Special Report – Managing Constipation in the Elderly HFA Healthcare by Global Business Media

SPECIAL REPORT

Managing Constipation in the Elderly

Unique Dual Combination of Herbs Produces Gentle, Safe Laxative Effect No Need to Suffer A Common Problem Not an Isolated Symptom or Condition Dealing with Constipation Risks, Complications and Treatments

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Unique Dual Combination of Herbs Produces Gentle Laxative Effect

Dr. Lucio Cavicchioli, Medical Director, Italy & International, Rottapharm Madaus, Monza, Italy

Composition of Manevac Unique Combination of P. Ovata and T.Senna Benefits the Elderly Combination of P. Ovata and T. Senna More Effective in Elderly Patients4 Conclusion

No Need to Suffer

John Hancock, Editor

What is constipation? The Causes Treatments that Work Stimulant Laxatives Rather Than Bulking Agents

A Common Problem

John Hancock, Editor

A Common Complaint Variations and Perceptions Prevalence and the Elderly An Elderly Issue

Not an Isolated Symptom or Condition

Peter Dunwell, Medical Correspondent

Looking at Constipation in a Wider Context Causes of Constipation Symptoms of Constipation Diagnosis and Treatment Decisions for Constipation

Dealing with Constipation

Francis Slade, Staff Writer

What Can Happen With Constipation Diet and Constipation Medication and Constipation Exercise and Constipation

Risks, Complications and Treatments

John Hancock, Editor

Lifestyles and Constipation Complications with Constipation Aneurysm and Stroke Treatments for Constipation

References 15

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SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Foreword I

F IT’S sometimes the subject of less than kind

Prevalence of constipation among the elderly is

comedy, for chronic sufferers, constipation is

high in western societies. Everything from processed

anything but a laughing matter. Apart from the

foods, which constitute the wrong types of inputs, to

fact that it often points to a range of health issues,

travelators (moving walkways), which promote the

not being able to go can cause embarrassment,

minimising of muscular action and the atrophying

discomfort, sometimes pain and, in extremis,

of muscles, to ‘Victorian throne’ style toilets, which

serious or even life threatening conditions and

maintain poor elimination posture; they all support a

outcomes. It is not something that can be safely

lifestyle not conducive to good digestion and natural

ignored. Because a lot of the problem originates

waste elimination. However, whatever the causes,

with type of food, lack of activity and medications

constipation is a problem, especially for the elderly

for other conditions, constipation is a particular

and so an understanding of it is important.

issue for older people whose lifestyle, hang-ups,

The second article in the Report carries an overview

slower pace of life, slower metabolism and long-

of the subject including what underlying conditions it

term medication can all result in inability to eliminate

might point to and where it could lead. Expanding on

faeces from the bowel.

this theme, Peter Dunwell then takes a more in-depth

This Special Report opens with an article that looks

look at some of the more serious conditions of which

at the gentle and safe laxative effect produced by a

constipation might be a symptom and of its misery-

unique dual combination of herbs, which is especially

causing potential. Francis Slade’s article considers

beneficial for elderly patients. It describes the

the impact of the condition on elderly people, its

composition of Manevac, which has been developed

complexity and pathology before we return to round up

using psyllium seeds and husks together with senna

the whole topic as well as introducing some contexts

fruits, using a unique, patented technology by which

and, briefly, some extremes.

the active ingredient, T.senna, is surrounded and

It might be no laughing matter but neither need

shielded by P.ovata fibres. Elderly patients may suffer

constipation be feared or erode the quality of life for

from acute constipation but, frequently, this takes the

older sufferers.

form of sub chronic constipation, so they should not take a laxative that is too active. Manevac retains the efficacy of senna but avoids the pitfalls and, therefore, is particularly suitable for elderly patients.

John Hancock Editor

John Hancock has been Editing Primary Care Reports since launch. A journalist for 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

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SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Unique Dual Combination of Herbs Produces Gentle Laxative Effect Dr. Lucio Cavicchioli, Medical Director, Italy & International, Rottapharm Madaus, Monza, Italy

HE UNIQUE combination of psyllium fibres and senna in Manevac® (HFA Healthcare) leads to a gentle laxative effect, which is especially beneficial for elderly patients.

