Irritable Bowel Syndrome (IBS) is a functional disorder that is not widely understood. TIBS is more likely to be diagnosed in younger people¹ and the prevalence decreases with age.³ Approximately 10-20% of elderly people in the general population have been recognised with IBS 1. As a result, people over 65 years of age continue to manage and treat symptoms of this painful and irritating disorder for many years, interfering with the regularity of their bowel motility and affecting their daily life.²

As research in IBS is highly specific, there is potential to gain the latest knowledge from leading scientists and researchers globally. Studies regarding the connection between the elderly and the incidence of IBS, are less widely available.³ Why? Mechanisms of IBS (pathophysiology) are unclear on a fundamental basis. However, what is understood is management and treatments available that target the symptoms displayed in all age groups. This article focuses on understanding IBS and its impact on the elderly. If you or your loved ones suffer from IBS, it is important to understand the treatments available and management strategies. So let’s explore together!

What is IBS?

IBS is a functional disorder in which the individual experiences recurrent abdominal pain (more than once a week for 3 months on average)⁵ and abnormal bowel motility. This includes changes in stool frequency and appearance. It is a gastrointestinal illness^3,5 and with significant disease burden due to its complexity as a chronic condition.⁵ This differs from Bowel disease (IBD), as IBD patients display IBS symptoms and also show inflammation and other forms of damage to the bowels, including ulcers. It is advised to screen IBS-D patients with faecal analysis to rule out IBD.⁵ The Rome Criteria is used to define IBS.^2,5 It is crucial to understand that IBS does not cause significant health issues, and with age, the IBS symptoms can improve or worsen over time.4 Underlying issues alongside IBS, are detrimental to the ageing population.

There are 4 subtypes of IBS, classified depending on stool frequency. These are 

• IBS-C (constipation predominant) where patients suffer from cycles of constipation
• IBS-D (diarrhoea predominant) patients suffer from repeating episodes of diarrhoea,
• IBS-M (mixed) with both constipation and diarrhoea cycle repeats 
• IBS-U (Unclassified)^5,6 

Stool, the body waste components after digestion from mouth to small intestine, is deposited in the large intestine. In all IBS patients, this stool causes irritation surrounding the intestinal tissues.

Women with IBS are likely to show more IBS-C symptoms, whilst men are more likely to show IB-D symptoms.⁵

Mechanisms of IBS are not fully known but age- related changes may not be interfering with underlying IBS pathophysiology.¹ One possible explanation is that there is a communication error and a defect in signalling at the axis between the brain and large intestine,⁶ causing an abnormal regulation of peristalsis. Peristalsis is the action of muscle contraction from the stomach to the large intestine, that is always present. Delayed brain nerve signals to the large intestine, leads to constipation. If the communication is hyperactive, then this leads to diarrhoea.

Symptoms of IBS In the elderly

The symptoms of IBS are not specific to the elderly, but more care and understanding is taken into account. Even though ageing itself is a symptom that needs to be analysed for IBS ², all symptoms are shared between all age groups.

Irritation/recurrent abdominal pain

The stools within the large intestine are likely to cause irritation . This can include cramps.

Abdominal bowel motility

IBS-D patients display repeat cycles of diarrhoea only, IBS-C display cycles of constipation only, whilst IBS-M and IBS-U display cycles of both diarrhoea and constipation.

Diagnosis Of IBS 

The exclusion principle is used to exclude signs and symptoms of other underlying medical conditions to diagnose IBS clinically.^5,7 A personal report is ideal for each patient with their practitioner, to evaluate and prescribe the best form of treatment, for that individual. Using the Rome Criteria² is the clinical criteria choice for IBS diagnosis.

The type of IBS is determined by the symptoms discussed.

A study⁹ that focused on chronic diarrhoea evaluation and the diagnosis of IBS-D found evidence that older individuals are at more risk of other disorders, as they show atypical presentations of symptoms for such disorders. Even though diagnostics tests work well with older individuals, there is a requirement for an elevated suspicion index for certain disorders.⁹ In other words, there is more difficulty in distinguishing an older individual having IBS-D or only chronic diarrhoea.

Risk factors for IBS in the elderly

IBS causes are not fully understood, but there are risk factors that contribute to the triggers of IBS like symptom episodes, specifically in the elderly. Some of these are:

• Gender
• Stress
• Mental health
• Chronic constipation
• Medication
• Gastrointestinal infection
• Hormonal fluctuations
• Lifestyle factors

Gender

The prevalence of IBS is higher for people assigned female at birth, even though the prevalence is mostly found in individuals under 50 years of age.⁶

Stress

Stress is one of the biggest culprits when it comes to the risk factors of IBS, especially in older individuals. Greater stress levels can trigger IBS symptoms. For example, work stress, poor mental health, and busy lifestyles.^10,15 Individuals over 85 years old, are more vulnerable to stress due to increase in age-related stressors, mainly impacting social relationships and health negatively.¹⁵

Mental health

Major studies have shown a link between IBS patients with psychiatric conditions.² The mental health suicide rate is shockingly high amongst the elderly, representing 27.2% of all suicides.¹¹ It is understood that factors such as harsh living conditions, immobility with poor physical health, and lack of quality services all lead to greater risk of anxiety, and depression as well as other psychiatric conditions.^2,12 Loneliness and social isolation are key risk factors for such mental health issues amongst the elderly, classifying 14% over 60 living with such disorders.¹³

