Prolonged use of laxatives, common with the elderly, can lead to altered blood chemistries, physical defects, dehydration, and dependence for evacuation.1 In addition, the use of drugs to control constipation, whether laxatives or stool softeners, may make it difficult for the aged individual to comply with his/her total medical regime because of increased financial expense and the number of medications that must be remembered, organized, and consumed.
In recent years, the importance of crude fiber in the diet as an aid to bowel elimination has been recognized. The addition of crude fiber to diets usually results in decreased colon transit time for greater ease and frequency of defecation.1 Bran cereal with two additional grams of fiber was added to the daily diet of chronically ill, elderly men on a neuropsychiatrie unit. This addition markedly increased the number of spontaneous bowel movements and decreased their use of cathartics, stool softeners, and enemas.2 In a study with severely demented, elderly men and women, consumption of high-bran bread decreased laxative consumption.3
Other reported effects of the addition of dietary fiber, such as bran, include reductions in: caloric density, digestion and absorption of protein, calcium, zinc, magnesium, and phosphorus secondary to the reduced transit time.4 These effects generally have been seen with relatively large amounts of dietary fiber. Levels did not change outside of the normal range in a study done by Battle and Hanna using 2.4 gm of dietary fiber.
In the Sandman study, postprandial blood glucose values and serum creatinine levels of elderly subjects were significantly reduced during the period of bran consumption.3 With the water-binding properties of dietary fiber, adequate fluid intake is most important.4
Although desirable, given the problems of poor dentition, anorexia, and dysphagia of many patients, it was viewed as unrealistic to try to modify the roughage of diets with fresh fruits, vegetables, and salads.
Our study sought to address two problems with bowel management in the elderly: (1) fecal incontinence with constipation, necessitating the establishment of a regular evacuation time as part of bowel retraining and (2) constipation with soft stool in the descending colon and/or rectum without the urge to defecate.
Bisacodyl, a contact-irritant laxative, stimulates the rectal mucosa, which results in peristaltic action and defecation in 15 to 30 minutes.5 Brocklehurst's study in of the use of bisacodyl suppositories with constipated patients on a geriatric unit found it to be an effective means of achieving a complete and controlled evacuation.6 Our program utilized bisacodyl as an aid in establishing a regular evacuation time for those individuals who do not evacuate in a thorough or controllable manner despite the dietary regime.
With repetition and patterning, the goal was mat, in time, the individual would begin to respond to the physical bulk agents (bran and fluids) without the need for a suppository to stimulate the defecation reflex.
This study took place on a 16-bed, geriatric rehabilitation unit of a Veterans Administration Hospital and Medical Center. Elderly patients are admitted directly from the community or from other units within the facility if they are in need of primary rehabilitative nursing or care by an interdisciplinary team, and are not acutely ill. The only patients excluded from the study were those with a history of large-bowel pathology and concurrent dietary restrictions, and patients unable to ingest fluids and soft foods.
Patients were kept on the study until one of the following conditions occurred: (1) the pattern of bowel evacuation was regular for at least 10 days without the use of any laxatives or suppositories; (2) they were transferred to another unit because of serious acute illness or surgery; or (3) they were discharged from the hospital.
Thirty-eight male patients, with an average age of 82 years, completed the study. These individuals had multiple health programs impairing their ability to function independently. The most common diagnoses were failure to thrive, genitourinary dysfunction, cognitive impairment, cerebrovascular disease, visual impairment, and cardiovascular disease.
Method - After consent was obtained, the primary or associate nurse initiated the following bowel program protocol with all subjects:
1. Obtain data base, which includes: age, diagnosis, normal bowel pattern (frequency and time of evacuation), history of constipation and laxative use, aids used at home ( including medications), gastrointestinal problems, nutritional status (weight/energy needs, food patterns and preferences), and date of last bowel movement. This information is recorded on the "Bowel Retraining Program Record" kept at the patient's bedside.
2. Conduct an assessment to rule out client constipation/impaction.
3. If the patient is constipated or impacted, interventions are initiated to foster a complete evacuation.
Until this occurs, the patient is not placed on the experimental or control bowel regime.
