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Constipation and risk factors in the elderly

Alison Griffiths
MA BSc DN RGN
Advanced Primary Nurse
Evercare Project Wandsworth PCT
London

Although this article will concentrate on the elderly, it must be remembered that constipation affects human beings of all ages, from the very young to the very elderly. It affects both males and females and is seen in all races and social classes.(1) There is not only the cost to the sufferer in the form of pain, discomfort and loss of quality of life: there is a further aspect to be considered.
The cost to the NHS caused by the problem of constipation is enormous. The Department of Health (DH) estimated that annual expenditure on laxatives alone was £46 million.(2) Some figures show that 3 million GP consultations each year involve constipation and suggest that 10% of the UK population regularly take laxatives.(3) One study has estimated that the cost of dealing with the problem of constipation is £810,000 per year of community nursing time.(4) The full extent and therefore the true costs of the problem are as yet unknown.
The importance of bowel management has been highlighted by the DH publication Good Practice in Continence Services.(5) Thirty per cent of elderly people living in the community consider themselves constipated, and those living in nursing homes also have a high prevalence of constipation.(6)

Definition of constipation
There have been several definitions of the term constipation, but most experts today recognise that it is more easily understood as a group of symptoms. It remains a subjective condition, as each person's perception of constipation differs widely. The term constipation has been used to indicate either the infrequent passage of stool (two or fewer stools passed per week) or excessive straining on attempted defecation. The definition of constipation has also been explained as a bowel movement less than three times a week or the passage of hard stools less frequently than the patient's own normal pattern.(7)
The classification of constipation that is used in research is that of the Rome II Criterion, which recognises that two or more of the following symptoms have to be present for more than 3 months to enable a diagnosis of constipation:(8)

  • Pain and straining at defecation for at least 25% of the time.
  • Lumpy/dry/hard stools for at least 25% of the time.
  • Feelings of incomplete evacuation of faeces at least 25% of the time.
  • Fewer than two bowel movements per week.

However, these are not the only symptoms to be associated with constipation. It is important to be aware of pain and abdominal discomfort, incomplete emptying of the bowel and flatus that may be reported by the patient. Ongoing problems may present, such as lethargy, halitosis, nausea and vomiting, and loss of appetite.  A level of increased agitation may be observed in patients with dementia.(9) In some cases, constipation may be the presenting symptom of colonic disease.

Classification
Constipation can be classified in three ways: primary, secondary or iatrogenically induced. Primary constipation arises from external factors, such as dehydration or environmental issues. Secondary constipation is attributed to diseases or conditions that can affect the bowel, such as dementia, diabetes or colorectal cancers. Constipation that is caused by drug side-effects, or interactions, is known as iatrogenically induced.(10) The causes of all classifications of constipation may appear to be compounded in the elderly.

Risk factors
The causes of constipation are numerous and vary in their complexity in each individual case. It is important to understand that, as Irwin states, "Constipation is not a disease, but a symptom of an underlying condition."(11)

  • Immobility is a primary risk factor for constipation in the elderly.(12) The reduction in exercise and their functional ability, such as dexterity, are ­factors that can enhance risks.
  • A reduced fluid intake due to the impaired thirst sensation increases the risk of dehydration and is a clearly understood phenomenon in the care of the elderly.
  • The inadequate intake of fibre in the diet is a risk factor of constipation.
  • Depression, anxiety and loneliness, which are common complaints among the elderly, can lead to a reduction in appetite and alteration in dietary habits. Nutritional status needs to be considered as an influence on the causes of constipation.(13)
  • Changes in physiological factors required for ­defecation, such as delayed colonic ­transit time and reduced abdominal muscle tone, can ­adversely affect bowel habit and function.(14)
  • Diseases and conditions, such as diabetes, Parkinson's disease and dementia, may cause severe symptoms of constipation.
  • Drugs and their side-effects and interactions are of particular relevance to the elderly, as they are often prescribed a number of medications daily. The consistent use of laxatives over a long period of time can reduce intestinal muscle tone, which can result in an atonic nonfunctioning colon.(15)
  • Environmental factors, such as access to toilet facilities, lack of privacy and changes in routine, have also been recognised as having adverse affects on bowel function.(16)
  • The issue of dignity for older people has been highlighted in the National Framework for Older People.(17) Some research suggests that the problem for the elderly may be bowel patterns and habits from childhood when access to toilets that were outside and not private led to postponing the urge to defecate, which perpetuates constipation.
  • Complications of constipation such as faecal ­loading, faecal impaction and faecal and urinary incontinence are increased in the elderly due to their high risk of constipation.