Unique Combination of P. Ovata and T.Senna Benefits the Elderly

Composition of Manevac Manevac granules contain psyllium (Plantago ovata) seeds and husks, and senna (Tinnevelly senna) fruits. (Figure 1 and 2) Each teaspoon of granules weighs 4 g and contains P. ovata seeds 2.6 g, P. ovata husks 0.11 g and T. senna 0.62 g (equivalent to 15 mg of sennosides)1. Both P. ovata and T. senna plants are harvested in plantations which are under strict quality control as required for medical-grade preparations. Manevac is manufactured using a unique, patented echnology by which the active ingredient T. senna, is surrounded and shielded by P. ovata fibres. T. senna and P. ovata particles are contained within brown polysaccharidecoated granules. (Figure 3 and 4). Manevac has been developed in this unique form for several reasons: • senna should be active mainly in the lower intestinal tract (large intestine) because if a laxative is already active in the upper intestinal tract, there are several possible negative consequences like cramps, induction of contractions (which, in women, may also involve the uterus), major interactions with food digestion/absorption, and potential negative interaction if the patient is concomitantly taking other oral medications, most of which are absorbed in the upper intestinal tract1. • by surrounding senna with fibres and then coating the granules, Manevac keeps senna ‘shielded’ until it reaches the place where it must act: the large intestine. • the fibres of P. ovata contribute to enriching the dietary fibre intake, and this leads to normal intestinal peristalsis over time.

FIGURE 2: TINNEVELLY SENNA PLANT

Elderly patients may suffer from acute constipation. However, they frequently have sub chronic constipation. Therefore, they should not take a laxative that is ‘too active’ because this would cause diarrhoea and, after a few days, constipation would still be present. On the contrary, the elderly need a treatment which has a long-lasting effect, but with a ‘gentler’ onset of efficacy. Manevac, like all laxatives, should be taken for short periods2. Senna is a natural product derived from the plant T. senna (also known as Cassia angustifoliae, Senna indica or Cassia elongata). The active principles are sennosides. These molecules are converted by normal bacteria in the colon into rheinanthrone which, in turn, has two effects. It first stimulates colon activity, thus speeding up bowel movements. Secondly, it increases fluid secretion by the colon. This is the desired action, which should be ‘gentle’. With Manevac, this is favored by the fibre-‘cocoon.’ Elderly people are potentially likely to experience side effects with other laxatives which are not colon specific. This is due to possible interactions with other drugs which are normally metabolized in the small intestine. The BNF3 and Summaries of Product Characteristic for individual products should be WWW.PRIMARYCAREREPORTS.CO.UK | 3

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

“Elderly patients may

consulted for specific information on possible drug interactions and side effects.

suffer from acute constipation. However, they frequently have sub

Combination of P. Ovata and T. Senna More Effective in Elderly Patients4

chronic constipation. Therefore, they should not take a laxative that is ‘too active’ because this would cause diarrhoea FIGURE 3: MANEVAC GRANULES

and, after a few days, constipation would still be present”

dosage adjustments, which may be important for elderly patients e.g. a very thin elderly woman may start with half a teaspoonful. In case there is no effect the day after, the dosage can be increased to one teaspoonful. This is important in order to determine the correct dosage for each patient so that the desired effect is obtained .

Kinnunen et al showed in a study that the combination of P. ovata and T. senna is more effective than lactulose in elderly patients. Thirty long stay patients were treated with either Manevac or Lactulose for a 5 week period followed by a week’s washout and another 5-week period with crossed medication. Bowel habits were significantly more frequent when on Manevac treatment for both periods. There was a tendency for the number of Bisacodyl doses to be greater when lactulose was used.

Manevac retains the efficacy of senna, but with its unique technology: • delivers senna only in the large intestine. Therefore, patients are less likely to have cramps and interactions with other oral therapies. • increases the mass of the swollen fibres of P.ovata by absorbing fluid. Therefore, evacuation of faeces is more physiological and soft instead of being more watery. The reasons explained above detail why Manevac is suitable for elderly patients. And very importantly for elderly patients – since most of them take other oral therapies – Manevac does not affect the transit in the small intestine. Therefore, absorption of other drugs is not reduced. Finally, since elderly patients usually have a diet lacking in fibre, Manevac enriches their diet with fibre. The usual dosage of Manevac is one or two 5ml spoonfuls taken daily at night. Each level spoonful contains 4g of Manevac granules. In most cases, there is evacuation the morning after. As Manevac comes in granules, this allows for

FIGURE 4: THE INNER STRUCTURE OF EACH GRANULE

You could consider Manevac as being an ‘active core’ within a ‘velvet glove’. It is effective in elderly patients5, and can be used in pregnancy (after the first trimester)1. Since Manevac is metabolized in the colon, it potentially results in less drug interactions. Manevac is a physiological way to resolve constipation.

References

FIGURE 1: PLANTAGO OVATA PLANT

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1. Manevac SMPC 2. http://www.nhs.uk/conditions/Laxatives/Pages/Introduction.aspx 3. British National Formulary. No 60. London: British Medical Association/Royal Pharmaceutical Society of Great Britain; 2013 4. O.Kinnunen et al – International Journal of Experimental and Clinical Pharmacology 1993 (Supp1) 5. Passmore et al., Brit Med J 307, 769-771.

