Constipation is a common problem for residents in long- term care facilities. So common that some research indicates that as many as 50% of nursing home residents experience constipation at some point during their stay and that 50-74% of nursing home residents use laxatives on a daily basis.1 Constipation is the most prevalent digestive complaint in elderly populations in the community, as well as in institutional care settings.1 Studies have found that in the older person, constipation is associated with a decline in the quality of life, a decrease in functional ability, increased pain, dysuria, and fecal incontinence.2 According to the American Dietetic Association, it is also “a frequently overlooked nutrition impact symptom.” One of the major problems associated with constipation is the development of fecal impaction that may result in intestinal obstruction, bowel perforation and even death. As staff are aware, the occurrence of fecal impaction is considered a sentinel event by the Centers for Medicare & Medicaid Services. The failure to correctly identify and treat constipation can have catastrophic consequences for the resident, as well as the care facility.
Despite the increased prevalence of constipation among the elderly, constipation is not a physiologic consequence of normal aging. There is no correlation between bowel movement frequency and age.3 That being said, there are many age-related problems and co-morbid medical conditions that contribute to the increased incidence in the elderly.
Since constipation is highly subjective, with the definition differing significantly between patient and healthcare provider, a concise set of criteria were established by an international congress of gastroenterologists. According to the newly updated Rome III criteria, constipation is diagnosed when at least two out of six of the following conditions are present for at least 12 weeks in the preceding 12 months.1, 2
- Straining during at least 25% of bowel movements.
- Pellet-like or hard stools for at least 25% of bowel movements.
- Sensation of incomplete evacuation for at least 25% of bowel movements.
- Using manual maneuvers to facilitate more than 25% of bowel movements.
- Sensation of anorectal obstruction/ blockage for at least 25% of bowel movements.
- Having fewer than three bowel movements per week.
Possible nutritional indicators of constipation include the following: poor appetite with complaints of fullness after eating small amounts, nausea, vomiting, weight loss, and excess flatus. Physical observations may include: abdominal distention, abdominal pain, hard/firm abdomen, low-grade fever, hypoactive bowel sounds, palpable stool in the lower quadrants, and hard/dry stool upon digital rectal exam.4 It should be noted that diarrhea may be present in combination with fecal impaction. Behavioral symptoms such as delirium and an increase in physical or verbal aggression have also been noted in older persons with untreated constipation.5
The causes of constipation are divided into primary and secondary causes. The primary causes are slow transit constipation, normal transit constipation and defecatory disorders (anorectal dysfunction). Normal transit constipation, also called chronic idiopathic or functional constipation, is the most frequent type.
Causes of secondary constipation include medical and psychiatric conditions, as well as the use of medications, especially those that affect the central nervous system, nerve conduction and smooth muscle function.3 The increase in prevalence of constipation in the elderly most likely results from a combination of risk factors including limited physical activity, inadequate diet and fluid intake, chronic medical conditions and use of medications known to be associated with constipation. Diseases such as Parkinson’s Disease, insulin-dependent diabetes, chronic renal disease, CVA, hypercalcemia, hypothyroidism, multiple sclerosis, dementia and depression are common co-morbidities of constipation.1,2,3 Medications most frequently associated with constipation are anticholinergics, opioids/narcotics, antihistamines, antidepressants, non-steroidal anti-inflammatory drugs, antipsychotics, diuretics, calcium-channel antagonists and iron and calcium supplements.1,3
All residents should be evaluated for the risk of constipation using a standardized assessment form. This may be included in the bowel and bladder assessment form your facility uses. The assessment should be completed upon admission, routinely per MDS schedule, and whenever there is a change in cognition or functional ability. 6 In addition to the nursing assessment, screening for constipation should be included as part of the overall nutrition assessment.4
The initial step in the treatment of constipation is appropriate medical management of any underlying disease, with the most useful intervention being the removal of any unnecessary medications, or the replacement of a medication that causes constipation with an alternative medication when feasible. 1 The basic management of constipation includes: a) adequate fluid intake b) bulking agents c) toileting and d) exercise.2
a) Unless contraindicated, a fluid intake of at least 1500 ml/day is generally recommended to avoid constipation. A registered dietitian should calculate the fluid needs of each resident. Increasing fluid intake in the resident who receives thickened liquids can pose a particular challenge and creativity in individualizing approaches is important.
b) Fiber is generally a safe, inexpensive, first-line approach that improves stool consistency and accelerates colon transit time. The recommendation for daily fiber intake is 25-30 grams.
c) Establishing a routine toileting pattern has been found to be beneficial in managing constipation. Residents should be encouraged to attempt a bowel movement the first thing in the morning and 30 minutes after meals to take advantage of the gastrocolic reflex.3 Toileting plans should be individualized for each resident. It is extremely important that bowel movements be accurately documented by the CNA on each resident in his/her care with review of these records each shift by the charge nurse to ensure timely intervention.
d) Immobility is a significant risk factor for constipation. Walking 15-20 minutes per day is recommended for those who are mobile. Colonic transit time in chair bound or bedridden long-term care residents can be as slow as two weeks compared to the normal time of less than three days.5 Activity recommendations should be tailored to the individual’s physical abilities and health conditions.
It is generally accepted that the above measures be attempted before medical therapy is tried. If the above approaches are not successful or if a resident has not had a bowel movement in three days, laxative treatment should be initiated. With regard to medical therapy, the following categories of drugs have been used to treat constipation.
a) Bulk or hydrophilic laxatives which include bran, psyllium (Metamucil) and methylcellulose (Citrucel) which work by absorbing water from the intestinal lumen to increase stool mass and soften the stool.
b) Softening or wetting agents, such as docusate (Colace), act by lowering surface tension of the stool. They are generally ineffective in treating constipation but may be beneficial in residents with hemorrhoids or anal fissure.3
c) Osmotic laxatives work by causing secretion of water into the intestinal lumen by osmotic activity and include magnesium hydroxide (Milk of Magnesia), sorbitol, lactulose and polyethylene glycol (Miralax). While Milk of Magnesia is commonly used in long-term care due to its effectiveness and low cost, it is contraindicated in many cases due to the potential for electrolyte imbalance in persons with chronic renal insufficiency and congestive heart failure.
d) Stimulant laxatives, sometimes called irritant laxatives include products containing bisacodyl and senna (Senakot). These laxatives increase intestinal motility and secretion of water into the bowel. They produce results quickly, but may lead to excessive cramping. Stimulant laxatives are usually reserved for patients with severe constipation who do not respond to fiber or osmotic laxatives.1,7
e) Suppositories are generally effective when necessary and are quick acting. Bisacodyl suppositories have been shown to be more effective than glycerine suppositories.5 Enemas should be limited to acute situations and should be used with caution, owing to the risk of colonic perforation.
Fecal impaction removal should be performed as a last resort and only after all other interventions have failed, and only at physician discretion.6
While there are no evidenced based guidelines on the preferred order of using different types of laxatives, the American Gastroenterological Association has developed an algorithm for the treatment of adults with normal-transit constipation.
Constipation is a distressing symptom that dramatically impacts quality of life and carries with it much risk for impairment of health and well being of our elderly population. By properly identifying those residents at risk and having appropriate interventions in place, you can protect your residents from unnecessary hardship and your facility from avoidable and costly citations and potential litigation.