Chronic constipation health issues

Risk factors specifically associated with chronic constipation (a symptom of IBS-C) and the elderly need to be understood. To rule out possible IBS-C, blood tests and colonoscopy may identify underlying causes of chronic constipation.^4,5,14 Rectal hypo-sensitivity and defecatory disorders¹⁴ can be ruled out as part of IBS diagnosis.^4,5,14

Medications

Certain medications may trigger IBS symptoms.⁴ These can include antibiotics, painkillers and laxatives.⁴

Gastrointestinal infections

Gastrointestinal infections such as gastroenteritis from norovirus can trigger IBS symptoms.⁴

Hormonal fluctuations

Hormonal fluctuations are common in post-menopausal women where the hormonal imbalance may cause gut sensitivity and even motility.⁴

Lifestyle factors

Sedentary lifestyle and lack of physical activity can trigger constipation by slowing down the digestive system. This is a common symptom of IBS in elderly people.⁴

Treatment 

The elderly are treated like any other age group for IBS.² Management is mainly symptomatic. It is known that treatment cost per IBS patient can add up to $7547 per year.⁶ For successful management of symptoms, it is key to achieve a strong relationship between physician and patient⁵ in order to effectively find a treatment plan that is specific, and effective for the individual patient.

Pharmaceutical options for treatment of IBS in the elderly

• Antidepressants
• Serotinergic agents
• Antibiotics
• Antidiarrhoeal agents

Antidepressants

Tricyclic antidepressants (TCAs) are widely given to IBS-D patients, to reduce pain, whilst selective serotonin reuptake inhibitors (SSRIs) such as duloxetine are more suitable for IBS-C patients to relieve IBS symptoms. These are antidepressants and thus, there is an issue of dispute, due to the patient may be less likely to consume these primarily for IBS.⁵ Linaclotide is an example of a prosecretory agent, prescribed to IBS-C to elevate electrolytes within the gastrointestinal transit, allowing for easier stool movement. This is good for abdominal pain relief but the side effects are diarrhoea.

Serotinergic agents

Serotonergic agents are not prescribed to the elderly, due to cardiovascular negative side effects.⁵

Antibiotics

Antibiotics such as rifaximin may be given to treat IBS-D.⁵

Anti-diarrhoeal agents

Anti-diarrheals such as Eluxadoline can also be prescribed but adverse side effects can affect the gall bladder.⁵

The lifestyle factors are less intense and the side effects of pharmaceutical forms of IBS treatment are not tolerable for the elderly.^1,2 Thus, greater caution needs to be undertaken in order to treat with pharmaceutical drug options.² Resetting the gut microbiome via natural remedies, diet and changing lifestyle will treat unwanted IBS symptoms.

Dietary intervention in IBS In the elderly

Certain foods increase the risk of IBS as they act as triggers for the possible recurring episodes of constipation, diarrhoea or both.^5,7 Foods low in fermentable oligo-, di-and monosaccharides and polyols, or what is known in short as a low-FODMAP diet with soluble fibre, may be recommended. Decreasing the consumption of short-chain fatty acids, which are usually found in foods such as apples may be beneficial in relieving the symptoms. Studies show that a low FODMAP diet is highly effective and favourable for improving gut health and modifying gut bacteria. A single randomised controlled trial found that 76% of the group that consumed a 4-week low FODMAP diet improved their main IBS symptom, more than the other groups (71% for low carbohydrate diet and 58% for medical treatment groups respectively ). With a significant difference between them (p=0·023), it is evident that a low FODMAP diet is highly advised as a first initial method of treatment therapy.⁸

Probiotics can improve intestinal health. They are live microorganisms that are useful in reducing the symptoms of IBS. However, they can be costly.⁷

Psychological treatments in IBS²

Psychological treatments may be more complicated in the elderly, as the increase in stress in adulthood is one of the major risk factors for IBS. Stress from work, mental health, social life limitations and busy lifestyles contribute to the worsening of IBS symptoms. There are a few things one can do to aid in improving stress levels to improve the quality of life of the elderly. These include finding ways to reduce financial insecurity, providing social support as many are lonely, long term care for those living with dementia, encouraging healthy behaviours and reducing tobacco/alcohol use.^11,12,13

Acupuncture as an alternative therapy for IBS In the elderly

This can be used alongside other forms of treatment. Ameta-analysis of 3440 patients, showed that acupuncture can reduce the symptoms of IBS for 3 months.⁵

Can IBS impact the life of an elderly person?

The quality of life can be drastically reduced with IBS, not only for the elderly. Engaging in daily activities can be a stressor, anticipating the triggering of IBS symptoms. This can impact mobility, as it causes fear in those to never leave an area that is close to a lavatory. The pain and discomfort through irritation of the large intestine^7,4 can take joy out of life. Loss of independence and not being able to be self-reliant, reduces one’s self worth.⁴

Summary

Irritable Bowel Syndrome, or IBS, is a functional gastrointestinal disorder that is diagnosed by the Rome Criteria and the exclusion principle. IBS-C, IBS-D, IBS-M, and IBS-U are the four subtypes, depending on bowel motility and stool frequency ⁵. Treatments are mainly aimed at symptom management as the condition is not very well understood. Other studies need to be undertaken to gain greater insight. Pharmaceutical therapies are available with side effects and dietary and lifestyle changes can significantly aid in reducing IBS symptoms in the elderly. Stress is a significant risk factor which needs to be reduced, in order to help IBS symptoms and their triggers.