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

No Need to Suffer John Hancock, Editor

And no need to risk complications or a reduction in the quality of life for constipation

What is Constipation? Most people will be constipated at some time in their life. Constipation is not itself a condition but rather it can be a symptom of a number of conditions. Sometimes they might be serious and requiring of significant clinical intervention but most often they will be temporary and/or not serious. Also, different people will have different interpretations of what constipation is; and sometimes patients will be embarrassed about conditions such as haemorrhoids. Perhaps, given what the digestive system does, we should not be surprised that we sometimes overload that digestive and waste disposal function. As WebMD UKA explains, “[The] digestive system is remarkably efficient. In the space of a few hours it extract nutrients from the foods you eat and drink, processes them into the bloodstream and prepares leftover material for disposal. That material passes through 6m or more of intestine before being stored temporarily in the colon, where water is removed. The residue is excreted through the bowels, normally within a day or two.” A critical factor is the speed at which matter passes through the system; the longer it remains in the colon, the harder it becomes and the more likely the person is to become constipated. The reasons why the process is sometimes slow can vary but understanding it can help clinicians choose the most appropriate treatment. Taking a careful history will help the clinician determine a possible cause and particular attention should be given to highlighting any serious issues such as weight loss or rectal bleeding. “The severity of constipation varies from person to person. Many people only experience constipation for a short time, but for others, constipation can be a long-term (chronic) condition that causes significant pain and discomfort and affect quality of life.”B These days pain and discomfort are not necessary and a number of treatments are available for moderate but possibly chronic constipation. Short duration constipation is common in primary care and may result from dietary changes (e.g. reduced fibre and fluid intake),

stress, or immobility (e.g. due to age or illness). In short duration constipation, a graded approach can be used… Constipation rarely causes any complications or long-term health problems. [But] Chronic constipation can lead to progressive faecal retention, distension of the rectum, loss of sensory and motor function, and faecal impaction (particularly in the elderly). Faecal impaction can lead to faecal incontinence, urinary tract infection, rectal bleeding, and rectal prolapse.C So while some constipation may well be regarded as moderate, it will still need to be treated in order to avoid the kind of progress outlined above.

The Causes Because constipation is a symptom, clinicians will need to first identify what is causing the problem in the patient. Diet is often the issue with lack of fresh vegetables or fruit with fibre being the most usual culprit. An obvious answer is for patients to be advised to take simple steps such as making sure that their bread, pasta and rice are all wholegrain and to try and get their ‘five a day’ as well as substituting fresh fruit for confectionery as a snack. But alongside diet, insufficient fluids can also cause the faecal matter in the bowel to become too hard when the natural water removal process takes place. Again, the advice can be fairly simple… drink more (non-alcoholic) fluids. One piece of general dietary advice is to eat a breakfast because that first meal of the day starts the digestive process, keeping the material at all stages in that process moving. Stress, that all too prevalent affliction of modern life, can cause the kind of muscular tightening which, in turn, can make it more difficult for the body to exercise the muscular effort needed to push material through the digestive system and out at the end. This may well be a lifestyle issue as is lack of exercise, another cause of muscular weakening or low activity. That, again, can make it more difficult for the body to push material through the digestive process and expel it at the end. Certainly exercise can be WWW.PRIMARYCAREREPORTS.CO.UK | 5

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Diet is often the issue with lack of fresh vegetables or fruit with fibre being the most usual culprit. An obvious answer is for patients to be advised to take simple steps such as making sure that their bread, pasta and rice are all wholegrain and to try and get their ‘five a day’

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of value in improving bowel motion and, as a side-effect, exercise might sometimes help with the alleviation of stress symptoms. Among the other causes of constipation and excluding the major health conditions such as cancer, the drugs that we take to deal with all sorts of medical issues can themselves cause constipation as a side-effect. The significance of drugs as a cause of constipation and lack of exercise as another cause often increase with age which is why older people suffer more often from this condition.

Treatments that Work There are several ways in which constipation can be resolved or managed. In the longer term, as we’ve already noted, changes to lifestyle, exercise regime, diet, fluid intake and drugs prescribed will make a difference. But the longer term may be unacceptably long for patients suffering immediate discomfort or pain. In those circumstances and when constipation is not linked to any serious condition, use of a laxative will bring more immediate relief. There are three basic types of laxative. Where for one reason or another dietary fibre intake cannot be increased sufficiently, bulk forming laxative will help the body to process food and turn it into normal density faecal matter over the longer term. For shorter term relief, osmotic laxative will soften the stool making bowel evacuation easier and

more comfortable. But for faster relief, stimulant laxatives will be the answer: usually the patient will take the laxative at bedtime to produce a normal stool in the morning. For almost immediate effect, suppositories or enemas containing phosphate or sodium nitrate will stimulate rapid evacuation but may not be suitable for patients who are either elderly or debilitated. The important thing is that, in order to avoid some of the more unpleasant complications such as faecal impaction, overflow incontinence, bleeding from the anus and hernia, constipation should be treated not neglected. Also, early use of laxatives can avoid unnecessary pain or discomfort.

