Journal of Gerontological Nursing

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RESEARCH-BASED PROTOCOL Management of Constipation

Marcia Hinrichs, MSN, RN, GNP; Jennifer Huseboe, MSN, RN, GNP

Abstract

Constipation is a concern for elderly individuals. It is estimated to affect more than 10% of the general American population and 25% of older adults, and is responsible for more than 2.5 million physician visits each year (Harris, 1998). Nearly half of all patients older than 65 years reported the routine use of laxatives. Approximately $400 million has been spent annually on laxatives and this is projected to increase over time (Wilson, 1999). The impact of constipation is not only on high expenditure of health care dollars, it also interferes with patients' quality of life and compliance with medications such as opioid analgesics (Hurdon, Viola, & Schröder, 2000; Weeks, Hubbartt, & Michaels, 2000).

Constipation is most prevalent among women, Blacks, individuals older than 60 years, individuals who have low income, poor education, and physical inactivity (Scandler, Jordan, OC Shelton, 1990; Sonnenberg & Koch, 1989). The high prevalence of constipation and its impact on individuals, as well as on public health, has convinced health care professionals to focus on this issue and provide optimum care.

Nurses are key to preventing and treating constipation. This article provides an overview of the researchbased practice protocol on management of constipation that provides an intervention guideline designed to prevent and treat constipation in older adults.

When laxative treatment is necessary, a prioritized approach to instituting the various categories of laxatives is advocated, depending on the acuteness of the constipation episode. Each category of laxative treatment should be trialed before progressing to the next level. A stepwise progression of laxative treatment is recommended (Figure 1 ). First, bulk-forming laxatives should be trialed. Thereafter stool softeners, osmotics, stimulants, suppositories, and lastly enemas should be trialed (Sanburg et al., 1996). Once constipation is resolved, management should be moved back to the top of the laxative pyramid to safer methods of management (Sanburg et al., 1996).

The first laxative treatment option is bulk-forming IaXaUVeS1 such as psyllium hydrophilic mucilloid. These cause absorption of water in the intestine, which increases stool volume, thus promoting evacuation (Semla et al., 1997, Harán, Gurwítz, Sc Minaker, 1993). Older adults may consume insufficient amounts of fluid in combination with such bulkforming laxatives, thus predisposing them to fecal impaction and bowel obstruction (Semla et al., 1997). It is therefore important to combine adequate fluid intake while using this lexative treatment.

The second laxative treatment option is stool softeners, such as docusate sodium. These cause absorption of water and fat. Stool softeners are recommended for situations where straining should be avoided (Semla et al., 1997; Harari et al., 1993).

The third laxative treatment option is osmotic laxatives, such as lactulose, magnesium hydroxide, magnesium sulfate, and sorbitol. These 1O1WCr the stool pH causing distention of the bowel that stimulates evacuation. Older adults may experience diarrhea, dehydration, or even fluid and electrolyte imbalance Semla et al., 1997; Harari et al., 1993).

The fourth laxative treatment option is stimulants, such as senna. These stimulate peristalsis in the distal colon, which causes mass movement of softened stool. Older adults may require up to 10 weeks of use to establish a regular pattern of elimination. Older adults may experience electrolyte imbalance and dehydration secondary to diarrhea. Prolonged use may predispose individuals to cathartic colon. Cathartic colon is the inability to have a bowel movement without the use of laxatives. Cathartic colon can be reversed by discontinuing use of laxatives and instituting the above regimen of fluids, high fiber diet, exercise, and toileting (Sémla et al., 1997; Harari et ai, 1993)

The last laxative treatment option is suppositories, such as glycerin or biscodyl. These stimulate intestinal muscle contraction, resulting in evacuation (Semla…

Constipation is a concern for elderly individuals. It is estimated to affect more than 10% of the general American population and 25% of older adults, and is responsible for more than 2.5 million physician visits each year (Harris, 1998). Nearly half of all patients older than 65 years reported the routine use of laxatives. Approximately $400 million has been spent annually on laxatives and this is projected to increase over time (Wilson, 1999). The impact of constipation is not only on high expenditure of health care dollars, it also interferes with patients' quality of life and compliance with medications such as opioid analgesics (Hurdon, Viola, & Schröder, 2000; Weeks, Hubbartt, & Michaels, 2000).

