Understanding common bowel changes in older adults

---

Case study – Story of Ms. Lau

---

10 Myths and misconceptions of bowel habit

---

What should the stool look like?

---

Case study – Common bowel problems among older adults in HK

---

- End of Chapter 1-

---

Reference

Constipation in older adults

What is constipation?

---

Constipation among older adults

---

What is faecal impaction?

• Faecal impaction is defined as the inability to pass hard, dry mass stool which stuck in the colon or rectum.
• As the mass of stools becomes bigger and more impacted, the rectum is stretched and enlarged, so the muscles within it do not work so well to push stools out. 
• However, faecal impaction can also involve loose stools formed above the impacted stool, and being squeezed around the blockage and the person having no control over their bowels.
• Watery stools can leak around the impacted stool mass, and out of the anus, causing bowel incontinence, often referred to as overflow.
• Unfortunately, this can lead to the person being wrongly diagnosed as suffering from diarrhoea and given treatment to prevent it, which only makes the faecal impaction worse.

(You may refer to Video 1 – Case Study - Story of Ms. Lau. Jane has bought antidiarrheal medication for Ms. Lau but her condition was even getting worse.)

(Image source from: https://www.pinterest.com/pin/182536591131752406/)

Factors contributing to fecal impaction

• Untreated constipation
• Overuse of laxatives
• Other medical conditions

   - commonly found in older adults with neuropsychiatric disorders 

(e.g. Alzheimer disease, Parkinson disease, and severe stroke)

• Medications that impair gastrointestinal motility, including: opiate analgesics, anticholinergic agents, calcium channel blockers, antacids and iron supplement

The incidence of fecal impaction increases with age and dramatically impairs the quality of life in older adults.

Associated factor - Dementia

• People with dementia in the later stages of the illness may be unable to describe the pain they are experiencing due to the mass of impacted stools developing in their bowel. 
• As many people in the late stages of dementia also go on to experience bowel incontinence, the symptoms may be put down to their dementia rather than a physical cause. 
• Faecal impaction is also linked to acute states of confusion and delirium in the elderly hospital population.

Associated factor – Parkinson’s Disease (PD)

A study indicated that constipation is particularly relevant occurring in up to 66% among PD patients, thus showing a higher prevalence than within the general population (Pedrosa Carrasco, Timmermann & Pedrosa, 2018).

• In some people with Parkinson's disease, constipation may occur due to the improper functioning of the autonomic nervous system. The autonomic nervous system is responsible for regulating smooth muscle activity. If this system is not working properly, the intestinal tract may operate slowly, causing constipation.
• Emptying the bowel can be more difficult because of poor coordination of the back passage (anal) muscles. These muscles may contract instead of relaxing making it difficult to pass the bowel motion completely.
• Medicines used to treat your Parkinson’s may be a factor in constipation either by directly affecting the bowel - slowing them up or by affecting the appetite. Anticholinergic drugs, in particular, make it difficult to relax the body and muscles effectively to pass the stool, resulting in constipation. (e.g. Amantadine, Levodopa, Madopar and Levodopa, Carbidopa).
• People with Parkinson’s disease experience difficulty with their movement. Thus, the bowel is less stimulated and the intestines can become sluggish.
• Chewing and swallowing difficulties can make eating adequate amounts of dietary fibre hard to achieve. Drinking sufficient fluid is essential in preventing constipation, but it is difficult if swallowing is affected. Many people with Parkinson’s disease limit their fluids to avoid making frequent trips to the bathroom due to their decreased physical activity.

Symptoms of fecal impaction

• Typical presenting symptoms:
• Abdominal pain and distention
• Nausea and vomiting
• Anorexia
• Older adults or institutionalized patients with dementia or psychosis may present with increased agitation, confusion, paradoxical diarrhea, and fecal incontinence.

Complications of faecal impaction

Untreated fecal impaction can result in serious health complications:

• Bowel ulceration
• Perforation
• Thrombosed hemorrhoids (a blood clot in a rectal blood vessel)
• Gastrointestinal infection
• Peritonitis (an infection that spreads outside the gastrointestinal system)

Investigation of faecal impaction

• Basic history taking for constipation

Age, acuteness of symptoms, and medication history is important to exclude various causes of constipation.

• Preliminary laboratory investigations

Complete blood count, serum calcium, glucose levels, and thyroid function tests are generally adequate to screen for underlying metabolic or other organic pathology

• Careful abdominal and digital rectal examinations 

It is important in the primary care setting. A rectal exam can reveal rectal tumours, haemorrhoids, impacted faeces, anal sphincter tone, presence of mucus, stool colour and palpation of abdominal mass.

