G E R I AT R I C T H E R A P E U T I C S

Editors: Dr Michael Woodward, Director of Aged Care Services, Dr Juli Moran, Consultant Geriatrician, Mr Rohan Elliott,
Clinical Pharmacist, Austin & Repatriation Medical Centre, Vic.; Ms Helen Lourens, Director of Pharmacy, Coffs Harbour
Hospital, NSW; Mrs Robyn Saunders, Consultant Pharmacist, Vic.

Constipation in Older People

Pharmacological Management Issues
Michael C Woodward
ABSTRACT
Constipation is a common complaint amongst older people
although they are often concerned about features of constipation other than bowel action frequency. A careful assessment
should be made, including a history, examination and appropriate investigations. Non-pharmacological management often
avoids the use of laxatives and includes adequate fibre, fluid
and exercise.
The laxatives most appropriate for older people include
stimulants such as senna, bulking agents and osmotic agents
such as polyethylene glycol plus electrolytes or sorbitol. Shortterm use is nearly always sufficient. Faecal impaction should
be sought and managed before giving oral agents. Enemas and
suppositories are usually appropriate for impaction and for
excessive straining. Management of constipation with these
measures will avoid long-term use and abuse of laxatives.
J Pharm Pract Res 2002; 32: 37-43.

INTRODUCTION
Constipation is not often regarded as a major therapeutic issue, but the use and abuse of laxatives by older
people is highly prevalent. It is important for clinicians
to have an understanding of the importance of constipation to older people, and of ways to improve laxative
usage. This article will review the range of laxatives available, their efficacy and adverse effects, and practical issues in the correct use and withdrawal of laxatives.
Readers are referred to reviews1-4 for causes, assessment
and complications of constipation.

shown no reduction in the frequency of bowel movements with normal ageing.6-11 Among the elderly who do
complain of constipation, 5265% report bowel movements at least once daily, and only 27% describe moving their bowels on no more than two occasions per
week.8-12 Furthermore, laxative use in these subjects has
been shown to be similar in individuals with and without
infrequent bowel movements, making laxative dependence an unlikely explanation for the normal stool frequencies seen in community-dwelling elderly people with
self-reported constipation.12.
This overestimation of constipation in older people
may result from differing definitions of constipation
older people are more likely to regard straining, passage
of hard stools or a feeling of incomplete evacuation as
due to constipation, but most definitions of constipation used in studies refer to bowel action frequencies.
Additionally, older people may be overly concerned and
more easily distressed by bowel action changesa legacy of being brought up in an era where regular bowel
actions were felt essential to good health, and any deviation led to a dose of castor oil or similar. Psychological
distress has been shown to be associated with complaints about constipation in older people living at home.6

PREVALENCE
Constipation is a common complaint amongst older people and a frequent concern for their healthcare providers
in hospitals, long-term care settings, clinics and community practice. Patient self-report may overestimate the
prevalence of constipation. For instance, a community
study of 3000 people over the age of 65 found that 34%
of women and 26% of men complained of being constipated,5 and a day hospital study reported that 55% complained of constipation.6 However, several studies have

Laxative Use
Whatever the explanation, this concern with constipation is undoubtedly a major reason behind the high usage of laxatives in older people. Laxatives are the second
most commonly acquired over-the-counter medication
by older people,13 with a third using them at least weekly.12 But self medication is not the sole reason for extensive laxative use by older people76% of hospitalised
elderly patients and 74% of nursing home residents are
prescribed at least one type of laxative.10-12,14 This high
usage is not confined to those who consider themselves
constipatedbetween a fifth and a third of regular laxative users do not consider themselves constipated,6,9
many taking laxatives in a misguided belief in the benefits of regular purgation.

