ARRC Medicine Education Series

Laxative Use & Bowel Management

2014

Why focus on constipation and laxatives?

Audit of HB ARRC facilities 2013Constipation– Serious consequences– You can do something

about it

Laxatives– Wise, safe and effective

use– Know what to use and

when

Learning Objectives: ConstipationBe able to describe the risks associated with constipation in the elderlyExplain factors contributing to constipationConfidently manage constipation

The above will lead to this ARRC facility having:Appropriate bowel management for residentsReduced incidence of residents experiencing constipation requiring hospital admission

Learning Objectives: LaxativesBe able to describe how the three main types of laxatives work Be able to safely administer laxativesBe able to use laxatives effectively to prevent constipation

This will lead to this ARRC facility having:Laxatives used appropriatelyReduced incidence of residents requiring emergency constipation treatment e.g. enemas and suppositories

ARRC Visits 2013Visited 24 ARRC facilitiesResults showed:– 74% of residents had documented evidence of having

laxatives either charted or administered– 54% had regular laxatives charted– 67% had ‘PRN’ laxatives charted– 3% had administration record with no charting (i.e.

standing order)

Regular laxative use ranged 13-71% between ARRCsFew facilities routinely used fibre or food as method to maintain regular bowel habits

ARRC Visits 2013Regular opioid and no regular laxative charted– 13 residents no laxative charted – regular or PRN– 23 residents no regular laxative (did have PRN)– Lack of laxative charted when opioid was charted PRN

General feeling by ARRC facility clinical nurse managers that bowel management successfully managed– Welcome general education and update

ConstipationConstipation cannot be defined objectively

3 times a day to 3 times a week may be ‘normal’ for a particular resident

Patient ≠ Healthcare provider definitionPatient definition: difficulty with defecation, straining, hard stools, non-productive urge, incomplete evacuation

Healthcare provider definition<3 bowel motions per week

Constipation in the elderlyIncreased incidence in elderlyAffects 22% of NZ individuals aged 70 years and older living in own homes Common in institutionalised elderly

Up to half of ARRC residents experience constipation74% receive at least one laxative preparation daily

17-40% of elderly have chronic functional constipationWomen (2-3 times) more common then menPrevention is better than cure

Causes of ConstipationFactors contributing to constipation in elderly include:– Reduced activity of daily living– Lack of exercise– Reduced intake of fibre-rich food– Dehydration or reduce fluid intake– Medicine side-effects– Co-existing medical conditions

Causes of ConstipationPrimary, or functional, constipation– Often unknown cause– Subgroups:

normal transitslow transitanorectal dysfunction

– Pelvic floor dysfunction– Irritable bowel syndrome

Secondary to organic disease or medicine

Secondary Causes of ConstipationDiseases and medical conditions– Depression– Hypothyroidism– Diabetes– Parkinson’s Disease– Dementia– History of stroke– Hypercalaemia

Secondary Causes of ConstipationTaking 5+ medicines is associated with increased constipation riskMedicine found to be a risk factor in >50% of constipated patientsMedicine can affect the normal bowel function– Decrease gastric motility– Decrease absorption rates– Limit general personal mobility

Secondary Causes of ConstipationMedicines which contribute to constipation– Antacids containing aluminium or calcium– Amiodarone– Anticholinergics e.g. tricyclic antidepressants, antihistamines, antipsychotics– Antidiarrhoeals– Antidepressants e.g. venalfaxine, mirtazapine, nefazodone– Antiparkinsonian medicines e.g. levodopa– Benzodiazepines– Calcium-channel blockers e.g. verapamil– Calcium and iron supplements– Diuretics– Lithium– Non-steroidal anti-inflammatory medicines (NSAIDs)– Opioids

Reversible Causes of ConstipationPhysical environment may discourage residents from using the toilet or commode– Access to a toilet or commode– Limited mobility– Lack of privacy– Need for nursing assistance to help with toileting

Consider this aspect during assessment of constipation

Constipation in the elderlyIn the elderly, constipation may present as:– Confusion– Overflow diarrhoea– Abdominal pain– Urinary retention– Nausea and loss of appetite

Consequences of ConstipationSuspect constipation if a resident:– complains of rectal pain, nausea or vomiting when attempting

to open bowels, sensation of anorectal obstruction– infrequent defecation– shows signs of straining when attempting to open bowels– complains of incomplete emptying after opening bowels– passes hard stools– complaints of abdominal pain or discomfort– does not open bowels for longer than his/her normal time

period– displays unmet need behaviour or pre-existing unmet need

behaviour worsens

Consequences of ConstipationResident experience: reduced quality of life, psychological distress – anxiety, depression, physical aggressive behaviour, poor health perception

