No organ in the body is so misunderstood, so slandered and maltreated as the colon!Sir Arthur Hurst, 1935

What is Constipation? Patient Definition: Hard Stools Infrequent stools (

Other symptoms of constipation Nausea +/- vomiting Abdominal and Rectal pain Flatulence Loss of appetite Lethargy DepressionPatients may not associate these with constipation

Nausea and reduced appetite weight lossBehavioural disturbances in dementia increased use of psychotropic medicationsExtra staff time needed for increased toiletting needsOverall increased number of medications in the regime

What are some of the consequences of constipation in the elderly?

Increased prevalence of Secondary Causes.. Immobility Improper Diet Endocrine & Metabolic Disorders Neurological Disorders Psychological Conditions Structural Abnormalities MedicationsWhy does constipation become a problem in the elderly?

Some medications associated with constipation Aluminium and calcium containing antacids Anticholinergic agents Calcium supplements Antipsychotics Iron Opioids

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Reference: Australian Journal of Hospital Pharmacy, 1998

1. Exercise - Fibre in the diet - Fluid Intake No evidence that increased exercise is beneficial in severe constipation Aim for 25-30g fibre/day Unless dehydrated, increasing fluid does not relieve chronic constipation and may increase the risk of fluid overload eg heart or renal failure

The kitchen can help! Add dry, fresh or canned fruit to cereal Add legumes to soups casseroles Include grated vegetables in rissoles, soups Choose fruit desserts Use high fibre snacks, raisin bread, date scones, carrot, muffins

2. Bulk Forming Laxatives eg psyllium (Metamucil), sterculia (Normacol), ispaghula (Fybogel) Improve stool consistency and frequency with regular use Ensure good fluid intake to prevent faecal impaction Onset of action 2-3 days Side Effects may include bloating, flatulence, distension

3. Stool Softeners & Lubricants eg docusate (Coloxyl), paraffin oil (Agarol) Efficacy of docusate is controversial May be useful with anal fissures of haemorrhoids or when straining is a hazard Liquid paraffin is not recommended for treatment of constipation - risk of aspiration and lipid pneumonia - long term use may result in depletion of Vitamins A, D, E and K

4. Osmotic Laxatives Lactulose (Duphalac), Sorbitol (Sorbilax), PEG products (Movicol)

Lactulose/Sorbitol-equally effective at improving stool frequency- onset of action up to 48 hours- metabolised by bacteria flatulence Movicol - improves stool frequency and consistency - iso-osmotic and therefore water and electrolyte loss is limited

Some precautions with osmotic laxatives Lactulose contains absorbable sugars and may adversely affect glycamic control in diabetics Overuse may result in dehydration Monitor for any signs of electrolyte disturbances - oedema, - shortness of breath, - increasing fatigue,- cardiac failure

Movicol and Thickeners IMPORTANT: Thicken the water as per the manufacturers instructions BEFORE adding Movicol1. Mix the required amount of thickened water. For convenience, this can be made ahead of time and stored in the refrigerator for up to 48 hours.2. To prepare Movicol for administration, spoon about cup thickened water into a glass and add Movicol powder. Stir thoroughly with a spoon.3. When mixed, add more thickened water to make up to cup (125mL) and again stir thoroughly.4. The mixture will return to the required thickened state within approximately one minute.

5. Stimulant LaxativesSenna (Senokot), bisacodyl (Durolax, Bisalax)

Increase intestinal motility by stimulating colonic nerves Useful with opioids Onset of action 8-12 hours Development of tolerance is reported to be uncommon Generally considered 2nd line therapy in elderly due to risk of electrolyte disturbances Other adverse effects include cramping, diarrhoea, dehydration

Nulax - the all natural and all organic in origin fruit laxative Is not formulated in a manner that ensures even distribution of the active ingredient inconsistent dosing Contains senna leaf powder 400mg/5g dose = 24mg sennosides/5g dose. Senokot tablets contain 7.5mg sennosides/tablet

6. Enemas & Suppositories Used when rapid relief from faecal loading is required Induce bowel movements by distension of the rectum and colon Frequent use may cause poor rectal tone and may exacerbate incontinence Tap water enemas are safest for regular use Phosphate enemas (Fleet) increase the risk of hyperphosphataemia in renal impairment Glycerine suppositories stimulate rectal secretion by osmotic action

Helping to prevent constipation Patient education Diet and Fluid Intake Exercise Effective Bowel Habits Toileting Facilities Medication Review Ensure a laxative is prescribed with opioids

An Effective Fibre Supplement 3 TBS unsweetened apple puree 1 TBS unprocessed bran 2-3 TBS prune juiceAdd 1 TBS to breakfast cerealImaginative ways to increase fibre:- Add dry, fresh or canned fruit to cereal Add legumes to soups and casseroles Include grated vegetables in rissoles & soups Choose fruit desserts High fibre snacks eg raisin bread, date scones, carrot muffins