Michael C Woodward, FRACP, Director, Aged Care Services, Austin &

Repatriation Medical Centre, Repatriation Campus, Heidelberg West,
Victoria
Address for correspondence: Michael C Woodward, Director, Aged Care
Services, Austin & Repatriation Medical Centre, Repatriation Campus,
Banksia Street, Heidelberg West Vic. 3081
E-mail: [email protected]

ASSESSMENT
A full assessment is required when there is complaint of
constipation, or laxatives are being used. A complete
history should be taken including relevant details as
outlined in Table 1, a physical examination performed
and, on occasions, investigations arranged.3,4 At the very
least, most patients should have abdominal palpation, a

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Table 1. Relevant details in the history

Past anorectal or bowel disease or surgery
Other illnesses
Diet and fluid intake
Mobility
Duration of episodes of constipation
Frequency of bowel actions
Character of stool (colour, volume, consistency)
Straining
Pain on defaecation
Faecal incontinence
Laxative use
Other medications (including non-prescribed medications)

Table 2. Causes of constipation in older people

rectal examination, and an abdominal X-ray. The purpose of this assessment is to exclude the reversible or
more serious causes of constipation, which are included
in Table 2. Many of these causes are more prevalent in
older people, but age alone is not a cause of constipation. Constipation is associated with numerous complications (Table 3), so prompt assessment is appropriate.

Medications
Opiates
Anticholinergics
antispasmodics
antidepressants (tricyclics)
antipsychotics
antiparkinsonian medications
Drugs that contain cations
iron
aluminium (antacids, sucralfate)
calcium (antacids, supplements)
Neurally active agents
antihypertensives (some)
calcium channel blockers (some e.g. verapamil)
anticonvulsants
Diuretics
Anti-inflammatories
Miscellaneous agents
octreotide
polystyrene resins
cholestyramine

NON-PHARMACOLOGICAL MANAGEMENT
Once constipation has been assessed, even if it is decided that the patient is not actually constipated, it is important to educate the person as to what constitutes
normal bowel habit, correcting common misconceptions.
Many patients are relieved to hear that between three
bowel actions a week, and three a day, is normal, as is
occasional straining and a variation in the amount and
consistency of faeces passed. Toileting habits should
be discussed, emphasising the need for sufficient time,
comfort and privacy, particularly in institutional settings.
Individuals should be encouraged to attempt defaecation half an hour following breakfast or other meals to
take advantage of the gastrocolic reflex. Where straining is predominant, care should be given to treating haemorrhoids or other anorectal lesions, and where possible,
elevating the legs whilst seated on the toilet so as to
facilitate effective use of weakened abdominal and pelvic floor musclesa moulded standing stool placed
around the toilet is available for this.
The essentials of healthy bowel function should be
attended tothese are adequate fluids, fibre and exercise. These approaches, described below, may take up
to several weeks to be effective.
Fluids
Unless contraindicated, older people should be reminded to drink at least 68 glasses (1500 mL) of fluid daily.
Increased fluid intake may be achieved through a jug of
water being freely accessible beside the bed for institutionalised patients, and provision of soups, jellies and
frozen ices. Fluid intake may need to be higher over summer and for those on diuretics who have a stable cardiovascular status.
Fibre
Whilst 1520 g of fibre is adequate, many sources recommend 3035 g per day. Dietary sources include bran,
wholegrain breads, cereals, pasta and rice (especially
brown rice), fruits, vegetables and legumes, and seeds
and nuts. Fibre facilitates bowel actions by increasing
faecal mass and reducing intestinal transit time. It also

Diet
Reduced food intake
Reduced fibre
Reduced fluid
Limited mobility
Illness
Pain
Sedentary lifestyle
Limited access to toilet
Inconveniently located toilet
Uncomfortable toilet
Lack of privacy
A long journey
(these all cause voluntary suppression of defaecation reflex)

Metabolic and endocrine causes

Hypercalcaemia
Hypokalaemia
Hypothyroidism
Porphyria
Gut lesions
Irritable bowel syndrome
Obstruction
carcinoma
volvulus
stricture
Aganglionosis
primary (adult onset is rare)
acquired (may be due to laxatives)
Diverticular disease (may be caused by constipation)
Anal lesions
Painful lesions
Fissures
Haemorrhoids
Neurogenic causes
Spinal cord lesions
Multiple sclerosis
Parkinson's disease
Shy-Drager syndrome
Stroke
Depression or isolation
Direct effect of depression
Increased preoccupation
States of confusion
Dementia
Delirium