Increased cost of care: nursing time, supply costs

Lower urinary tract symptoms: urinary frequency, urgency, poor stream force, incomplete bladder emptying

Chronic constipation: anal fissures, haemorrhoids, faecal impaction, bowel obstruction, incontinence, delirium, hospitalisation

Constipation ManagementIndividualised according to resident’s needs– Type of constipation

Acute or chronic constipationSpecialised bowel management e.g. spinal injuries, long-term opioid analgesics

– Physical condition– Mental capacity

Stepwise approach – Waitemata DHB Residential Aged Care Integration

Programme (RACIP) Care Guides

Constipation Management

AssessmentSystematic and ongoing assessment of bowel habit is the key to good managementAccurate history

Frequency and consistency of stool (Bristol Stool Chart)

Other symptoms: nausea, vomiting, abdominal pain and distensionDiarrhoea: distinguish from overflow due to faecal impaction

Exclude underlying conditions

Daily AssessmentWhen did the resident’s bowels last move?Stool consistency?Stool size/volume?Is there blood or mucus?Ease of passage?Faecal incontinence?Overflow?Use Bristol Stool Chart

Assessment when constipation suspected

Oral examination – check for oral thrush, dehydration

Physical examination of abdomen – listen for bowel sounds

Rectal examination– Rectum empty and collapses: functioning bowel, no

further action, continue daily assessment– Rectum empty and dilated: gross constipation?– Faeces in rectum: determine consistency

LearningsWhich of the following are factors which may contribute to constipation?

A. Reduced mobility or daily activities of livingB. High fibre rich food intake with inadequate

fluid intakeC. Dehydration or reduce fluid intakeD. Medicine side-effectsE. Physical environment

LearningsWhich if the following diseases may increase a resident’s risk of experiencing constipation?

A. Parkinson’s DiseaseB. DiabetesC. HyperthyroidismD. Myocardial infarction

LearningsWhich of the following may be present in a resident who is constipated?

A. DiarrhoeaB. ConfusionC. Urinary frequencyD. Aggressive behaviour

LearningsWhat assessment should be undertaken when constipation is suspected?

A. Review of daily historyB. Oral assessmentC. Bowel soundsD. Rectal examination

Constipation Management: Diet & Lifestyle are first step

Fluid intake – No evidence increased intake as single course of action

improves constipation unless there is dehydration– Dehydration common in residents

Diminished thirst reflex in elderlyDecreased fluid intake due to urinary incontinence

Recommendation: consume >1500mL fluid dailyConsider risk of fluid overload in residents with – Heart failure– Renal impairment

Constipation Management: Diet & Lifestyle are first step

Dietary fibre benefits: – prevent constipation– increases stool bulk, frequency and weight– reduces bowel transit time (stimulates peristalsis)– reduces laxative use– benefit residents without mobility disorders

Increase dietary fibre intake graduallyRisk of faecal impaction in immobile resident if fibre increased without adequate fluid intakeAvoid high fibre intake in residents who are frail, immobile or have faecal impaction

Constipation Management: Diet & Lifestyle are first step

Fibre sources: – Cereals, nuts and seeds, wholemeal breads, vegetables and

fruit– Ground flaxseed (soluble fibre, insoluble fibre, omega 3)– Chia seeds

One study: use of laxatives 80% in those receiving daily branRCT dried plums more effective than psyllium

Constipation Management: Diet & Lifestyle are first step

Bowel Mixture– 1 cup of stewed apples– 1 cup of stewed prunes– ½ cup of cooking bran– Mix all together

Dose: 2 tablespoons daily

Warfarin & Kiwi CrushTM

Kiwi Crush – frozen kiwifruit drinkInteraction with warfarin – Kiwifruit is high in vitamin K– A change in diet to contain foods that are richer in vitamin K

may alter INR (lower INR, increasing stroke risk)

Tell GP before adding Kiwi Crush into diet– Increase INR monitoring frequency – Warfarin dose modified (may need to be increased)

Constipation Management: Diet & Lifestyle are first step

Non-medicine strategies– Toileting– Bowel routines

Regular pattern of defecationAttempt bowel management twice a day – 30 minutes after a meal– no more than 5 minutes (avoid straining)

Patient with normal bowel function moves bowels same time each day – defecation is conditioned reflex