• Abdominal X-ray 

It is a simple, non-invasive investigation that may show faecal impaction. 

 Advanced diagnostic procedures, such as barium enema, defaecography, colonic transit studies, magnetic resonance imaging, manometry, and balloon expulsion test should be reserved for patients with suspected slow transit constipation and defaecatory disorder in the specialist care setting.

Treatment of faecal impaction

Fecal impaction can be treated with medication and may require a procedural intervention for particularly resistant situations. 

1. Oral laxatives: 

- The first line of treatment involves the use of laxatives to soften the hardened stool so that it can be passed.

2. Suppositories: 

- Sometimes a laxative is used as a suppository, meaning that it is taken in a form that is inserted into the rectum, rather than taken by mouth. It works more quickly than an oral laxative and is a preferred method if the impaction is particularly distal (low down) in the colon.

3. Enema: 

- An enema is the introduction of liquid, most often Bisacodyl, mineral oil or saline solution, through the anus and into the large intestine. The goal is to loosen stuck stool and encourage a bowel movement. Enema is generally recommended when first-line treatments have not worked.

4. Water irrigation: 

- It is a medical procedure that performed by health care professionals. A tube is inserted through patient’s anus and then injects water into the rectum to loosen the stool, allowing to have a bowel movement. 

5. Manual evacuation:

- Used in severe cases.

- Areas of faecal impaction will be located by feeling the outside of your abdomen, stool is emptied by gently inserting a finger into the rectum and removing it. 

---

Hemorrhoids

Management of Hemorrhoids among older adults

---

Medical treatment of hemorrhoids

Medical treatment will depend on the symptoms of hemorrhoids. They usually prescribe topical creams and ointments or suppositories as a first line treatment. These medications contain steroids which reduces inflammation and relieves pain. Some of them also have anesthetic effects to relieve the discomfort. It should be noted that medication can only relieve the symptoms, but not eliminate the hemorrhoids.

If the hemorrhoids are severe, they can be removed by surgery. However, people usually mistakenly think that removing the hemorrhoids surgically can cure the problem. Since hemorrhoids are caused by varicose veins in the rectum, even if the hemorrhoids are removed, if the poor lifestyles persist, the remaining blood vessels in the rectum will also be persistently compressed, and hemorrhoids may still recur. Therefore, it is very important to maintain healthy lifestyles, such as eating enough vegetables and fruits, getting enough water, doing more exercise, increasing activity level, reducing abdominal pressure, and maintaining good bowel habits.

---

- End of Chapter 2-

---

Reference

Assessment of Constipation

Introduction

In your daily practice, did you know any older adults who complain of constipation problem?

If you want to help, you must know how to assess the problem in order to provide appropriate action.

Do you have any idea of how to assess this problem?

Let’s discuss about this topic!

Assessment of Constipation:

• History taking

• Red flags

• Clinical assessment

• Further Investigations

---

History Taking

History Taking

• A comprehensive history taking help to understand the patient’s condition. If patient has communication problem and unable to provide medical history, caregiver is important resource to collect information.

• Medical history

• Any past medical history and present complaint? 

• Any medication in use that may induce constipation? 

• Any presence of other gastrointestinal symptoms e.g. abdominal pain, bloating, and vomiting?

• Investigate the stool form and defaecation pattern such as the time, frequency, amount and consistency of stools.

• Any signs of Red flags?

• Stool diary

---

Stool Diary

Stool Diary

• Help to understand the history and current situation of constipation. 

• Investigate the stool form and defaecation pattern

• Ask patient to record the frequency, amount, type and any abnormality of defaecation. Use Bristol stool scale to describe the type of stools.

Example of Stool Diary

For details of Bristol stool form scale, please refer to Chapter 1.3. 

---

Red Flags

Rule out the Red Flags that indicate something more serious, such as colon cancer.

Red Flags Alert:

• Recent onset of chronic constipation associated with:

• Unintentional weight loss

• Aneaemia

• Abdominal pain

• Blood per rectum or presence of faecal occult blood

• Unexplained change in bowel habit, involving stool frequency or consistency

• Failure to alleviate constipation despite compliance with adequate lifestyle modification

• Chronic constipation necessitating use of high doses of laxatives

• Recent-onset faecal incontinence

Consult family doctor or gastroenterologist if identified any sign of Red Flat.

---

Clinical Assessment

Clinical Assessment

• Roma IV Criteria

• Abdominal examination

• Digital rectal examination

• Proctoscopy examination

• Laboratory investigations

• Blood testing including: Complete blood count, Renal function, Electrolytes, Calcium, Glucose, Thyroid function 

• Faecal occult blood

Rome IV Diagnostic Criteria for Constipation

Symptoms started six months before diagnosis, and during the last three months, two or more of the following symptoms occurred:

(i) Straining in more than 25% of defecations.