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Table 3. Complications of constipation

Gastrointestinal
Impaction
Obstruction
Megacolon
Faecal incontinence
Rectal distension
Rectal prolapse
Haemorrhoids
Anorexia and vomiting

cereals varies widely (the more palatable are often the

saltiest), so large amounts may be unsafe in patients
with cardiac disease, renal impairment or hypertension.
Exercise
This may be as simple as a daily walk or even standing
up for those who are otherwise bed-bound.15 Indeed,
bed-bound people may benefit from being helped to the
toilet or commode, rather than being offered a bed pan,
and may also benefit from abdominal massage.

Urological
Retention
Incontinence
Urinary infection

LAXATIVES
Where non-pharmacological therapy has failed, laxatives
may be needed. Whilst a large range of oral laxatives,
suppositories and enemas are available, there have been
relatively few new medications developed in recent years.
Those available can be categorised as shown in Table 4.
The mechanism, efficacy and adverse effects of the drugs
in these classes vary widely and warrant further discussion.

Cardiac and vascular

Arrhythmias
Vasovagal episodes
Angina
Pulmonary emboli
Other
Delirium
Laxative abuse
Anxiety

provides a substrate for colonic bacteria, with the production of gases and short chain fatty acids that increase stool bulk. The increased bacterial numbers
themselves contribute to stool bulk.
Fibre is not effective without adequate fluids, and is
contraindicated in patients with faecal impaction or colonic dilatation. The salt content of processed breakfast

Bulking Agents
Some of these are extracted from natural sources such as
seeds, bark and gum, and some are synthetic compounds
such as methylcellulose. These agents work similarly to
dietary fibre, itself a bulking agent. They may have additional actionspsyllium, for instance, also lowers cholesterol. As with dietary fibre, they must be taken with
adequate fluid.
Adverse effects also shared with dietary fibre include bloating and flatulence which may discourage the
older patient from continuing with them. However, these

Table 4. Examples of oral laxatives and enemas and suppositories

Type

Products

Time to onset

Oral agents
Bulking agents

Psyllium (Agiofibe*, Agiolax*, Metamucil*, Mucilax, Nucolox)

Ispaghula (Fybogel, Agiofibe*, Agiolax*, Metamucil*)
Methylcellulose (Cellulone)
Sterculia (Granolcol*, Normacol Plus*, Normafibe)

Stool softeners

Docusate Sodium (Coloxyl tablets, Sennesoft*)

Stimulants and secretagogues

Senna (Agiolax*, Bekunis Senna Tablets, Coloxyl with Senna*, Laxettes with
Senna, Sennesoft*, Senokot)
Phenolphthalein (Figsen laxative tablets, Laxettes)
Bisacodyl (Bisalax, Durolax)
Frangula (Granocol*, Normacol Plus*)
Lactulose (Actilax, Duphalac, Lac-Dol)
Sorbitol (Sorbilax)
Polyethylene glycol plus electrolytes (Colonlytely, Glycoprep, Golytely, Movicol)
Magnesium sulphate (Epsom Salts)
Soda buffered saline laxative mixture (Kwikprep, Fleet)
Sodium picosulphate (Picolax*)

2-3 days
2-3 days
2-3 days
2-3 days
1-3 days
8-12 hours
6-12 hours
6 hours
2-3 days
24-48 hours
6-12 hours
6-12 hours
1-3 hours
6-12 hours
6-12 hours

Osmotic laxatives

Lubricants

Paraffin liquid (Parachoc, Agarol)

6-12 hours

Prokinetic drugs

Colchicine (Colgout)
Misoprostol (Cytotec)
Cisapride (Prepulsid)

4-6 hours
4-6 hours
6-12 hours

Enemas and suppositories

Docusate and bisacodyl (Coloxyl Suppositories)

