ARRC Medicine Education Series Laxative Use & Bowel Management 2014

1. ARRC Medicine Education SeriesLaxative Use & Bowel Management2014

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Secondary Causes of Constipation • Diseases and medical conditions • Depression • Hypothyroidism • Diabetes • Parkinson’s Disease • Dementia • History of stroke • Hypercalaemia

12. 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

13. 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

14. 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

15. Constipation in the elderly • In the elderly, constipation may present as: • Confusion • Overflow diarrhoea • Abdominal pain • Urinary retention • Nausea and loss of appetite

16. 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

17. 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

18. 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

19. Constipation Management

20. 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

21. 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

22. 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

23. 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

24. 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

25. Learnings Which of the following may be present in a resident who is constipated? • A. Diarrhoea • B. Confusion • C. Urinary frequency • D. Aggressive behaviour

26. Learnings What assessment should be undertaken when constipation is suspected? • A. Review of daily history • B. Oral assessment • C. Bowel sounds • D. Rectal examination

27. 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

28. 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

29. 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

30. 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

31. 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)

32. 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

33. 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

34. Laxative Selection • Other considerations include: • Presenting symptoms • Nature of the complaint • Patient acceptability • Relative effectiveness • Tolerability • Cost

35. Laxative Selection • Presenting symptoms • Hard / lumpy stools • Osmotic laxatives • Defecating < once a week • Prokinetic or contact (stimulant & softener) laxatives • Manual manoeuvers • Enema and osmotic

36. 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

37. 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

38. Laxative Types • Laxatives are categorised according to their principle mode of action • Bulk • Osmotic • Softening • Stimulant

39. 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

40. 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

41. Laxative Types: Osmotic • Draw water into colon by osmosis • Important resident has good fluid intact • 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

42. 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)

43. 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

44. 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)

45. 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

46. 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

47. 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

48. 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

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

50. 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