(ii) Lumpy or hard stools (Bristol stool form scale type 1 or 2) in more than 25% of defecations.

(iii) Sensation of incomplete evacuation in more than one-fourth (25%) of defecations.

(iv) Sensation of anorectal obstruction/blockage in more than one-fourth (25%) of defecations.

(v) Manual maneuvers to facilitate in more than one-fourth (25%) of defecations.

(vi) Fewer than three spontaneous bowel movements per week.

---

Further Investigations

Referral to gastroenterologist for further investigation such as:

• Colonoscopy

• Sophisticated investigations

• Balloon expulsion test

• Colonic transit study

• Anorectal manometry

• Defaecography

---

- End of Chapter 3-

---

Reference

Lifestyle modification to prevent constipation

Case study - Lifestyles of Ms. Lau

---

High fiber dietary advice

What is dietary fibre?

• Dietary fibre is the edible part of plants that cannot be digested in the human small intestine. It passes into the large intestine to be partly or completely broken down by gut bacteria
• It is found only in foods from plant sources such as grains, fruits, vegetables, legumes, nuts and seeds
• Fibre plays a vital role in maintaining gut health: 
• Add bulk to stool
• Soften stool
• Speed up removal of waste from the gut
• Stimulate the growth and/or activities of certain good bacteria in the large intestine 
• There are mainly 2 types of fibre: insoluble and soluble fibre
• Different fibre types vary in how they perform their role in the gut. Almost all plant foods contain a combination of both insoluble and soluble fibre
• Hence it is important to eat a wide variety of foods to ensure you are getting enough of both fibre

---

Insoluble and soluble fibre

---

High fibre diet of preventing constipation

---

How to get adequate dietary fibre in our daily menu?

---

Tips to achieve adequate fibre intake

• The Chinese Nutrition Society recommend consuming at least 25-30 g of fibre everyday
• Get fibre from a variety of food sources, to ensure that we are obtaining the different type of fibres which served different functions in our gut 
• Obtain fibre from food rather than fibre supplements. Eating the whole food will allow us to consume the other beneficial nutrients in that food
• Follow a healthy balanced diet
• Below are some strategies and advices for Ms. Lau to add fibre foods into her daily diet:

1. Choose wholegrains over refined grains
2. Eat a variety of vegetables and fruits 
3. Include legumes and beans in daily cooking
4. Include nuts and seeds in diet
5. Choose high fibre foods as snacks 
6. Drink enough water
7. Increase fibre gradually

---

Learn about the fibre content of different kinds of food - Tips to achieve adequate fibre intake

1. Choose wholegrains over refined grains

• Wholegrain foods include wheat, brown rice, wholegrain bread, oats, barley, whole wheat pasta, buckwheat
• Wholegrain foods contain higher fibre content than refined grains (e.g. fibre content in brown rice is nearly three times as much as white rice) 
• Simple strategies to include more wholegrains in daily diet: 
• Eat at least half of the daily grains as wholegrains
• Choose brown instead of white rice. If the switch is too hard mix 1/3 of brown rice with 2/3 of white rice for a start
• Mix brown rice, barley, oats, millet when cooking rice or congee
• Choose wholegrain bread instead of white bread
• Eat oats or wholegrain cereal for breakfast
• Check the food label for fibre content. Solid foods with at least 6g of dietary fibre per 100g of food and liquid food with at least 3g of fiber per 100ml are considered as a high source of dietary fibre

Fibre content of some common grains and grain products 

1 bowl=250ml; Source: USDA. FoodData Central 2019. fdc.nal.usda.gov.

---

2. Eat a variety of vegetables and fruits

• Eat a rainbow colour of vegetables and fruits! Red, orange, yellow, green, blue, purple and white
• Eating a variety of different colours and type of vegetables and fruits will ensure a diversity of nutrient intake
• Vegetables and fruits are a great source of dietary fibre. While all vegetables and fruits have some fibre, there are some that are higher than others
• Peeling the skin of vegetables and fruit is most likely to reduce its fibre content. So where possible, leave the skin on (e.g. potatoes, sweet potatoes, apples, pear)
• Eat at least 3 serves of vegetables and 2-3 serves of fruits everyday

