ARRC Medicine Education Series
Laxative Use & Bowel
Management
2014
Why focus on constipation and
laxatives?
Audit of HB ARRC
facilities 2013
Constipation
– Serious consequences
– You can do something
about it
Laxatives
– Wise, safe and effective
use
– Know what to use and
when
Learning Objectives: Constipation
Be able to describe the risks associated with
constipation in the elderly
Explain factors contributing to constipation
Confidently manage constipation
The above will lead to this ARRC facility having:
Appropriate bowel management for residents
Reduced incidence of residents experiencing
constipation requiring hospital admission
Learning Objectives: Laxatives
Be able to describe how the three main types of
laxatives work
Be able to safely administer laxatives
Be able to use laxatives effectively to prevent
constipation
This will lead to this ARRC facility having:
Laxatives used appropriately
Reduced incidence of residents requiring
emergency constipation treatment e.g. enemas and
suppositories
ARRC Visits 2013
Visited 24 ARRC facilities
Results showed:
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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 ARRCs
Few facilities routinely used fibre or food as method
to maintain regular bowel habits
ARRC Visits 2013
Regular opioid and no regular laxative charted
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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
Constipation
Constipation cannot be defined objectively
3 times a day to 3 times a week may be ‘normal’ for a
particular resident
Patient ≠ Healthcare provider definition
Patient definition: difficulty with defecation, straining,
hard stools, non-productive urge, incomplete evacuation
Healthcare provider definition
<3 bowel motions per week
Constipation in the elderly
Increased incidence in elderly
Affects 22% of NZ individuals aged 70 years and older
living in own homes
Common in institutionalised elderly
Up to half of ARRC residents experience constipation
74% receive at least one laxative preparation daily
17-40% of elderly have chronic functional constipation
Women (2-3 times) more common then men
Prevention is better than cure
Causes of Constipation
Factors 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 Constipation
Primary, or functional, constipation
– Often unknown cause
– Subgroups:
normal transit
slow transit
anorectal dysfunction
– Pelvic floor dysfunction
– Irritable bowel syndrome
Secondary to organic disease or medicine
Secondary Causes of Constipation
Diseases and medical conditions
– Depression
– Hypothyroidism
– Diabetes
– Parkinson’s Disease
– Dementia
– History of stroke
– Hypercalaemia
Secondary Causes of Constipation
Taking 5+ medicines is associated with
increased constipation risk
Medicine found to be a risk factor in >50% of
constipated patients
Medicine can affect the normal bowel function
– Decrease gastric motility
– Decrease absorption rates
– Limit general personal mobility
Secondary Causes of Constipation
Medicines which contribute to constipation
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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 Constipation
Physical environment may discourage
residents from using the toilet or commode
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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 elderly
In the elderly, constipation may present as:
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Confusion
Overflow diarrhoea
Abdominal pain
Urinary retention
Nausea and loss of appetite
Consequences of Constipation
Suspect 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 Constipation
Resident 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 Management
Individualised according to resident’s needs
– Type of constipation
Acute or chronic constipation
Specialised bowel management e.g. spinal injuries, longterm opioid analgesics
– Physical condition
– Mental capacity
Stepwise approach
– Waitemata DHB Residential Aged Care Integration
Programme (RACIP) Care Guides
Constipation Management
Assessment
Systematic and ongoing assessment of bowel
habit is the key to good management
Accurate history
Frequency and consistency of stool (Bristol Stool Chart)
Other symptoms: nausea, vomiting, abdominal pain and
distension
Diarrhoea: distinguish from overflow due to faecal
impaction
Exclude underlying conditions
Daily Assessment
When 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
Learnings
Which of the following are factors which may
contribute to constipation?
A. Reduced mobility or daily activities of living
B. High fibre rich food intake with
inadequate fluid intake
C. Dehydration or reduce fluid intake
D. Medicine side-effects
E. Physical environment
Learnings
Which if the following diseases may increase a
resident’s risk of experiencing constipation?
A. Parkinson’s Disease
B. Diabetes
C. Hyperthyroidism
D. Myocardial infarction
Learnings
Which of the following may be present in a resident
who is constipated?
A. Diarrhoea
B. Confusion
C. Urinary frequency
D. Aggressive behaviour
Learnings
What assessment should be undertaken when
constipation is suspected?
A. Review of daily history
B. Oral assessment
C. Bowel sounds
D. 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 elderly
Decreased fluid intake due to urinary incontinence
Recommendation: consume >1500mL fluid daily
Consider risk of fluid overload in residents with
– Heart failure
– Renal impairment
Constipation Management: Diet &
Lifestyle are first step
Dietary fibre benefits:
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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 gradually
Risk of faecal impaction in immobile resident if fibre
increased without adequate fluid intake
Avoid 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 bran
RCT 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 drink
Interaction 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 defecation
Attempt 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 programmes
For residents with agitation and aggressive behaviours
Laxative Selection
Choice of laxative should be determined by:
1. Cause
2. Degree of constipation
1.
