Elder Care In Hospital

Constipation is defined as having three or less bowel movements per week (Basson & Anand, 2019). The Rome IV diagnostic criteria for constipation is the most widely used method of identifying constipation.

Constipation is considered to be a symptom of another problem and is not a disease in itself (Bassoon & Anand, 2019). Patients admitted to the hospital for fecal impaction have a mean hospital length of stay of 7 days (Emmanuel et al., 2016), so it is important to implement proactive interventions. This means close monitoring of bowel movements by health care providers.

Generally, there are four potential reasons for constipation in older adults presenting to the hospital:

1. Functional constipation (the most common) 
2. Pelvic Floor constipation: the pelvic floor muscle is impaired because of structural abnormalities, or impaired innervation to assist with perianal descent
3. Slow transit constipation
4. Other issues such as Irritable Bowel Syndrome (IBS)

(Somes & Donatelli, 2013)

Functional constipation using the Rome IV diagnostic criteria (Lacy et al., 2016): 

1. Must include two or more of the following in the previous three months:
   1. Straining during more than one-fourth (25%) of defecations
   2. Lumpy or hard stools more than one-fourth (25%) of defecations
   3. Sensation of incomplete evacuation more than one fourth (25%) of defecations
   4. Sensation of anorectal obstruction/blockage more than one-fourth (25%) of defecations
   5. Manual maneuvers required to facilitate more than one-fourth (25%) of defecations (e.g. digital evacuation, support of pelvic floor)
   6. Fewer than 3 spontaneous bowel movements per week
2. Loose stools are rarely present without the use of laxatives
3. Patient does not meet Rome IV criteria for Irritable Bowel Syndrome (IBS)

The most common symptoms of patients who complain of constipation, according to Lacy et al. (2016), are straining, hard stools, infrequent bowel movements, abdominal discomfort, bloating, and a feeling of incomplete evacuation after a bowel movement. 

Risk factors for developing functional constipation include:

• older age
• female
• reduced caloric and fluid intake
• reduced mobility
• polypharmacy
• institutionalization
• environmental barriers 

An interdisciplinary team approach to addressing bowel continence is recommended.

(Lacy et al., 2016 and RNAO, 2011)

The Registered Nurses' Association of Ontario (2011), in their Best Practice Guideline Supplement, emphasize the importance of a baseline bowel history and assessment. This includes documenting:

• History of problem
• Client beliefs about bowel movements
• Details of bowel habits such as frequency of bowel movements, consistency, any oozing, size of stool, ease of stool expulsion
• Use of laxatives or non-pharmacological interventions
• Any problems with soiling or incontinence
• Usual fluid intake amount 
• Diet and fiber intake, including amount of caffeine and alcohol
• Medication review (highlighting medications contributing to constipation)
• Level of physical activity / mobility
• Past medical history that may include health concerns related to constipation such as diabetes, hemorrhoids, bowel surgery, depression, dementia, neurological disorders, etc. 
• Physical exam of patient’s abdomen
• Have patient complete a 7 day bowel record

Medications associated with causing constipation are many. See Forootan, Bagheri & Darvishi (2018) for a more specific list of medications causing constipation. Some typical ones often listed as culprits are anticholinergics, antidepressants, antihistamines, anti-nauseants, antiparkinsonian agents, diuretics, opioids, etc.

As always, one should try to introduce non-pharmacological interventions first such as increasing:

• Fluid (strive for 1500-2000ml per day)
• Fiber intake (gradually increase fiber intake to 21-25 grams per day)
• Physical mobility (walking at least 50 feet twice a day is recommended even for those patients with limited mobility) 

(RNAO, 2011)

Evidence indicates that exercise alone will not alleviate constipation.  Reducing or eliminating constipation causing medications should be trialed. Sometimes simply adding a serving of prunes daily to the diet may be sufficient. Engaging the dietician in improving the patient’s fiber intake may also be beneficial. 

A squat position is the preferred positioning on a toilet/commode to encourage defecation. Sometimes a small footstool under the patient’s feet can be helpful while they sit. For patients confined to bed, positioning the patient on their left side while flexing the knees upward toward the abdomen may help.

Timed or prompted toileting can also optimize continence (having a bowel movement within 30 minutes of eating). Share the schedule in the patient’s care plan. 

In addition, adjusting the physical environment so that perhaps a commode is nearer the bedside may help. Occupational Therapy may be helpful in obtaining over-the-toilet raised seating. 