---

   Eat a variety of vegetables and fruits - Vegetables

• Examples of some vegetables with higher fiber content: dark green vegetables (broccoli, spinach, okra), starchy root (corn, carrot, sweet potato, taro), peas (green peas, snowpeas), fungus (cloud ear)
• Preserved vegetables are high in sodium, so it is better to eat fresh vegetables 
• Eat at least 3 serves of vegetables with different colours and types everyday 
• What is 1 serve of vegetable? 
• Using 250ml bowl as reference: ½ bowl of cooked vegetable or 1 bowl of salad
• Simple strategies to include more vegetables in daily diet: 
• Always include vegetables in meals
• Add vegetables e.g. corn, carrot, winter melon, mushroom, tomato into soup and eat them
• Cook dishes with vegetables, peas or mushrooms
• Mix starchy root vegetables into rice e.g. sweet potato, corn, taro
• Include vegetables in sandwich e.g. tomato, cucumber 
• Snack on vegetables e.g. cherry tomatoes, cucumber, sweet potatoes

Fibre content of some common vegetables

1 bowl=250ml; Source: USDA. FoodData Central 2019. fdc.nal.usda.gov.

---

   Eat a variety of vegetables and fruits - Fruits

• Fruits with higher fiber: berries, pear, apple, orange
• Peeling the skin will lose the fruit fibre content. Apples with skin has about 4g of fibre while peeling the skin will reduce it by half 
• Eating fresh fruit instead of drinking juice. Fibre will be reduced and sugar content is higher. Choose pure fruit juice without added sugar
• Dried fruit contains similar health benefits as fresh fruit, however dried fruits are high in sugar, so should be careful with the portion size eaten. Choose dried fruits without added sugar 
• Some fruits contain sorbitol, a laxative which may help to relief constipation. Foods with higher amount of sorbitol include apple, blackberries, pear, peach, plum, dried fruits such as prune 

Fibre content of some common fruits

1 bowl=250ml; Source: USDA. FoodData Central 2019. fdc.nal.usda.gov.

---

Eat a variety of vegetables and fruits (2)

• Eat 2-3 serves of fruits everyday
• What is 1 serve of fruit? 
• A medium size fresh fruit e.g. apple, orange or,
• 2 small fresh fruits e.g. 2 kiwis or, 
• 30g dried fruits without added sugar ~ 1 tbsp of raisin, 3 prunes or, 
• 3/4 cup (~180ml) of pure fruit juice without added sugar
• Simple strategies to increase fruit intake 
• Eat fruit for snacks between meals
• Add fresh or dried fruits into salad, yoghurt or cereal

---

3. Include legumes and beans in daily cooking

• Legumes are rich in dietary fibre and good source of protein 
• Some people my experience wind, bloating, gas when eating legumes and beans
• Start by eating small serving and gradually increase the amount to avoid stomach discomfort 
• Simple strategies to increase legumes/beans intake
• Add beans to rice, soup, salad, dishes, desserts
• Substitute legumes and beans for meat two to three times per week 

Fibre content of some common legumes and beans

1 bowl=250ml; Source: USDA. FoodData Central 2019. fdc.nal.usda.gov.

---

4. Include nuts and seeds in diet

• Nut is a good source of fibre but high in fat and calories, so should be eaten in moderation 
• Choose plain, unsalted nuts
• Seeds such as flaxseed and chia seeds are high in dietary fibre. Chia seeds must be soaked in water for expansion before consumption. It should never be eaten in its raw dry state. Not recommended for people with swallowing difficulties
• Simple strategies to increase nuts and seeds 
• Eat nuts or seeds as snacks
• Add nuts into dishes 
• Add chopped nuts or seeds (such as sesame seeds, almonds, walnuts) into yoghurt, cereal, oats or salad
• Add flaxseeds or chia seeds into yoghurt 

Fibre content of some common nuts and seeds 

1 bowl =250ml; Source: USDA. FoodData Central 2019. fdc.nal.usda.gov.

---

5. Choose high fibre foods as snack

• Choose wholegrain snacks such as wholgrain bread or biscuit , popcorn 
• Check food label for fibre content
• Eat fresh vegetables, fruits and nuts as snack
• Vegetables: carrot, cherry tomato, celery, cucumber, sweet potato
• Fruits: apple, pear, berries, prune without added sugar
• Nuts: handful of plain mixed nuts such as almonds, walnuts, brazil nuts
• Make own high fibre snacks 
• Use agar to make desserts 
• Low fat yoghurt top with berries and chia seeds or flaxseeds
• Wholegrain bread with avocado and banana
• Low sugar red bean soup/mung bean soup (or even make it without sugar)