Stimulant Laxatives Rather Than Bulking Agents As noted in the MeReC Bulletin – ‘The management of constipation’, in elderly patients constipation may be caused or compounded by lack of mobility and use of one or more constipating medicines. Treatment is the same as for younger adults, with an emphasis on changing lifestyle and diet wherever possible. If medication is required, stimulant laxatives should be considered ahead of bulking agents for treating constipation caused by lack of mobility. It is also important to review drugs that could potentially cause constipation and consider alternatives, where possible.C

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

A Common Problem John Hancock, Editor

But not a simple set of causes or effects

A Common Complaint Constipation is the most common digestive complaint in Western societies but it’s a symptom as much as a complaint inasmuch as the inability to defecate is usually indicative of a number of other issues. Also, because of the nature of this condition, constipation and the consequent retention of faeces can foster other problems so, while it can usually be easily treated, it is best not neglected. The UK National Institute for Health and Care Excellence (NICE)1 describes constipation as, “defecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.” Using slightly more accessible terminology, according to netdoctor2, constipation is defined as, “A condition in which bowel emptying occurs infrequently or in which the stools are hard and small or where bowel movement causes difficulty or pain.” The article continues to explain that defining ‘infrequent’ is difficult when some 90 per cent of people in Western countries have a bowel pattern that ranges from three bowel movements a day to three per week. And it’s possible to move your bowels every day and still be constipated if the stools are hard and difficult to pass. Equally, a daily bowel movement is by no means essential for, nor a sign of, good health.

Variations and Perceptions Adding to that, clinicians recognise three types of constipation3. 1. The most common is functional constipation. Patients with this type frequently experience small, hard stools that are difficult to pass and they will be straining. They may also have abdominal pain or discomfort that is relieved with stool passage. 2. The second type is pelvic floor constipation – difficult or inadequate expulsion of stool – due to faulty coordination of the abdominal and pelvic floor muscles, excessive or impaired perineal descent, or anorectal structural abnormalities.

3. T he third type is usually called slow transit constipation, or by the clinical term colonoparesis because its mechanism is similar to that of gastroparesis. There is some degree of partial paralysis in the colon resulting from dysfunction of the colonic nerves, smooth muscle or both, resulting in delayed evacuation. It may occur as part of a generalized motility disorder affecting the stomach, intestine and/ or colon. These different types are often expressed in different ways by various contributors to the understanding and treatment of constipation. There is also a distinction between constipation as a symptom of issues to do with the patient’s physical condition, i.e. something relating to the functional levels or quality of function in their body, and constipation related to other factors such as another clinical condition and/or any pharmacological therapy used to treat it. There is also a degree of perception involved in that one person’s expectations of normal bowel movements might differ from another’s. Older people might have been brought up in the belief that if they don’t succeed with a daily bowel movement, they must be constipated. This is not automatically true. Straining with defecation is a better identifier of constipation.

Prevalence and the Elderly In the USA, incidences of constipation have been loosely linked to three socio-economic and geographical environmental factors… rural living, colder temperatures and low socio-economic status. Some wider risk factors have also been identified: • Older age; • African-American; • Female; • Poor socio-economic status; • Less exercise; • Less education; • Low calorie intake. It is the older age group on which this Report focuses and, for them, constipation can dominate and degrade their psychological and physical well-being as well as make them vulnerable to WWW.PRIMARYCAREREPORTS.CO.UK | 7

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Older people might have been brought up in the belief that if they don’t succeed with a daily bowel movement, they must be constipated.

other conditions – see later in this paper. And4, “Although people of any age can experience constipation, elderly people may be at higher risk for this unpleasant condition because of a variety of factors, such as diet, exercise, bowel habits, medical conditions, and medications. Elderly people may have one or a combination of these risk factors, which makes constipation even more likely.” This comment from Constipation Matters is prefaced by further confirmation of the significance of the condition among older people, “The incidence of constipation increases with age and almost 30% elderly in the UK suffer from constipation.” That 30% figure for the whole elderly population correlates to studies that have found a 26% rate of constipation in elderly men and 34% in women5.

This is not automatically true. Straining with defecation is a better identifier of constipation

Studies vary in their conclusions depending on the country and scope but seem consistent in supporting that 30% incidence rate based on a similar level of laxative use in the older age groups who favour treating the problem with over-thecounter products. This rises to nearly 60% among nursing home residents where their presence would indicate underlying health problems. All of these figures can be set against a prevalence of constipation in the wider community at about 1215% depending on how the condition is defined. The prevalence of constipation as a condition of old age is itself as old as time with Hippocrates recording more than two and a half millennia ago

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that, “the intestines tend to become sluggish with age.” Given also that a principal cause of constipation is delay in processing waste through the colon, it is significant that colonic transfer times increase with advancing years. This doesn’t simply reflect aging although the strength of muscles driving the bowel can decline with age and/or a lack of general exercise often accompanying aging. Another factor can be consequent upon one of the other side effects of aging in a modern western society: there are more medicines available to treat more conditions associated with aging and some of these medicines include constipation among their side effects.

