Grades are shown as the source states them. AGA–ACG and the BDA use GRADE: AGA–ACG grades recommendations strong or conditional, and the BDA strong or qualified, each with the certainty of evidence. The Chinese consensus does not grade its own advice. Medicines and their availability differ between countries.
Key recommendations
Chronic constipation becomes more common with age: about 15–20% of people over 60 and 20–37% of those over 84 in community studies, and up to 80% of people in long-term care.
IntroductionChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Diagnose with the Rome IV criteria: symptoms that began at least 6 months ago and are present in the last 3 months, with two or more of straining, lumpy or hard stools, incomplete evacuation, a sense of blockage, or manual help to defecate (each in over a quarter of defecations), or fewer than 3 spontaneous bowel movements a week.
IntroductionChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Most chronic constipation in older people is functional — slow transit, an evacuation disorder, or both — but look for organic disease and constipating medicines first.
Types of chronic constipation in the eldersChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Lifestyle is the foundation: at least 25 g of dietary fibre a day (cooked soft if chewing is difficult), 1.5–1.7 litres of fluid a day drunk before thirst is felt, regular activity without long periods of sitting, and a toilet routine within 2 hours of waking or after meals.
Adjustment of lifestyleChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Use a stepwise approach: lifestyle changes, stopping or reducing constipating medicines, and fibre or an osmotic laxative first, adding a prokinetic if needed.
Graded approach to the treatment of chronic constipation in elderlyChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Polyethylene glycol (PEG) is recommended; its effect has been shown to last over 6 months. Side effects include bloating, loose stools, flatulence and nausea.
Strong; moderate certaintyRecommendation 2American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Diagnosis
Medicines that commonly cause or worsen constipation in older people: opioids, tricyclic antidepressants, anticholinergics, antihistamines, antiparkinsonian drugs, NSAIDs, calcium- or aluminium-containing antacids, bismuth, iron, calcium channel blockers, diuretics and some antibiotics.
Types of chronic constipation in the elders: drug-induced constipationChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Organic causes include bowel tumours, diverticular disease, strictures, rectal prolapse and rectocele; stroke, Parkinson's disease, spinal cord disease, autonomic neuropathy and dementia; hypercalcaemia and hypokalaemia; diabetes, hypothyroidism and hyperparathyroidism; and heart failure.
Table 1Chinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Assess risk factors: fluid intake (under 1.5 litres a day, with thirst blunted by age), fibre intake (often low when chewing is difficult), mobility, the toilet environment (privacy, needing help, facilities), mood, and social support.
Risk factors assessmentChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Digital rectal examination is especially important: it finds faecal impaction, anal stricture, rectal prolapse or a mass, and paradoxical contraction of the pelvic floor.
Clinical assessment: physical examinationChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Ask about every laxative, suppository and enema — type, dose, frequency and duration — and assess cognition, which is often impaired in older people with constipation and shapes the plan.
Clinical assessment: medication; cognitive functionChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Investigations
Check a full blood count, urinalysis and faecal occult blood test. With severe constipation or alarm features, add colonoscopy, biochemistry, thyroid function and imaging as needed. In very old, frail or immobile people, weigh whether tests are acceptable and feasible to avoid over-investigation.
Clinical assessment: screening examinationChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
When functional constipation does not respond, colonic transit studies, anorectal manometry and the balloon expulsion test show which type it is.
Clinical assessment: screening examination; Graded approachChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Treatment
Fibre supplements are suggested, especially when dietary fibre is low; of those studied, only psyllium clearly works. Encourage fluids with fibre; flatulence is common.
Conditional; low certaintyRecommendation 1American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Psyllium increases the chance of improvement, increases stool frequency, softens stools and reduces straining. Fibre works best at more than 10 g a day for at least 4 weeks; build up gradually if it causes bloating or flatulence, and take extra fluid.
Strong; low certaintyFibre supplements: statements 1.1, 2.1 and 3.1; good practice statementsBritish Dietetic Association (BDA) 2025
Two or three kiwifruit a day for at least 4 weeks may help, with a similar chance of improvement to psyllium; kiwifruit may suit people who get bloating, pain or flatulence with psyllium.
Qualified; low certaintyFruits: statement 23; Kiwifruits: good practice statementsBritish Dietetic Association (BDA) 2025
Magnesium oxide is suggested; start at a low dose and increase if needed. Avoid it in renal insufficiency because of the risk of hypermagnesaemia.
Conditional; very low certaintyRecommendation 3American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Lactulose is suggested for people who do not respond to, or cannot tolerate, over-the-counter treatments; bloating and flatulence are common and dose-dependent.
Conditional; very low certaintyRecommendation 4American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Bisacodyl or sodium picosulfate are recommended for short-term use (daily for up to 4 weeks) or as rescue treatment. Longer use is probably appropriate but less studied; abdominal pain, cramps and diarrhoea are common, so start low.
Strong; moderate certaintyRecommendation 5American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Senna is suggested, starting at a low dose; trial doses were higher than usual practice, and cramping is more likely at higher doses.