Constipation is most prevalent among women, Blacks, individuals older than 60 years, individuals who have low income, poor education, and physical inactivity (Scandler, Jordan, OC Shelton, 1990; Sonnenberg & Koch, 1989). The high prevalence of constipation and its impact on individuals, as well as on public health, has convinced health care professionals to focus on this issue and provide optimum care.

Nurses are key to preventing and treating constipation. This article provides an overview of the researchbased practice protocol on management of constipation that provides an intervention guideline designed to prevent and treat constipation in older adults.

PURPOSE

The purpose of this researchbased protocol is to reduce the frequency and severity of constipation among older adults. The goal is to maintain normal bowel movements, at least three times per week with straining at stool less than 25% of the time (Donald, Smith, Cruikshank, Elton, & Stoddard, 1985; Harari, Gurwitz, Avorn, Choodnovskiy, & Minaker, 1 994). This protocol is applicable to older adults who are hospitalized, residing in long-term care or skilled care facilities, or living in the community. This protocol is not intended for the populations of enterally fed, paraplegic, or quadriplegic individuals.

DEFINITION OF CONSTIPATION

Individuals are considered constipated if bowel movement frequency is less than three times per week (Cheskin, Kamel, Croweü, Schuster, & Whitehead, 1995; Hagberg, Fines, & Doyle, 1987; Voderholzer et al-, 1997; Whitehead, Drinkwater, Cheskin, Heller, & Schuster, 1989) and/or if straining is experienced with more than 25% of bowel movements (Cheskin et al., 1995; Donald et al., 1985; Harari et al., 1994; Ross, 1993; Towers et al., 1994; Voderholzer et al., 1997; Whitehead et al., 1989).

INDIVIDUALS AT RISK FOR CONSTIPATION

Several factors place older adults at risk for constipation. If an individual is at risk according to any of the following factors, an assessment needs to be made to determine if symptoms of constipation are present, and if they are, the interventions described in this protocol may be implemented. The risk factors for constipation include:

* Older than age 55 (Meza, Peggs, & O'Brien, 1984; Campbell, Busby, & Horwath, 1993).

* Recent abdominal or perianal surgery (Voderholzer et al-, 1997) or general anesthesia (Schmelzer, 1990).

* Limited physical activity, such as bedrest (Sanburg, McGuire, &: Lee, 1996), poor mobility secondary to chronic disability (Donald et al., 1985), and decline in general physical activity (Brockiehurst, 1977; Brocklehurst, 1980; Kochen, Wegschieder, & Abholz, 1985; Meza et al., 1984; Neal, 1995; Ouellet, Turner, Pond, McLaughlin, & Knorr, 1996; Sanburg et al, 1996).

Table

TABLE 1SELECTED DISEASES AND CONDITIONS KNOWN TO BE ASSOCIATED WITH CONSTIPATION

TABLE 1

SELECTED DISEASES AND CONDITIONS KNOWN TO BE ASSOCIATED WITH CONSTIPATION

* Inadequate diet, (Meza et al., 1984; Neal, 1996, Sanburg et al., 1996, Wrenn, 1989) including less than 15 grams of dietary fiber per day (Campbell, Busby, OC Horwath, 1993).

* Inadequate fluid intake (Meza et al-, 1984; Neal, 1995; Sanburg et al., 1996; Wrenn, 1989), less than 1000 milmiters per day (Campbell, Busby, & Horwath, 1993).

* Use of drugs known to be associated with increased risk of constipation, such as anti-cholingergics, anti-emetics, anti-histamines, analgesic/nonsteroidal anti-inflammatory drugs (NSAIDS), and hypotensives. (Evans, Fleming, Talley, Schleck, Zinsmeister, & Melton, 1998; Meza et al., 1984; Voderholzer et al., 1997; Whitehead et al., 1989)

* History of chronic constipation (Corazziari et al., 1987; Donald et al., 1985; Evans et al., 1998; Towers et al., 1994).

* History of laxative abuse (Corazziari et al-, 1987; Evans et al., 1998; Everhart et al, 1989; Donald et al., 1985; Meza et al., 1984; Neal, 1995; Towers et al., 1994; Wrenn, 1989).

* Comorbìdities known to be associated with constipation (Table 1).

ASSESSMENT CRITERIA

The first step in managing constipation is to assess for risk of constipation using an assessment inventory (Table 2). Recall of bowel frequency has been found to be unreliable in establishing the presence of constipation. Documentation of bowel movement patterns by the patient/client completing some type of bowel diary has proven more accurate than recall in determining the presence of constipation (Orr, Johnson, & Yates, 1997) (Table 3). It is important to determine that constipation is actually present before initiating interventions to treat it.

