the case with most new drugs, the safety and
efficacy of lubiprostone has not been explored in older per-
sons. The mean ages of participants in the two phase III tri-
als evaluating the safety and efficacy of lubiprostone were 49
and 46 years, respectively, limiting the usefulness of these
studies regarding the safety and efficacy of the agent in older
populations. Additionally, the effectiveness of lubiprostone
may be limited by its adverse effect profile, with significant
nausea reported to affect up to 30% of users [10], although
there is some indication that tolerance of lubiprostone may
be better among older populations [44].
Linaclotide is also a secretory laxative; however, the
mechanism of action of linaclotide is via stimulation of
intestinal guanylate cyclase type C receptors, resulting in
secretion of water in to the GI tract, decreasing GI transit
time [45]. Initial studies into the efficacy of linaclotide,
L. G. Pont et al.
while demonstrating improvements in stool consistency
and straining, were conducted in young adults (median
age of 48 years), potentially limiting their extrapolation to
older adult populations [16]. The most commonly reported
adverse effects in the linaclotide clinical trials were primar-
ily GI related, including diarrhoea, flatulence and abdominal
pain [10].
3 Prevention of Constipation
The majority of studies examining the safety and efficacy of
laxatives in older people have focussed on the use of laxa-
tives for the treatment of constipation. Yet research into the
use of laxatives in an older Australian cohort suggests that
laxatives may be commonly used by older individuals for
prevention, as well as treatment, of constipation [32, 33].
A systematic review of laxative use reported that a single
randomised controlled trial examining the efficacy of laxa-
tives on prevention of constipation in an older population
has been conducted [25]. The study evaluated the efficacy
of sterculia in the prevention of constipation, finding no sig-
nificant benefit for the bulking agent in the prevention of
constipation [23].
4 Quality of Evidence for Safety and Efficacy
of Laxatives in Older Populations
The extent and quality of studies examining the safety and
efficacy of laxatives in both general adult and older popu-
lations varies considerably. A 2014 review by the Ameri-
can College of Gastroenterology reported low evidence
for fibre, moderate evidence for stimulants (bisacodyl and
sodium picosulfate) and high evidence for newer agents, pru-
calopride and lubiprostone, in the general adult population
[16]. Only two of the 28 studies in the American College
of Gastroenterology review, one from 1978 examining the
safety and efficacy of lactulose [46] and one from 2010 on
prucalopride [39], were considered to be of moderate qual-
ity. A 2016 review of the efficacy and safety of laxatives
specifically targeting older populations included nine studies
[47]. While no formal quality assessment was undertaken,
it should be noted that while all of the studies reported the
use of control groups, all studies were relatively small, three
were subanalyses of geriatric populations in larger trials,
and only two were double-blind, randomised controlled
trials [47]. The lack of high-quality evidence of the safety
and effectiveness of laxatives in older adults is problematic
as this is the population with the highest need for safe and
effective management of constipation.
Appropriate Use of Laxatives in the Older Person
Table 2  Stepwise approach to laxative choice and special considerations among older persons. Adapted from Wald, 2016 [35]
Step 1 Consider and address secondary causes of constipation
Step 2 Consider increasing fibre intake and/or use of bulking agent Ensuring adequate fluid intake among older persons may be difficult
Step 3 Consider an osmotic or stimulant laxative
Step 4 Consider a secretory laxative
5 Choice of Laxative for Management
of Constipation in Older Persons
Choice of laxative for management of constipation in older
individuals should be individualised, focusing on co-morbid
conditions, drug interactions and potential side effects [15].
Caution must be taken when extrapolating recommendations
for general adult populations to older populations [29]. Many
guidelines recommend increased fluid, dietary fibre and exer-
cise as initial management for constipation [48, 49], yet this
may not be realistic or achievable for older persons [18]. Tra-
ditionally, the use of bulking agents and fibre supplements
were seen as the first step for management of constipation [50];
however, in the elderly, the increased fluid requirements asso-
ciated with these agents may be problematic. Both osmotic
and stimulant laxatives are effective in the management of
constipation, and the choice between these will depend on the
clinical profile of the individual person. The long-term safety
of the newer prokinetic and secretory laxatives in older popu-
lations remains unknown, and as such, these agents may need
to be considered as second-line agents behind the stimulant
and osmotic agents. Recommendations for the management
of constipation generally follow a stepwise approach, starting
with increasing fibre intake and then progressing as necessary
to use of secretory agents [35]. A similar stepwise approach is
recommended for management of constipation among older
adults; however, consideration needs to be given at each step
regarding laxative suitability, safety and efficacy for older per-
sons (Table 2).
6 Conclusions
In conclusion, constipation is a common condition among
older individuals, with considerable impact on health and
quality of life. Effective laxatives are available to manage con-
stipation, yet, in general, the safety and efficacy of laxatives
among older populations remain unknown, with the majority
Special considerations for older persons
Concomitant disease and competing medical conditions may limit the
extent to which secondary causes can be addressed among older popula-
tions
Gradual introduction of bulk forming laxatives may minimise bloating and
abdominal distension
Bloating and cramping may occur with stimulant laxatives
Limited evidence for both osmotic and stimulant laxatives among older
populations
No evidence for long-term harm with stimulant laxatives
Monitor for electrolyte disturbances
Long-term safety of the prokinetic and secretary laxatives in older popula-
tions remains unknown
of clinical trials being conducted in younger populations. Man-
agement of constipation in older populations differs from that
in younger age groups, and treatment should be tailored to the
needs and response of the older individual.
Compliance with Ethical Standards 
Funding  No sources of funding were used in the preparation of this
review.
Conflict of interest  Lisa Pont, Murray Fisher and Kylie Williams de-
clare no conflicts of interest relevant to the content of this review.
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