老年人便秘的評估與處置

Evaluation and Treatment of Constipation in the Elderly

10.29461/TGG.200902.0002

黃建勳(Chien-Hsun Huang)；蘇奕彰(Yi-Chang Su)；洪壽宏(Shou-Hung Hung)；邱泰源(Tai-Yuan Chiu)；曾慶孝(Chin-Hsiao Tseng)

老年人 ； 便秘 ； 瀉劑 ； elderly ； constipation ； clinical practice ； laxatives

台灣老年醫學暨老年學雜誌

4卷1期（2009 / 02 / 01）

15 - 26

繁體中文

便秘是老年人很常見的健康問題，男性有四分之一，女性有三分之一有便秘，在住院的老人和護理之家的住民更多爲75%以上，便秘不僅會嚴重影響生活品質，也是身體不適的常見起因。便秘並不是老化的正常生理現象，但老年人卻因多種疾病與多重用藥的關係而容易發生便秘。臨床上，便秘是老年人尋求家庭醫師協助的常見原因，因此瀉劑在老年人的處方中相當普遍，但浮濫或過度使用的情形也很常見。 便秘並沒有單一或公認的定義，流行病學的研究將每週解便次數小於三次者定義爲便秘，實際上，許多病患儘管排便頻率正常仍有便秘困擾。便秘依病理機轉可分爲三類，「正常傳輸型」常見於功能性便秘，此外還有「排便障礙型」、「慢傳輸型」或混合型。老人便秘需作周全性的評估，病史詢問應包括飲食與生活習慣、病歷回顧、排便日誌與完整的用藥記錄，身體理學檢查則以腹部和會陰部爲重點，另外還須評估其活動力、認知功能、情緒狀態等可能與便秘相關的因素。處置方法則視個案的自我需求而定，適度增加水分、運動和纖維攝取量仍是老人便秘的基本建議。許多常用瀉劑缺乏實證基礎，包括鎂、刺激性瀉劑和洋車前子以外的纖維製劑。此外，鎂不適合用在腎功能不全的老年人、刺激性瀉劑因副作用只適合短期使用，bisacodyl因不宜磨粉也不適合鼻胃管使用者、滲透性瀉劑如polyethylene glycol和lactulose則爲老人便秘之首選。對於五十歲以上的便秘病患，應鼓勵其接受大腸癌篩檢，有血便、體重減輕、大腸癌病史或家族史等警訊的個案，更應接受大腸鏡檢查。

Constipation is highly prevalent in old adults and also a common health problem in clinical practice. Although constipation is not a physiologic consequence of normative aging, decreased mobility and other comorbid medical conditions may contribute to the increasing prevalence in older adults. Though there was no consistency on the definition of constipation, ”constipation” can be diagnosed without preliminary causes identified, such as a unique medical condition or some side effect from the medication. Management of chronic constipation includes keeping a defecation diary of the bowel movements, counseling on bowel retraining, increasing fluid and dietary fiber intake, and enhancing physical activity. Medication decisions should be made on thorough individualized examination. Empiric treatment may be tried initially for patients with the functional constipation. For the secondary constipation, treatment should address on the underlying conditions. There are a variety of over-the-counter and prescription laxatives available for the constipation. Based on the literature review, osmotic laxatives, such as polyethylene glycol and lactulose, are effective in old adults and well tolerated. Psyllium, a bulk laxative, is also effective in the treatment of constipation, while there has been the limited evidence for stimulants, stool softeners, and other bulk laxatives. If constipation is refractory to medical treatment, further clinical evaluation may be warranted to assess colonic transit time and anorectal dysfunction. Alternative treatment approaches such as biofeedback and surgery may be considered.