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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 1  |  Page : 145-150

Risk factors for constipation among elderly attending family health center in Damietta District, Damietta Governorate, Egypt


1 Family Medicine Department, Faculty of Medicine, Menofia University, Shebeen El-Kom, Egypt
2 Family Medicine Department, Family Health Center, Damietta, Egypt

Date of Submission07-Jun-2017
Date of Acceptance31-Jul-2017
Date of Web Publication17-Apr-2019

Correspondence Address:
Wafaa El-Said Ibrahim Salama
Family Medicine Department, Family Health Center, Damietta Governorate, Damietta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_388_17

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  Abstract 


Background
Approximately one-third of adults 60 years or older report at least occasional constipation, and in nursing home residents, the prevalence is 50% or more. It accounts for ~2.5 million physician office visits yearly.
Aim
The aim of the present work was to assess the prevalence and risk factors of constipation among the studied elderly population.
Patients and methods
A cross-sectional study was conducted on 258 elderly population (>60 years old) attending the Hai Tany Family Health Center, Damietta Governorate, from 1 November 2015 to 1 January 2016. A predesigned questionnaire was used to assess the presence of constipation and its risk factors. It included four parts: sociodemographic characteristics, Bristol scale and ROME III diagnostic criteria for constipation, mini-mental status examination (to assess cognitive function), and mini-nutritional assessment scale (to assess nutritional status).
Results
The results of this study revealed that 64/258 of the studied population had primary (functional) constipation. Constipation was more significant in patients older than 75 years (P < 0.001). The most important risk factors associated with constipation in the studied group were advanced age, nutritional impairment, and cognitive impairment.
Conclusion
This study concluded that about one-fourth of the studied population had (functional) constipation. The most important risk factors associated with constipation in elderly population were advanced age, nutritional impairment, and cognitive impairment. Therefore, the study recommends prevention and treatment of constipation through nutritional education and screening for cognitive impairment in elderly.

Keywords: cognitive impairment, constipation, elderly


How to cite this article:
Farahat TM, El-Esrigy FA, Ibrahim Salama WE. Risk factors for constipation among elderly attending family health center in Damietta District, Damietta Governorate, Egypt. Menoufia Med J 2019;32:145-50

How to cite this URL:
Farahat TM, El-Esrigy FA, Ibrahim Salama WE. Risk factors for constipation among elderly attending family health center in Damietta District, Damietta Governorate, Egypt. Menoufia Med J [serial online] 2019 [cited 2019 Aug 25];32:145-50. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/145/256108




  Introduction Top


Elderly are affected by constipation more frequently than younger individuals. This is caused by a variety of factors, which correlated with the geriatric age group [1].

It is noted that the prevalence of constipation increases with age, especially those older than 65 years [2]. Chronic constipation affects 17–40% of the elderly, which interferes with their quality of life [3].

According to Rome III criteria for adults, constipation is diagnosed as follows: 25% of bowel movements are associated with at least two of the following symptoms (straining, hard or lumpy stools, a sense of incomplete evacuation, a sense of anorectal obstruction, the need for manual maneuvers, and fewer than three defecations per week), occurring in the previous 3 months with an onset of symptoms of at least 6 months; loose stools are rarely present without the use of laxatives; and there are insufficient criteria for irritable bowel syndrome [4].

Low fluid intake, less mobile patients, delay in emptying bowels, poor dentition, use of a number of medicines, including antacids, calcium, and iron supplements, as well as radiotherapy and opioid pain relief for cancer treatment and development of comorbid medical conditions that resulting in polypharmacy are risk factors for constipation [5],[6],[7],[8].

The aim of the present work was to assess the prevalence and risk factors of constipation among the studied elderly population.


  Patients and Methods Top


All elderly patients (aged 60 years and above) attending Hai Tany Family Health Center, Damietta District, Damietta Governorate, from the first of April 2016 till the end of June 2016 were included in the study.

This was a cross-sectional case–control study.

The sample size was calculated using EPI-Info developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US) based on the prevalence of constipation in elderly from the previous literature, which was 27% [9]. The sample size was 196, and it was increased to 258 to overcome the dropout and the adherence to the study. Uncooperative elderly people, elderly people with terminal illness, that is, malignancy, and those who were not living in Damietta District were excluded.