Constipation is the second most common GI complaint after dyspepsiaDefinition:- generally described as infrequent defaecation, often with straining and the passage of hard, uncomfortable stoolsInternational surveys suggest 50-80% aged care residents have symptoms of constipation and 40-50% use at least one laxative at least 3x/weekNausea is a very common symptom of constipation in the elderlyIdentification of the presence of these on admission may enable preventative strategies to be put in place:- Immobility - osteoarthritis, advanced cancer Improper Diet - inadequate fibre/fluid Endocrine + Metabolic Disorders Diabetes, Hypercalcaemia, Hyperparathyroidism, Hypothyroidism Neurological Disorders cerebrovascular disease, MS, Parkinsons Disease, Spinal cord injury/tumours Psychological conditions anxiety, depression Structural abnormalities haemorrhoids, anal fissures, IBS, obstructive colonic lesion, rectal prolapse

A medication review may be beneficial to a resident with constipationAnticholinergic agents include: Ditropan, Spiriva, Antipsychotics constipation not such a problem with newer atypical antipsychotics such as risperidone, olanzapineThere is some evidence that laxatives can improve outcomes such as bowel movement frequency, stool consistency and other symptoms however there is little high quality evidence. The treatment of chronic constipation remains empirical. Increased physical activity should be encouraged as part of the overall care plan however, Dietary fibre - insoluble variety is important as it absorbs water, increases faecal bulk and shortens time in colon- add into diet slowly to minimise flatulence and bloating- examples - unprocessed wheat, bran, fruit, vegetables (25-30g/day)- NOTE - fibre can worsen constipation in the elderly, immobile resident. May result in impaction and faecal incontinence Fluid - ensure adequate fluid intake with increased fibre - 1500mL/day

Increased physical activity should be encouraged as part of the overall care plan however, Dietary fibre - insoluble variety is important as it absorbs water, increases faecal bulk and shortens time in colon- add into diet slowly to minimise flatulence and bloating- examples - unprocessed wheat, bran, fruit, vegetables (25-30g/day)- NOTE - fibre can worsen constipation in the elderly, immobile resident. May result in impaction and faecal incontinence Fluid - ensure adequate fluid intake with increased fibre - 1500mL/day

Regular use is requiredMuch better at absorbing water than bran resulting in softer stools. Provide bulk and keep stool soft through water resorptionDiabetics should check sugar content

Docusate - Lowers surface tension to allow water to penetrate into faeces to produce a softer motionParaffin coats the faecal mass to facilitate passageDo not benefit drug induced constipation as intestinal peristalsis is reducedRecommended dose of docusate 120mg bd although greater doses than recommended by manufacturer are often requiredParaffin Oil - depletion of fat soluble vitamins A,D,E and K- risk of aspiration- Agarol has been reformulated to contain phenolphthalein - associated with dermatitis, photosensitivity and Steven Johnson SyndromeAct in small and large intestinePoorly/not absorbed from the gut. Osmotic gradient causes influx of fluid into lumenSide effects - flatulence, cramp, diarrhoea, electrolyte imbalanceDose 15mL bd increasing to desired effectGI Disorders - IBS, DiverticulitisMetabolic Disorders - DiabetesEndocrine Disorders - Hypothyroidism, HypercalcaemiaImmobility - osteoarthritis, advanced cancerImproper Diet - inadequate fibre/fluid

Elderly residents with swallowing difficulties may be at risk of aspirating MovicolMay be thickened with xanthum gum thickeners such as Keltrol, Easy Thick or Thick Plus II

For acute constipation only unless no muscle toneData does not support the theory that chronic use results in colonic inertia, structural or functional nerve damageSide effects - cramping, electrolyte imbalance, dehydration, diarrhoeaBisacodyl - broken down by intestinal enzymes and acts on small and large intestine- enteric coated to minimise impact on small bowel - 5mg-20mg nocte or bd (tablets)- suppositories - onset of action 20-60minsSenna - broken down in large intestine by bacteria to produce active compound- increases propulsive waves in bowel- onset 8-12 hours

Not formulated in a manner that ensures even distribution of active ingredientVariations in dosage both from product and from administering person.Senokot tablets contain 7.5mg sennosides/tabletFrequent use can cause poor rectal tone and/or incontinenceOsmotic - Microlax; Fleet (C/I in renal failure); Travadproduce an immediate effectside effects - flatulence; cramp; diarrhoeaStimulant - Bisalax; Durolax; Glycerincan use every three daysSofteners - Coloxyl enema concentratePatient education:-impact of diet and fluid intake; effectiveness of exercise; effective toilet habits; side effects of medicationsDiet and fluid intake:-encourage high fibre diet; 6-8 glasses of water per day; increase fluids relative to fibre intake to minimise constipationEncourage regular exercise within patients capabilitiesEffective Bowel habits:- make use of gastro-colic reflex (15-30 after meals); regular toilet times; ensure toilet is correct height; encourage patient to sit with feet flat on the floor, leaning forward to minimise need for strainingToileting facilities;- privacy, assistance with mobility; facilities to call for assistance if needed, individual comfort measures