4. Initiate fluid intake records. All subjects must maintain a minimum 1500 cc/24 hour fluid intake. Intake records are kept for at least three days. They are discontinued only when the minimum intake has been consistently maintained.
The head nurse then randomly assigned subjects, via coin toss, to the experimental or control groups. All laxatives and stool softeners for subjects in the experimental group were discontinued and the "bowel program protocol" was ordered.
* 15 gm bran flour (3 tbsp) in hot cereal every morning.
* 120 cc prune juice with breakfast
* 120 cc juice with lunch and dinner daily.
Bisacodyl Suppository Regime
* Administer one every day in the morning if no bowel movement the previous day. The time of suppository administration can be modified according to the patient's usual time of evacuation. The frequency of administration can be decreased to parallel the subject's normal bowel pattern.
Patients in the control group could have any bowel regime recommended by the patient and primary nurse and prescribed by the physician/physician assistant, excluding the use of hot bran cereal, bisacodyl suppositories, or enemas (except as described below). The medication regime could be changed according to the primary nurse's judgment in discussion with patient and medical staff.
To protect subjects from discomfort, additional interventions were initiated if the patient did not have a complete evacuation within four-day periods. Subjects in the experimental group were to receive bisacodyl, 5 mg tablet, by mouth on the fourth evening, followed by a Fleets enema by the middle of day five if there was no passage of stool or an incomplete evacuation. Control group subjects could receive the bisacodyl tablet or any other prescribed regime. The Fleets enema was administered according to the same criteria. An additional Fleets enema or tapwater enema was administered as necessary.
The absence of a complete evacuation, requiring the administration of a Fleets enema on the fifth day defines, for the purpose of this study, a nonresponder and constipation. An incomplete evacuation is defined as having none or small quantities of feces in relation to food intake; and/or patient complaints of abdominal fullness, anorexia, or constipation; and/or abdominal distension; and/or rectum filled with stool.
Non-responders in the experimental group would then resume the bowel program protocol. Control group nonresponders could resume their previous bowel regime or have it changed.
Subject Response to Bowel Program
Descriptive Data - Examination of the descriptive data indicates that the sample was at high risk for developing alterations in bowel function. Of the 38 subjects in the study, 24 (63%) had difficulties with bowel elimination. Despite the unit goal of limiting the use of medication, 32 of the 38 subjects (84%) were receiving at least one drug with side effects that could affect elimination.
Subjects in the two groups were similar in relationship to difficulties with elimination, medications, mental status, and food intake. However, those in the experimental group were significantly less active, as reflected in ambulatory capabilities. The average length of patient stay, which was 20 days and similar for both groups, provided patients with the opportunity to benefit from the rehabilitating milieu.
Relationship Between Factors - Age, mental status, activity, appetite, admission to the unit with constipation, and a history of constipation or laxative use were not strongly associated with a nonresponder. A history of constipation or laxative use, however, was related to age. Subjects who were active used fewer suppositories than those who were inactive.
For the purposes of study and discussion, evacuation aids were placed in two categories: preventive (stool softeners, bulk agents) and interventions (suppositories, laxatives). The use of laxatives was positively related to the number of preventive agents taken by subjects. The classification of nonresponder was highly associated with bom preventive drugs and laxatives.
Response - Patients in the control group received a variety of preventive evacuation aids, which included: Colace, Metamucil, Sorbitol, Cephulac, and Dialose. Sixteen patients in the control group received a total of 26 preventive evacuation aids at least daily, either with concurrent or sequential administration.
Seven subjects in the control group, defined as non-responders, received 17 enemas. No patients in the experimental group required an enema. The experimental group had a significantly low incidence of constipation, as defined by non-responder (p = 0.015), thereby supporting the study question.
As seen in the Table, subjects in the experimental group required fewer interventions (enema and non-enema) than those in the control group.
Gerontological nurses independently reviewed each subjects' bowel retraining program record to give a clinically relevant judgment of bowel regulation.
Subjects in the experimental group received the rating of good bowel regulation much more often than those in the control group.
During the study, five subjects in each group had gastrointestinal complaints (flatus, constipation, cramps).
Three of these ten patients had a complaint on more than one occasion. The low frequency of complaints must be interpreted with caution, since patients may be reluctant to discuss bowel discomfort. Those with a history of bowel management problems also may regard gastrointestinal distress as normal and to be tolerated.