Bisacodyl (Durolax, Fleet)
Glycerol (Glycerin Suppositories, Glycerol Suppositories)
Sorbitol and sodium salts (Fleet Micro-Enema, Microlax)
Soap and water
Phosphate (Fleet Ready-to-Use Enema, Travard Phosphate Enema)

minutes
minutes
minutes
minutes
minutes
minutes

* combination products

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symptoms tend to resolve in the second week of treatment,16 so the patient should be encouraged to persist.
Temporarily reducing the dose may also be helpful. Bulk
laxatives do not cause malabsorption of iron (unlike unprocessed bran), fat-soluble vitamins or digoxin.17,18
The actual fibre content of the recommended daily
dose of agents varies widely, from 1.612.1 g,19 so care
should be taken to recommend an adequate dose: this
should be around 10 g of fibre a day, along with dietary
fibre. In addition, preparations can vary in electrolyte
and sugar content e.g. regular and orange-flavoured
Metamucil contain different amounts of sucrose, which
needs to be considered in diabetic people.
The efficacy of bulking agents and fibre has, surprisingly, not been well established. Studies have shown
that whilst these agents increase stool output and reduce intestinal transit time in people with normal colonic
function, a meta-analysis of these studies showed that
this effect is reduced in patients with constipation, who
do not achieve a return to normal stool output or transit
time.20
In nursing homes, addition of dietary fibre has been
shown to decrease laxative use.21 Despite these conflicting results, bulking agents remain a preferred laxative for
older people but may need to be combined with, or substituted by, other agents if found ineffective.
Stool Softeners
Docusate sodium acts as a surfactant, lowering stool
surface tension to allow water to penetrate and soften
the stool. It stimulates cyclic AMP to increase the secretion of water, sodium and chloride into the gut. It also
causes mucosal irritation with release of histamine and
5-hydroxytryptamine22 and desquamation of gut epithelial cells.23 It has no effect on colonic motility.24
Adverse effects of docusate include melanosis coli
and, through altering intestinal mucosal permeability,
increased absorption of some medications including other laxatives such as mineral oil and phenolphthalein.
At least six randomised trials have examined the efficacy of docusate for prophylaxis and treatment of constipation.25-30 None provides convincing evidence of a
beneficial effect despite doses of up to 300 mg daily, but
most show non-significant trends towards increased
stool frequency and reduced frequency of hard stools.
The extensive use of docusate, especially in institutional settings,2 does not seem warranted on this evidence
base. It may be more useful when confined to patients
who strain excessively, or where straining should be prevented (e.g. crescendo angina or painful haemorrhoids).
The usual dose is 50120 mg a day.
Stimulants and Secretagogues
Senna, an anthracine glycoside manufactured from the
dried leaflets or legumes of Cassia acutifolia or C. angustifolia, is hydrolysed by colonic bacteria into free
absorbable anthraquinones, which alter electrolyte transport and increase intraluminal fluids, thus generating
propulsive activity.31,32 The overall effect is to increase
peristalsis in the distal colon and to stimulate a mass
peristalsis, followed shortly by evacuation of softened
stool.33
Senna generally induces evacuation 8-12 hours after administration but frail elderly patients have slower
response times34 and may require up to 10 weeks of daily