An Elderly Issue Many of the causes of constipation are true for all sufferers but can be more prevalent in the elderly. Physical inactivity, poor diet (especially one that is low in fibre) and not drinking enough water are often cited as major contributors. But, as noted above, some medication can cause constipation as a side-effect; also, stress and/or depression have both been identified as further factors in causing constipation. As well as a poor diet, an insufficient diet can contribute to the condition and we cannot rule out more serious causes. ‘The Doctor will see you now’6 reminds us that, “Colon cancer may cause any kind of change of bowel habits in the elderly and should always be considered a possibility.” The article continues to highlight that often these causes can be combined as a result of something else such as a stay in hospital (more likely as we get older) when inactivity and, at least, altered dietary routines can be issues. Well known conditions such as Parkinson’s, stroke and diabetes can all be associated with constipation. In summary, while constipation might be a common symptomatic presentation it is by no means simple and can point to one of a number of health issues or be as a result of a range of conditions.

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Not an Isolated Symptom or Condition Peter Dunwell, Medical Correspondent

Constipation in the elderly has both causes and symptoms of its own

Looking at Constipation in a Wider Context Like most health issues, constipation does not stand in isolation. Rather, as a symptom, it will reflect underlying causes and, as a condition, it might lead to other health problems. In this vein, we can also identify a number of factors that might increase the chance of developing constipation. The Mayo Clinic7 nicely summarises these as… • Being an older adult; • Being a woman; • Being dehydrated; • Eating a diet that’s low in fibre; • Getting little or no physical activity; •T aking certain medications, including sedatives, narcotics or certain medications to lower blood pressure.

Causes of Constipation These factors tend to point to particular causes and in older patients such causes might not reflect a direct link to the aging process but rather some associated factors. For instance, older people tend to take more medication and might not have a diet sufficiently rich in fibre. It is possible that for convenience or ease of chewing they will use more

ready-to-eat or heat-and-eat processed foods. They also might drink less water than they should because they worry about frequency of urination (‘being caught short’), will often move less than they should and might well suffer cognitive impairment with some age related conditions so could ‘forget’ to do the right things. There are also some physical changes as a result of aging. Less colonic force and increased production of bowel movement inhibiting chemicals contribute to constipation as will a reduction in the muscular pressure on the anal sphincter. The causes of constipation are well documented and disseminated but their availability should not detract from the potentially serious nature of the problem. Persistent constipation or any change in bowel habit will warrant investigation, especially in older patients and that means over 40. It can sometimes point to a more serious matter. For instance hyperthyroidism, an underactive thyroid gland, can slow the body’s metabolic processes, including mobility in the gut. While not everyone with thyroid problems will get constipated and certainly not the other way around, it’s always worth investigating. WWW.PRIMARYCAREREPORTS.CO.UK | 9

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

The causes of constipation are well documented and disseminated but their availability should not detract from the potentially serious nature of the problem. Persistent constipation or any change in bowel habit will warrant investigation

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Other less commonly cited potential causes of constipation include painkillers, chocolate, vitamins, laxatives (if over-used), dairy products, depression and the antidepressants taken for it, antacids, inflammatory bowel disease, childbirth (not an issue for the elderly) and diabetes or neurological conditions8. We also cannot discount more tangential causes9 such as “reduced privacy, inaccessible toileting facilities and reliance on other people for assistance, [which] may contribute to the development of constipation.”

Symptoms of Constipation While this might seem self-evident, there are a few things for which clinicians, in particular, should be alert when dealing with older patients who might be reluctant to freely discuss matters such as bowel movements. For instance, constipation can share a number of symptoms in common with bowel cancer such as bleeding from the bottom, changes in bowel habits, abdominal pain or a lump in that area, or even weight loss and tiredness – also symptoms of anaemia – and excess flatulence. In this context, a diagnosis of constipation can bring to a patient the sort of relief from worry which might, in itself, help with the condition. Symptoms usually indicative of constipation are: •T ummy pain associated with bowel movements. • A feeling of incomplete emptying of the bowel. • A bloated feeling in the stomach region. •D iarrhoea: constipation is one of the most common causes of diarrhoea, especially in the elderly in care. Diarrhoea caused by constipation is known as bypass diarrhoea. What we do know is that10, “The onset of constipation is generally insidious, unrelated to any known initiating event. Early in the course of constipation, infrequent or difficult evacuation may represent the only symptom. As constipation progresses in severity, patients typically develop bloating and mild cramping type abdominal pain that is frequently worse after meals. Patients who have suffered from constipation for many years may additionally note fatigue, malaise and anorexia.” This last point ‘fatigue, malaise and anorexia’ is indicative of how uncomfortable and debilitating

constipation can be: it is not a minor matter. Therefore, diagnosis is an important first step towards treatment and relief.

