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Assessment and treatment of older patients with constipation

Kyle G (2006) Assessment and treatment of older patients with constipation. Nursing Standard. 21, 8, 41-46. Date of acceptance: February 14 2006.

Summary
This article examines the experiences of an older patient with constipation to illustrate the importance of thorough assessment. The interaction between another medical condition and constipation is discussed, and indications for laxative use are outlined. The current evidence base for bowel care is limited. Tools for risk assessment are required and further research is needed to improve patient care in this area.

Case study
Day one Mary, a healthy and active 83-year-old, had a fall at her great-grandsons third birthday. As a consequence of the fall Mary experienced pain in her back, however, she was still able to mobilise independently. Her family took Mary home because she was adamant that she would be best equipped to cope there. Day two Mary had difficulties overnight with pain in her back and was taken to her local accident and emergency department in the morning. Mary was diagnosed with a crush fracture of the second lumbar vertebra, caused by the trauma of her fall, and osteoporosis which was previously undiagnosed. She was commenced on two tablets of co-dydramol four times a day, which she agreed to take because of the considerable pain she was experiencing. Mary was also given calcium supplements and prescribed alendronic acid (as sodium alendronate) 70mg once weekly for osteoporosis. Her mobility became greatly diminished and her appetite was poor because of the pain. She asked a neighbour to purchase some senna at the local chemist, because Mary worries if she does not open her bowels daily. Day three Mary was in great distress because of severe back pain. She contacted the GP who prescribed an opioid analgesic, tramadol, 50mg three times a day, and advised her to discontinue taking co-dydramol. Day four Mary was unable to move and sat all day with a heat pad behind her back. She continued to take tramadol and was also taking two senna tablets each night. She informed her family that her stomach was swollen and bloated, and that she had not opened her bowels since the day before her fall. Lack of exercise, inability to prepare food and abdominal discomfort resulting from constipation contributed to Marys poor food intake. However, Mary made every effort to keep her fluid intake as usual. She knew from past experience when she was on holiday that any november 1 :: vol 21 no 8 :: 2006 41

Author
Gaye Kyle is senior lecturer, Faculty of Health and Human Science, Thames Valley University, Slough, Berkshire. Email: gaye.kyle@tvu.ac.uk

Keywords
Bowel management; Constipation; Suppositories These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

CONSTIPATION IS a problem that can affect any person at any time in life. Those who are ill, in hospital or in an institution are particularly at risk of developing constipation. It is rarely life-threatening, but the distress it causes can lead to reduced patient comfort and diminished quality of life (Sweeney 1997). Constipation affects the patients physical, psychological and social wellbeing, yet there is a reluctance by patients and healthcare professionals to discuss bowel function until it has become a significant problem. Successful treatment of constipation depends on defining the patients symptoms following careful assessment. The case study described in this article enables the examination of variables that resulted in the patients distressing situation. The contributing factors are identified and discussed. A short interview with the patient and a review of her medical and nursing notes supplied the details for the article. Permission has been given to publish this case study and a pseudonym is used to maintain confidentiality (Nursing and Midwifery Council 2004). NURSING STANDARD

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reduction in her usual fluid intake could result in constipation, and she was anxious to prevent this reoccurring. Day five Mary contacted the surgery to say that her pain was no better and that she was finding it difficult to get out of bed. When the GP visited, Mary mentioned that she had not opened her bowels since before her fall, despite taking two senna every night. She was given a prescription changing her analgesia to tramadol-modified release 100mg twice daily. She was also given a prescription for lactulose 15ml at night. Mary tried to take the lactulose but the sweetness of the medication exacerbated her feelings of nausea. Day six Mary telephoned the surgery and asked to speak to the district nurse. Mary requested an enema because it was seven days since her last bowel action. Mary was told that there were no enemas available at the surgery but that the district nurse or community staff nurse would visit her. The district nurse visited Mary but no physical examination was undertaken. Two FIGURE 1 The Bristol Stool Form Scale
Type 1 Separate hard lumps like nuts (hard to pass)

