Community Pharmacy Audit: Laxative use in Care Homes
Background
In 2012/13, 71,232 prescriptions were dispensed in primary care for laxatives in North Staffordshire CCG at a cost of £366,572.
Most adults with mild or acute functional (idiopathic) constipation can be managed by dietary and lifestyle changes. Laxatives should therefore
be reserved for cases where simple interventions have failed, or where rapid relief of symptoms is required.
The evidence for the safety and efficacy of all laxatives is limited. This is mainly because many laxatives have been in use for a long time and
clinical trials were less frequently conducted when they were first licensed. Few new clinical trials have been performed, although there are
some studies in children and adults which demonstrate benefits to the quality of patient care with polyethylene glycols (e.g laxido and movicol)
over lactulose.
The type of laxative prescribed (e.g. bulk forming, osmotic and/or stimulant laxatives) mainly depends on the presenting symptoms, patient
acceptability and cost. Prolonged treatment in adults is seldom necessary, except occasionally in the elderly or in palliative care.
Patients on laxatives should be reviewed and, where appropriate, revised to ensure that they are only prescribed routinely for the short-term
treatment of constipation, where dietary and lifestyle measures have proven unsuccessful or where there is an immediate clinical need.
Bowel habit can vary considerably in frequency without the patient suffering and care staff need to be aware of this and educated to improve
their understanding. Misconceptions about normal bowel function can lead to excessive laxative use. Abuse may lead to diarrhoea, dehydration
and hypokalaemia.
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Inadequate fluid intake is one of the most frequent causes of chronic constipation. It is more frequent in incapacitated
or institutionalised older people, affecting some 42 per cent of patients admitted to geriatric wards. In individuals who are not adequately
hydrated, drinking more water can increase stool frequency and enhance the beneficial effect of daily dietary fibre intake. In some care settings
it can be hard to encourage older people to drink, access to fresh water will improve the quality of life for residents and reduce the costs of
healthcare.
A toolkit designed to encourage hydration best practice in the care of older people in care homes is available from Water UK at
http://www.water.org.uk/home/policy/publications/archive/health/healthy-ageing-toolkit/hydration-toolkit-for-carehomes.pdf?s1=care&s2=homes
Further
information
on
the
management
of
constipation
can
http://www.npc.nhs.uk/merec/therap/other/merec_bulletin_vol21_no2.php
be
)
found
and
in
in
a
CKS
MeReC
guidance
Bulletin
from
(updated
January
September
2011(
2010).(
http://www.cks.nhs.uk ).
Purpose
The purpose of this audit is to ensure that:
 A stepwise approach to the management of constipation is adopted and that laxative prescribing is in accordance with national
guidelines.
 Medicines waste is reduced by ensuring that laxatives are only ordered if they are needed.
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 Use of laxatives is regularly/periodically reviewed to determine ongoing need. The visits will also be used as an opportunity to raise
awareness among care home staff of the Water UK: Hydration tool kit and how to increase fibre in the diet (see Appendix 3 for
resources)
Objectives

To obtain an overview of the standard of laxative prescribing and review in the care home setting

To ensure laxatives are prescribed appropriately.
o
There should be agreed and documented goals of treatment – ensure a clear diagnosis of constipation before considering a
laxative.
o
Measures are in place to encourage patients to eat a high fibre diet and have an adequate fluid intake
o
Prescribing of laxatives are regularly reviewed for ongoing need and gradually withdrawn when regular bowel movements occur
without difficulty.
o
Measures should be taken to minimise drug induced constipation e.g. opioid pain killers stepped down/stopped once pain under
control
o
The prescribing of laxatives should be tailored to the individual patient to reduce wastage i.e. ensure monthly prescribed
quantities are in line with usage
o
Care homes have a robust ordering system and checking process in place to ensure laxatives (and other medicines) are only
ordered if needed
o
Ensure ‘prn’ laxatives are not routinely ordered on a monthly basis, and if unused, are carried forward from one cycle to the next

To identify areas for improvement including training needs.

