Constipation in the elderlyAll backed up and no where to go Annette T. Carron, DO Director Geriatrics and Palliative Care Botsford Hospital
Objectives • Pathophysiology of constipation, with focus on changes with aging • Assessment and diagnosis of constipation • Standard of care treatment for constipation • Constipation and survey implications
Definition –constipation • Feeling of constipation is defined differently by different people • Defined by self-report or objective assessment-based • Clinical – finding fecal loading in the rectum on exam and/or colonic fecal loading on xray • Subtype – rectal outlet delay • Feeling of anal blockage at least a quarter of the time and prolonged defecation (>10 min to complete bowel movement) or need for self-digitization on any occasion
Defininition chronic constipation Rome III Criteria* During at least 25% of defecations • Sensation of Anorectal Obstruction/Blockage • Manual Maneuvers to Facilitate Defecations • Sensation of Incomplete Evacuation <3 Defecations per Week • Lumpy or Hard Stools Straining • Loose stools are rarely present without the use of laxatives • There are insufficient criteria for IBS *Criteria fulfilled for at least 3 months, with symptom onset at least 6 months prior to diagnosis. IBS = irritable bowel syndrome. Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491. Chronic constipation must include 2 or more of the following: (self-report)
Prevalence Higgins PD, et al. Am J Gastroenterol. 2004;99:750-759. Pare P, et al. Am J Gastroenterol. 2001;96:3130-3137. Garrigues V, et al. Am J Epidemiol. 2004;159:520-526. Walter S, et al. Scand J Gastroenterol. 2002;37:911-916. Chiarelli P, et al. Int UrogynecolJ. 2000;11:71-78. Cheng C, et al. Aliment Pharmacol Ther. 2003;18:319-326. • North America: estimates range from 2% to 28%; 15% ≈ 63 million North Americans fulfill criteria for constipation • Variations due to • Criteria/symptoms definitions used (multiple definitions) • Survey collection methods • Self-report vs diagnosis • Worldwide • Similar rates in developed and undeveloped countries • 14%-30% (Spain, Sweden, Australia, China)
Constipation Increases with Age Study 1* N=42,375 Study 2† N=NR 12 12 10 10 8 8 Prevalence (%) Prevalence (%) 6 6 4 4 2 2 0 0 ≥75 ≥80 <18 40-49 50-59 60-69 70-79 65-74 <40 18-44 45-64 Age (Years) Age (Years) *Harari D, et al. Population: NHIS 1987; criteria: self-report; †Johanson JF, et al. Population: NHIS 1983-1987; criteria: self-report. NHIS = National Health Interview Survey. Higgins PDR, et al. Am J Gastroenterol. 2004;99:750-759.
Factors contributing to underestimation of constipation in elderly Unable to report bowel-related symptoms Have regular bowel movements despite have rectal or colonic fecal impaction Have impaired rectal sensation and inhibited urge to go and so be unaware of rectal stool impaction Nonspecific symptoms associated with colonic fecal impaction (e.g., delirium, anorexia, functional decline)
Gut changes with aging Collagen deposition in the left side of the colon increases Total number of neurons in the myenteric plexus is decreased Decrease in internal sphincter tone Decline in external anal sphincter and pelvic muscle strength Reduction in rectal motility with normal aging
Etiologies Primary • Slow-transit constipation • Dyssynergic defecation • Normal-transit constipation • IBS-C Secondary • Lifestyle • Organic GI disease • Medications • Metabolic • Postsurgical • Psychological • Neurological • Systemic disorders IBS-C = irritable bowel syndrome with a predominant bowel complaint of constipation
Examples of Medications Associated With Constipation* Locke GR III, et al. Gastroenterology. 2000;119:1766-1778. *This is not a complete list
Constipation Endemic in the Elderly Approximately half of residents in nursing homes have constipation De Lillo AR, et al. Am J Gastroenterol. 2000;95:901-905. Tariq SH. JAm Med Dir Assoc. 2007;8:209-218.