Table

TABLE 2MANAGEMENT OF CONSTIPATION ASSESSMENT INVENTORY

TABLE 2

MANAGEMENT OF CONSTIPATION ASSESSMENT INVENTORY

Table

TABLE 2MANAGEMENT OF CONSTIPATION ASSESSMENT INVENTORY

TABLE 2

MANAGEMENT OF CONSTIPATION ASSESSMENT INVENTORY

If constipation is suspected, the individual should be assessed for rectal impaction by digital examination. If stool is present, disimpaction is necessary prior to initiating the following interventions (Gibson, Opalka, Moore, Brady, & Mion, 1995; Wrenn, 1989).

During the course of instituting this Management of Constipation Protocol, individuals at risk for fecal impaction should be periodically reevaluated with a digital rectal examination (Gibson et al, 1995; Wrenn, 1989). The presence of bowel sounds and abdominal rigidity, distension, or tenderness should also be assessed (Gibson et al., 1995).

The following assessment criteria indicate patients/clients who are likely to benefit most from the use of this research-based protocol:

1. Patients/clients older than 55 years (Campbell, Busby, & Horwath, 1993; Meza et al., 1984).

2. Patients/clients who have less than three bowel movements per week and/or experience straining at stool more than 25% of the time (Harari et al., 1994).

3. Patients/clients who experience any of the following:

* Hard or dry stool (Brocklehurst, 1977; Cheskin et al., 1995; Corazziari et aL, 1987; Donald et al., 1985; Rodriquez-Fisher, Bourguignon, & Good, 1993; Ross, 1993; Whitehead et al., 1989; Wrenn, 1989).

* Abdominal distention, fullness and/or bloating in the presence of rectal fullness and pressure (Brocklehurst, 1977; Cheskin et al, 1995; Corazziari et al., 1987; Ross, 1993).

* Absence of a bowel movement accompanied by an empty rectum on digital examination (Donald et al., 1985).

* Rectal pain with passing stool (Ross,1993)

* A feeling of incomplete evacuation of stool (Cheskin et al., 1995; Whitehead et al., 1989)

DESCRIPTION OF INTERVENTION

Following identification of an individual at high risk for constipation, the following actions can be implemented. Initial management of constipation (prevention of constipation) is recommended as a combination of fluids, diet, exercise, and toileting regimen (Karam & Nies, I994; Meza et al., 1984)

Fluid intake

Older adults may consume insufficient amounts of fluid that may predispose them to constipation (Semla, Beizer, & Higbee, 1997). Untreated constipation may lead to fecal impaction and bowel obstruction (Semla et al., 1997). Thus, fluid intake of at least 1 .5 liters per day is recommended to avoid constipation (Meza et al., 1984; Iserninger & Hardy, 1982; Mentes & the Iowa Veterans Affairs Nursing Research Consortium, 1998).

Water is preferred, although other fluids such as juices are equally beneficial (Badiali, et al, 1995; Bradford & Dunbar, 1987; Brockelhurst, 1980; Gibson et al., 1995; Karam Oc Nies, 1994; Meza et al., 1984; Neal, 1995). Coffee, tea, and alcohol should be avoided due to their diuretic properties (Badiali et al., 1995; Bradford & Dunbar, 1987; Brockelhurst, 1980; Gibson et al., 1995; Karam Sc Nies, 1994; Meza et al., 1984; Neal, 1995).

Table

TABLE 3BOWEL PATTERN ASSESSMENT FORM*

TABLE 3

BOWEL PATTERN ASSESSMENT FORM*

Table

TABLE 3BOWEL PATTERN ASSESSMENT FORM*

TABLE 3

BOWEL PATTERN ASSESSMENT FORM*

Diet

A high fiber diet has been found to increase bowel frequency and to be effective in treatment of constipation (Badiali et al., 1995; Brown & Everett, 1990; Cheskin et al, 1995; Gibson et al., 1995; Gray, 1995; Groth, 1988; Hagberg et al., 1987; Iseminger & Hardy, 1982; Kochen et aL, 1985; Mullen-Lissner, 1988; Ouellet et al., 1996; Pringle, Pennington, Pennington, Si Ritchie, 1984; RodriquezFisher, Bourguignon, & Good, 1993; Sanburg et al., 1996; Schmelzer, 1990; Tramonte, et al., 1997; Valle-Jones, 1985; Voderholzer et al., 1997). Dietary fiber is a natural component of plant products, such as fruit, végétables, and grains. It provides the bulk needed by the colon to eliminate body waste (Di Lima, 1997). As fiber passes through the colon, it acts as a sponge by absorbing water. This results in bulkier and softer stools. Waste then moves through the body more quickly, allowing easier and more regular bowel movements. This may help prevent constipation (Di Lima, 1997).