All elderly patients who participated in the study were evaluated by using a predesigned questionnaire which consisted of four sections.

First section

It included sociodemographic data involving the following: name, age, residence, educational level, occupation, income, and the crowding index (number of persons per room) to assess the socioeconomic standard as per Fahmy et al. [10].

Second section

It included the following:

Diagnosis of constipation using Bristol stool scale [11] and ROME III diagnostic criteria [12]. The English version of Rome III Functional Constipation Diagnostic questionnaire was translated into the Arabic language. It consisted of 14 items, with answers in ordinal scale and individual frequency thresholds: items 1–7 are questions that characterize functional constipation in the last 3 months (frequency, consistency, straining, incomplete evacuation sense, manual maneuver for evacuation, and difficulty), item 8 is duration of symptoms listed in previous questions for 6 months or longer in a yes or no response, and items 9–14 are questions for alarming symptoms.

Exclusion of alarm symptoms (recent onset of constipation, bleeding per rectum, weight loss, and anemia) and known organic causes of constipation owing to gastrointestinal disorders (diverticulosis, Hirschsprung disease, irritable bowel syndrome, megacolon, pelvic floor dysfunction, rectoceles, strictures).

Past medical history: diabetes mellitus, hypertension, hepatitis, cardiac diseases, polypharmacy, and dental loss.

Third section

It included assessment of nutrition status as a risk factor for constipation by using mini-nutritional assessment [13] that included 15 items: six for screening and nine for assessment of malnutrition (number of full meals per day, consumption for protein intake, fruit or vegetables, and total fluid intake per day).

Fourth section

It included assessment of cognitive function by using mini-mental state examination. It consisted of eleven questions that test five areas of cognitive function: orientation, registration, attention and calculation, recall, and language [14].

The participants were classified into two groups: group 1: those with constipation and group 2: those without constipation

Ethical consideration

Human rights and ethical consideration were followed during the study with total confidentiality of any obtained data. The Menoufia Faculty of Medicine Committee for Medical Research Ethics reviewed and formally approved the study. An official permission letter was obtained from the authorities of the Menoufia Faculty of Medicine Committee for Medical Research Ethics and directed to the authorities of selected family health centers.

Statistical design and analysis

The results from this study were collected, revised, coded, tabulated, and statistically analyzed by statistical package for the social science (SPSS version 20; SPSS Inc., Chicago, Illinois, USA) (using IBM personal computer). Qualitative data were expressed as number and percentage and analyzed applying χ2-test.


  Results Top


Of 258 studied elderly population, 64 (24.8%) were diagnosed as having primary (functional) constipation by using Bristol stool scale and ROME III diagnostic criteria [Figure 1].
Figure 1: Frequency of primary (functional) constipation in the studied elderly population.

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[Table 1] reveals that the prevalence of constipation increased with increasing age, where most of elderly population more than 75 years experienced constipation (P < 0.001) [Table 1].
Table 1: Comparison between the studied elderly population with or without constipation regarding sociodemographic data

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[Table 2] shows that there was significant relation between constipation and malnutrition in elderly patients, where approximately half of malnourished patient (55.6%) reported constipation (P = 0.002). Constipation was present in all elderly population with severe decrease in food intake, had one meal per day, and with neuropsychological problem (P = 0.008, 0.008, and 0.03, respectively). Moreover, approximately one-third (35.2%) of patients with three protein servings per day and approximately half of patients who self-fed with some difficulty (48.5%) experienced constipation (P < 0.001 and 0.001, respectively). On the contrary, constipation was absent among most of elderly population who ate fruits and vegetables (78.5%, P < 0.001) and drank more than five cups of fluids per day (83%, P = 0.002), respectively [Table 2].
Table 2: Comparison between the studied elderly population with or without constipation regarding mini-nutritional assessment scale

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[Table 3] shows that most of the studied elderly patients with mild cognitive impairment experienced constipation (72.7%, P = 0.001) [Table 3].
Table 3: Comparison between the studied elderly population with or without constipation regarding using constipating drugs, comorbidities, dental loss, and mini-mental state examination

