Q& A With the Expert on: Constipation
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Q: How do you manage constipation in the long-term care setting?
A: There is no clinical definition of constipation. Physicians describe constipation as less than three bowel movements per week, while patients describe constipation as passing hard stools or straining to have a bowel movement. Thus, there is no agreement between the patient and physician. Because of this dispute about the definition, there is little correlation between self-reported constipation and number of bowel movement in epidemiologic surveys. The Rome Criteria defines constipation as outlined in Table I, a consensus definition used by experts for the primary purpose of use in clinical trials.
The prevalence of self-reported constipation and laxative use increases with aging, while the prevalence of stool frequency does not change with age.1, 2 Constipation is more common in the elderly, African-Americans, women, and persons of lower socioeconomic class.
In frail elderly individuals, up to 45% reported constipation as a health issue. The prevalence of constipation is higher in nursing home residents, a finding not well explained by the increased use of laxatives, but which could be explained with higher use of medications and other comorbidities.3
Factors associated with constipation development in nursing homes include: race, decreased fluid intake, pneumonia, Parkinson’s disease, and presence of allergies.4 Congestive heart failure and the use of a feeding tube were two factors identified as having a protective effect.4
The average cost per long-term care resident with constipation is $2253.5 Health-related quality of life is reduced in patients with chronic constipation.6 The presence of constipation has been hypothesized to increase urinary tract symptoms, fecal incontinence, fecal impaction, and stercoral ulceration.7-9
CAUSES OF CONSTIPATION
Causes of constipation can be divided into primary and secondary causes.
Primary causes of constipation could be classified into three groups: (1) normal transit constipation, (2) slow transit constipation, and (3) anorectal dysfunction. Secondary causes are outlined in Table II. The most common ones are medications and coexistent medical conditions.
EVALUATION OF CONSTIPATION
Regulatory guidelines require that a comprehensive patient assessment, the Minimum Data Set (MDS), be completed within 14 days of admission to a nursing home. The MDS addresses how the resident uses the toilet, transfer on/off the toilet, and bowel pattern elimination. It is important to address constipation from the start, as it could lead to impaction, decrease in activities of daily living, incontinence of bowel and bladder, and at times, delirium, which could lead to resident assessment protocol trigger. Bowel elimination continues to be an important indicator on the MDS on the quarterly/annual assessment forms.
The steps involved in the evaluation of constipation are outlined in Table III. In acute or subacute onset, it is important to exclude structural lesions such as neoplasia or volvulus. The presence of weight loss along with rectal bleeding and/or iron deficiency anemia also requires examination of the colon to exclude cancer.
Additional tests that are used in the evaluation of constipation but are rarely needed in nursing home patients include colon transit measurements, colonic manometry, anorectal manometry, balloon expulsion testing, and defecography. Of patients undergoing extensive exhaustive investigations, the cause of constipation is determined in only about 50%.10
TREATMENT OF CONSTIPATION
The best strategy for managing constipation is to divide the symptoms into degrees of severity. The first step is to take a careful history, remembering that the patient often is talking about an entirely different symptom complex.
References
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