Diagnosis and Treatment Decisions for Constipation The Mayo Clinic again offers a clear guidance from Dr Amy E Foxx-Orenstein who explains that, the type of constipation can usually be determined without extensive testing. “The first step in evaluating an older patient with constipation should always be a detailed history and complete physical exam, including a digital rectal exam,” she says. “The digital exam is often overlooked, but it can provide so much information.”… Although requiring patience and persistence, treatment should focus on education, Dr. Foxx-Orenstein says. “Informing patients about diet, exercise and bowel techniques, including evacuation timing, breathing and the way they position themselves on the toilet, is usually incredibly effective.”’ Some doctors suggest asking these questions to decide if [a patient is] constipated11: • Do you often have fewer than three bowel movements a week? • Do you often have a hard time passing stools? • Are stools often lumpy or hard? • Do you have a feeling of being blocked or of not having fully emptied your bowel? If the patient answers ‘yes’ to one or more questions, they might have a constipation problem. Most professional sources, including CME Corner again, recommend that clinicians “obtain a detailed history to determine what symptoms are not being addressed by current treatments, ensure the patient has had adequate trials of any medications taken, consider combining treatments, and evaluate patients for pelvic floor dysfunction...” Tests such as Anorectal manometry and defecography will help to assess a patient. We can perhaps leave the final word to another professional source, Web MD12. “Most people do not need extensive testing to diagnose constipation. Only a small number of patients with constipation have a more serious medical problem.”

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Dealing with Constipation Francis Slade, Staff Writer

Just as there are multiple causes, there are multiple treatment options for constipation in older people

What Can Happen With Constipation The UK National health Service (NHS )13 explains that the severity of constipation varies from person to person. Many people only experience constipation for a short time, but for others, constipation can be a long-term (chronic) condition that causes significant pain and discomfort and affects quality of life. While anyone can become constipated, elderly people are more prone as the result of a number of factors explained in the previous articles. In addition to the direct causes, older people with cognitive impairment and dementia causing conditions might also ignore or not recognise the need to defecate and even healthy older people are more likely to over-use laxatives. Too much reliance on self-medication laxatives to ensure a normal bowel motion can leave the natural muscles that manage defecation weakened and can therefore cause the very condition that users are trying to avoid. While most of the issues around constipation will not be serious in themselves (unless another condition such as cancer is involved) one consequence can be painful, distressing and potentially damaging. That is faecal impaction, where faeces that has not been passed accumulates into a hard mass in the bowel. This is painful and can potentially harbour or initiate infection as well as having the potential, in extreme cases, of bursting the bowel wall – colonic perforation. This is a major concern for the institutionalised elderly; “Indeed, it is of such concern that a faecal impaction is now a reportable quality event in nursing homes.”

Diet and Constipation There are dietary links to constipation including the importance of high fibre, lower fat, lower sugar foods plus adequate hydration to avoid the risk of a hard stool which could become impacted. NetDoctor offers typical dietary advice to help prevent constipation. •A well-balanced diet high in fibre, including bran, fruits and vegetables, is often helpful.

•C utting down on white bread, cakes and sugar. •D rinking at least 6 to 8 glasses of water a day. Hot beverages, such as coffee, tea or hot water, may stimulate bowel movements. • Prunes and plum juice can also be beneficial. •R egular exercise improves digestion and reduces stress. •A regular bowel habit. The best time is usually the first hour after breakfast. Don’t hurry and sit for at least 10 minutes, regardless of whether you manage to pass a stool. Don’t strain. Most advice on the subject follows a similar pattern and all emphasise that dietary adjustments are best followed after confirmation by the patient’s GP that the condition is constipation and not something else. Fibre seems to be a dietary determinant in constipation. The recommended fibre intake for a healthy adult is 20-35 grams daily. However, evidence in the USA suggests that average Americans consume only 5-10 grams daily and it is unlikely to be much different in other western societies such as the United Kingdom. But patients should avoiding going in one step from the average to the desirable intake as such a sudden change could itself cause, at the very least, discomfort. Huffington Post14 suggests, “… to avoid bloating and cramping, you shouldn’t suddenly add 30 grams of fibre to your plate, according to EverydayHealth.com. Instead, eating smaller portions daily and balancing your diet with fluids are all ways to get your digestive system back to where it should be.” As has also been stated above, fluid intake is important and, while little research has been conducted in this area, a three-month study of 21 nursing home with residents aged less than 65 years15 found a link between insufficient fluid intake and constipation. One controlled trial showed that higher fluid intake improved chronic constipation in the presence of a high-fibre diet. There are lots of good/bad food and fluid ‘lists’ to which people can refer but with such a choice, it can be difficult for most people to identify foods that are likely to cause and those that will help WWW.PRIMARYCAREREPORTS.CO.UK | 11

