A goal of care for older patients is to encourage and support continence for as long as possible. Keeping that in mind, one needs to understand two primary barriers that may be encountered when an older patient is admitted to the hospital:
A discussion on bowel continence with the older hospitalized adult explores both constipation and fecal incontinence. Prevalence of constipation in older adults is estimated to be approximately 33% (Emmanuel et al., 2016). Untreated constipation may lead to fecal impaction, increased risk of hospitalization and fecal incontinence (Emmanuel et.al, 2016). Laxative use is common in community dwelling older adults (50%), and it is anticipated that this use increases once an individual moves to an institution (Registered Nurses' Association of Ontario, 2011).
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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:
(Somes & Donatelli, 2013)
Functional constipation using the Rome IV diagnostic criteria (Lacy et al., 2016):
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:
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:
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:
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):
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:
(Stokes et al., 2016 and Cabrera et al., 2018)
How to Treat FI:
(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.
Basson, M., & Anand, B. (2019, July). Constipation. MedScape. Retrieved from https://emedicine.medscape.com/article/184704-overview.
Cabrera, A. M. G., Rodriquez, R. M. J., Diaz, M. L. R., Monchul, J. M. V., Fernandez, M. R., Pavon, J. M. D., Gonzalez, C. P., Ruiz, F. J. P., & de Juan, F. D. L. P. (2018). Fecal incontinence in older patients: A narrative review. Cirugia Espanola (English Edition), 96(3), 131-137. doi: 10.1016/j.ciresp.2017.12.005.
Emmanuel, A., Mattace-Raso, F., Neri, C., Petersen, K-W., Rey, E., & Rogers, J. (2016). Constipation in older people: A consensus statement. International Journal of Clinical Practice, 71(1), e12920.
Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation: A review of literature. Medicine, 97(20), e10631. https://doi.org/10.1097/MD.0000000000010631
Hauber, A. B., Mohamed, A. F., Johnson, F. R., Cook, M., Arrighi, H. M., Zhang, J., Grundman, M. (2014). Understanding the relative importance of preserving functional abilities in Alzheimer’s disease in the United States and Germany. Quality Life Research, 23(6), 1813-21.
Lacy, B. E., Mearin, F., Chang, L., Chey, W. D., Lembo, A. J., Simren, M., & Spiller, R. (2016). Bowel disorders. Gastroenterology, 150(6), 1393-1407.
Registered Nurses' Association of Ontario (2011). Nursing Best Practice Guideline: Prevention of constipation in the older adult population.Toronto: Nursing Best Practices Guidelines Program. Retrieved from https://rnao.ca/sites/rnao-ca/files/Prevention_of_Constipation_in_the_Older_Adult_Population.pdf.
Somes, J., & Donatelli, N. S. (2013). Constipation and the geriatric patient: Treatment in the emergency department. Journal of Emergency Nursing, 39(4), 372-375.
Stokes, A. L., Crumley, C., Taylor-Thompson, K. & Cheng, A-L. (2016). Prevalence of fecal incontinence in the acute care setting. Journal of Wound, Ostomy and Continence Nursing, 43(5), 517-522.