Medications and Constipation in the Elderly

1. Constipation is the second most common GI complaint after dyspepsiaConstipation is the second most common GI complaint after dyspepsia

2. 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? Definition:- generally described as infrequent defaecation, often with straining and the passage of hard, uncomfortable stools International surveys suggest 50-80% aged care residents have symptoms of constipation and 40-50% use at least one laxative at least 3x/weekDefinition:- generally described as infrequent defaecation, often with straining and the passage of hard, uncomfortable stools International surveys suggest 50-80% aged care residents have symptoms of constipation and 40-50% use at least one laxative at least 3x/week

3. Nausea +/- vomiting Abdominal and Rectal pain Flatulence Loss of appetite Lethargy Depression Other symptoms of constipation Nausea is a very common symptom of constipation in the elderlyNausea is a very common symptom of constipation in the elderly

4. 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

5. Immobility Improper Diet Endocrine & Metabolic Disorders Neurological Disorders Psychological Conditions Structural Abnormalities Medications Increased prevalence of Secondary Causes….. Identification of the presence of these on admission may enable preventative strategies to be put in place:- Immobility - osteoarthritis, advanced cancer Improper Diet - inadequate fibre/fluid Endocrine + Metabolic Disorders – Diabetes, Hypercalcaemia, Hyperparathyroidism, Hypothyroidism Neurological Disorders – cerebrovascular disease, MS, Parkinson’s Disease, Spinal cord injury/tumours Psychological conditions – anxiety, depression Structural abnormalities – haemorrhoids, anal fissures, IBS, obstructive colonic lesion, rectal prolapse Identification of the presence of these on admission may enable preventative strategies to be put in place:- Immobility - osteoarthritis, advanced cancer Improper Diet - inadequate fibre/fluid Endocrine + Metabolic Disorders – Diabetes, Hypercalcaemia, Hyperparathyroidism, Hypothyroidism Neurological Disorders – cerebrovascular disease, MS, Parkinson’s Disease, Spinal cord injury/tumours Psychological conditions – anxiety, depression Structural abnormalities – haemorrhoids, anal fissures, IBS, obstructive colonic lesion, rectal prolapse

6. Aluminium and calcium containing antacids Anticholinergic agents Calcium supplements Antipsychotics Iron Opioids Some medications associated with constipation A medication review may be beneficial to a resident with constipation Anticholinergic agents include: Ditropan, Spiriva, Antipsychotics – constipation not such a problem with newer atypical antipsychotics such as risperidone, olanzapineA medication review may be beneficial to a resident with constipation Anticholinergic agents include: Ditropan, Spiriva, Antipsychotics – constipation not such a problem with newer atypical antipsychotics such as risperidone, olanzapine

7. . There is some evidence that laxatives can improve outcomes such as bowel movement frequency, stool consistency and other symptoms however there is little high quality evidence. The treatment of chronic constipation remains empirical.There is some evidence that laxatives can improve outcomes such as bowel movement frequency, stool consistency and other symptoms however there is little high quality evidence. The treatment of chronic constipation remains empirical.

8. 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 Increased physical activity should be encouraged as part of the overall care plan however,… Dietary fibre - insoluble variety is important as it absorbs water, increases faecal bulk and shortens time in colon - add into diet slowly to minimise flatulence and bloating - examples - unprocessed wheat, bran, fruit, vegetables (25-30g/day) - NOTE - fibre can worsen constipation in the elderly, immobile resident. May result in impaction and faecal incontinence Fluid - ensure adequate fluid intake with increased fibre - 1500mL/day Increased physical activity should be encouraged as part of the overall care plan however,… Dietary fibre - insoluble variety is important as it absorbs water, increases faecal bulk and shortens time in colon - add into diet slowly to minimise flatulence and bloating - examples - unprocessed wheat, bran, fruit, vegetables (25-30g/day) - NOTE - fibre can worsen constipation in the elderly, immobile resident. May result in impaction and faecal incontinence Fluid - ensure adequate fluid intake with increased fibre - 1500mL/day

9. 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! Increased physical activity should be encouraged as part of the overall care plan however,… Dietary fibre - insoluble variety is important as it absorbs water, increases faecal bulk and shortens time in colon - add into diet slowly to minimise flatulence and bloating - examples - unprocessed wheat, bran, fruit, vegetables (25-30g/day) - NOTE - fibre can worsen constipation in the elderly, immobile resident. May result in impaction and faecal incontinence Fluid - ensure adequate fluid intake with increased fibre - 1500mL/day Increased physical activity should be encouraged as part of the overall care plan however,… Dietary fibre - insoluble variety is important as it absorbs water, increases faecal bulk and shortens time in colon - add into diet slowly to minimise flatulence and bloating - examples - unprocessed wheat, bran, fruit, vegetables (25-30g/day) - NOTE - fibre can worsen constipation in the elderly, immobile resident. May result in impaction and faecal incontinence Fluid - ensure adequate fluid intake with increased fibre - 1500mL/day

10. 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 Regular use is required Much better at absorbing water than bran resulting in softer stools. Provide bulk and keep stool soft through water resorption Diabetics should check sugar content Regular use is required Much better at absorbing water than bran resulting in softer stools. Provide bulk and keep stool soft through water resorption Diabetics should check sugar content