– Behavioural management programmesFor residents with agitation and aggressive behaviours

Laxative SelectionChoice of laxative should be determined by:1. Cause2. Degree of constipation

1. Type of constipation: acute or chronic constipation

3. Subgroup1. Slow transit2. Normal transit3. Anorectal outlet obstruction

4. Individualised

Laxative SelectionOther considerations include:– Presenting symptoms– Nature of the complaint– Patient acceptability– Relative effectiveness– Tolerability– Cost

Laxative SelectionPresenting symptoms– Hard / lumpy stools

Osmotic laxatives

– Defecating < once a weekProkinetic or contact (stimulant & softener) laxatives

– Manual manoeuversEnema and osmotic

Acute constipationModerate to severe acute constipation– Suppositories, enema or osmotic laxative to clear

rectum initially– Bowel management programme to prevent

recurrenceDietary modificationFluid intakeEducationEffective bowel habits

Unresponsive, severe constipation – refer to GP

Chronic constipationAim regular bowel habit rather than intermittent ‘clean out’– use small regular doses of laxatives

Bulking agents in residents– with low dietary fibre intake– no specific underlying cause of constipation– who are mobile

Osmotic agents– more effective for bed-bound residents– stimulant laxatives if osmotic agents not effective or not

tolerated

Laxative Types

Laxatives are categorised according to their principle mode of action – Bulk– Osmotic– Softening– Stimulant

Laxative Types: BulkHydrophilic – absorb water– Increase stool mass– Soften stool consistency

Must have adequate fluid with administration 2-3 days to exert action – not suitable for treatment of acute constipationAdverse effects– Bloating– Flatulence

Contraindicated: faecal impaction; peristalsis impaired e.g. Parkinson’s Disease; stroke; spinal injury; bowel obstruction

Laxative Types: Bulk

Psyllium seed (Konsyl-D, Metamucil) – easy to take, dissolves easily into a flavoured drink – may be more likely to increase bloating and wind– Konsyl-D high sugar content (residents with

diabetes)

Isphagula (Normacol, Normacol Plus)mostly insoluble fibre (inert) less likely to aggravate abdominal bloatingNormacol Plus also contains stimulant laxative

Laxative Types: OsmoticDraw water into colon by osmosisImportant resident has good fluid intakeOften first choice – gentle and few side-effectsLactulose (Laevolac)– More effective than placebo, less effective than

senna/fibre combination– Cause dehydration if poor oral fluid intake – Expected time of action is 1–3 days

Macrogol 3350 (Lax-Sachets, Movicol)– Less flatulence than lactulose– Requires Special Authority

Laxative Types: SofteningLowers surface tension allowing stool to absorb more water e.g. detergent actionMaybe combined with another laxative e.g. sennaNo role in treatment of chronic constipation– Less effective than bulk laxatives – No value if patient has impaired peristalsis

Limit use to patients with primary cause of constipation who have– Excessive straining– Anal fissures or haemorrhoids

Example: docusate (Laxofast)

Laxative Types: Stimulant

Induce rhythmic muscle contractions in intestinesAdverse effects: cramping, abdominal pain, electrolyte imbalance with prolonged use e.g. hypokalaemiaContraindicated: intestinal/bowel obstructionNo evidence that chronic oral use is harmfulExamples: – senna (Senokot, Laxsol)– bisacodyl (Lax-Tab, Dulcolax)– danthron (Pinorax)

If senna/docusate e.g. Laxsol not effective consider docusate/bisacodyl combination e.g. Laxofast & Lax-Tab

Rectal laxatives - Suppositories

Use when oral therapy– Not producing bowel motion– Need rapid relief

Choice depends on– Site– Stool type in rectum

Soft stools – bisacodyl suppositoryHard stools – glycerol suppository (stimulant & softening)

Rectal laxatives - SuppositoriesLubricant suppositories– Glycerol (combined irritant and softener)– Insert into faecal mass– Insert pointed end first– 20 minutes for effect

Stimulant suppositories– Bisacodyl– Insert against mucus membrane– Insert blunt end first at least 4cm into rectum

Rectal laxatives - EnemaLimit use of enemas to acute situationsOsmotic e.g. Fleet Phosphate Enema, Micolette Stool softening e.g. docusate sodium (Coloxyl), liquid paraffin (Fleet Mineral Oil)Adverse effects– Risk of colonic perforation– Large volume enema: hyponatraemia– Phosphate enema: hyperphosphataemia in patients

with renal impairment, irritation if haemorrhoids present

Constipation management of patient on opioid analgesics

Opiate receptors in gut increased sensitivity with agingElderly tolerance to sedating effects of opioids but DO NOT develop tolerance to effects on transit time ( as we age)If resident becomes constipated while taking opioid = give stimulant laxative with each opioid dose