Conclusion
There needs to be more awareness of the problem of constipation and a positive approach to its management. An effort to alleviate the risk factors would result in the reduction of the amount of constipation suffered. There needs to be greater emphasis on education about the risk factors. Information should be available for patients and those caring for the elderly, many of whom are informal or unqualified carers. This reason underlines the importance of adequate training and education for all those caregivers and good assessment skills for the healthcare professionals involved.
Primarily, the nurse's responsibility is to recognise those who are at risk and identify the factors that will cause constipation. This will enable a preventative plan of care to be implemented. The emphasis should be placed on the proactive management of this condition.  This involves the need for nurses to prioritise the problem and be educated in the assessment and management of bowel care. There are a number of tools available that can be used to assist nurses with their assessment. A more holistic and multidisciplinary approach to the problem of constipation is required to enable prevention.

References

  1. Richmond J. Prevention of ­constipation through risk management. Nurs Stand 2003;17:39-46.
  2. Department of Health. The essence of care: patient-focused benchmarking for health care practitioners. London: Department of Health; 2001.
  3. Rigby D. Managing incontinence in primary care. Nursing in Practice 2001;2:79-80.
  4. Available at URL:  http://www.seekwellness.com/incontinence/bowel.htm
  5. Department of Health. Good ­practice in continence services. London: Department of Health; 2000.
  6. Black D.Constipation in the elderly: causes and treatments. Prescriber 1998;9:105-8.
  7. National Prescribing Centre. The management of constipation. MeReC_Bulletin. Available at: http://www.npc.co.uk/MeReC_Bulletins/bulletin1999.htm
  8. Thompson W, et al. Functional bowel disorders and functional abdominal pain. Gut 1999;45:1143-7.
  9. Cayton H, Graham N, Warner J. Dementia, Alzheimer's and other dementias. London: Class Publishing; 2002. p. 170.
  10. Wright PS, Thomas SL. Constipation and diarrhoea: the neglected symptoms. Semin Oncol Nurs 1995;4:289-97.
  11. Irwin K. Constipation. 2003 Mimms. London: Haymarket Medical Publications Ltd; 2003 p. 1-2.
  12. Potter J, Norton C, Cottenden A.  Bowel care in older people. London: Royal College of Physicians; 2002.
  13. Eberhardie C. Constipation: ­identifying the problem. Nurs Older People 2003;15:22-6.
  14. Ellickson E. Bowel management plan for the homebound elderly.J Gerontol Nurs 1988;14:16-9.
  15. Courtenay M, Butler M. Nurse prescribing principles and practice. Oxford: Oxford University Press; 1999.
  16. Sheehy C, Hall G. Rethinking the obvious: a model for preventing ­constipation. J Gerentol Nurs 1998;24:38-44.
  17. Department of Health. National Service Framework for Older People.  London: Department of Health; 2001.

Resources
Association for Continence Advice
W:www.aca.uk.com
Royal College of Nursing
Digital rectal examination and manual removal of faeces
W:www.rcn.org.uk
Reckitt Beckinser
W:www.constipationadvice.co.uk

Further ­reading
Bardsley A, et al. Managing ­constipation in adults - a patient-centred approach. Berkhamstead: Schwarz Pharma/Medendium Group Publishing Ltd; 2003.