To structure an action plan with timescales, led by the nursing/residential home staff.
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Description of the audit process
(A copy of the audit paperwork will be sent to the care home in advance)
1. Complete Section 1 of the audit paperwork as described to obtain a general overview of laxative prescribing in the care home.
2. Ask the Care Home prior to the visit to select a minimum sample of 15 patients taking laxatives, (ideally those on multiple regimes)
or all patients if less than 15 and complete a detailed audit as described in Section 2. (Please make additional copies where
needed). Please note: If the Care Home has less than 5 patients on laxatives do not conduct this audit and select another
audit.
3. Ensure prescribing of laxatives is in accordance with guidelines and that patients are receiving appropriate fluid intake and dietary
fibre.
4. Ensure monthly quantities of laxatives are in line with usage
5. Complete action plan with agreed timescales.
6. Submit all original paperwork within 2 weeks of completion FAO Meds Opt Team member (See Appendix 2)
Please retain a copy of the audit for your records and a copy for the care home.
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Community Pharmacy Audit 4: Laxative use in Care Homes
Name of Care Home
Care Home Staff Liaison
(name and position)
Address
Pharmacist Name
Pharmacy Address
Date of Visit
Send the completed audit no later than 31st March 2014 or sooner and within 2 weeks of completion of audit to the Medicines Optimisation Team
for the attention of Lisa Minshull, Morston House, The Midway, Newcastle under Lyme, Staffs. ST5 1QG.
If you have difficulty completing the audit in the specified timescale please contact Surinder Kumar, on 0845 602 6772 ext. 1657.
Please DO NOT fax completed audit.
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Section 1 - Community Pharmacy Audit 4: Laxative use in Care Homes
Adequate fluid intake provided
Y/N
Comments/ Recommended actions
Y/N
Comments/ Recommended actions
Fluid intake documented in care plans ?
Carers trained and measures in place to encourage
fluid intake? (give examples)
Patients reportedly constipated are assessed for
dehydration?
Fluid intake reviewed regularly?
Care home staff are offered a copy of the Water UK:
Hydration toolkit (Appendix 3)
Dietary Measures
Care home staff aware of recommended foods high in
dietary fibre?
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Documented in patient’s care plan if to have high fibre
diet?
Kitchens have stock of high fibre foods?
Care Home Staff offered a copy of Dietary Fibre Advice
Guidelines? (Appendix 3)
Laxative prescribing
Y/N
Comments/ Recommended actions
Clear diagnosis of constipation established prior to
laxative prescribing?
Are staff aware that bowel habit can vary considerably
in frequency without the patient suffering any harm?
Care home Staff trained in Bristol Stool chart
assessments?
Care home staff trained to refer patients not taking
laxatives in accordance with prescribed dose?
Are ‘prn’ laxatives ‘carried forward’ (where unused) to
next prescription cycle?
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Additional Information:
Number of residents in home _________
Number of patients in care home prescribed laxatives
__________
(Use additional sheets if needed)
Action plan*
Who to
Action?
Target completion date
Pharmacist: I confirm that I have provided advice in accordance with the Community Pharmacy Care Homes Project
Pharmacist Signature..................................................................
Length of visit………….…….hours
…………. minutes
I confirm that I have received pharmaceutical advice as detailed above and will ensure the recommendations are actioned.
Signature of Home Manager/ Person in Charge: ....................……..........………Date………...………
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Section 2 - Community Pharmacy Audit 4: Laxative use in Care Homes
Community Pharmacist Care Home audit: Management of patients with constipation
GP Practice name…………………………………………………................Care Home name...........................................................................................................
Name of carer/nurse involved with audit queries……………………………………………………………… Date of Data collection………………………………
Patient Details
Patient initials
Date of Birth
Gender
Risk factors for constipation (Please tick any that apply)
 Rapid relief of

Dietary and
Straining will exacerbate medical
lifestyle
symptoms
condition (e.g. angina) or increase
measures
required
risk of rectal bleeding
unsuccessful
Other (give details)/ list causative medications............

