Acute constipation constipation as a symptom Objective organic cause

1. Constipation is not a well known topic unless pearhaps you experiment it……….. For my own I’ll say that this is a quite new topic but on physician point of view What could be said about the management of Constipation in older people?Constipation is not a well known topic unless pearhaps you experiment it……….. For my own I’ll say that this is a quite new topic but on physician point of view What could be said about the management of Constipation in older people?

2. Firts I would like to point out the problem of the definition of constipation Is it only a Short part of time in the week with some incomfortable efforts which are forgotten just after… Or is it something about which people worries along the day life depressing, asssociated with numerous others functional complaints?Firts I would like to point out the problem of the definition of constipation Is it only a Short part of time in the week with some incomfortable efforts which are forgotten just after… Or is it something about which people worries along the day life depressing, asssociated with numerous others functional complaints?

3. IN fact, Physicians and older patients don’t define constipation in the same way Actually, Physicians define 3 types of constipation. Functional constipation or Slow transit constipation, based on Rectal outlet delay (or Pelvic floor syndrome) based on….. Irritable Bowel Syndrom based on Rome II criteria. However there are some discrepancies when compared with self reported constipation or when you look after the laxative use. 60% of self reported constipation meet the full criteria of physician definitions. 60% of self reported constipated elderly and 65 % of laxative users had one bowel movement at least once a day. However, for some authors self reported constipation or laxative use underestimate the prevalence of constipation (Talley NJ ) IN fact, Physicians and older patients don’t define constipation in the same way Actually, Physicians define 3 types of constipation. Functional constipation or Slow transit constipation, based on Rectal outlet delay (or Pelvic floor syndrome) based on….. Irritable Bowel Syndrom based on Rome II criteria. However there are some discrepancies when compared with self reported constipation or when you look after the laxative use. 60% of self reported constipation meet the full criteria of physician definitions. 60% of self reported constipated elderly and 65 % of laxative users had one bowel movement at least once a day. However, for some authors self reported constipation or laxative use underestimate the prevalence of constipation (Talley NJ )

4. 2 conclusions about this problem of definition: first it minimizes the impact of recommendations of management of something not well define Second, prevalences among elderly are variable from 2 to 50% according to different factors An overview of the literature find theses following in differents studies However, even factors as dietary, fluid intake, mobility, ……… are not completly established 2 conclusions about this problem of definition: first it minimizes the impact of recommendations of management of something not well define Second, prevalences among elderly are variable from 2 to 50% according to different factors An overview of the literature find theses following in differents studies However, even factors as dietary, fluid intake, mobility, ……… are not completly established

5. On another hand we can ask if constipation is so important ? Wiwh is its impact ? Clearly some complications are reported such as Fecal impaction or fecal incontinence, ….. but with a little idea of the rate for each The Impact on health status have been also studied: Constipation is associated with decreased functionnal status, increase depression and anxiety symptoms and decrease on social activity However, constipation may be the consequence of its and not the cause Finally, The rate of physician visits for constipation is also increased. This lead to say that constipation may be a a significant driver of health care cost. Because of all of this the management of constipation should be well define. On another hand we can ask if constipation is so important ? Wiwh is its impact ? Clearly some complications are reported such as Fecal impaction or fecal incontinence, ….. but with a little idea of the rate for each The Impact on health status have been also studied: Constipation is associated with decreased functionnal status, increase depression and anxiety symptoms and decrease on social activity However, constipation may be the consequence of its and not the cause Finally, The rate of physician visits for constipation is also increased. This lead to say that constipation may be a a significant driver of health care cost. Because of all of this the management of constipation should be well define.