Potential Complications of Constipation Read NW, et al. J Clin Gastroenterol. 1995;20:61-70. De Lillo AR, et al. Am J Gastroenterol. 2000;95:901-905. Read NW, et al. Gastroenterology. 1985;89:959-966. • Fecal impaction • Identified in up to 40% of elderly adults hospitalized in the United Kingdom • Rare complications • Obstipation: obstruction with stool • Urinary and fecal incontinence • Stercoral ulceration: rectal “pressure” ulcers from impacted stool and obstipation • Megacolon: dilation of the colon that is not caused by obstruction (rectosigmoid diameter >6.5 cm) • Bowel perforation (new onset or from above etiologies)
Potential Complications of Constipation Fecal incontinence Fecal impaction Urinary retention Sigmoid volvulus Rectal prolapse Diverticular disease Impaired quality of life Agitation in dementia patients
Chronic Constipation:Costs of Care • Direct costs (typically individual or third party) • Physician visits • Diagnostic tests • Medications • Indirect costs (individual or societal) • Reduced productivity • Lost wages • Impaired QOL QOL = quality of life.
Medication Use in Older Adults With Chronic Constipation Ruby CM, et al. Am J Geriatr Pharmacother. 2003;1:11-17.Passmore AP. Pharmacoeconomics. 1995;7:14-24. • In 2 large cross-sectional surveys of community-dwelling older adult patients: • Laxatives were third and fourth most frequently used nonprescription drugs • In cross-sectional survey of 4136 participants • Stimulant and bulking laxatives were most commonly used
Effect of Constipation on Quality of Life (SF-36) Dyssynergia (n = 76) *P < 0.05 vs controls 100 Slow transit (n = 38) Controls (n = 54) * * * * 80 * * * * 60 Subscale Score (Mean ± S.E.M.) 40 20 0 Physical Role physical Bodily pain General health functioning Rao SSC, et al. Gastroenterology. 2005;128:A-123.
Chronic Constipation Interferes With Daily Lives of the Aging Population No GI symptoms Constipation 100 80 Mean MOS Score 60 40 20 MOS = medical outcomes survey 0 Physical functioning Role functioning Social functioning Mental health Health perception Bodily pain Impact of chronic constipation on quality of life in Olmsted County, Minnesota residents aged ≥ 65 years Lower score indicates worse quality of life Talley NJ. Rev Gastroenterol Disord. 2004;4(suppl 2):S3-S10.
Patients with Constipation Have a Broad Set of Complaints 90 81 Physicians think: <3 BMs per week 80 72 70 54 60 Patients (%) 50 39 37 36 40 28 30 20 10 0 Straining Hard or lumpy stools Incomplete emptying Stool cannot be passed Abdominal fullness or bloating <3 BMs per week Need to press on anus Patient Descriptions • In another study, only 13% of individuals with constipation reported having <3 BMs per week Pare P, et al. Am J Gastroenterol. 2001;96:3130-3137. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.
Chronic Constipation vs IBS-C Recurrent abdominal pain/ discomfort with: Improvement with defecation Onset associated with change in frequency of stool Onset associated with change in form (appearance) of stool Must include ≥ 2 of: Hard or lumpy stool Straining Incomplete evacuation Sensation of anorectal obstruction/blockage Manual maneuvers < 3 defecations/week Pain not usually present Symptoms for 3 months, onset ≥ 6 months Chronic Constipation IBS-C Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491.
Subtype Prevalence of Chronic Constipation 70 60 N=1009 50 40 30 Prevalence (%) 20 10 0 Normal transit + defecatory function (n=597) Defecatory disorder (n=249) Slow transit (n=131) Slow transit + defecatory disorder (n=32) Nyam DCNK, et al. Dis Colon Rectum. 1997;40:273-279.
Definitions Locke GR III, et al. Gastroenterology. 2000;119:1761-1778. Rao SSC. Gastroenterol Clin North Am. 2003;32:659-683. • Slow-transit constipation – “colonic inertia” • Slower than normal movement of contents from the proximal to the distal colon and rectum • Dyssynergic defecation (pelvic floor dysfunction) • Inability or difficulty with evacuation of stool from the rectum in patients with normal or slowed colonic transit • IBS-C • Abdominal pain or discomfort associated with normal- or slow-transit constipation or pelvic floor dysfunction
Primary Causes of Chronic Constipation Subtypes of Constipation Normal-transit constipation Slow-transit constipation Defecatory dysfunction IBS with constipation Intestinal transit and stool frequency are within normal range The most common subtype Bosshard W, et al. Drugs Aging. 2004;21:911-930.
Primary Causes of Chronic Constipation Subtypes of Constipation Normal-transit constipation Slow-transit constipation Defecatory dysfunction IBS with constipation Characterized by decreased intestinal transit time Neurohormonal control abnormal? Decreased nitric oxide production, impaired gastrocolic response, alteration of neuropeptides (VIP, substance P), decreased interstitial cells of Cajal VIP = vasoactive intestinal polypeptide Bosshard W, et al. Drugs Aging. 2004;21:911-930.