---

6. Drink enough water

• Drink plenty of water when increasing fiber intake
• Fiber absorbs water as it passess through your digestive tract which help to make stool bulkier and softer
• Drinking sufficient water will allow fibre to travel easily through your system, making it easier for stool to pass
• With insufficient of water, it leads to dry and hard stools and causes digestive problems such as constipation
• Healthy individuals should aim for 6-8 glasses of water per day
• Milk, fruit juice, hot drinks, soup also count as fluid
• Water is the best drink for hydration. Lemon, mint leave or cucumber can be added for taste
• Limit caffeine containing drinks such as tea or coffee as these contribute to dehydration
• Try to drink all fluids 2-3 hours before going to sleep to avoid going to the toilet at night

---

7. Increase fibre gradually

• It is important to increase fibre gradually as increasing the fibre intake all at once can lead to stomach discomfort or bloating. The body would need time to adjust to the increasing level of fibre intake

• Make small changes in the eating habit each week such as
• Week 1: Adding brown rice to white rice
• Week 2: Switching from white bread to whole wheat bread
• Week 3: Adding extra vegetables or fruits
• Week 4: Adding a high fibre snack between meals such as sweet potatoes, wholegrain biscuit

---

Sample menu with around 25 grams of fibre

---

Can you modify this diet to one with a higher fibre intake?

Hints

• Are most of the grains eaten wholegrains? 

- aim for at least 50% of daily grain as wholegrains

• Are the fruits and vegetables intake enough?

- at least 3 serves of vegetables and 2-3 serves of fruits

• Are there any legumes, beans, nuts, seeds in the diet?
• Are there any snacks between meals and are they high fibre choices?
• Also don’t forget to check the fluid intake!

---

A modified diet with high fibre

---

High fibre diet recipe

High fibre diet recipe

---

Gut microbiome

Gut microbiome

---

Regular exercise

Recommended exercises to prevent constipation by physiotherapist

Pelvic Floor Muscle Stimulation

In daily practice, using dry cell driven electrical stimulator to stimulate pelvic floor muscle cam improve the strength and endurance. The electrical pads placement is as shown in the following picture.

(Image source from: https://ars.els-cdn.com/content/image/1-s2.0-S0022346818303804-gr1.jpg)

When the electrical stimulator is turned on, electric current would be delivered to the pelvic floor muscle via the electrical pads. When the current intensity is strong enough, the pelvic floor muscles will contract. During current is coming, the subject should voluntarily contract the urethra sphincter muscles and the anal sphincter muscle simultaneously. The former muscle will help to hold the urine from leaking out and the latter will help the bowel empting action respectively.

---

Chinese medicine

Constipation – perspectives from Chinese medicine

Constipation is a disease of spleen and stomach within the scope of internal medicine of traditional Chinese medicine (TCM). It generally means a decrease of defecation frequency, a difficulty in defecation, straining or a prolongation of defecation time. In terms of modern medicine, constipation is generally classified into organic or functional type. An organic constipation is mainly caused by a substantial disease in organs such as digestive tract disease and endocrine system disease; if the above definite cause is not confirmed for constipation, a functional constipation may be considered.

As early as the Warring States Period, constipation was recognized in TCM; its cause was considered as related to coldness of spleen and stomach or heat in intestine. In the late Eastern Han Dynasty, constipation was understood more comprehensively by Zhang Zhongjing (a famous TCM doctor); it was classified into a syndrome of cold, heat, deficiency and excess. Based on such classification, TCM prescription was created for constipation treatment respectively: Chengqi Decoction (bitter flavor, cold nature and purgation effect); Maziren Pills (Yin nourishing and moistened catharsis); and Houpu Sanwu Decoction (Qi-flow regulation and catharsis). Subsequent TCM masters were deeply enlightened by his prospective advocacy. His prescriptions for constipation treatment have been popular until now; they are still common prescriptions for clinical treatment of constipation.

For ordinary people, it is normal to defecate once or twice a day. When defecation is made once every not less than 3 days or when defecation frequency is normal but the stool is hard to cause a difficult or incomplete defecation, constipation can be considered.

As shown by a foreign statistical investigation, 70% of older adults of >65 years old were vexed at difficult defecation. Compared with young people, older adults are more prone to suffer from constipation, mainly due to a decrease in bowel movement caused by the degeneration of neuromuscular system or other chronic diseases such as diabetes or diseases of nervous system. In addition, due to the degeneration of nervous system in rectum, the activity of anal sphincter and the sensitivity of receptors in rectal wall, an obstructive constipation is caused at rectal outlet. Under general conditions, the severity of constipation will tend to increase with age. In many older adults, due to the retained stool, some discomforts occur such as abdominal distension, abdominal pain and poor appetite, which greatly reduce the quality of their life. Meanwhile, the difficult defecation is closely related to colorectal cancer; thus the risk for colorectal cancer is increased in older adults with constipation. In addition, at a forced defecation, abdominal pressure is increased to change the blood flow in coronary artery and cerebral blood vessel, which have an opportunity to induce serious outcome such as cardiovascular/cerebrovascular accident. Therefore, the constipation in older adults should undoubtedly be closely concerned and solved.