6. Acute constipation constipation as a symptom Objective organic cause /secondary * Risk factors- Dietary, mobility, hydratation * Drug effects * Mechanical obstructiion * Metabolic disorders * Neuropathies Chronic constipation constipation as a syndrome Objective Functional * Risk factors : Dietary, mobility, hydratation, drugs * Functional activity * Psychological factors * Quality of life The Management of constipation has to began by a carefull history of constipation related symptoms (Date of onset,outcome with or without treatment, kind of constipation associated symptoms…….) This provide to distinguish 2 kinds of constipation First an acute or subacute constipation for which the objective is to know wether there is an organic cause. The second type should be an old story of constipation and may be consider as a syndrom The objective should be functional. It needs the assessment of risk factors others functional disorders, and quality of lifeThe Management of constipation has to began by a carefull history of constipation related symptoms (Date of onset,outcome with or without treatment, kind of constipation associated symptoms…….) This provide to distinguish 2 kinds of constipation First an acute or subacute constipation for which the objective is to know wether there is an organic cause. The second type should be an old story of constipation and may be consider as a syndrom The objective should be functional. It needs the assessment of risk factors others functional disorders, and quality of life

7. First part of management of acute constipation is Evaluation History has to look for past medical history looking for diseases associated with constipation and for intestinal and extraintestinal symptoms related to a specific cause. Physical examination with a special attention of perianal skin and digital rectal exam Basis biological investigations are recommended. Others biological and morphological investigations depend on history and physical exmination. However, No assessment of the yield of different investigations are available. First part of management of acute constipation is Evaluation History has to look for past medical history looking for diseases associated with constipation and for intestinal and extraintestinal symptoms related to a specific cause. Physical examination with a special attention of perianal skin and digital rectal exam Basis biological investigations are recommended. Others biological and morphological investigations depend on history and physical exmination. However, No assessment of the yield of different investigations are available.

8. Wathever the investigations, a empiric therapy could be begun Treatment of risk factors are recommended: modifications in life style (dietary, hydratation, mobility, drug) are wondering if possible Laxatives may be use when there is no evident treatable risk factors or directly. The recommendations are based on the ratio between efficiency and adverse reactions and on the kind of symptoms that we’ll see further. Fibers and bulk laxatives associated with fluid intake are used on 1st line as well as Osmotic agents on Enemas are used on 2 line therapy. Finally, Treat the cause when one is founded.Wathever the investigations, a empiric therapy could be begun Treatment of risk factors are recommended: modifications in life style (dietary, hydratation, mobility, drug) are wondering if possible Laxatives may be use when there is no evident treatable risk factors or directly. The recommendations are based on the ratio between efficiency and adverse reactions and on the kind of symptoms that we’ll see further. Fibers and bulk laxatives associated with fluid intake are used on 1st line as well as Osmotic agents on Enemas are used on 2 line therapy. Finally, Treat the cause when one is founded.

9. Concerning chronic constipation the history may classify constipation on Functional constipation or Rectal outlet Delay. During Physical examination anal reflex and sphinter tone have to be evaluated Few investigation have to be done if the constipation has never been evaluated. Colonoscopy is not necessary The yield of Manometry, Defecography and colonic transit have nor been studied. Probably some subgroups of patients may have a benefice of it Finally the impact of constipation on functionnal capacities, psychological and global quality of life Concerning chronic constipation the history may classify constipation on Functional constipation or Rectal outlet Delay. During Physical examination anal reflex and sphinter tone have to be evaluated Few investigation have to be done if the constipation has never been evaluated. Colonoscopy is not necessary The yield of Manometry, Defecography and colonic transit have nor been studied. Probably some subgroups of patients may have a benefice of it Finally the impact of constipation on functionnal capacities, psychological and global quality of life