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Aerobic activities are good for relieving constipation: they increase blood flow to organs including the gastrointestinal tract, and thus result in stronger intestinal contractions and production of more digestive enzymes

prevent constipation. And, of course, many patients presenting to their clinician will have tried the dietary/fluids route already with insufficient success. So it might be useful for a clinical practice to offer a dietary and fluids guide sheet to use in combination with any medication that is prescribed: which brings us nicely to the matter of medication.

possible and should periodically reduce or discontinue them to determine if long-term use is necessary.” As well as oral medications, more immediate conditions such as faecal impaction might be treated with a suppository or an enema to avoid unnecessary straining by the patient.

Medication and Constipation

Lack of exercise is often a contributor to constipation but might be unavoidable in some cases such as following an accident or during a lengthy illness. This is why modern hospital practice gets patients out of bed as often and for as long as possible. Aerobic activities are good for relieving constipation: they increase blood flow to organs including the gastrointestinal tract, and thus result in stronger intestinal contractions and production of more digestive enzymes. Equally, a brisk walk to the shops or with the dog will serve for most people to ensure a bowel-moving level of exercise. It’s less a case of going to extremes but more a case of going to sensible.

Numerous medication routes are available. According to CME Corner16, “Pharmacological options include bulking agents, stool softeners, stimulant laxatives and osmotic laxatives. A reasonable pharmacological approach for a patient with chronic constipation is to start with a bulk forming agent… followed by a stool softener or osmotic agent... If necessary, a stimulant laxative… could be used. Finally, the chloride channel activator lubiprostone could be tried in patients with persistent symptoms. These therapies appear to be safe for long-term use but patients [guided by their clinicians] should limit their use whenever

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Exercise and Constipation

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Risks, Complications and Treatments John Hancock, Editor

Interventions focus as much on prevention to avoid collateral problems as on cure

Lifestyles and Constipation

Complications with Constipation

While diet, fluid and medication all have their parts to play, there are more prosaic aspects of modern western society that are also thought to contribute to constipation. Posture is important: not the way you stand or hold your head but how you position yourself to defecate. Many modern toilets are high; we even colloquially refer to them as ‘thrones’. While this might make for impressive bathroom furniture it does not make for good bowel elimination. In his Everyday Health article ‘Are You Pooping Wrong?’17, James Delassio reports that “There is definitely some physiologic sense to squatting,” says gastroenterologist Anish Sheth, MD. “Simply put, it straightens out the colon.” When we’re standing, the colon (where waste is stored) gets pushed up against the puborecatlis muscle, which keeps fecal continence until it’s time to hit the bathroom. Sitting down only partially relaxes that muscle. Squatting fully relaxes it, essentially straightening out the colon. That, in turn, eases the elimination pooping process. Away from western society, squat toilets are the rule rather than the exception but, of course, as people get older, squatting becomes increasingly difficult… or, at least, rising from a squatting position does! It is also important that people, especially older people, ‘answer the call of nature’ as soon as possible. Most of us know when our bowel needs to empty and should act on that signal. Delay can stop the muscles working properly. People at any age should also ensure that they allow sufficient time to empty their bowel but this does not equate to sitting and reading on the loo which can create a number of other problems including haemorrhoids also known as piles. Haemorrhoids are also a complication that can arise from constipation or, at least, the straining to pass a stool that accompanies it. As well as that, the straining can also cause rectal bleeding if a small tear (anal fissure) occurs around the anus.

Faecal impaction is a further complication that has been covered in an earlier article in this Report. It is more prevalent in elderly and infirm patients and can sometimes cause a type of diarrhoea and incontinence where liquid faeces from above the impacted blockage leaks around the faecal mass. Other complications identified by the UK National Health Service (NHS) include… • Swelling of the rectum. • Losing sensation in and around your anus. • Bowel incontinence, when you uncontrollably leak soft or liquid stools. • Bleeding from your anus. • ‘Rectal prolapse, when part of your lower intestine falls out of place and protrudes from your anus (this can also occur as a result of repeated straining caused in people with chronic constipation). In CME Corner18, John F Johanson affirms that; “Given the potential for serious complications among elderly patients with constipation, particularly those who are institutionalized, it is important to provide effective therapy with consistent follow-up to ensure that these patients first and foremost are comfortable, but also to optimize their quality of life and to ensure that these potentially serious complications of constipation are avoided.” As my colleagues have already covered, there can be complications with constipation and, while these might not often be life threatening, they can diminish the quality of life with discomfort and restricted mobility.