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glycerine suppositories were administered. Mary tried to keep the suppositories in her rectum, but after one hour she had to urinate and, to use Marys words, the suppositories just blew out. Day seven Marys stomach was now distended and hard, her mobility was greatly reduced and her feeling of nausea was increasing. Despite the fracture in her back, Mary was now primarily concerned about her worsening constipation, which made her feel isolated and low in mood. She was no longer trying to mobilise, which is important in the initial stage of rehabilitation for patients with back fractures. She also experienced fullness in her rectum and a feeling that faeces was pushing against her anus. Mary contacted the surgery again. Another GP visited and undertook an abdominal examination revealing a constipated sigmoid colon. A full digital rectal examination was not conducted because the GP observed that Mary had a gaping anus full of impacted faeces. Mary was prescribed Movicol and an anti-emetic. She was initially prescribed four sachets of Movicol to take immediately, and a further four sachets to take that evening. Day eight Mary had a successful bowel evacuation. She felt much relieved and started to rehabilitate successfully. Her appetite returned and she began preparing her own food again. She continued to take one sachet of Movicol twice a day until her bowels were consistently between types 3 and 4 on the Bristol Stool Form Scale (Figure 1). She now takes one sachet of Movicol if she goes more than one day without opening her bowels.

Type 2

Sausage-shaped but lumpy

Discussion
Constipation can be influenced by physical, psychological, physiological, emotional and environmental factors. It is largely a subjective sensation and has many interrelated causes. Constipation can be clinically classified into three categories, and may result from one or more of these: Primary. Secondary. Iatrogenic.

Type 3

Like a sausage but with cracks on its surface

Type 4

Like a sausage or snake, smooth and soft

Type 5

Soft blobs with clear-cut edges (passed easily)

Type 6

Fluffy pieces with ragged edges, a mushy stool

Type 7

Watery, no solid pieces, entirely liquid

Reproduced by kind permission of Dr KW Heaton, reader in medicine at the University of Bristol. 2000 Norgine Ltd

Primary constipation, also referred to as simple or idiopathic, is associated mainly with lifestyle changes and where there is no underlying pathophysiology causing the constipation. Secondary constipation results from physiological diseases or conditions that affect bowel function. Iatrogenic-induced constipation results from medication or treatment (Box 1). NURSING STANDARD

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There continues to be much debate in the literature as to what constitutes a clear definition of constipation (Richmond 2003). The British National Formulary (BNF) (2006) states that constipation is: the passage of hard stools less frequently than the patients own normal pattern. This definition is open to great variation in bowel habits. Most definitions now include symptoms such as frequency of defecation, hardness of stools, abdominal fullness or bloating and feelings of incomplete evacuation, although patients tend to emphasise symptoms such as pain and straining rather than frequency (Romero et al 1996). The Rome II criteria (Box 2) are frequently used to define constipation (Thompson et al 1999). However, they are mainly used as inclusion criteria for research purposes and have limited use in practice, as demonstrated in the case study where they could not be applied. The American College of Gastroenterology Chronic Constipation Task Force (2005) states that the widespread use of Rome II criteria is impractical because observation studies indicate that most patients who report constipation do not fulfil these criteria. Nevertheless, a definition in terms of bowel frequency alone is imprecise, because bowel habits vary from one individual to another. This lack of clarity of what constitutes constipation could limit treatment strategies. In the case study, Mary knew she was constipated, so any confusion about what BOX 1 Drugs that commonly cause constipation
Antacids (containing aluminium hydroxide or calcium carbonate). Amiodarone. Anticholinergics (tricyclic antidepressants, antihistamines and antipsychotics). Antidiarrhoeal agents. Antiparkinsonian agents. Calcium-channel blockers. Calcium supplements. Clonidine. Disopyramide. Diuretics. Iron preparations. Lithium. Non-steroidal anti-inflammatory drugs. Opioids, analgesics and cough suppressants
(Prodigy Guidance 2005)