Constipation Management: Referral

Constipation ‘Red Flags’– Blood in the stools or persistent rectal bleeding without anal symptoms– Severe abdominal pain– Co-existing or alternating diarrhoea– Persistent symptoms– Tenesmum – Persistent unexplained change in bowel habit– Palpable mass in the lower right abdomen or the pelvis– Narrowing of stool calibre– Family history of colon cancer, or inflammatory bowel disease– Unexplained weight loss, iron deficiency anaemia, fever, nausea, vomiting,

anorexia, or nocturnal symptoms– Severe, persistent constipation that is unresponsive to treatment

LearningsProvide an example of each of the following types of laxatives?

A. BulkB. OsmoticC. SofteningD. Stimulant

LearningsMatch the laxative type with correct mode of action. The first one has been completed for you.

Laxative type Mode of ActionA. Bulk A. Reduces stool surface tensionB. Osmotic B. Induces muscle contractionsC. Softening C. Draw water into stoolD. Stimulant D. Draw water into colon

LearningsWhat are the advantages of bulk laxatives or increasing fibre content of diet?

A. Soften stoolB. Reduces laxative useC. Reduces stool frequencyD. Stimulates peristalsis

LearningsBulk laxatives or increasing fibre content of diet are not recommended for which residents?

A. Those who are immobileB. Those with Parkinson’s DiseaseC. Those with limited fluid intakeD. Those with acute constipation

LearningsWhen stools are hard and lumpy (Bristol Stool Chart type 1 or 2) osmotic laxatives are recommended. Which of the following are examples of osmotic laxatives?

A. Normacol PlusB. LactuloseC. SennaD. Movicol

LearningsWhen a suppository is necessary for the management of acute constipation and the stool is hard, which of the following do you select?

A. Lubricant suppositoryB. Stimulant suppositoryC. Bisacodyl suppositoryD. Glycerol suppository

LearningsWhich of the following laxatives may cause bloating or flatulence?

A. Konsyl DB. LactuloseC. SennaD. Glycerol suppository

LearningsWhich of the following laxatives can cause electrolyte disturbances?

A. Chronic use of Laxsol B. Fleet Phosphate EnemaC. Stimulant laxativesD. All the above

ReferencesNational Prescribing Service Limited. Drug Use Evaluation: Laxative use for chronic constipation in aged care homes. May 2009. Available from: http://www.nps.org.au/__data/assets/pdf_file/0010/72010/DUE_LaxativesSample.pdfRao SSC, Go JT. Update on the management of constipation in the elderly: new treatment options. Clinical Interventions in Aging 2010;5:164-171Tariq SH. Constipation in Long-Term Care. Journal of American Medical Directors Association. 2007;8:209-218National Institute for Health and Care Excellence. Constipation. January 2013. Available from http://cks.nice.org.uk/constipation#!diagnosissubFosnes GS, Lydersen S, Farup PG. Effectiveness of laxatives in elderly – a cross sectional study in nursing homes. BMC Geriatrics. 2011;11:76Fosnes GS, Lydersen S, Farup PG. Drugs and constipation in elderly in nursing homes: what is the relation? Gastroenterology Research and Practice. 2012. doi:10.1155/2012/290231Victoria Department of Health. Standardised care process (SCP): constipation. Melbourne. August 2012Waitemata DHB. Registered Nurse Care Guides for residential aged care - CONSTIPATION & GASTRO INTESTINAL CARE GUIDE. http://www.waitematadhb.govt.nz/LinkClick.aspx?fileticket=kEVKXe877KE%3d&tabid=92&mid=964

ReferencesGinsberg DA, Phillips SF, Wallace J, Josephson KL. Evaluating and managing constipation in the elderly. Urol Nurs. 2007;27(3):191-200,212Fundamentals of Palliative Care. Pain and symptom management pre-reading. Waikato Community Pharmacy Group. Warfarin Quick Reference Guide http://www.hqsc.govt.nz/assets/Medication-Safety/Alerts-PR/Reference-Guide-for-Warfarin-Treatment-for-Community-Pharmacists.pdfManagement of constipation in older adults. Best Practice. 2008;12(7):1-4