Guidelines for Integrated Care (Psychiatric & Medical) In the Community

1. Guidelines for Integrated Care (Psychiatric & Medical) In the Community Module III: Management of Bowel Dysfunction

2. Training Objectives • Appreciate the need for integrated care in the mental health community to prevent premature deaths and increased disability from bowel dysfunction • Understand the levels of risk and factors associated with bowel dysfunction. • Identify persons with mental illness in their caseload who are at risk for or who have already experienced bowel dysfunction. • Identify actions that will aid the persons with bowel dysfunction in communicating their needs and manage their symptoms.

3. Physiology of Digestion

4. Realistic Diagram

5. Understanding the problem • Bowel dysfunction: Problems with the frequency, consistency and/or ability to control bowel movements such as: • Constipation • Fecal impaction • Obstruction • Perforation • Megacolon development • Deaths in psychiatric settings are increasingly reported as a result of bowel dysfunction.

6. Role of Guidelines • Guidelines can serve as aids in development of protocols for working with affected persons in community case loads. • Guidelines begin with knowing who in community-based case loads is at risk, who is already diagnosed, and who is showing signs of consequences of bowel dysfunction. • Implementation includes identifying and communicating with both client and team members. It includes: • The ability to identify symptoms, consult, advise, educate, support and refer persons with bowel dysfunction. • To recognize and get appropriate help for potentially deadly symptoms of MEGACOLON—a true medical emergency.

7. Bowel Dysfunction and Mental Illness • Elimination of body waste is not a usual or particularly comfortable topic and is not generally discussed. • However, dysfunction in bowel evacuation is not a laughing matter when outside of the normal experience. • Extremes of bowel dysfunction disrupt a person’s entire life, and if not recognized or not treated, may result in death. • Persons with mental illnesses are particularly vulnerable to bowel dysfunction. • Rendering support and assistance are more likely to happen when mental health community providers have knowledge the skills to recognize, support and intervene/refer when appropriate. • FIRST YOU HAVE TO ASK.

8. Case Managers and Integrated Care • Knowledge needed by case managers when their clients who have, or are at risk for developing bowel dysfunction include: • Understanding the potential for serious complication • Understanding the necessity for supporting preventative activities such as adherence to dietary restrictions, exercise and self-monitoring/management needs • Case managers also need the support of their team members and agencies in providing much needed integrated care.

9. Role of Psychiatric Medication • Risk for bowel dysfunction is, in part, related to medications that block the nerves that control the automatic functions of certain muscles in the body (Anticholinergic effect). • The affected muscles are particularly important to the normal movement of the intestines in the elimination of body waste products.

10. Warning Signs/Sx of Anticholinergic Effects • Memory loss and confusion • Lightheadedness and mental fogginess/inability to concentrate • Wandering/inability to sustain a train of thought • Incoherent speech • Visual and auditory hallucinations/illusions • Agitation • Euphoria or Dysphoria • Respiratory depression

11. Warning Signs/Sx of Anticholinergic Effects • Dry mouth • Loss of coordination (ataxia) • Dry, sore throat • Increased body temperature • Dilated pupils and loss of visual ability to focus/accommodate/double vision • Increased heart rate • Tendency to be easily startled • Urinary retention • Shaking

12. Bowel Dysfunction: Contributing Factors • Genetic predisposition • Narcotic pain-killers such as benzodiazepines (Valium, Xanax, Ativan, etc.) • Low fiber diet • Limited fluid intake • Disruption in routine • Ignoring the urge • Lack of privacy • Sedentary life style

13. Bowel Dysfunction: Contributing Factors • Stress • Hypothyroidism • Neurological conditions such as Parkinson’s disease or multiple sclerosis • Overuse of antacid medicines containing calcium or aluminum • Depression • Eating disorders • Colon Cancer

14. Bowel Dysfunction: Contributing Factors • Medication • Narcotics such as benzodiazapines • (Valium, Ativan, Xanax, etc.) • Antidepressants such as tricyclics , SSRIs, SNRIs • Elavil, Desyrel, etc. • Celexa, Prozac, Paxil, etc. • Cynbalta, Effexor, etc. • Second Generation/Atypical antipsychotics • Ablify, Clozaril, Zyprexa, etc. • Iron pills

