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: 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 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 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 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: 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 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.

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, long-term 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 Rectum empty and dilated - ballooning of the rectum

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: 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: Cause Degree of constipation Type of constipation: acute or chronic constipation Subgroup Slow transit Normal transit Anorectal outlet obstruction 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 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 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

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: 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 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 fleet mineral oil enema also as softening enema

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.

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

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

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

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

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

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

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

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

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

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-for-Warfarin-Treatment-for-Community-Pharmacists.pdf Management of constipation in older adults. Best Practice. 2008;12(7):1-4