use before achieving a regular bowel habit.35 Bedtime

use reduces the risk of nocturnal faecal incontinence.
The usual dose is 12 tablets (7.515 mg) or 12 teaspoons daily.
Phenolphthalein acts similarly to cholera enterotoxin, increasing intestinal water and electrolyte content.
Approximately 15% is absorbed and undergoes enterohepatic circulation, prolonging its duration of action.
Bisacodyl is structurally related to phenolphthalein
and has mechanisms of action similar to free anthraquinones.33,36 There is also a suppository form of bisacodyl
that has minimal systemic absorption37 and is most useful for older people who strain to defaecate. Daily use
may result in a sensation of rectal burning so administration three times a week is recommended.38 Castor oil is
also a stimulant laxative but is now rarely used.
Adverse effects of stimulant laxatives may include
malabsorption of fats, protein, calcium and potassium.
However, administration of high doses of senna to patients over the age of 80 for 6 months did not cause any
significant losses of protein or potassium.39 Oral bisacodyl is more likely to cause electrolyte disturbances
than senna.31 All stimulant laxatives can cause dosedependent cramping and diarrhoea. Cathartic colon is
said to be another adverse effect of stimulant laxatives
and is suspected when increasing laxative doses are required, but it is ill defined and based largely on a 1968
study40 in mice using unspecified doses of senna. The
damage to the myenteric plexus seen in that study has
not been replicated in subsequent studies in men,41,42
and similar changes have been found in patients with
diabetes and Crohns disease without prior laxative use.43
The present evidence suggests that cathartic colon is
an unusual complication arising from the heavy ingestion of stimulant laxatives for many years, which, as one
case report illustrates may be reversed following cessation of laxative use.44
Melanosis coli is a histological finding that is also
associated with the consumption of stimulant laxatives,
but not however with symptoms of constipation nor prolonged transit time.
Phenolphthalein and castor oil are associated with a
high risk of malabsorption and dehydration and are not
recommended for older people.
Demonstration of the efficacy of stimulants and
secretagogues suffers the same problems that plague
many trials of laxatives in older peoplepoorly defined
end points, small numbers of patients and the frequent
use of combination laxatives, precluding a conclusion
on which agent was effective. Indeed, a recent review of
randomised trials of laxatives in four classes (bulking,
stimulant, stool softeners and osmotic) concluded that
there were only non-significant trends in favour of treatments over placebo when the end points were number of
bowel actions per week.45 In a randomised double-blind
cross-over study of 77 institutionalised elderly patients,
a senna-fibre combination was found to be significantly
more effective than lactulose.46
Osmotic Laxatives
Osmotic Agents
Hyperosmolar laxatives include the non-absorbable disaccharides lactulose and sorbitol. They pass unchanged
into the colon to be metabolised by colonic bacteria into
lactic, acetic and formic acids, with the liberation of car-

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bon dioxide. These low molecular weight organic acids

osmotically increase intraluminal fluid and lower stool pH.
Lactulose has been shown to be more effective than
placebo in elderly patients.47A well designed trial has
shown lactulose and sorbitol to be equally efficacious in
treating severe constipation in ambulatory elderly people48 but, as described above, lactulose has been shown
to be less effective than a senna-fibre combination.46
Lactulose is considerably more expensive than sorbitol and, as it is equally efficacious, sorbitol is preferred
at a dose of 2030 mL up to four times a day. However,
the long-term safety data available for lactulose are not
yet available for sorbitol.
Polyethylene glycol is a potent hyperosmolar laxative that moves a large amount of fluid into the lumen. It
is an effective bowel cleaning agent49 and is also effective in the treatment of faecal impaction.50,51
Large volume polyethylene glycol (up to 3000 mL) is
used mainly as a bowel preparation but can, in extreme
cases, be used for constipation. Polyethylene glycol with
electrolytes is recommended for faecal impaction and is
probably also effective for chronic constipation, at a dose
of up to 8 sachets per day, each mixed with 125 mL of
water. The usual dose is 13 sachets per day.
Saline Laxatives
Magnesium salts osmotically draw fluid into the small
bowel lumen, inducing mixing actions and contractions
of the colonic wall. Magnesium hydroxide also stimulates the release of cholecystokinin, which shortens transit through the colon as well as small intestine. Because
of their adverse effects, magnesium salts are not recommended for the treatment of constipation in older people. There is one published study on the benefits of
saline laxatives in elderly people.52
Oral phosphate works similarly but appears to be
more potent. It can be used for severe constipation but
there is little published data on its effectiveness.
Adverse Effects
All osmotic laxatives can cause excessive fluid and electrolyte shifts, and have been associated with hypotension, collapse and death. Additionally, magnesium salts
and oral phosphate can be absorbed, causing hypermagnesaemia and hyperphosphataemia. Hyperosmolar
laxatives promote bacterial overgrowth which can cause
flatulence and colic but rarely to the degree of affecting
compliance. The long-term safety of lactulose has been
demonstrated in elderly users.53,54 Polyethylene glycol
can be associated with hyponatraemia and hypokalaemia but this is less likely when it is combined with electrolytes.55
Lubricants
Paraffin liquid lubricates faeces and is particularly useful when straining is a major problem, which probably
explains its continued popularity amongst older people.
However, it has been associated with a wide range of
adverse effects including lipoid pneumonia from aspiration, granulomatous hepatitis from systemic absorption,
deficiencies in the fat soluble vitamins A, D, E and K,
and pruritus ani and faecal incontinence from anal leakage of the oily stool. As aspiration is more likely in older
patients with dysphagia or oesophageal motility disorders, paraffin should be particularly avoided by these