BOX 2 Rome II criteria for definition of constipation

For definition of constipation, two or more of the following symptoms should be present for at least 12 weeks out of the preceding 12 months. Straining at defecation for at least a quarter of the time. Lumpy and or hard stools for at least a quarter of the time. A sensation of incomplete evacuation for at least a quarter of the time. Three or fewer bowel movements per week.
(Thompson et al 1999)

constitutes constipation did not affect Marys outcome. Initially, Mary tried to treat herself by asking a neighbour to purchase over-the-counter laxatives for her. Harari et al (1996) state that constipation is common in older people and is often treated with numerous prescriptions and over-the-counter laxatives. Management Prodigy Guidance (2005) advises a stepped approach to the management of constipation. After excluding any underlying medical conditions, the first step is dietary advice and the second is the use of laxatives. The National Prescribing Centre (NPC) (2004) reviewed trials on the effectiveness of laxatives in adults. They concluded that there is insufficient clinical evidence to assess objectively the relative effectiveness and tolerability of laxatives (Petticrew 1997, Tramonte et al 1997, Petticrew et al 2001, Jones et al 2002). However, there are seven indications for when laxatives should be used (Prodigy Guidance 2005): No response to adequate non-drug treatment (after one month of dietary advice). Faecal impaction. Constipation or painful defecation associated with illness, surgery or pregnancy. Older age and poor diet. Drug-induced (iatrogenic) constipation. Medical conditions in which bowel strain is undesirable, for example, haemorrhoids or rectal prolapse. Preparation for an operation or investigation. Mary fulfilled four of these criteria: faecal impaction, constipation associated with illness, poor diet because of nausea and immobility, and drug-induced constipation from opioids and calcium supplements. Laxatives are the obvious treatment when these criteria are present. However, it is important to adopt a proactive november 1 :: vol 21 no 8 :: 2006 43

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approach when assessing older patients with constipation. A prompt and comprehensive patient assessment would have resulted in earlier identification and treatment of the risk factors involved, thereby relieving Marys constipation sooner and minimising any distress and discomfort. Numerous studies support the benefit of a high fibre diet to prevent constipation (NPC 2004). Therefore, the first step of giving dietary advice to address constipation would have been appropriate for Mary if given concurrently with laxative advice (Prodigy Guidance 2005). Constipation is a common side effect of opioid analgesia. Even compound analgesic preparations, such as co-dydramol, contain sufficient opioid to cause constipation (BNF 2006). This raises the question of why the healthcare team did not advise Mary about the BOX 3 Assessment of bowel function
When assessing a patients bowel habits, a careful history should be taken and the following points noted: Description of problem, sensation, wind, feelings of discomfort or incomplete evacuation. Frequency of normal and current bowel movement. Description of normal diet and fluid intake. Any changes to normal diet or fluid intake. Any change in mobility. Whether the patient is able to prepare food, and whether the patient is reliant on others for shopping and preparation of food. Check condition of tongue and breath for signs of dehydration. Check for poorly fitting dentures or decayed teeth. Check medication. Bowel habit may change as a result of taking medication for the alleviation or prevention of another pathophysiological condition. Five or more medications are a particular risk for constipation (Potter et al 2002). Description of stool: colour, mucous, consistency (use Bristol Stool Form Scale, Figure 1). Any unusually offensive odour to stool (may be due to diet or malabsorption). Pain or bleeding on defecation (may suggest local injury, for example, haemorrhoids, anal fissure or underlying pathology such as colorectal cancer). Unexplained change in bowel habit (may suggest underlying pathology such as colorectal cancer). Ask the patient how he or she usually copes with the problem. It may be that the patient uses digital rectal stimulation.
(Adapted from Norton and Chelvanayagam 2000)