Aneurysm and Stroke But there is a complication or side effect from constipation that can be life threatening or can bring on a life threatening condition. This is the risk from aneurism and/or stroke. A brain aneurysm describes a bulge in the blood vessels located in the brain. It is possible to have an undetected

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SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

Once a brain aneurysm ruptures the risk of stroke increases. Death might also occur. In advice given to patients at risk of bursting an aneurysm, constipation figures as a significant contributor to risk

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aneurysm because it has not ruptured but once a brain aneurysm ruptures the risk of stroke increases. Death might also occur. In advice given to patients at risk of bursting an aneurysm, constipation figures as a significant contributor to risk. VC Higeura in ‘Ways to Prevent a Brain Aneurysm’19 includes: “Treat Constipation. Any type of straining can cause an aneurysm to burst.” Straining at a bowel movement is known as a Valsalva manoeuvre. If the pressure is maintained, it might feel as if there is pressure in the head, leading to dizziness and light-headedness upon relaxing the strain. We have already covered that straining during a bowel movement can lead to haemorrhoids. It can also increase blood pressure, which, although only temporary, may be extreme. There have been cases where defecation has caused blood pressure to rise enough to cause the rupture of an aneurysm or to dislodge blood clots and that is likely to lead to death. This is especially a risk for older people who are more likely to suffer from both constipation and high blood pressure related conditions. The Brain Aneurysm Foundation’s paper, ‘A patient guide to recovery from brain aneurysm treatment’20 also offers tips on dealing with constipation.

Furthermore, straining at a stool can cause Valsalva retinopathy, where blood vessels rupture in the eyes due to the pressure. This can result in blindness, which might or might not be reversible.

Treatments for Constipation Probably a majority of people with constipation will self-medicate using over-the-counter remedies available from pharmacies. Also, the ubiquitous Internet will quickly reveal appropriate dietary and fluid intake mechanisms – fluids meaning water and soft drinks that will raise hydration as opposed to the dehydrating effect of alcohol and caffeine drinks. Also, a lot of treatment programmes focus on education while exercise is an important part of any healthy routine: as is ensuring a proper emptying of the bowel when the urge is apparent. Laxatives, whether to support healthy digestion, soften the stool or to stimulate bowel muscle action can all be prescribed. While surgery can be used to treat constipation, for elderly patients it is not often the answer unless other complicating factors are present. In most cases, an appropriate laxative will resolve the problem, improving comfort and quality of life.

SPECIAL REPORT:MANAGING CONSTIPATION IN THE ELDERLY

References: A

WebMD UK http://www.webmd.boots.com/digestive-disorders/constipation

NHS Choices ‘Constipation’ http://www.nhs.uk/Conditions/Constipation/Pages/Introduction.aspx

MeReC Publications, The management of constipation http://www.npc.nhs.uk/merec/therap/other/resources/merec_bulletin_vol21_no2.pdf

NICE http://cks.nice.org.uk/constipation#!topicsummary

netdoctor http://www.netdoctor.co.uk/diseases/facts/constipation.htm

The Mayo Clinic http://www.mayoclinic.org/medical-professionals/clinical-updates/digestive-diseases/chronic-constipation-older-patients-educational-approach

Constipation Matters http://www.constipationmatters.com/constipation-in-elderly.html

American Family Physician; Schaefer and Cheskin http://www.aafp.org/afp/1998/0915/p907.html

The Doctor will see you now http://www.thedoctorwillseeyounow.com/content/aging/art2080.html

The Mayo Clinic http://www.mayoclinic.org/diseases-conditions/constipation/basics/risk-factors/con-20032773

Health http://www.health.com/health/gallery/0,,20452199,00.html

Best Practice http://connect.jbiconnectplus.org/ViewSourceFile.aspx?0=453

CME Corner https://www.cmecorner.com/portal/topic_detail.asp?id=elderlyconstipation.org&cid=38

Medicine Net http://www.medicinenet.com/script/main/art.asp?articlekey=60503

Web MD http://www.webmd.com/digestive-disorders/digestive-diseases-constipation

NHS http://www.nhs.uk/Conditions/Constipation/Pages/Introduction.aspx

Huffington Post http://www.huffingtonpost.ca/2012/07/04/10-foods-for-constipation_n_1647050.html

JABFM http://www.jabfm.org/content/24/4/436.full

CME Corner https://www.cmecorner.com/portal/topic_detail.asp?id=elderlyconstipation.org&cid=38

Everyday Health http://www.everydayhealth.com/digestive-health/are-you-pooping-wrong.aspx

CME Corner https://www.cmecorner.com/portal/topic_detail.asp?id=elderlyconstipation.org&cid=38

Ways to Prevent a Brain Aneurysm http://voices.yahoo.com/ways-prevent-brain-aneurysm-32895.html?cat=5

A patient guide to recovery from brain aneurysm treatment http://www.bafound.org/sites/default/files/A%20Patient%20Guide%20to%20Recovery.pdf

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