Conditional; low certaintyRecommendation 6American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Pooling two trials of senna as a dietary supplement found no significant effect on stool frequency; in one trial most people taking senna needed a lower dose because of abdominal pain or diarrhoea.
Qualified; low certaintySenna supplements: statement 19British Dietetic Association (BDA) 2025
When over-the-counter treatments fail, linaclotide, plecanatide or prucalopride are recommended, either instead of or in addition to them.
Strong; moderate certaintyRecommendations 8–10American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Lubiprostone is suggested when over-the-counter treatments fail; nausea is dose-dependent and less likely when it is taken with food and water.
Conditional; low certaintyRecommendation 7American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Probiotics may help some people, but it is unclear which strains work; people who want to try one can use a product of their choice for at least 4 weeks.
Qualified; low certaintyProbiotic supplements: statement 6; good practice statementsBritish Dietetic Association (BDA) 2025
Stop or reduce a constipating medicine where possible; if it cannot be stopped, add a laxative.
Treatment for different types of elderly chronic constipationChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
For an evacuation disorder, biofeedback is first-line, though it is not suitable for people with cognitive impairment; enemas or suppositories help with hard stools or impaction.
Biofeedback therapy; Treatment for different types of elderly chronic constipationChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Important geriatric considerations
In older people with heart or kidney disease or frailty, prefer gentle laxatives such as lactulose over osmotic laxatives that contain magnesium, phosphate or sodium.
Pharmaceutical therapyChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Avoid long-term stimulant laxatives in older people: prolonged use can disturb fluid, electrolyte and vitamin absorption and damage the bowel's nerve plexus, and long-term use of anthraquinones such as senna can cause melanosis coli.
Pharmaceutical therapyChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Avoid oral liquid paraffin: it reduces absorption of fat-soluble vitamins and can cause aspiration pneumonia in people with swallowing difficulty.
Pharmaceutical therapy: lubricating agentsChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Bulk-forming laxatives need enough fluid; avoid them with faecal impaction or suspected obstruction, and note that they can affect absorption of warfarin, digoxin and antibiotics.
Pharmaceutical therapy: bulk-forming laxativesChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Loose stool leaking around a rectal faecal impaction (overflow, or pseudodiarrhoea) in a frail older person can be mistaken for diarrhoea.
Pharmaceutical therapyChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Colonic transit takes under 5 days in healthy older people but up to 8 days in frail people, and pelvic floor changes (rectocele, mucosal prolapse, perineal descent) add to evacuation difficulty, especially in women.
Clinical assessment: comorbidity and general conditionChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
In trials, lubiprostone and prucalopride worked about as well in people aged 65 and over as in younger adults; for linaclotide and plecanatide there were no clear differences by age, but too few older people to analyse formally.
Lubiprostone, linaclotide, plecanatide and prucalopride: DiscussionAmerican Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Surgery rarely helps and carries high risk in older people; consider it only for severe refractory constipation after full review.
SurgeryChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Drug doses
Prucalopride: 2 mg once daily, or 1 mg daily in severe renal impairment (creatinine clearance under 30 mL/min). Do not use with intestinal perforation or obstruction, Crohn's disease, ulcerative colitis or toxic megacolon.
Prucalopride: DiscussionAmerican Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023
Magnesium oxide: 0.5–1.5 g a day for at least 4 weeks, starting at 0.5 g and increasing weekly as tolerated.
Magnesium oxide supplements: good practice statementsBritish Dietetic Association (BDA) 2025
A lubricant enema such as glycerin, 10–15 mL, softens hard stools and suits evacuation difficulty or impaction.
Pharmaceutical therapy: lubricating agentsChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
When to refer
If first-line treatment fails, re-evaluate and refer for transit and anorectal function testing to guide combined treatment; if that fails too, a multidisciplinary team should reassess.
Graded approach to the treatment of chronic constipation in elderlyChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Red flags
Alarm features: rectal bleeding or a positive faecal occult blood test, anaemia, abdominal pain or a mass, and changes in appetite, weight or bowel habit; also a family history of colorectal polyps, colorectal cancer or inflammatory bowel disease.
Clinical assessment: alarming signsChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Hard impacted stool can cause obstruction, ulceration of the bowel wall and perforation, and a loaded rectum can cause urinary retention and urinary infection.
Complications and impact of CC in the eldersChinese Geriatric Society and the Editorial Board of the Chinese Journal of Geriatrics 2018
Recent updates
The 2025 BDA guidelines are the first comprehensive dietary guidelines for constipation. They support psyllium, kiwifruit, magnesium oxide and high mineral-content water, but found too little evidence to recommend any whole-diet approach.
Abstract; Whole diet interventionsBritish Dietetic Association (BDA) 2025
The 2023 AGA–ACG guideline recommends PEG, sodium picosulfate, linaclotide, plecanatide and prucalopride, and suggests fibre, lactulose, senna, magnesium oxide and lubiprostone.
AbstractAmerican Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) 2023