Primary Causes of Chronic Constipation Subtypes of Constipation Normal-transit constipation Slow-transit constipation Defecatory dysfunction IBS with constipation • Pelvic floor dyssynergia, megarectum, rectocele, perineal descent • More frequent in older women – childbirth trauma • Pathogenesis may be multifactorial – structural problem Bosshard W, et al. Drugs Aging. 2004;21:911-930.
Primary Causes of Chronic Constipation Subtypes of Constipation Normal-transit constipation Slow-transit constipation Defecatory dysfunction IBS with constipation • Brain-gut axis is impaired? • Stress, visceral hypersensitivity, abnormal brain activation, altered colonic motility, inflammation, bradykinins, adenosine, and 5-hydroxytryptamine Bosshard W, et al. Drugs Aging. 2004;21:911-930. Hadley SK, et al. Am Fam Physician. 2005;72:2501-2506.
“Alarm Symptoms” that Require Diagnostic Studies Lembo A, et al. N Engl J Med. 2003;349:1360-1368. Brandt LJ, et al. Am J Gastroenterol. 2005;100(Suppl 1):S5-21. Weight loss Rectal bleeding Occult blood in stool Older age of onset/new onset Vomiting Family history of colon cancer Family history of inflammatory bowel disease
ACG Task Force Recommendations on Diagnostic Testing • Among chronic constipation patients without alarm symptoms or signs, routine use of diagnostic tests is not recommended • The routine approach to a patient with symptoms of chronic constipation without alarm signs or symptoms should be empiric treatment without performance of diagnostic testing • Diagnostic studies are indicated in patients with alarm signs or symptoms • Routine use of colon cancer screening tools is recommended in patients aged ≥ 50 years ACG = American College of Gastroenterology Brandt LJ, et al. Am J Gastroenterol. 2005;100(Suppl 1):S5-S21.
Assessment of Constipation in Nursing Facilities • Multidisciplinary approach • MD, nursing, pharmacist, dietician • MDS initial evaluation • Bowel function • Ability to use toilet • Accurate bowel history • From resident, if possible • Rule out secondary factors • Medications, disease states, diet
Non-Medical Risk Factors for Constipation in Nursing Facilities • Immobility • Inadequate fluid intake • Diet – not enough fiber, reduced intake • Medications • Narcotics • Iron • Anticholinergic side effects
Laxative Use in Nursing Facilities • 59%-78% of residents use laxatives at least on an intermittent basis • 50% were on more than 1 laxative • Most commonly used: • Stool softeners • Saline laxatives • Stimulant laxatives • Osmotic laxatives Phillips C, et al. J Am Med Dir Assoc.2001;2:149-154.
Opioid-Induced Constipation • 41% of patients on long-term opioids develop constipation • Delayed gastric emptying • Delayed stool transit throughout the GI tract • Decreased peristalsis • These changes can be seen almost immediately, therefore, start laxatives prophylactically • Treat with stimulant or osmotic laxatives Kalso E, et al. Pain.2004;112:372-380.
Dietary Fiber • Trials of fiber have been inconsistent, but generally fiber in diet leads to laxative use and bowel movements • No set guidelines for the elderly • American Dietetic Association– 10-13 Gm/1000 kcal • Studies have used: • “laxative” pudding (dates & prunes) • Bran, applesauce, & prune juice mixture • Fiber-rich porridge Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
Fluids Exercise • Convincing data is lacking as to efficacy,but overall well-being may improve May only be helpful in dehydrated patients, not in chronic constipation Adequate hydration is important to general health
Toileting • Set time for defecation • Morning or 30 minutes after meal • Comfortable, safe toilet or commode • Privacy
Analysis of Laxative Studies* *Lubiprostone was not approved at the time of this analysis Ramkumar D, et al. Am J Gastroenterol. 2005;100:936-971.