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possibility of constipation, especially as her usual level of mobility was greatly reduced. Immobility is a primary risk factor in constipation (Harari 2004). Marys diminished mobility resulted in reduced colonic motor activity and eventual weakening of the abdominal wall muscles. This led to difficulty in raising intra-abdominal pressure sufficiently for defecation which would have been exacerbated by Marys back pain. The decision to prescribe lactulose 15ml at night to an older patient who is already constipated and feeling nauseous may not have been the best treatment option because lactulose may take up to two to three days to have an effect and is not suitable for rapid relief of constipation (NPC 2004). It should not be regarded as firstchoice therapy in the management of patients with constipation (Prodigy Guidance 2005). Macrogols, such as Movicol and Idrolax, are inert polymers of ethylene glycol. There is limited evidence from several trials that polyethylene glycol is a safe and effective alternative to lactulose in the management of patients with constipation (Attar et al 1999, Corazziari et al 2000). Movicol is the only laxative recommended in the treatment of faecal impaction, so it was an appropriate laxative for Mary when it was prescribed (BNF 2006). However, when Mary first consulted the GP she may not have been impacted, although this was not confirmed because a comprehensive bowel assessment was not undertaken. Assessment Assessment is important for the effective management of any distressing symptom. Mary should have received an initial assessment to ascertain the possible causes of her constipation, for example, medication, poor diet and reduced mobility. Accurate assessment of the cause of constipation is the first crucial stage in developing a treatment plan (Koch and Hudson 2000). Points to consider during assessment have been outlined by Norton and Chelvanayagam (2000) and adapted in Box 3. There is no conclusive evidence that one laxative is more effective than another in treating older patients (Petticrew et al 1999). The appropriate laxative should be chosen according to the individual patients needs and circumstances. Glycerine suppositories act as a rectal stimulant because of the mildly irritant action of glycerol (BNF 2006). A stimulant laxative is a suitable choice for short-term use to allow usual bowel function to be restored (NPC 2004). Despite a lack of assessment, the use of suppositories appears to have been appropriate for Mary. However, as the suppositories remained intact after one hour in the rectum, they may not have been appropriately administered. NURSING STANDARD

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Glycerine suppositories should be moistened before insertion and then placed alongside the bowel wall. Suppositories need body heat to dissolve so that the glycerol can act as a bowel irritant. If suppositories are placed in the middle of faecal matter they remain intact and serve no purpose. There are conflicting recommendations about the administration of suppositories. Baxter et al (2004) advocate insertion of the blunt end of suppositories first, using previous research to substantiate this viewpoint (Abd-el-Maeboud et al 1991). However, Abd-el-Maeboud et al (1991) make no reference to the insertion of suppositories for bowel care, so their research could be interpreted for systemic or local action of suppositories or both. The application of research that is reported in clinical textbooks, such as The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Dougherty and Lister 2004), can be problematic if the research has used simple descriptive statistics. The findings of Abd-el-Maeboud et al (1991) suggest that although the apex foremost mode of insertion is common sense, base foremost insertion is preferable for administering rectal suppositories (Abd-el-Maeboud 1992). This conflicting advice can mean that healthcare professionals are unsure about what constitutes best practice in the administration of suppositories. It is often assumed that constipation is an inevitable consequence of older age. However,

Koch and Hudson (2000) found no evidence that a change in bowel motility is an inevitable consequence of ageing. Nevertheless, the rate of regular laxative use among older people is reported to be between 7 and 10 per cent (Harari et al 1994, Pahor et al 1995). This rate rises to between 50 and 75 per cent in nursing homes (Harari et al 1994, 1995). The apparent reduction in bowel movement frequency observed in older people appears to be related to contributory factors associated with ageing, such as reduced mobility, polypharmacy, chronic disease and poor diet, rather than ageing itself (Harari 2004). Risk assessment data are not yet available to assist healthcare professionals with interpretation of contributing factors to constipation (Richmond and Wright 2004). The use of such data or a risk assessment tool may have prevented the exacerbation of Marys constipation. If Marys constipation had persisted or continued to be inappropriately managed, certain complications could have ensued, including haemorrhoids, urinary incontinence, urinary tract infection, rectal bleeding and possible hospitalisation. Any of these complications would have adversely affected Marys quality of life and would have had cost implications for the NHS. It is estimated that 10 per cent of district nursing time is spent on bowel management (Poulton and Thomas 1999). In 2001, more than 12 million prescriptions for laxatives were