Patient and/or caregiver education is a necessary component for improving a patient’s understanding of constipation. Health care providers should have a basic understanding of the contributors to constipation as well as treatment options, both non-pharmacological and pharmacological. It is poor clinical practice not to explore why a patient may be constipated and to solely rely on prolonged laxative use. An educational brochure developed by the unit, may be helpful for discharge planning.

If the above interventions are unsuccessful or not possible, staff may have to resort to medication management of the patient’s functional constipation. In 2016, a consensus panel of international experts developed a treatment flowchart outlining recommendations for the treatment of constipation in older adults (Emmanuel et al., 2016).

If the above non-pharmacological interventions fail, then the next recommendation is to use an osmotic laxative like Lax-a-Day, Lactulose, Glycerine suppository or PEG. Evidence suggests that PEG is superior to Lactulose. These agents should be avoided in patients with renal impairment (Lacey et al, 2016). Side effects of osmotic agents include bloating, cramps and flatulence.

Stimulants such as Senna, Cascara and Bisacodyl may be the next option but again these medications may have side effects such as abdominal pain and diarrhea (Lacy et al., 2016). 

In patients who are still constipated despite the use of laxatives, then prucalopride is recommended (Emmanuel et al., 2016). These authors further suggest that one may treat fecal impaction with macrogol to soften the stool and then a stimulant laxative to promote a bowel movement. 

Stokes et al. state that fecal incontinence is an “involuntary loss of liquid or loose stool”.

There are two main types of fecal incontinence (FI):

• Urge FI occurs when the patient is aware that they need to defecate but cannot stop it
• Passive FI occurs when the patient is unaware that they have to defecate

Preventing impaction reduces the risk of fecal incontinence (Emmanuel et al., 2016).

According to Stokes, Crumley, Taylor-Thompson & Cheng (2016), fecal incontinence is more likely to occur in individuals who are hospitalized (7-37%) or those who live in an institution such as a long-term care facility (20-50%). More than 80% of patient who are hospitalized and have dementia experience fecal incontinence (Cabrera et al., 2018). Constipation and FI are often linked. Both can have a significant impact on one’s quality of life. 

Hospitalized patients are at an increased risk for FI if they have any of the following:

• Increased age
• Immobility
• Clostridium Difficile
• Fecal impaction or anorectal problems
• Neurological disease (cardiovascular accident, Parkinson’s Disease)
• Impaired cognition
• Diarrhea
• Urinary incontinence
• Rectal prolapse
• Chronic constipation
• Receiving certain medications (e.g. laxatives, metformin, antibiotics, acetylcholinesterase inhibitors) or polypharmacy
• Radiation exposure
• Having a complicated vaginal delivery

(Stokes et al., 2016 and Cabrera et al., 2018)

How to Treat FI:

• Rule out viral infection
• Review all medications for any that may cause loose stools or diarrhea. For example, prolonged use of Bisacodyl can lead to an atonic colon
• Make sure the patient does not have fecal impaction and this is overflow (may require abdominal x-ray)
• Rule out chronic diarrhea by obtaining a detailed history
• Assess abdomen for distention, bowel sounds, etc. 
• Complete an anorectal examination to assess for sphincter tone, fissures or hemorrhoids
• Determine need to send stool specimen for bacteria, occult and parasites
• Use a moisturizing barrier cream (that has zinc oxide of hydrocolloids) to protect skin from breakdown
• If there is irreversible causes of incontinence or a high level of frailty, consider incontinence product use. This would include personal products plus a soaker pad or mattress cover as required to preserve patient dignity and cleanliness
• Take cognitively impaired patient to the bathroom every 3-4 hours to support continence
• Reduce fat intake
• Be cautious with lactulose or sorbitol containing products
• Adding fiber may help, but remember to increase fluid intake as well to at least one liter per day. Psyllium use has been linked to a lower rate of fecal incontinence
• An enema can be helpful if the patient is seeping and yet has not had a bowel movement for 2-3 days
• Anal plugs may be an option but may be difficult for the patient to tolerate
• Rectal prolapse repair and sacral nerve stimulation are also possibilities for elderly patients after a thorough investigation by a physician

(Lacy et al., 2016 and Cabrera et al., 2018)

Cabrera et al. (2018) provide an algorithm for the clinician interested in exploring treatment suggestions further:

Medications to treat Fecal Incontinence (Cabrera et al., 2018):
Medications such as loperamide or codeine, osmotic laxatives, laxatives, lubricants and stimulating laxatives may be options that the physician may explore.