11. 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 Docusate - Lowers surface tension to allow water to penetrate into faeces to produce a softer motion Paraffin coats the faecal mass to facilitate passage Do not benefit drug induced constipation as intestinal peristalsis is reduced Recommended dose of docusate 120mg bd although greater doses than recommended by manufacturer are often required Paraffin Oil - depletion of fat soluble vitamins A,D,E and K - risk of aspiration - Agarol has been reformulated to contain phenolphthalein - associated with dermatitis, photosensitivity and Steven Johnson SyndromeDocusate - Lowers surface tension to allow water to penetrate into faeces to produce a softer motion Paraffin coats the faecal mass to facilitate passage Do not benefit drug induced constipation as intestinal peristalsis is reduced Recommended dose of docusate 120mg bd although greater doses than recommended by manufacturer are often required Paraffin Oil - depletion of fat soluble vitamins A,D,E and K - risk of aspiration - Agarol has been reformulated to contain phenolphthalein - associated with dermatitis, photosensitivity and Steven Johnson Syndrome

12. 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 Act in small and large intestine Poorly/not absorbed from the gut. Osmotic gradient causes influx of fluid into lumen Side effects - flatulence, cramp, diarrhoea, electrolyte imbalance Dose 15mL bd increasing to desired effectAct in small and large intestine Poorly/not absorbed from the gut. Osmotic gradient causes influx of fluid into lumen Side effects - flatulence, cramp, diarrhoea, electrolyte imbalance Dose 15mL bd increasing to desired effect

13. 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 GI Disorders - IBS, Diverticulitis Metabolic Disorders - Diabetes Endocrine Disorders - Hypothyroidism, Hypercalcaemia Immobility - osteoarthritis, advanced cancer Improper Diet - inadequate fibre/fluid GI Disorders - IBS, Diverticulitis Metabolic Disorders - Diabetes Endocrine Disorders - Hypothyroidism, Hypercalcaemia Immobility - osteoarthritis, advanced cancer Improper Diet - inadequate fibre/fluid

14. IMPORTANT: Thicken the water as per the manufacturer’s instructions BEFORE adding Movicol® Movicol® and Thickeners Elderly residents with swallowing difficulties may be at risk of aspirating Movicol® May be thickened with xanthum gum thickeners such as Keltrol®, Easy Thick® or Thick Plus II® Elderly residents with swallowing difficulties may be at risk of aspirating Movicol® May be thickened with xanthum gum thickeners such as Keltrol®, Easy Thick® or Thick Plus II®

15. 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 2nd line therapy in elderly due to risk of electrolyte disturbances Other adverse effects include cramping, diarrhoea, dehydration 5. Stimulant Laxatives For acute constipation only unless no muscle tone Data does not support the theory that chronic use results in colonic inertia, structural or functional nerve damage Side effects - cramping, electrolyte imbalance, dehydration, diarrhoea Bisacodyl - broken down by intestinal enzymes and acts on small and large intestine - enteric coated to minimise impact on small bowel - 5mg-20mg nocte or bd (tablets) - suppositories - onset of action 20-60mins Senna - broken down in large intestine by bacteria to produce active compound - increases propulsive waves in bowel - onset 8-12 hours For acute constipation only unless no muscle tone Data does not support the theory that chronic use results in colonic inertia, structural or functional nerve damage Side effects - cramping, electrolyte imbalance, dehydration, diarrhoea Bisacodyl - broken down by intestinal enzymes and acts on small and large intestine - enteric coated to minimise impact on small bowel - 5mg-20mg nocte or bd (tablets) - suppositories - onset of action 20-60mins Senna - broken down in large intestine by bacteria to produce active compound - increases propulsive waves in bowel - onset 8-12 hours

16. 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 Not formulated in a manner that ensures even distribution of active ingredient Variations in dosage both from product and from administering person. Senokot tablets contain 7.5mg sennosides/tabletNot formulated in a manner that ensures even distribution of active ingredient Variations in dosage both from product and from administering person. Senokot tablets contain 7.5mg sennosides/tablet

17. 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 Frequent use can cause poor rectal tone and/or incontinence Osmotic - Microlax; Fleet (C/I in renal failure); Travad produce an immediate effect side effects - flatulence; cramp; diarrhoea Stimulant - Bisalax; Durolax; Glycerin can use every three days Softeners - Coloxyl enema concentrateFrequent use can cause poor rectal tone and/or incontinence Osmotic - Microlax; Fleet (C/I in renal failure); Travad produce an immediate effect side effects - flatulence; cramp; diarrhoea Stimulant - Bisalax; Durolax; Glycerin can use every three days Softeners - Coloxyl enema concentrate

18. 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 Patient education:-impact of diet and fluid intake; effectiveness of exercise; effective toilet habits; side effects of medications Diet and fluid intake:-encourage high fibre diet; 6-8 glasses of water per day; increase fluids relative to fibre intake to minimise constipation Encourage regular exercise within patients capabilities Effective Bowel habits:- make use of gastro-colic reflex (15-30’ after meals); regular toilet times; ensure toilet is correct height; encourage patient to sit with feet flat on the floor, leaning forward to minimise need for straining Toileting facilities;- privacy, assistance with mobility; facilities to call for assistance if needed, individual comfort measures Patient education:-impact of diet and fluid intake; effectiveness of exercise; effective toilet habits; side effects of medications Diet and fluid intake:-encourage high fibre diet; 6-8 glasses of water per day; increase fluids relative to fibre intake to minimise constipation Encourage regular exercise within patients capabilities Effective Bowel habits:- make use of gastro-colic reflex (15-30’ after meals); regular toilet times; ensure toilet is correct height; encourage patient to sit with feet flat on the floor, leaning forward to minimise need for straining Toileting facilities;- privacy, assistance with mobility; facilities to call for assistance if needed, individual comfort measures