REPLY POSTS:Reply separately to two of your classmates posts (See attached classmates posts, post#1 and post#2). Instructions: - In your reply posts, include how the information you learned from your

POST # 2 ANITA

Anita’s Topic: Physiological changes related to constipation and the elderly
The process of aging is irreversible, and the rate and effects of aging vary from person to person (Hubert & VanMeter, 2018). Aging and the changes that occur within the body do not necessary correlate to chronological age so as clinician’s it is important to understand the effects of aging on the various systems within the body and use age as a relative marker (Hubert & VanMeter, 2018). This post will explore the physiological changes related to constipation and the elderly, along with guidance on assessment and management of constipation within this patient population. 
Prior to understanding gastrointestinal changes that contribute to constipation it is important to also understand how the digestive system and nutrition impact constipation. Maintaining a balanced diet and good nutrition is a challenge for many older adults (Hubert & VanMeter, 2018). Environmental, physical and personal choices impact food choices and intake which can lead to nutritional deficiencies, reduced intake, and reduced consumption of certain foods, like protein (Hubert & VanMeter, 2018). Physical changes include losing teeth due to periodontal disease and decreased salivary secretions (Hubert & VanMeter, 2018). These physical changes impair chewing options for elderly persons and fragile gum tissue in the mouth may be irritated by denture use which can lead to infection from food residue or altered nutritional status (Hubert & VanMeter, 2018). The need for a soft diet also affects nutritional status and intake (Hubert & VanMeter, 2018).
Constipation is a common issue in the elderly (Rao, 2020). The definition of constipation varies across clinicians and patients. Following the Rome IV criteria, functional constipation includes straining, hard stools, sensation of incomplete evacuation, using digital manuevers to remove stool, sensation of an anorectal obstruction or blockage, and/or a decrease in stool frequency (usually less than three bowel movements a week) (Rao, 2020). The patient must experience these symptoms for at least three months with symptom onset for six months prior to the diagnosis (Rao, 2020). The prevalence of constipation in older adults occurs between 24-50 percent (Rao, 2020). Rao (2020) states that laxative use in older adults can be up to 74% in nursing home residents (compared to 10-18% in community residents). 
Rao (2020) outlines risk factors that may lead to constipation include age, female gender, physical inactivity, low socioeconomic status, concurrent medication use, depression and educational status. Other risk factors include meal frequency, caloric intake, co-morbid illnesses and nursing home residence (Rao, 2020).
The pathophysiology of constipation in the older adult is mainly due to two reasons: colorectal dysfunction or secondary constipation as result of various organic and inorganic causes (Rao, 2020). One important note Rao (2020) makes is that constipation in the elderly is usually multifactorial. Some pathological reasons for constipation include colorectal dysfunction (Rao, 2020). Primary colorectal dysfunction can be broken down into three major subtypes: slow transit constipation (STC), dyssynergic defecation, and irritable bowel syndrome (Rao, 2020). STC could be caused by a primary dysfunction of the patient’s colonic muscle (myopathy) or neuronal innervation (neuropathy). The motor functions of the colonic and anorectal area is coordinated by enteric, sympathetic and parasympathetic nerves (Wald, 2020). The distal colon receives parasympathetic innervation from sacral nerves that go through the pelvis and enter the bowel wall in the rectum (Wald, 2020). Disruption of those nerves can result in constipation associated with hypomotility, colonic dilation, decreased rectal tone and sensation, distal colonic stasis, and impaired defecation (Wald, 2020). Dyssynergic defecation (DD) is caused by difficulty or inability to expel stool from the anorectum due to anal sphincter dysfunction and slow colonic transit (Rao, 2020). 
Secondary causes of constipation, typically more prevalent in older persons, include endocrine or metabolic conditions, neurologic disorders, myogenic disorders or medication (ie. Opioid induced constipation, laxative overuse). Older adults are predisposed to malignancies in the digestive tract (Hubert & VanMeter, 2018). Carcinogenic substances become more hazardous because of the prolonged exposure of the tissues due to longer transit times (Hubert & VanMeter, 2018).
Constipation in older adults is also seen with decreased fluid intake and subsequent dehydration (Hubert & VanMeter, 2018). Decreased physical activity affects gastrointestinal motility as well as decreased fiber intake (Hubert & VanMeter, 2018). Exercise promotes normal muscle contractions in the bowel wall, so decreasing physical activity, results in an increased risk for constipation for elderly persons (Wald, 2020).
When conducting an history and physical a complete review of medications, medical history, physical activity, 24-hour diet recall, and nutritional status must be reviewed with your patient. A comprehensive physical exam, including a rectal exam is important, to assess for hemorrhoids, fissures, sphincter tone, push effort during defecation, prostatic hypertrophy, and posterior vaginal masses (Wald, 2020). Lab testing would include a complete metabolic panel to assess for diabetes, nutritional status, electrolyte imbalances, and kidney and liver function (Wald, 2020). A complete blood count, thyroid function tests are also important to assess for anemia and thyroid disorders (Wald, 2020). The main thing to consider when assessing a older person to include a thorough history and physical. 
References 
Hubert, R. J., & VanMeter, K. C. (2018). Gould's: Pathophysiology for the Health Professions (6th ed.). St. Louis, Missouri: Elsevier.
Rao, S. (2020). Constipation in the older adult. Retrieved from UpToDate: https://www.uptodate.com/contents/constipation-in-the-older-adult?search=constipation%20adult&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Wald, A. (2020). Etiology and evaluation of chronic constipation in adults. Retrieved from UpToDate: https://www.uptodate.com/contents/etiology-and-evaluation-of-chronic-constipation-in-adults?search=constipation%20adult&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3