Bulk Formers Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21. Tariq SH. J Am Med Dir Assoc. 2007;8:209-218. MOA: absorbs water from intestinal lumen, softens stool, decreases bowel transit time Not suitable for acute relief Requires adequate fluid intake Avoid in patients with dysphagia Potential for drug interactions (digoxin, warfarin, salicylates, ciprofloxacin) AEs: flatulence, abdominal pain, GI obstruction
Stool Softeners (Emollients) Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21. Tariq SH. J Am Med Dir Assoc. 2007;8:209-218. MOA: act as surfactants, lowering surface tension and facilitating the mixing of aqueous and fatty substances in the intestinal lumen Primarily used for patients with painful defecation due to hemorrhoids or anal fissures No role in chronic constipation AE’s: potential diarrhea, mild cramping
Osmotic Laxatives Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21. Tariq SH. J Am Med Dir Assoc. 2007;8:209-218. • MOA: draws fluid into the intestinal lumen by osmotic action, thus increasing intraluminal pressure & stimulating gut motility • PEG – no studies yet in older adults • Lactulose & sorbitol – similar effects in older adults • Saline laxatives can cause electrolyte imbalance • Avoid use in patients with renal impairment • AE’s: diarrhea, abdominal discomfort, flatulence
Stimulant Laxatives Brandt LJ, et al. Am J Gastroenterol. 2005;100:S5-S21. Tariq SH. J Am Med Dir Assoc. 2007;8:209-218. MOA: stimulates nerve plexus of intestines, increases peristalsis, increases secretion of fluid & electrolytes Use in lowest effective dose Chronic use leads to tolerance Useful in opioid-induced constipation AE’s: abdominal pain, electrolyte imbalance, melanosis coli (long-term use)
Prokinetic Agents • Metoclopramide & erythromycin work on the upper GI tract to promote peristalsis • Little benefit for constipation • Tegaserod was approved for chronic constipation in persons <65 yo, but voluntarily suspended from market by the manufacturer in March 2007 after a pooled analysis of 29 placebo-controlled short-term trials found a statistically significant increase in cardiovascular ischemic events, including heart attack, angina, and stroke • July 2007 – FDA approved restricted use under investigational treatment protocol for women <55 yowith IBS-C or chronic idiopathic constipation Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
Chloride Channel ActivatorLubiprostone Tariq SH. J Am Med Dir Assoc. 2007;8:209-218. Johanson JF, et al. Gastroenterology.2004;126(Suppl 2): A100. Abstract 749. Johanson JF. Gastroenterology. 2003;124:A-48. MOA: enhances chloride-rich fluid secretion into intestinal lumen without affecting Na+, K+, or Cl- levels. No effect on selected smooth muscle (ileum longitudinal smooth muscle, ileum circular smooth muscle, vas deferens, and iris sphincter) contraction Approved for treatment of chronic idiopathic constipation in adults Minimal systemic absorption, no significant drug interactions Compared to placebo, increases bowel movements, decreases straining, improves stool consistency
Enemas Reserve for acute situations Avoid soap suds Small volume tap water enemas are preferred Phosphate containing enemas may cause hyperphosphatemia, especially in renal impairment Watch for abuse in the elderly Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
When to refer for treatment constipation Refractory constipation for anorectal testing Dyssynergic defecation may benefit from biofeedback therapy Alarm symptoms or over age 50 for colonoscopy Surgery for severe colonic inertia If chronic complaint but having BMs –consider depression, refer psych
Approach to Management Constipation in Long Term Care Subjective c/o constipation • Adequate hydration and fiber in diet • Exercise if mobile • Eliminate drugs that cause constipation Constipation with mental status changes or abdominal pain and/or bleeding • R/O delirium • R/O impaction or obstruction • Treat the underlying problem Acute Chronic • Iron deficiency anemia • Stool for blood • Digital rectal exam • Abdominal X-Ray • TSH, calcium, magnesium • Exclude depression Avoiddocusate (Colace) ? Refer to GI For colonoscopy/transit studies Empirically treat Sorbitol/lactulose/polyethylene glycol Stimulant laxative short term If none of the above measures work, use Lubiprostone No Improvement Switch empiricagents & try adifferent agent Improved No Improvement Improved Tariq SH. J Am Med Dir Assoc. 2007;8:209-218.
Constipation and survey implications Care plan Quality of Life evaluation Medication review Scheduled treatment, not prn Know adult bowel history Doctor involved Refer when appropriate Quality Indicator
Constipation and survey implications • F309 Quality of Care –Each resident must receive and the facility must provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care • May include fecal impaction
Constipation and surveyimplications • F309- Highest possible level of functioning and well-being, limited by individual recognized pathology and normal aging • Determine if avoidable or unavoidable • Need: • Accurate and complete assessment • Care plan • Evaluation of the results of the interventions and revising the interventions as necessary
Constipation Summary Know your patient Common problem in elderly related to aging process and multiple illnesses in elderly Medications for etiology and treatment Exercise/increase activity Fiber Care plan Quality of life