15. Bowel Dysfunction: Contributing Factors • Overuse of laxatives can weaken the bowel muscles: • Metamucil • FiberCon • Citrucel • Glycerin suppositories • Docusate/Colace • Polyethylene Glycol • Milk of Magnesia • Bisacodyl/Dulcolax/Correctol (these stimulant laxative should only be used for a few days at most)

16. Symptoms of Constipation • Infrequent bowel movements and/or difficulty having bowel movements as evidenced by: • Less than 3 bowel movements a week • Straining or difficulty in evacuating bowel at least 25% of the time

17. More Serious Symptoms That may Indicate Obstructed Bowel • Swollen abdomen or abdominal pain • Pain • Vomiting • Cramping and belly pain that comes and goes • Pain occur around or below the belly button • Bloating • Constipation and a lack of gas indicate complete blockage of the intestine • Diarrhea, if intestine is partly blocked

18. Chronic Constipation

19. Immediate Medical Attention Required: Megacolon

20. What is Megacolon? • Megacolon is an abnormal dilation of the colon (a part of the large intestines)  • The dilatation is often accompanied by a paralysis of the peristaltic movements of the bowel • In more extreme cases, the feces consolidate into hard masses inside the colon, called fecalomas (literally, fecal tumor), which can require surgery to be removed • THIS IS A MEDICAL EMERGENCY! • All of the symptoms of obstruction may be present • ABDOMINAL PAIN IS SEVERE AND CONSTANT

21. What is Megacolon? • Rare event—a portion of the large intestine is paralyzed and swells to many times its normal size • Happens suddenly • Worsening abdominal pain • Visibly distended or bloated abdomen • Abdominal tenderness • Fever • Vomiting

22. Megacolon: Signs/Sx • Constipation of very long duration • Abdominal bloating • Abdominal tenderness and tympany, abdominal pain, palpation of hard fecal masses • In toxic megacolon: fever, low blood potassium, tachycardia and shock • Stercoral ulcers (ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation) are sometimes observed in chronic megacolon - which may lead to perforation of the intestinal wall in approximately 3% of the cases, leading to sepsis and risk of death

23. Megacolonhttp://medlineplus.gov

24. Megacolon66 y.o. man with schizophrenia – no BM for 1 month, presented with constipation, shortness of breath, and severe abdominal pain

25. Risk classifications • Please remember that the level of risk for megacolon is determined by RN or MD • If you notice the client is having difficulties—consult with RN or MD

26. Low Risk • No personal or family history of bowel problem • No abnormal findings on medical record or alerts from RN’s/Psychiatrist on team re medications/blood and other medical tests • No report from client regarding any difficulty with bowel movement (when asked or spontaneously)

27. Low Risk • Does not take medication with known anti-cholinergic effects/nervous system depressants: • pain medications • muscle relaxants • anti-anxiety medications (benzodiazepines) • sleeping agents (Benadryl/diphenhydramine) • EPS prophylactic agents (Cogentin/benztropine, Artane) • anti-psychotic medications • anti-depressants

28. Moderate risk • Meets some of the following criteria but no current problem  refer to team RN/MD • Personal past history of bowel problems • Family history reported • Takes one or more medications with some anti-cholinergic activity e.g. Clozaril (antipsychotic) and Cogentin (antiparkinsonian agent)—check over the counter medication and from primary care practitioners • History of occasional constipation • RN/Psychiatrist report some abnormal findings indicative of bowel dysfunction

29. High Risk • Current problems • Refer to team RN/MD—possible specialty referral needed • Personal and family history of bowel problems • Takes more than one medication with high anticholinergic activity/constipation effect (polypharmacy) • History of fecal impaction, and/or current constipation • Current or recent (possibly chronic) use of laxatives • Frequent complaints of constipation

30. Approaching the Question of Bowel Dysfunction: • How to approach this topic ---- which tends to be uncomfortable for both the person asking the questions and the person of whom they are being asked. • One example: • “The medications you are taking can make it difficult for you to have a bowel movement. That can have very serious consequences. It is important for you to keep track of any issues you might be having.”