---

Etiology and pathogenesis of TCM for constipation with recommendations on tea and soup

---

Relief of constipation through acupoint pressing

---

Constipation – perspectives from Chinese medicine

1. Properly replenish the water

About 1500 mL water is drunk at a fixed time point of every day. For example: At the getup of every day, one cup of warm boiled water is drunk; then an appropriate amount of water is drunk every 2 hours. Through such water replenishing, the necessary moisture can be effectively absorbed by somatic cell so as to prevent the occurrence of constipation.

2. Take more vegetables and foods of high fiber

Older adults are suggested to take more vegetables of fiber, such as celery, mustard and cabbage. However, with an insufficient or loose tooth, older adults are more difficult to make a chewing. Therefore, a soup made from high-fiber vegetables is suggested for older adults, such as borscht soup and long-stewed watercress soup. The vegetables cooked to soft state are taken together with soup. Some fruits such as banana or papaya can be taken by older adults to facilitate the defecation. For the people with diabetes, the ground powder of walnut meat, apricot kernel, edestan and sesame can be added to make a pasty diet. 

3. Properly avoid a certain food

A fried, roasted, greasy or spicy food should be avoided as far as possible, so as to reduce the heat accumulation in gastrointestinal tract. 

4. Keep an ease mind, and take appropriate exercise

5. Without prior suggestion of doctor, do not misuse laxatives or folk prescriptions.

6. For older adults with hypertension, avoid a forced defecation so as to prevent the occurrence of cardiovascular/cerebrovascular accident.

7. If the problem of constipation in older adults is not yet solved despite diet therapy, massage or exercise, please turn to medical care personnel. 

---

Manual abdominal massage

---

Bowel habit

---

Common laxatives for constipation

Common laxatives for constipation

---

Newer pharmacological therapies

• Prosecretory agents and Prokinetic agents 

• Prosecretory agents is the only registered for use in Hong Kong

• Used as second-line pharmacological management

Type:

• Prosecretory agents: Linzess®(Linaclotide)

Action:

• Promote gut motility and increase intestinal secretion.

Side effect:

• Diarrhea

• Stomach pain

• Bloating and flatulence

Form:

• Tablet

Caution:

• Monitor renal function for patients who are at risk of dehydration and renal dysfunction.

---

How to use an anal suppository?

1. Wash your hands.

2. Put on disposable gloves if needed.

3. Remove the suppository from the wrapping.

4. Most people find it helps to insert the suppository if it is moistened with a little tap water first.

5. Patient in lateral position and bend the upper leg towards to the chest, lower leg bend slightly.

(Image source from: Hong Kong Emergency Nurses Association)

6. Using a finger, gently push the suppository into your rectum about 3cm depth.

7. Remain still for 10 minutes to help hold the suppository in place. 

8. It will start to work in about 15-30 minutes.

9. Remove your gloves.

10. Wash your hands.

---

- End of Chapter 4-

---

Reference

Management of Constipation in Long-Term Care Settings

Why institutionalized older adults are more prone to constipation?

Constipation is the most common defaecatory disorders seen in older adults. This is particularly prevalent among older patients in hospital and long-term care (LTC) setting. For hospitalized older patient, the reasons are multiple, including medical conditions, drug sides effects, dehydration, immobility, and poor oral intake. Constipation in hospitalized older adults is indeed associated with adverse events, prolonged stay, and increased medical cost. Older adults living in LTC homes are vulnerable and reliance on high level of assistance, specialist nursing and medical care. They are suffering from multiple comorbidities and taking numerous medications. Most of older adults living in LTC homes are chairbound or bedridden. Deconditioning, dehydration, limited mobility and at risks of malnutrition that make them more prone to constipation.

Constipation causes abdominal discomfort or pain. In severe cases, it can cause faecal impaction, urinary incontinence or retention, bowel obstruction, bowel perforation and suffering. The consequence of constipation has significant impacts on physical, psychosocial, quality of life and health expenditure among older adults and caregivers. 

---

Prevalence of constipation

• In general population worldwide ranges from 0.7-79%.

• Institutionalized older adults are more likely suffering from constipation. 

• The prevalence of constipation increases with age. 

• Women are more likely suffering from constipation than men. 