10. Differents Laxatives available are presented here, Their goal is to change the stool frequecency and/orthe stool consistency. Several randomized studies have found an efficiency on short term treatment for most of them.Activity have been assess on stool frequency and consistency as well as several symptoms. Data concerning superiority of various treatment are inconclusive No severe adverse drug reactions are reported ; There is no evidence thatcathartic colon is related to anthraquinone. Laxative use is one of the explanations for Diarrhea However, there is a lack of data concerning objective effects and safety on chronic use. The latest laxatives as 5HT4 agonist have not been assess in elderly population but seems to have a great effect.Differents Laxatives available are presented here, Their goal is to change the stool frequecency and/orthe stool consistency. Several randomized studies have found an efficiency on short term treatment for most of them.Activity have been assess on stool frequency and consistency as well as several symptoms. Data concerning superiority of various treatment are inconclusive No severe adverse drug reactions are reported ; There is no evidence thatcathartic colon is related to anthraquinone. Laxative use is one of the explanations for Diarrhea However, there is a lack of data concerning objective effects and safety on chronic use. The latest laxatives as 5HT4 agonist have not been assess in elderly population but seems to have a great effect.

11. Whatever, treat all treatables risk factors remains important for the majority of authors For Functional constipation dietary or medicinal fibre with fluid intake are recommended on first line and osmotic agents later For Rectal outlet delay : Osmotic agents and mineral oil are prefered, Biofeedback may be considered for some patients. Finally Improve functional capacities, depressive and anxiety symptoms, social isolation or a global feeling of well being is another goal of the treatment as far as theses factors are associated to chronic constipation. Some studies concerning 5HT4 agonist measure an improvement on quality of life. Of course, a multidisciplinary approach should be the best. Whatever, treat all treatables risk factors remains important for the majority of authors For Functional constipation dietary or medicinal fibre with fluid intake are recommended on first line and osmotic agents later For Rectal outlet delay : Osmotic agents and mineral oil are prefered, Biofeedback may be considered for some patients. Finally Improve functional capacities, depressive and anxiety symptoms, social isolation or a global feeling of well being is another goal of the treatment as far as theses factors are associated to chronic constipation. Some studies concerning 5HT4 agonist measure an improvement on quality of life. Of course, a multidisciplinary approach should be the best.

12. Furthermore, Prevention should be the best way to avoid all this latter problems. It may appear difficult becase of the lack of clear definitions. However, some nursing staff had elaborate a constipation risk assesment scale associated with bowel management protocols. These Interventions indicate that this kind of tool could be efficient to prevent constipation in high risk patients. The efficiency is also linked to education programs during implementation In the same way, this kind of tools should be include in a global assessment/ it leads to improve the management of chronic constipation Furthermore, Prevention should be the best way to avoid all this latter problems. It may appear difficult becase of the lack of clear definitions. However, some nursing staff had elaborate a constipation risk assesment scale associated with bowel management protocols. These Interventions indicate that this kind of tool could be efficient to prevent constipation in high risk patients. The efficiency is also linked to education programs during implementation In the same way, this kind of tools should be include in a global assessment/ it leads to improve the management of chronic constipation

13. In conclusion, As far as there are no clear definitions EBM had not yet answer to many questions about constipation in elderly However Management of constipation should be more efficient If Health care workers pay attention to this problem Because simple and rapid evaluation may lead ofently to a simple efficient treatment for acute constipation On another hand chronic Constipation needs a global and then multidisciplinary assessment. Impact of laxative use on chronic constipation need further trials which would include quality of life parameters. Finally, Prevention is possible with definitions and Implementations of a risk assessment scale by a multidisciplinary team And certainly may avoid this so common problem In conclusion, As far as there are no clear definitions EBM had not yet answer to many questions about constipation in elderly However Management of constipation should be more efficient If Health care workers pay attention to this problem Because simple and rapid evaluation may lead ofently to a simple efficient treatment for acute constipation On another hand chronic Constipation needs a global and then multidisciplinary assessment. Impact of laxative use on chronic constipation need further trials which would include quality of life parameters. Finally, Prevention is possible with definitions and Implementations of a risk assessment scale by a multidisciplinary team And certainly may avoid this so common problem

14. And certainly may avoid this so common problemAnd certainly may avoid this so common problem