31. “When is my constipation a more serious problem?” • Only a small number of patients with constipation have a more serious medical problem • If constipation persists for more than two weeks, a physician or nurse practitioner should be seen to determine the source of the problem and treat it • If constipation is caused by colon cancer, early detection and treatment is very important

32. Healthy Assumption • Assume that all vomiting clients (especially those in high risk categories) to have a bowel obstruction • A person with schizophrenia may have altered pain perception and therefore may not notice bowel issues

33. Self-management strategies • Monitoring Questions: • Are you having less that 3 bowel movements a week? • Do you strain a lot when you are trying to have a bowel movement? • Do you have lumpy hard stools or a sensation of not getting it all out more than 25% of time? • Use of a monthly “calendar” might be helpful to keep track

34. Suggestions on Approaching the Subject • Treat this issue like any sensitive and confidential clinical issue. Find a private place and suitable time to talk • Tell the client that you want to discuss the client’s bowel management issue • Explain that it is part of the client’s overall health and it is oftentimes a difficult and private subject to discuss • Explain that because clients sometimes are too embarrassed to discuss bowel management issues, some encounter problems which could have been prevented if dealt with sooner

35. Clinically Precise and Sensitive Wording • Words and how they are used are very important to how your conversation will move forward • Use words like: “bowel movement”, “stool”, “constipation”, and “diarrhea” • What are some other words that you can use to discuss this topic in a kind and sensitive way?

36. All Risk Groups Need • Education: • High fiber diet • Exercise • Drinking fluids (6-8 ounces water or other non-carbonated fluids--not to excess) • Keep track of bowel movements

37. Reminder • Mental health is essential to overall health and other physical health • Physical health is essential to mental health and recovery

38. Reminder • Develop primary/specialty care resources available • Develop relationships in community • Develop protocols for consistent collaboration and prevention/wellness services • For example, finance/billing: Review use of Behavioral Health (Community) Medicaid and inclusion of collaborating in indirect service costs

39. Reminder • Encouraging services that include identification and monitoring of other physical health issues: • Amended job descriptions • Updated policies and forms • Staff performance indicators and evaluation • Amended mission and vision

40. CASE STUDIES See Handout

41. Case Study 1 • Joseph is an African-American male in his mid 50s. He has a long history of Schizoaffective disorder with multiple hospitalizations. Joseph lives in a group home. He smokes heavily and has a diagnosis of COPD. He often complains of indigestion, bloating and constipation and he was treated for fecal impaction about 8 months ago. • He is currently prescribed Seroquel, Haldol, and Cogentin. He has been also taking medication for constipation and heartburn. Joseph has not had a bowel movement for the past 14 days.

42. Case Study 1 • You are a CPST worker • Create a set of specific talking points on how to approach Harry • Role play this interaction with a partner next to you. Take turns playing the CPST worker and Joseph • Have fun role playing. Be imaginative but realistic

43. Case Study 2 • Harry is a Caucasian male in his late 20s. He was diagnosed with paranoid schizophrenia four years ago with history of multiple involuntary hospitalizations. During the past 12 months, Harry was prescribed Prolixin, Risperdal Consta, Zyprexa, Cogentin and anti-anxiety medication. • Harry has been complaining of GI symptoms such as heartburn, indigestion and constipation for the past several months and was prescribed Mylanta and Milk of Magnesia for GI related problems. • Yesterday, a CPST worker observed Harry to have diarrhea during transport to a housing appointment and just this morning the same CPST worker observed Harry vomited in his apartment.

44. Case Study 2 • You are that CPST worker • Create a set of specific talking points on what you would say to Harry • Role play this interaction with a partner next to you. Take turns playing the CPST worker and Harry • Have fun role playing. Be imaginative but realistic

45. Case Study 3 • Sarah was a 14 year old teenager hospitalized at a state mental facility. She was diagnosed with Autism and Schizophrenia. Sarah passed away on February 13, 2006. • The medical examiner said the 14-year-old died of severe intestinal blockage that medical records showed went unnoticed by doctors and nurses. • Sarah vomited several times the night before she died. The next morning, staffers found her body with an enlarged abdomen and brown substance oozing from her mouth. Sarah had no pulse and was lying in vomit.

46. Case Study 3 • You are a member of the Critical Incident Committee, the committee that examines critical incidences at the hospital and to recommend quality improvement measures to the Medical Director of that state psychiatric facility. • What are some early warning signs and symptoms that this patient may have exhibited or reported? • How would you as a line staff at the hospital approach the patient when you see her not eat for the past day or so? • Recommend some specific and sensitive talking points in broaching the subject of bowel management with the patient.