patients, but its use in all elderly people is not recommended due to its overall adverse effect profile.
Prokinetic Agents
Colchicine works by increasing intestinal motility and
increasing prostaglandin secretion. It may also cause
some malabsorption, contributing to its laxative efficacy. However, it can cause renal failure so should not be
used as a first-line agent, and should only be used in the
recommended dose of 0.5 mg three times daily.
Cisapride directly increases gastrointestinal motor
activity, as does misoprostol, a synthetic prostaglandin
E1 analogue. Both are systemically active and have been
shown to be effective in single studies.56,57 Cisapride
has recently been associated with cardiac arrhythmias
so should only be considered as a laxative where all
other measures have failed. The recommended doses
are 1540 mg daily for cisapride and up to 1200 mg a day
for misoprostol. These drugs should only be used short
term in patients refactory to more standard approaches.
Enemas and Suppositories
Enemas induce evacuation as a response to colonic distension as well as by plain lavage. Enemas given three
times a day to nursing home residents did not increase
their baseline slow intestinal transit times.58 The multiple
active components of some small volume enemas also
irritate the rectal mucosa and cause release of electrolytes and water, further increasing rectal distension. Paraffin and glycerol suppositories soften and lubricate
faeces.
Phosphate and soap enemas have been associated
with rectal mucosal damage and even rectal necrosis,59,60
and all enemas, especially if used frequently and if used
before manual disimpaction, can risk perforation of the
rectum.61 Enemas have also been associated with fluid
and electrolyte disturbancesphosphate enemas, for
instance, can cause hyperphosphataemia.62 Paraffin and
glycerol suppositories can cause faecal leakage and pruritus ani.
There is little published evidence on the effectiveness of enemas and suppositories, but clinical experience does suggest they can be effective. They are most
appropriate for faecal impaction (after manual disimpaction, if needed) and for patients who strain to defaecate.
The commonest reason for their failure is probably inadequate administration.
PRACTICAL APPROACH TO MANAGEMENT
Prevention
For patients who are concerned about the possibility of
constipation reassurance may be all that is required. The
non-pharmacological approaches, discussed above,
should be emphasised. However, when constipation is
highly likely to occur (for example, in a patient who will
be having abdominal surgery or who will be treated with
narcotic analgesics) it may be justifiable to prescribe a
short course of a laxativefor instance an osmotic agent
or senna.
Impaction
Faecal impaction must be excluded in all more severely
or chronically constipated people by both a rectal examination and an abdominal X-ray. Impaction should be
dealt with before fibre or oral laxatives are used. Suppos-

