1. ARRC Medicine Education Series Laxative Use & Bowel Management 2014

2. 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

3. 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

4. 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

5. ARRC Visits 2013 Visited 24 ARRC facilities Results 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 ARRCs
Few facilities routinely used fibre or food as method to maintain regular bowel habits

6. ARRC Visits 2013
Regular 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

7. 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

8. 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

9. 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

10. 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

11. Secondary Causes of Constipation
Diseases and medical conditions
Depression
Hypothyroidism
Diabetes
Parkinson’s Disease
Dementia
History of stroke
Hypercalaemia

12. 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

13. Secondary Causes of Constipation
Medicines 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

14. Reversible Causes of Constipation
Physical 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

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

16. 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
generally the nausea + vomiting that comes with constipation is related to delayed gastric stasis hence is present at sight or thought of food, may present as decreased appetite. Not normally n+V while opening bowels.

17. 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

18. Constipation Management
Individualised according to resident’s needs
Type of constipation
Acute or chronic constipation
Specialised 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

19. Constipation Management

20. 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

21. 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

22. 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
Rectum empty and dilated - ballooning of the rectum

23. 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

24. 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

25. Learnings
Which of the following may be present in a resident who is constipated?
A. Diarrhoea
B. Confusion
C. Urinary frequency
D. Aggressive behaviour

26. Learnings
What assessment should be undertaken when constipation is suspected?
A. Review of daily history
B. Oral assessment
C. Bowel sounds
D. Rectal examination

27. 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

28. 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 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

29. 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 % in those receiving daily bran
RCT dried plums more effective than psyllium

30. 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

31. 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)

32. 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

33. Laxative Selection Choice of laxative should be determined by: Cause
Degree of constipation
Type of constipation: acute or chronic constipation
Subgroup
Slow transit
Normal transit
Anorectal outlet obstruction
Individualised

34. Laxative Selection Other considerations include: Presenting symptoms
Nature of the complaint
Patient acceptability
Relative effectiveness
Tolerability
Cost

35. Laxative Selection Presenting symptoms Hard / lumpy stools
Osmotic laxatives
Defecating < once a week
Prokinetic or contact (stimulant & softener) laxatives
Manual manoeuvers
Enema and osmotic

36. 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

37. 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

38. Laxative Types
Laxatives are categorised according to their principle mode of action
Bulk
Osmotic
Softening
Stimulant

39. 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
Dietary fibre and bulk laxatives
Increase and retain amount of fluid in the stool
Increase faecal mass
Stimulates peristalsis
Produce bulker and softer stool
Cautions:
Unsuitable for elderly or debilitated patients as they need to drink extra fluids
Not normally used in palliative patients
Advantages of bulk laxatives - can be really useful to decrease stool freq in IBS + diverticulitis

40. 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

41. 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

42. 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)

43. 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:
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

44. 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)

45. Rectal laxatives - Suppositories
Lubricant 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

46. 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
fleet mineral oil enema also as softening enema

47. 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
all patients on opioids (step 2 or 3) should have stimulant laxatives prescribed as least PRN. Don’t wait until issue presents. (prevention better than treatment)
ARRC Audit 2014
As part of the audit, documentation occurred when a resident was being administered a regular opioid and no regular laxative charted.
8 ARRC facilities had no incidence of opioids prescribed without laxatives charged regularly (or had no residents on regular opioids)
13 residents were Ided has having regular opoids administered without laxative – regular or PRN.
23 residents received regular opioids without regular laxatives – however laxatives where charted PRN
Themes around lack of laxative charting were when opioids were charted PRN but given regularly or opioids were codeine, tramadol or fentanly. There were few incidences of morphine or oxycodone being administered without laxatives charted.

48. 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
tenesmus pain is a cramping type pain around rectal area associated with constipation or nerve damage around rectum.
Consider more serious conditions if constipation is chronic or does not respond to laxatives
Exclude faecal impaction – rectal examination, GP may consider need for abdominal Xray
Idiopathic megacolon is potentially serious consequence of constipation
Onset can be insidious in frail elderly
If the painless progressive abdominal distension of this condition is missed, results in a very poor prognosis for pt
Long term use of laxatives may be unnecessary
Unpalatable and burdensome to take
Carry risk of adverse effects
- electrolyte abnormalities, diarrhoea, abdom bloating and flatulance
Aspiration pneumonia in residents with dysphagia should also be considered if liquid preps are used
Ongoing process of weighing benefits against the harms

49. Learnings
Provide an example of each of the following types of laxatives?
A. Bulk
B. Osmotic
C. Softening
D. Stimulant

50. Learnings Match the laxative type with correct mode of action.
The first one has been completed for you.
Laxative type Mode of Action
A. Bulk A. Reduces stool surface tension
B. Osmotic B. Induces muscle contractions
C. Softening C. Draw water into stool
D. Stimulant D. Draw water into colon

51. Learnings
What are the advantages of bulk laxatives or increasing fibre content of diet?
A. Soften stool
B. Reduces laxative use
C. Reduces stool frequency
D. Stimulates peristalsis

52. Learnings
Bulk laxatives or increasing fibre content of diet are not recommended for which residents?
A. Those who are immobile
B. Those with Parkinson’s Disease
C. Those with limited fluid intake
D. Those with acute constipation

53. 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. Normacol Plus
B. Lactulose
C. Senna
D. Movicol

54. 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. Lubricant suppository
B. Stimulant suppository
C. Bisacodyl suppository
D. Glycerol suppository

55. Learnings
Which of the following laxatives may cause bloating or flatulence?
A. Konsyl D
B. Lactulose
C. Senna
D. Glycerol suppository

56. Learnings
Which of the following laxatives can cause electrolyte disturbances?
A. Chronic use of Laxsol
B. Fleet Phosphate Enema
C. Stimulant laxatives
D. All the above

57. References
National Prescribing Service Limited. Drug Use Evaluation: Laxative use for chronic constipation in aged care homes. May Available from:
Rao SSC, Go JT. Update on the management of constipation in the elderly: new treatment options. Clinical Interventions in Aging 2010;5:
Tariq SH. Constipation in Long-Term Care. Journal of American Medical Directors Association. 2007;8:
National Institute for Health and Care Excellence. Constipation. January Available from
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 doi: /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.

58. References
Ginsberg DA, Phillips SF, Wallace J, Josephson KL. Evaluating and managing constipation in the elderly. Urol Nurs. 2007;27(3): ,212
Fundamentals of Palliative Care. Pain and symptom management pre-reading.
Waikato Community Pharmacy Group. Warfarin Quick Reference Guide
Management of constipation in older adults. Best Practice. 2008;12(7):1-4