Dietary fiber includes insoluble and soluble fiber. Insoluble fiber is found in wheat bran, vegetables, and whole grains. It does not dissolve in water. This type of fiber is most helpful in preventing constipation. Soluble fiber is found in oat bran, barley, some beans, and certain fruits and vegetables. This fiber forms a gel when mixed with water. Soluble fiber has minimal benefit in preventing or treating constipation (Di Lima, 1997).

Several studies have shown the effectiveness of fiber supplements such as "power pudding" (see Table 4 for recipes), which may be used in combination with a high fiber diet (Brown, & Everett, 1990; Gibson et al., 1995; Hull, Greco, & Brooks, 1980; NeaL, 1995). Other high fiber recipes are in the complete constipation protocol. High fiber bran products, such as wheat bran, bran flakes, or bran cereals, can be substituted in recipes to increase the fiber content of the food (Di Lima, 1997; Kochen et al., 1985; Woodruff, 1995). The most beneficial means to prevent constipation is a combination of insoluble and soluble fiber by increasing dietary intake of bran, fruits, and vegetables (Wichita, 1977).

Recommendations for dietary fiber intake vary from 25 to 30 grams per day (Brown & Everett, 1990; Cheskin et al., 1995; Gray, 1995; Mullen-Lissner, 1988; Sanburg et al., 1996) to 20-35 grams per day minimum (Di Lima, 1997) when fluid intake is at least 1,500 milliliters per day (Ouellet et al., 1996). For individuals who are immobile or who do not consume at least 1,500 milliliters of fluids per day, a diet high in fiber is not recommended (Donald et al., 1995). Dietary Fiber Values for Selected Foods are in the complete protocol.

Physical Activity

Limited mobility is associated with constipation (Donald et al., 1995 & Everhart et al., 1989). Physical activity in association with adequate fluid intake and a high fiber diet has been found to be beneficial in management of constipation (Meza et al., 1984). Activity recommendations must be tailored to the individual's physical abilities and health condition (Karam Oc Nies, 1994). Interventions include:

* Walking 15-20 minutes once or twice a day, or more as tolerated for those who are fuljy mobile (Karam & Nies, 1994).

* Ambulating at least 50 feet twice a day for individuals with limited mobility (Karam & Nies, 1994).

* Chair or bed exercises, such as pelvic tilt, low trunk rotation, and single leg lifts, for individuals who are unable to walk or are restricted to bedrest.

The exercises should be performed for 15 to 20 minutes at least twice a day (Karam Si Nies, 1994).

Table

TABLE 4POWER PUDDING RECIPES

TABLE 4

POWER PUDDING RECIPES

Toileting

Ignoring or suppressing the urge to defecate contributes to constipation (Sanburg et al., 1996). Establishing a routine toileting pattern has been found to be beneficial in management of constipation (Gibson et al., 1995). Toileting is recommended 5 to 15 minutes after meals and as needed, especially after breakfast when the gastrocolic reflex is strongest (Karam & Nies, 1994). Getting the individual into an upright position for toileting (e.g., to the bathroom or the commode) facilitates bowel evacuation (Karam & Nies, 1994).

Laxatives

Laxative use may be considered to treat constipation if there is no bowel movement for more than three days (Gibson et al, 1995). A significant association has been found, however, between chronic laxative use and slowed fecal mass intestinal transit time that further contributes to constipation. Therefore chronic laxative use is strongly discouraged (Evans et al., 1998). For chronic constipation, constipation of longer than six months duration (Towers et al., 1994; Voderholzer et al., 1997), laxative use is advocated only as supplement to the above regimen of adequate fluid intake, high fiber diet, exercise, and toileting routine and when there is no bowel movement for more than three days (Gibson et al., 1995). It is also advocated that all laxative use be either decreased or eliminated when initiating the fluid, fiber, exercise, and toileting regimen (Neal, 1995).

