Download Constipation

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 (<3 per week)

Excessive straining

Sense of incomplete bowel emptying

Excessive, unsuccessful time spent on toilet
Constipation is NOT a normal part of ageing….
Other symptoms of constipation
Nausea +/- vomiting
Abdominal and Rectal pain
Flatulence
Loss of appetite
Lethargy
Depression
Patients may not associate these with constipation
What are some of the consequences of constipation in the elderly?
Nausea and reduced appetite  weight loss
Behavioural disturbances in dementia  increased use
of psychotropic medications
Extra staff time needed for increased toiletting needs
Overall increased number of medications in the regime
Why does constipation become a problem in the elderly?
Increased prevalence of Secondary Causes…..
Immobility
Improper Diet
Endocrine & Metabolic Disorders
Neurological Disorders
Psychological Conditions
Structural Abnormalities
Medications
Some medications associated with constipation
Aluminium and calcium containing antacids
Anticholinergic agents
Calcium supplements
Antipsychotics
Iron
Opioids
.
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
EASY FIBRE
SUPPLEMENT
3 TBS unsweetened apple puree
1 TBS unprocessed bran
2-3 TBS prune juice
Use 1 TBS on breakfast cereal
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 manufacturer’s
instructions BEFORE adding Movicol®
1. 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 ¼ 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 ½
cup (125mL) and again stir thoroughly.
4. The mixture will return to the required thickened state
within approximately one minute.
5. Stimulant Laxatives
Senna (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
Imaginative ways to increase fibre:•
Add dry, fresh or canned fruit to cereal
Exercise
•
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


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 juice
Add 1 TBS to breakfast cereal