Medication
(see Appendix
2)

Bed
Bound

Confused
and/or
depressed
(may
ignore sensation of
stool in rectum)

Details of laxatives taken
1 
2 
Name
Dose as
prescribed
3 
Dose as taken
Other  Please state:
Quantity
prescribed
Monthly quantity needed
in accordance with usage
*Make recommendation in discussion with carer – see hint
sheet in Appendix 4
*Medicines Optimisation technician will follow up recommendations with care home and on confirmation will action with consent of GP surgery.
Give brief description of dietary/fluid intake e.g. well balanced, poor nutritional intake, sip feeds only etc
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Appendix 1: Bristol Stool Chart.
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Appendix 2: Medications causing constipation
Antacids containing aluminium,
Antidepressants - especially tricyclic antidepressants,
Antiepileptics (e.g. carbamazepine, gabapentin,pregabalin, phenytoin),
Antihistamines (especially older, sedating ones),
Antimuscarinics (e.g. procyclidine, oxybutynin),
Antipsychotics,
Antispasmodics (e.g. dicycloverine, hyoscine),
Antiparkinsonism drugs including those with anticholinergic effects (e.g. benztropine, orphenadrine, procyclidine) and dopamine agonists,
Calcium supplements,
Diuretics (secondary to dehydration),
Iron supplements,
Opioids,
Proton pump inhibitors,
Verapamil
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Appendix 3: Useful reference sources
Water UK:
Hydration Toolkit
for Care Homes
Dietary Fibre
advice from
Sandwell and
West Birmingham
Hospitals NHS
Trust
http://www.water.org.uk/home/policy/publications/archive/health/healthyageing-toolkit/hydration-toolkit-for-care-homes.pdf?s1=care&s2=homes
https://www.swbh.nhs.uk/wp-content/uploads/2012/07/How-to-increase-thefibre-in-your-diet-ML3357.pdf
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Appendix 4: Hint sheet for recommendations
Examples of recommendations you may wish to make:
Amendment of quantities prescribed in line with monthly usage e.g. 60 macrogol sachets may be prescribed 1 bd prn but patient takes less frequently, amend
lactulose from 1000ml to 840ml in line with usage
Adjustment of laxative dose e.g Reduce senna tabs from 2 nocte 56 to 1 nocte 28
Patient on macrogol reluctant to take as doesn't like taste - hides tablets therefore consider senna liquid on acute and remove laxido altogether, only occasional
use so Rx 5-10ml nocte prn 300ml
Very infrequent use of laxido - only occasionally constipated - senna liquid would be sufficient - consider in place of laxido - senna 300ml 5-10ml prn
Prn laxido mainly only taken in morning and bowels regular, home happy to try senna liquid in place of laxido as not previously tried Rx senna liquid 5-10ml om
prn 300ml
Stop laxative – dietary and fluid intake good and currently no issues – care staff to monitor
Continue laxative at prescribed dose – patient continues to struggle with bowels
Only taking lactulose on prn basis, explained needs to be taken regularly to work effectively, consider senna liquid as prn alternative
Patient no longer on co-codamol tablets, trial stop laxative and monitor, encourage fluids and fibre intake
Patient unable to swallow/struggles with swallowing tablets/refuses to take tablets - consider liquid as alternative
Laxative prescribed and supplied as macrogol/movicol – consider laxido as cost effective alternative (in line with CCG switch programme)
? Need for lactulose if not eating (sustained on ensure twocal) STOP and monitor
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Appendix 5: Useful Contacts
Surinder Kumar
Senior Medicines Optimisation Pharmacist
Email: surinder.kumar@northstaffs.nhs.uk
Tel: 0845 602 6772 ext. 1657
Lisa Minshull
Medicines Optimisation
Email: lisa.minshull@northstaffs.nhs.uk
Tel: 0845 602 6772 ext 1611
Address for sending paperwork:
NHS North Staffordshire CCG
Morston House
The Midway
Newcastle under Lyme
Staffordshire
ST5 1QG
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