References
Abd-el-Maeboud K (1992) The best way to insert rectal suppositories. Nursing Times. 88, 10, 50. Abd-el-Maeboud KH, el-Naggar T, el-Hawi EM, Mahmoud SA, Abd-el-Hay S (1991) Rectal suppository: commonsense and mode of insertion. The Lancet. 338, 8770, 798-800. American College of Gastroenterology Chronic Constipation Task Force (2005) An evidence-based approach to the management of chronic constipation in North America. American Journal of Gastroenterology. 100, Suppl 1, S1-4. Attar A, Lemann M, Ferguson A et al (1999) Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation. Gut. 44, 2, 226-230. Baxter A, Regan F, Watts C (2004) Elimination: bowel care. In Dougherty L, Lister SE (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Sixth edition. Blackwell Publishing, Oxford, 285-303. Bayliss V, Cherry M, Locke R, Salter L (2000) Pathways for continence care: background and audit. British Journal of Nursing. 9, 9, 590-596. British National Formulary (2006) British National Formulary No 51. British Medical Association and the Royal Pharmaceutical Society of Great Britain, London. Corazziari E, Badiali D, Bazzocchi G et al (2000) Long term efficacy, safety, and tolerability of low daily doses of isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in the treatment of functional chronic constipation. Gut. 46, 4, 522-526. Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. The Stationery Office, London. Department of Health (2001) Prescription Cost Analysis. The Stationery Office, London. Department of Health (2003) Essence of Care: Patient-focused Benchmarks for Clinical Governance. The Stationery Office, London. Dougherty L, Lister SE (Eds) (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Sixth edition. Blackwell Publishing, Oxford. Harari D (2004) Bowel care in old age. In Norton C, Chelvanayagam S (Eds) Bowel Continence Nursing. Beaconsfield Publishers, Beaconsfield, 132-149. Harari D, Gurwitz JH, Avorn J, Choodnovskiy I, Minaker KL (1994) Constipation: assessment and management in an institutionalized elderly population. Journal of the American Geriatrics Society. 42, 9, 947-952. Harari D, Gurwitz JH, Avorn J, Choodnovskiy I, Minaker KL (1995) Correlates of regular laxative use by frail elderly persons. American Journal of Medicine. 99, 5, 513-518. Harari D, Gurwitz JH, Avorn J, Bohn R, Minaker KL (1996) Bowel habit in relation to age and gender. Findings from the National Health Interview Survey and clinical implications. Archives of Internal Medicine. 156, 3, 315-320. Jones MP, Talley NJ, Nuyts G, Dubois D (2002) Lack of objective evidence of efficacy of laxatives in chronic constipation. Digestive Diseases and Sciences. 47, 10, 2222-2230. Koch T, Hudson S (2000) Older people and laxative use: literature review and pilot study report. Journal of Clinical Nursing. 9, 4, 516-525.

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written in England in general practice (Department of Health (DH) 2001).

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Conclusion
Discussion of the issues raised in the case study highlights the lack of agreement on what constitutes a working definition of constipation. Poor understanding of the use of laxatives and limited assessment protocols indicate the need for a national consensus on bowel management. The introduction of bowel assessment pathways will provide healthcare professionals with a clear structure for assessing patients with constipation (Bayliss et al 2000). The response of NHS trusts to the Essence of Care document (DH 2003) will help to ensure the development of benchmarks on bowel management that are based on best patientfocused practice. Continual improvement of these benchmarks will be maintained by comparison and sharing of knowledge and expertise from similar clinical areas. Digital rectal examination courses are now run throughout the UK. They provide an ideal forum for enhancing education on all aspects of bowel management. However, bowel management remains an underfunded and under-researched area of health care (Kyle 2005). Constipation rarely receives attention