Type of constipation: acute or chronic constipation
3. Subgroup
1.
2.
3.
Slow transit
Normal transit
Anorectal outlet obstruction
4. Individualised
Laxative Selection
Other considerations include:
– Presenting symptoms
– Nature of the complaint
– Patient acceptability
– Relative effectiveness
– Tolerability
– Cost
Laxative Selection
Presenting symptoms
– Hard / lumpy stools
Osmotic laxatives
– Defecating < once a week
Prokinetic or contact (stimulant & softener) laxatives
– Manual manoeuvers
Enema and osmotic
Acute constipation
Moderate to severe acute constipation
– Suppositories, enema or osmotic laxative to clear
rectum initially
– Bowel management programme to prevent
recurrence
Dietary modification
Fluid intake
Education
Effective bowel habits
Unresponsive, severe constipation – refer to GP
Chronic constipation
Aim 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
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Bulk
Osmotic
Softening
Stimulant
Laxative Types: Bulk
Hydrophilic – 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
constipation
Adverse 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 bloating
– Normacol Plus also contains stimulant laxative
Laxative Types: Osmotic
Draw water into colon by osmosis
Important resident has good fluid intake
Often first choice – gentle and few side-effects
Lactulose (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: Softening
Lowers surface tension allowing stool to absorb more
water e.g. detergent action
Maybe combined with another laxative e.g. senna
No 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 intestines
Adverse effects: cramping, abdominal pain, electrolyte
imbalance with prolonged use e.g. hypokalaemia
Contraindicated: intestinal/bowel obstruction
No evidence that chronic oral use is harmful
Examples:
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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 suppository
Hard stools – glycerol suppository (stimulant &
softening)
Rectal laxatives - Suppositories
Lubricant suppositories
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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 - Enema
Limit use of enemas to acute situations
Osmotic 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 aging
Elderly 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’
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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
Learnings
Provide an example of each of the following types of
laxatives?
A.
B.
C.
D.
Bulk
Osmotic
Softening
Stimulant
Learnings
Match the laxative type with correct mode of action.
The first one has been completed for you.
Laxative type
A. Bulk
B. Osmotic
C. Softening
D. Stimulant
Mode of Action
A. Reduces stool surface tension
B. Induces muscle contractions
C. Draw water into stool
D. Draw water into colon
Learnings
What are the advantages of bulk laxatives or increasing
fibre content of diet?
A.
B.
C.
D.
Soften stool
Reduces laxative use
Reduces stool frequency
Stimulates peristalsis
Learnings
Bulk laxatives or increasing fibre content of diet are not
recommended for which residents?
A.
B.
C.
D.
Those who are immobile
Those with Parkinson’s Disease
Those with limited fluid intake
Those with acute constipation
Learnings
When 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.
B.
C.
D.
Normacol Plus
Lactulose
Senna
Movicol
Learnings
When a suppository is necessary for the management
of acute constipation and the stool is
hard, which of the following do you
select?
A.
B.
C.
D.
Lubricant suppository
Stimulant suppository
Bisacodyl suppository
Glycerol suppository
Learnings
Which of the following laxatives may cause bloating or
flatulence?
A.
B.
C.
D.
Konsyl D
Lactulose
Senna
Glycerol suppository
Learnings
Which of the following laxatives can cause electrolyte
disturbances?
A.
B.
C.
D.
Chronic use of Laxsol
Fleet Phosphate Enema
Stimulant laxatives
All the above
References
National 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.pdf
Rao SSC, Go JT. Update on the management of constipation in the elderly: new treatment
options. Clinical Interventions in Aging 2010;5:164-171
Tariq SH. Constipation in Long-Term Care. Journal of American Medical Directors
Association. 2007;8:209-218
National Institute for Health and Care Excellence. Constipation. January 2013. Available
from http://cks.nice.org.uk/constipation#!diagnosissub
Fosnes GS, Lydersen S, Farup PG. Effectiveness of laxatives in elderly – a cross sectional
study in nursing homes. BMC Geriatrics. 2011;11:76
Fosnes GS, Lydersen S, Farup PG. Drugs and constipation in elderly in nursing homes: what
is the relation? Gastroenterology Research and Practice. 2012. doi:10.1155/2012/290231
Victoria Department of Health. Standardised care process (SCP): constipation. Melbourne.
August 2012
Waitemata 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
References
Ginsberg DA, Phillips SF, Wallace J, Josephson KL. Evaluating and managing constipation in
the elderly. Urol Nurs. 2007;27(3):191-200,212
Fundamentals 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-forWarfarin-Treatment-for-Community-Pharmacists.pdf
Management of constipation in older adults. Best Practice. 2008;12(7):1-4