Table

TABLE 5BOWEL FUNCTION DIARY

TABLE 5

BOWEL FUNCTION DIARY

Table

TABLE 6MANAGEMENT OF CONSTIPATION OUTCOMES MONITOR

TABLE 6

MANAGEMENT OF CONSTIPATION OUTCOMES MONITOR

Table

TABLE 6AAANAGEMENT OF CONSTIPATION OUTCOMES MONITOR

TABLE 6

AAANAGEMENT OF CONSTIPATION OUTCOMES MONITOR

When laxative treatment is necessary, a prioritized approach to instituting the various categories of laxatives is advocated, depending on the acuteness of the constipation episode. Each category of laxative treatment should be trialed before progressing to the next level. A stepwise progression of laxative treatment is recommended (Figure 1 ). First, bulk-forming laxatives should be trialed. Thereafter stool softeners, osmotics, stimulants, suppositories, and lastly enemas should be trialed (Sanburg et al., 1996). Once constipation is resolved, management should be moved back to the top of the laxative pyramid to safer methods of management (Sanburg et al., 1996).

The first laxative treatment option is bulk-forming IaXaUVeS1 such as psyllium hydrophilic mucilloid. These cause absorption of water in the intestine, which increases stool volume, thus promoting evacuation (Semla et al., 1997, Harán, Gurwítz, Sc Minaker, 1993). Older adults may consume insufficient amounts of fluid in combination with such bulkforming laxatives, thus predisposing them to fecal impaction and bowel obstruction (Semla et al., 1997). It is therefore important to combine adequate fluid intake while using this lexative treatment.

The second laxative treatment option is stool softeners, such as docusate sodium. These cause absorption of water and fat. Stool softeners are recommended for situations where straining should be avoided (Semla et al., 1997; Harari et al., 1993).

The third laxative treatment option is osmotic laxatives, such as lactulose, magnesium hydroxide, magnesium sulfate, and sorbitol. These 1O1WCr the stool pH causing distention of the bowel that stimulates evacuation. Older adults may experience diarrhea, dehydration, or even fluid and electrolyte imbalance Semla et al., 1997; Harari et al., 1993).

The fourth laxative treatment option is stimulants, such as senna. These stimulate peristalsis in the distal colon, which causes mass movement of softened stool. Older adults may require up to 10 weeks of use to establish a regular pattern of elimination. Older adults may experience electrolyte imbalance and dehydration secondary to diarrhea. Prolonged use may predispose individuals to cathartic colon. Cathartic colon is the inability to have a bowel movement without the use of laxatives. Cathartic colon can be reversed by discontinuing use of laxatives and instituting the above regimen of fluids, high fiber diet, exercise, and toileting (Sémla et al., 1997; Harari et ai, 1993)

The last laxative treatment option is suppositories, such as glycerin or biscodyl. These stimulate intestinal muscle contraction, resulting in evacuation (Semla et al., 1997). Enemas, such as sodium/potassium phosphate, stimulate evacuation in response to colonie distension. There is a risk of electrolyte imbalance or perforation of the colon (Harari et al., 1993). Because many laxatives predispose older adults to dehydration, maintaining adequate fluid intake is essential.

EVALUATION OF PATIENT OUTCOMES

To evaluate the use of this protocol among patients/clients at risk for constipation, both outcome and process factors should be evaluated. Patient outcomes can be evaluated by using the Bowel Function Diary

(Table 5) and the Management of Constipation Outcomes Monitor forms (Table 6). These outcome measures should be carried out frequently throughout the use of the protocol as outlined on the forms.

REFERENCES

  • Key: (R)=Research
  • (L)=Literature
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TABLE 1

SELECTED DISEASES AND CONDITIONS KNOWN TO BE ASSOCIATED WITH CONSTIPATION

TABLE 2

MANAGEMENT OF CONSTIPATION ASSESSMENT INVENTORY

TABLE 2

MANAGEMENT OF CONSTIPATION ASSESSMENT INVENTORY

TABLE 3

BOWEL PATTERN ASSESSMENT FORM*

TABLE 3

BOWEL PATTERN ASSESSMENT FORM*

TABLE 4

POWER PUDDING RECIPES

TABLE 5

BOWEL FUNCTION DIARY

TABLE 6

MANAGEMENT OF CONSTIPATION OUTCOMES MONITOR

TABLE 6

AAANAGEMENT OF CONSTIPATION OUTCOMES MONITOR

10.3928/0098-9134-20010201-11

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