Tong (2017)

         

In Hong Kong, the Population Health Survey 2014-2015 from Department of Health reported: 

• Increased prevalence of acute constipation

• Aged 15 to 64 range from 1.6% to 3.1%

• Aged >65 range from 4.2% to 7.9%

• (Aged 65-74: 4.4%; Aged 75-84:7.9%; Aged>85 12%)

---

Factors contributing to constipation

Factors contributing to constipation

The “Ds” refer to the varies factors associated with constipation including:

• Dementia

• Depression

• Degenerative disease

• Drugs side effects

• Decreased dietary intake especially fiber

• Dehydration

• Decreased mobility or immobility

• Defaecatory dysfunction

---

Medical conditions associated with constipation

---

What are the unique issues related to constipation in LTC settings?

The unique issues related to constipation in LTC settings

• High prevalence of dementia

• Co-morbidities

• Polypharmacy

• Inadequate food and fluid intake

• Environmental limitations

• Multifactorial

• More severe complications

• High usage of laxatives

Older adults living in LTC homes are old and frail. They suffer from multiple comorbidities. According to the Census and Statistics Department (2009), 97.1% of residents had one and above chronic illnesses and 57.2% of them needed 1 to 4 kinds of drug treatment. About 42.5% needed 5 types and more medications. Their medical conditions and drug side effects add together to increase the chance of constipation in LTC residents.

Institutionalized older adults are vulnerable group that require a higher level of care assistance, nursing and medical care. Mostly, impaired mobility in chairbound or bedridden residents are more prone to constipation. Studies found that laxatives use is high in LTC settings.

---

High prevalence of dementia

The increasing number of dementia cases in LTC requires special nursing care attention. Dementia is a clinical syndrome leading to cognitive impairment. People with dementia are having difficulty in communication and self-care in their daily lives. They deserve greater nursing care support to address their special needs, bowel and bladder issues in particular.

Dementia with constipation

• Neglect

• Under-reporting

• Difficult to monitor

• Inadequate food and fluid intake

• Dependence for toileting

• Impaired rectal sensation

• Atypical presentations

Atypical presentation of constipation is commonly found as they are unable to express their discomfort and needs. They may have behaviour problem duo to their inability to voice out this problem. Health care professionals must understand the meaning behind their behaviour and pay special attention to the atypical presentation to detect any clinical sign and symptoms of health problem.

Atypical Presentation of Constipation in LTC Residents with Dementia

• Anorexia

• Abdominal discomfort/distension

• Urinary and/or faecal incontinence

• Behavioral changes

• Functional decline

• Delirium

Polypharmacy

• Comorbidities

• 92.7% taking routine medications

• 57.2% taking 1 to 4 kinds mediations

• 42.5% taking 5 types and more medications.

• Drug side effects cause constipation

• Drugs may have cumulative anticholinergic effects

(Census and Statistics Department, 2009)

---

Medications cause constipation

• Anticholinergics (psychotropics, antihistamines, anti-parkinsonian drugs, antiemetics, antimuscarinics for incontinence)

• Iron supplements

• Calcium supplements

• Opiates

• Calcium channel blockers

• NSAIDS

• Diuretics

Inadequate food and fluid intake

• Feeding self-care deficits

• Tooth decay

• Minimal fiber intake

• Altered thirst sensation

• Medication side effects e.g. diuretics

Impaired Mobility

• Dependence for toileting

• Deconditioning

• Chairbound or bedridden

• Low physical activity

• Decreased ability to generate abdominal force

Environmental limitations

• Communal living environment

• Lack of privacy, shared bathroom

• Rarely provide a stress-free and private bathroom

• Staff too busy in assisting toileting

• Continence devices not comfortable

---

Cause of Constipation in LTC is Multifactorial

• Complex medical condition

• Comorbidities

• Polypharmacy

• Poor dietary intake

• Immobility

Pathophysiology of chronic constipation (Andrews & Storr, 2011)

Primary causes are intrinsic problems of colonic or anorectal function, whereas secondary causes are related to organic disease, systemic diseases or medications.

The consequence of constipation can be critical and impact on physical, psychological health and well-being.

---

What are the roles of nurses in managing constipation?

The roles of nurses in managing constipation

• Care Coordinator

• Collaborate with team to plan for patient care

• Professional Caregivers

• Perform assessment and diagnostic tests

• Record medical history and symptoms

• Monitor patient health condition

• Administer medications and treatments

• Monitor medication side effects

• Advocator

• Advocate for health and well-being

• Educator

• Disease education to manage the health problem

Nurses are playing important roles in managing constipation. Older adults living in hospital or LTC settings are having moderate to severe physical or cognitive problems. Most of them are dependent and require nurses to provide personal and nursing care for activities of daily livings. Nurses should strengthen their roles in caring of institutionalized older adults to meet their individual needs. Nursing process with a systematic approach should be applied including assessment, diagnosis, outcomes identification, planning, implementation, and outcome evaluation. Using the fundamental principles of critical thinking and client-centered approaches with evidence-based practice are important to ensure the care quality in managing constipation.

