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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.
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ARRC Medicine Education SeriesLaxative Use & Bowel Management2014
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
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
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
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
Laxative Types: Bulk • Psylliumseed (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/bisacodylcombination 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
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
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
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