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itories or enemas may be sufficient, but manual disimpaction is sometimes required first. This is very un- comfortable and may need to be carried out over a day rather
than on one occasion. A local gel anaesthetic should be
used liberally and sometimes a general anaesthetic is
required. After manual disimpaction, or if this is not required, management is as for severe acute constipation
(below).
Acute Constipation
After impaction has been excluded, a short course of an
oral agent is appropriate (e.g. senna) in conjunction with
the non-pharmacological approaches. Fibre and bulking
agents should only be used if the bowel is not dilated
an abdominal X-ray can be helpful. For patients who fail
to respond, sorbitol or polyethylene glycol with electrolytes can be used in increasing doses, to the recommended maximum, if necessary. If straining is a major
symptom, a suppository or enema can be used. Some
would recommend docusate for these patients, despite
the lack of convincing evidence of efficacy.
If the patient remains constipated, especially if ongoing impaction is confirmed by an abdominal X-ray, a
repeat search for more serious causes of constipation
should be made.
Chronic Constipation
For these patients, an underlying cause should be
sought. Bowel dilation is more common so an abdominal
X-ray should be performed before using bulking agents.
The colon should be emptied and this may require frequent enemas or higher doses of oral agents such as
sorbitol or polyethylene glycol with electrolytes. Once
the colon is empty and not dilated (an abdominal X-ray
will confirm this) non-pharmacological approaches
should be instituted. Bowel retraining with appropriate
use of enemas can be helpfulmany continence clinics
can assist here. These patients are often long-term laxative abusers and this should be addressed (see below),
although success may be limited.
Laxative Abuse
Management of this can be very difficult. The patient
should be educated about normal bowel function and
the other non-pharmacological approaches instituted. If
the patient is unwilling to completely cease all laxatives,
attempts should be made to change them to safer agents
such as sorbitol, lactulose or senna, and then to progressively wean them (for example, reduce from daily to
second daily). A good therapeutic relationship is important. Again, bowel retraining may be helpful, under expert supervision.
Residents of Long-Term Care Facilities
The first principles of non-pharmacological management
pertain, but may need to be modified (e.g. simply standing rather than exercise). Fibre and bulking agents should
be avoided until an abdominal X-ray shows no colonic
dilation. Faecal impaction should also be sought and
treated first. Oral agents, enemas and suppositories, if
necessary, should be used for short courses only. As
soon as possible, dietary fibre should be increased.
Faecal Incontinence
This is commonly due to faecal impaction, so there should

be a high index of suspicion that this is present. If in

doubt, the patient should be treated as if impacted.
Cost Containment
Most laxatives are relatively cheappartly because there
are several competing brands or generics, and most are
available over the counter. Dietary fibre is nearly always
cheaper than bulking agents. Sorbitol is cheaper than
lactulose and as effective. Polyethylene glycol with electrolytes is relatively expensive but may be very effective
for more severe constipation or faecal impaction.
CONCLUSION
Constipation is a common clinical issue and should certainly be taken seriously. Most elderly people improve
with advice about normal bowel function, and recommendations about fibre, fluid and exercise. Older people
will enjoy a better quality of life, wherever they are resident, if they are satisfied with their bowel function. This
is nearly always achievable.
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Submitted: October 2001

Accepted after external review: January 2002

Journal of Pharmacy Practice and Research Volume 32, No. 1, 2002.

THE CANBERRA HOSPITAL

VACANCY
SENIOR PHARMACIST
STERILE PRODUCTION
ASEPTIC DISPENSING
Senior Professional Officer Grade C
The Canberra Hospital is a major teaching
centre for the ACT and surrounding NSW
region. The hospital has a progressive
Pharmacy Department with a staff of forty
offering a full range of services.
A vacancy exists for a Pharmacist to
manage the centralised intravenous admixture service. The successful applicant will
supervise Technicians for the day-to-day
preparation of intravenous admixtures
(excluding cytotoxics), parenteral nutrition
solutions and other sterile products, will act
as a resource person for intravenous
therapy and parenteral nutrition, liaise with
medical and nursing staff on a daily basis
and be part of a dynamic clinical team. The
salary range is $55,684$60,040.
The Canberra Hospital offers Salary
Packaging with fringe benefits tax-free
threshold up to $8755. Employees can also
package beyond the FBT-free threshold up
to 30% of gross salary.
CONTACT AND FURTHER INFORMATION:
Sue Alexander (02) 6244-2121

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