until it has become a significant problem for the patient (Ross 1998). The problems associated with a reactive approach to constipation are compounded by ongoing reference to management of constipation, rather than prevention, in the literature (Harari et al 1994, Powell and Rigby 2000, NPC 2004). The case study demonstrates that, despite Marys awareness of her constipation, healthcare professionals did not respond effectively until Marys constipation was affecting her general wellbeing and quality of life. Evidence-based health care is an NHS priority (DH 2000). There is increasing emphasis on supporting all clinical practices with quality evidence. However, the common nursing procedure of inserting rectal suppositories for bowel care is not supported by quality evidence. This highlights the need for more rigorous bowel care research. An emerging theme from much of the nursing literature is the importance of assessing patients to identify those at risk of constipation (Richmond 2003, Richmond and Wright 2004). Assessment strategies are necessary to prevent the development of this distressing condition. Risk assessment tools have been described as the backbone of prevention (Thompson 2005), therefore a prerequisite for the prevention of constipation is the development of such a tool. To date no such risk assessment tool exists. Once healthcare professionals can easily identify patients at risk, they can institute preventive measures to meet each patients needs NS

References continued
Kyle G (2005) Steps to best practice in bowel care. Nursing Times. 101, 2, 47. National Prescribing Centre (2004) The management of constipation. MeReC Bulletin. 14, 6. Norton C, Chelvanayagam S (2000) A nursing assessment tool for adults with fecal incontinence. Journal of Wound, Ostomy, and Continence Nursing. 27, 5, 279-291. Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC, London. Pahor M, Mugelli A, Guralnik JM et al (1995) Age and laxative use in hospitalized patients. A report of the Gruppo Italiano di Farmacovigilanza nellAnziano GIFA. Aging (Milan). 7, 2, 128-135. Petticrew M (1997) Treatment of constipation in older people. Nursing Times. 93, 48, 55-56. Petticrew M, Watt I, Brand M (1999) Whats the best buy for treatment of constipation? Results of a systematic review of the efficacy and comparative efficacy of laxatives in the elderly. British Journal of General Practice. 49, 442, 387-393. Petticrew M, Rodgers M, Booth A (2001) Effectiveness of laxatives in adults. Quality in Health Care. 10, 4, 268-273. Potter JM, Norton C, Cottenden A (Eds) (2002) Bowel Care in Older People: Research and Practice. Royal College of Physicians, London. Poulton B, Thomas S (1999) The nursing cost of constipation: clinical update. Primary Health Care. 9, 9, 17-22. Powell M, Rigby D (2000) Management of bowel dysfunction: evacuation difficulties. Nursing Standard. 14, 47, 47-51. Prodigy Guidance (2005) Constipation. www.prodigy.nhs.uk/ constipation (Last accessed: October 18 2006.) Richmond J (2003) Prevention of constipation through risk management. Nursing Standard. 17, 16, 39-46. Richmond JP, Wright ME (2004) Review of the literature on constipation to enable development of a constipation risk assessment scale. Clinical Effectiveness in Nursing. 8, 1, 11-25. Romero Y, Evans JM, Fleming KC, Phillips SF (1996) Constipation and fecal incontinence in the elderly population. Mayo Clinic Proceedings. 71, 1, 81-92. Ross H (1998) Constipation: cause and control in an acute hospital setting. British Journal of Nursing. 7, 15, 907-913. Sweeney M (1997) Constipation. Diagnosis and treatment. Home Care Provider. 2, 5, 250-255. Thompson D (2005) An evaluation of the Waterlow pressure ulcer risk-assessment tool. British Journal of Nursing. 14, 8, 455-459. Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA (1999) Functional bowel disorders and functional abdominal pain. Gut. 45, Suppl 2, II43-II47. Tramonte SM, Brand MB, Mulrow CD, Amato MG, OKeefe ME, Ramirez G (1997) The treatment of chronic constipation in adults. A systematic review. Journal of General Internal Medicine. 12, 1, 15-24.

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