Significance and Implications
Because of the wide variation in patterns of elimination, the definition of normal evacuation frequency and constipation remains somewhat arbitrary. This can be viewed as a limitation of the study. The high incidence in this study of laxative use and constipation by history supports the need for nurses to work with elderly clients to define and establish a reasonable and comfortable bowel regime. As the results of this study indicated, previous problems with bowel regulation did not significantly affect the response of subjects in either group.
The finding that most of these ill and elderly subjects did well in the study is noteworthy. It is suggested that the maintenance of an adequate fluid intake, the rehabilitative environment of the unit, and nursing care that was sustained and attentive were important contributing factors.
Subjects in this study who had a history of laxative use did not exhibit significant problems. However, examination of the relationship between variables supports concern regarding the deleterious effect of laxatives on bowel function.7
The study indicates that the use of laxatives and preventive drugs were highly related. The classification of subjects as non-responders also was highly correlated both with the use of laxatives and the use of preventive drugs. This means that nurses administered preventive and intervention agents in an attempt to prevent further constipation when they were aware of a patient's problem. One must question the effectiveness of these agents in reducing the need for enemas.
It is recommended that further study be done on the effect of long-term use of preventive and intervention agents on bowel function of the elderly. Particularly in working with elderly of an advanced age, nurses need to share information regarding the possible effects of these drugs on evacuation.
Our results indicate that the bowel regime was significantly more effective than other medication regimes in reducing the incidence of constipation. The positive effect of the dietary regime is shown by the absence of significantly increased use of suppositories by subjects in the experimental group as compared to the use of suppositories alone or the use of laxatives and suppositories combined among subjects in the control group. At the onset of the study, there was concern that the average length of a patient's hospitalization would not provide enough time to reflect changes in bowel patterns and response to me bowel program. Pearson and Kotthoff recommend a minimum three-week trial of a constipation management plan. Hull et al identified the first two weeks of a bran program as causing erratic bowel habits.8·9
Although our study demonstrated the effectiveness of the bowel program, its short duration compared to other studies may have contributed to the lack of an overall reduction in the number of interventions needed by subjects in both groups. Because the small number of interventions per patient days inhibits interpretation, further long-term study is recommended. If the need for suppositories does not decrease, then the amount of bran and its use should be reexamined. The long-term effects of suppository use cannot be underestimated.
Several studies have examined the use of fiber-supplemented diets for the elderly. As identified by Pollman, interpretation of the results of these studies is difficult because of the failure to control laxative administration, activity, fluid intake, medications, and disease processes.4 Comparison among studies is limited by the differences in sample populations and a failure to randomize or control for sample selection. The variations in definition and amount of crude fiber used to supplement diets, and a lack of statistical analysis in many studies must be considered in reviewing the use of fiber-supplemented diets for the elderly.
Our study did control for many of the identified weaknesses in this area of research. Although our results strongly support the use of bran and the findings of other studies, it is recommended that further work be done before implementing changes in bowel programs.2·3·9
Because of the low cost of bran fiber and the patient satisfaction with the regime, many of the study patients have continued the program after their discharge from the hospital. From a nursing program perspective, however, sound practice would dictate replication of the study with healthy elderly in the community, the acutely ill elderly, and chronically ill men and women before implementing this program in practice. The long-term study of subjects and a refined definition and qualification of constipation and bowel regulation is also recommended.
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- 3. Sandman PO, et al: Treatment of constipation with high-bran bread in long-term care of severely demented elderly patients. J Am Geriatr Soc 1983; 3K5V.289-293.
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- Almy T: Fiber and the gut. Am J Med 1981; 71:193-195.
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- Cefalu Charoles, et al: Treating impaction: a practical approach to an unpleasant problem. Geriatrics 1981; 36(5): 143- 146.
- Connell AM, et al: Variation of bowel habits in two populations. Br Med J 1965; 11:10931099.
- Kelsay J: A review of research of effects of fiber intake on man. Am J Clin Nutr 1978; 31: 142-159.
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- Physician Desk Reference, ed 34. Oradell, NJ, Medical Economics Company, 1980.
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Subject Response to Bowel Program