No organ in the body is so misunderstood, so slandered and maltreated as the colon! Sir Arthur Hurst, 1935

Patient Definition:  Hard Stools  Infrequent stools (<3 per week)  Excessive straining  Sense of incomplete bowel emptying  Excessive, unsuccessful time spent on toilet Constipation is NOT a normal part of ageing…. What is Constipation?

Nausea +/- vomiting Abdominal and Rectal pain Flatulence Loss of appetite Lethargy Depression Other symptoms of constipation Patients may not associate these with constipation

Nausea and reduced appetite  weight loss Behavioural disturbances in dementia  increased use of psychotropic medications Extra staff time needed for increased toiletting needs Overall increased number of medications in the regime What are some of the consequences of constipation in the elderly?

Immobility Improper Diet Endocrine & Metabolic Disorders Neurological Disorders Psychological Conditions Structural Abnormalities Medications Increased prevalence of Secondary Causes….. Why does constipation become a problem in the elderly?

Aluminium and calcium containing antacids Anticholinergic agents Calcium supplements Antipsychotics Iron Opioids Some medications associated with constipation

. Reference: Australian Journal of Hospital Pharmacy, 1998

No evidence that increased exercise is beneficial in severe constipation Aim for 25-30g fibre/day Unless dehydrated, increasing fluid does not relieve chronic constipation and may increase the risk of fluid overload eg heart or renal failure 1. Exercise - Fibre in the diet - Fluid Intake

Add dry, fresh or canned fruit to cereal Add legumes to soups casseroles Include grated vegetables in rissoles, soups Choose fruit desserts Use high fibre snacks, raisin bread, date scones, carrot, muffins The kitchen can help! EASY FIBRE SUPPLEMENT 3 TBS unsweetened apple puree 1 TBS unprocessed bran 2-3 TBS prune juice Use 1 TBS on breakfast cereal

eg psyllium (Metamucil®), sterculia (Normacol®), ispaghula (Fybogel®) Improve stool consistency and frequency with regular use Ensure good fluid intake to prevent faecal impaction Onset of action 2-3 days Side Effects may include bloating, flatulence, distension 2. Bulk Forming Laxatives

eg docusate (Coloxyl®), paraffin oil (Agarol®) Efficacy of docusate is controversial May be useful with anal fissures of haemorrhoids or when straining is a hazard Liquid paraffin is not recommended for treatment of constipation - risk of aspiration and lipid pneumonia - long term use may result in depletion of Vitamins A, D, E and K 3. Stool Softeners & Lubricants

4. Osmotic Laxatives Lactulose (Duphalac®), Sorbitol (Sorbilax®), PEG products (Movicol®)  Lactulose/Sorbitol -equally effective at improving stool frequency - onset of action – up to 48 hours - metabolised by bacteria  flatulence  Movicol® - improves stool frequency and consistency - iso-osmotic and therefore water and electrolyte loss is limited 

Lactulose contains absorbable sugars and may adversely affect glycamic control in diabetics Overuse may result in dehydration Monitor for any signs of electrolyte disturbances - oedema, - shortness of breath, - increasing fatigue, - cardiac failure Some precautions with osmotic laxatives

IMPORTANT: Thicken the water as per the manufacturer’s instructions BEFORE adding Movicol® Movicol® and Thickeners 1. Mix the required amount of thickened water. For convenience, this can be made ahead of time and stored in the refrigerator for up to 48 hours. 2. To prepare Movicol® for administration, spoon about ¼ cup thickened water into a glass and add Movicol® powder. Stir thoroughly with a spoon. 3. When mixed, add more thickened water to make up to ½ cup (125mL) and again stir thoroughly. 4. The mixture will return to the required thickened state within approximately one minute.

Senna (Senokot®), bisacodyl (Durolax®, Bisalax®)  Increase intestinal motility by stimulating colonic nerves  Useful with opioids  Onset of action 8-12 hours  Development of tolerance is reported to be uncommon  Generally considered 2 nd line therapy in elderly due to risk of electrolyte disturbances  Other adverse effects include cramping, diarrhoea, dehydration 5. Stimulant Laxatives

Nulax® - “the all natural and all organic in origin fruit laxative” Is not formulated in a manner that ensures even distribution of the active ingredient  inconsistent dosing Contains senna leaf powder 400mg/5g dose = 24mg sennosides/5g dose. Senokot tablets contain 7.5mg sennosides/tablet

Used when rapid relief from faecal loading is required Induce bowel movements by distension of the rectum and colon Frequent use may cause poor rectal tone and may exacerbate incontinence Tap water enemas are safest for regular use Phosphate enemas (Fleet®) increase the risk of hyperphosphataemia in renal impairment Glycerine suppositories stimulate rectal secretion by osmotic action 6. Enemas & Suppositories

Patient education Diet and Fluid Intake Exercise Effective Bowel Habits Toileting Facilities Medication Review Ensure a laxative is prescribed with opioids Helping to prevent constipation An Effective Fibre Supplement 3 TBS unsweetened apple puree 1 TBS unprocessed bran 2-3 TBS prune juice Add 1 TBS to breakfast cereal Imaginative ways to increase fibre:- Add dry, fresh or canned fruit to cereal Add legumes to soups and casseroles Include grated vegetables in rissoles & soups Choose fruit desserts High fibre snacks eg raisin bread, date scones, carrot muffins