---

How to assess constipation?

Assessment of constipation

Details assessment of constipation is discussed in the Chapter 2: Assessment of Constipation which included:

•           History taking

•           Red flags

•           Clinical assessment

•           Further Investigations

Effective constipation management requires thorough assessment. Professional communication skill is essential to collect sufficient information for diagnosis. Defaecation problem is an embarrassing issue that older adults may be reluctance to talk about this. A non-judgmental and empathetic professional manner is recommended. Patient particular information can be collected from caregivers if patient has any communication problem such as dementia. Nurses can also perform the physical assessment such as palpation of abdominal mass and auscultation of bowel sounds to detect any abnormality and make the diagnosis or referral. Investigate any Red Flags that indicate something more serious.

Refer to Chapter 2 Assessment of Constipation for details.

---

How to assess constipation? (2)

In Hong Kong, daily assessment of bowel movement is common practice in LTC settings. The assessment form included the following items: frequency of bowel movements, time of bowel movement, amount of stool, stool consistency and use of laxatives. A stool diary is useful to record the defaecation pattern. Bristol Stool Form Scale should be used to facilitate the mutual understanding and communication of the stool form. If the daily monitoring is delegated to the frontline care workers, nurses should provide sufficient education and monitor the care quality. If self-reporting is applied, nurses should provide education to make sure patient and family caregivers understand how to record the stool diary correctly.

Refer to Chapter 1.3 “What should the stool look like?” for Bristol Stool Form Scale.

---

How to manage and prevent constipation?

For mild to moderate constipation, maintain healthy lifestyle is essential to prevent constipation. Lifestyle modification including increased fluid intake, increased physical activity, regular toileting schedule, and intake of dietary fiber and probiotic products are recommended to prevent and treat constipation.

Details refer to Chapter 4: Lifestyles modification to prevent constipation and Exercise videos

Pharmacological intervention is initiated if non-pharmacological intervention is not successful. Different kinds of laxatives would be considered to treat constipation. 

In general, laxatives can be classified into four main categories: 

1. Bulk-forming laxatives

2. Osmotic laxatives

3. Stimulant laxatives

4. Stool softeners 

Single or combination of laxatives would be prescribed according to different types of constipation. However, overuse of laxatives should be avoided to prevent severer complications.

Details refer to Chapter 4.8 Pharmacological Intervention for Constipation

---

How to manage and prevent constipation? (2)

Bowel Management Programme

Bowel management may be neglected in our daily clinical practice. However, it can cause severer complications if unattended. Systematic management approach is recommended to prevent and treat constipation.

Sit and her team in the ICU at Tuen Mun Hospital developed a bowel management guideline to guide the clinical practice in management of constipation. The bowel management programme was implemented and reported effectively in improving constipation and diarrhea events as well as patients’ health outcomes. (Sit, 2013)

Link to view: http://www.hkaccn.org/newsletter/news201308.pdf

• Leung et al. (2013) recommended a practical triage approach to family physician for the management of constipation by systematic reviews of research studies.

Link to view: https://www.jabfm.org/content/24/4/436/tab-figures-data

• Mounsey et al. (2015) suggested the management of chronic constipation in older adults

Link: https://www.aafp.org/afp/2015/0915/p500.html#afp20150915p500-f1

---

How to manage and prevent constipation? (3)

Factors affecting nurses to preform constipation management 

• Busy working schedule 

• Lack of case conferences

• Lack of staff resources

• Lack of educational opportunities

(Takaoka, 2020)

Bowel care should be put in the priority of care. Education and management support for healthcare professionals is important to ensure effective clinical practice in constipation management. A clinical guideline according to different LTC settings is recommended to ensure quality management of constipation for older adults. This will facilitate professional reflective practice concerning the management of constipation to meet the individual care needs of institutionalized older adults for better health outcomes. 

---

- End of Chapter 5-

---

Reference

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Public Seminars

慢性疾病處理及臨終關懷 - 長者腸胃疾病的預防與治療

Workshops

健康老齡化及代際關係之凝聚 - 四季養生篇2

慢性疾病處理及臨終關懷 - 長者排泄問題多面睇1

慢性疾病處理及臨終關懷 - 長者排泄問題多面睇2

慢性疾病處理及臨終關懷 - 長者排泄問題多面睇3

慢性疾病處理及臨終關懷 - 長者排泄問題多面睇4

慢性疾病處理及臨終關懷 - 長者排泄問題多面睇5

Professional Courses

Chronic Disease Management and End-of-life Care 1