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The binary logistic regression [Table 4] shows that most significant risk factors were patients aged more than 75 years [odds (OR): 20.2; 95% confidence interval (CI): 5.9–69.7] followed by those who drank less than three cups of fluid intake per day (OR: 13; 95% CI: 2.6–63.7), those with mild cognitive impairment (OR: 9.9; 95% CI: 1.6–62.9), those aged 66–75 years (OR: 5.9; 95% CI: 2.6–13.2), those taking two full meals per day (OR: 3.6; 95% CI: 1.7–7.6) and those taking three protein servings per day (OR: 2.9; 95% CI: 1.4–6.1) whereas the most protective was fruits and vegetables intake (P = 0.016; OR: 0.047; 95% CI: 0.004–0.565) [Table 4].
Table 4: Binary logistic regression for prediction of constipation in elderly population

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  Discussion Top


Constipation is a common gastrointestinal disease affecting all age groups. Elderly individuals experience it particularly more than younger individuals, among whom females have higher prevalence than males.

In the present study, the frequency of constipation among the studied elderly patients was 24.8% and increased with increasing age, where most of elderly patients more than 75 years experienced constipation, which may be attributed to the health status, medication, and physical inactivity. This was similar to Higgins and Johanson [15] who found that the prevalence increases with increasing age. Bharucha et al. [16] found that constipation affects 16% of adults and up to 33% of those older than 60 years. Moreover, McCrea et al. [17] found that constipation rates appear to increase gradually after the age of 50 years, with the largest increase after 70 years. For example, after 70 years, the rates ranged from 7.7 to 42.8%. This variation in prevalence estimates may be related to the different definitions of constipation used across studies and the methods of data collection.

Regarding sex, residence, and constipation, there was insignificant difference between male and female and urban and rural areas. This is similar to Kan et al. [18] who showed that there was no difference in the constipation prevalence between urban and rural areas. On the contrary, Zhang et al. [19] found that in the Beijing region, elderly population in the urban areas had a higher prevalence in constipation than rural areas but there is no specific description in either domestic or international research to explain this difference.

A study conducted by Nour-Eldein et al. [20] on 23 elderly people experiencing functional constipation found that half of them (52.2%) were aged between 70 and 80 years. More than two-thirds (69.6%) were females. Most of the sample was divorced or widowed (82.6%). Half of the sample (52.2%) had no formal education.

Regarding the effect of nutritional status, there was statistical significance relation between constipation and malnutrition, where the percentage of constipation was significantly lower among elderly patients who ate fruits and vegetables and those who drank more than five cups of fluids per day. This may be attributed to low fluid intake, which is linked to slow colonic transit and low stool output [5]. This is in agreement with Klaus et al. [21] who found that all the elderly individuals evaluated as having a mean fiber intake below the recommended levels were considered constipated as compared with others. Moreover, Dukas et al. [22] found that higher fiber intake was associated with reduced risk of constipation after controlling for numerous factors. Markland et al. [23] found that low consumption of water appeared as a predictive factor for constipation in men and women.

In the current study regarding mini-mental status, most of the studied elderly patients with mild cognitive impairment experienced constipation.

In agreement with our study, Gallagher and O'Mahoney [7] found that people with severe cognitive problems may become less concerned or less aware about their bowel habits. If they depend on other people for their care or if they cannot easily find or access the toilet, this can also affect their bowel habits.

In the present study, there was no significant statistical difference among the studied elderly patients as regarding constipating drugs use [antihypertensive drugs (α, β, and calcium channel) blockers, diuretics, antipsychotics, and analgesics (NSAIDs)] and presence of comorbidities (hypertension, diabetes mellitus, ischemic heart disease, hepatic disease, and stroke), but Phillips et al. [24] found that more than 70% of the 392 patients with a diagnosis of constipation and/or who are receiving routine laxative/constipation therapy had a condition known to increase constipation.


  Conclusion Top


This study concluded that approximately one-fourth of the studied elderly patients had (functional) constipation. The most important risk factors associated with constipation in elderly patients were advanced age, nutritional impairment, and cognitive impairment. Therefore, the study recommends prevention and treatment of constipation through nutritional education and screening for cognitive impairment in elderly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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