A case study presentation focusing on laxative abuse in older adults

1. Chronic Constipation and
Laxative Abuse
LAURA HUTCHINSON
DIETETIC INTERN
BENEDICTINE UNIVERSITY

2. Patient Profile
 Age: 84
 Gender: Female
 Race: Caucasian
 Height: 4’11
 Weight: 95 lb
 Changes in Weight: 5# weight loss in previous 2 months.
 BMI: 19.1 (WNL)
 Social hx: Married, Jewish, retired, lives at home.
 Current medical diagnoses: Small bowel obstruction d/t
adhesions, chronic renal insufficiency, chronic
constipation/obstipation

3. Patient Hx
 Past dx: B12 deficiency anemia, pure
hypercholesterolemia, chronic kidney disease stage
III, gastric ulcer, osteoporosis, depression, closed
Colles’ fx of right arm, hiatal hernia, breast cancer,
endometrial cancer, hypertension
 Nutrition hx: Follows Kosher diet. Severe, chronic
constipation x 10 years.

4. Interrelationships of Medical Dx
Hypertension  CKD Stage III


Anemia

Osteoporosis



Increased Age Fluid Restriction Small Stature Mobility

Depression



Chronic Constipation

Laxative Abuse?

5. Nutrition Diagnoses
 Altered GI Function related to Chronic
Constipation/Obstipation as evidenced by
patient need to supplement with Colace,
Senna, and Glycerine suppositories to have a
normal bowel movement.
 Inadequate oral intake related to poor appetite secondary to abdominal
distension and chronic constipation as evidenced by 25-50% intake at
meals per patient and dietitian.
 Altered GI Function related to Small Bowel Obstruction as evidenced
by CT scan of pelvis/abdomen.

6. Back to this Nutrition Dx..
 Altered GI function related to chronic
constipation/obstipation as evidenced by
patient needs to supplement with Colace,
senna, and glycerine suppositories to have a
normal bowel movement.
Is this normal laxative use?

7. What is Laxative Abuse?
 Laxative abuse is the repeated misuse and overuse of
laxatives involving





Dosing too frequently
Overdosing
Using laxatives for non-intended reasons (such as weight loss)
Using multiple types of laxatives at once
Using the wrong type of laxative (such as a purgative laxative
when a stool softener would have been appropriate)
 Overuse can lead to dependency and a decrease in
bowel function
(Fruit Eze)

8. Types of Laxatives
 Bulk-Forming Laxatives
 Saline Laxatives
 Osmotic Laxatives
 Surfactant Laxatives 
 Lubricants
 Stimulant Laxatives
 Diphenylmethane derivatives
 Anthraquinone derivatives
(Roerig)

9. Profile of a Laxative Abuser
 Eating Disorder patients





Histrionic personality traits
Lower self-esteem
Lower “self-liking”
Weight and shape concerns
Depression
 Middle aged or older adults

Perceived poor physical health
 Athletes in sports with
weight limits
 Factitious disorder patients
 Comorbidities
(Roerig, Steffen, Pryor, Harari, Surgenor, Weltzin)

10. A Vicious Cycle
–with
dehydration, the
reninangiotensin
system kicks in,
following by
rehydration and
water weight
gain
Complications
(Roerig)

11. Electrolyte
Disturbances
Metabolic
Disturbances
Bowel
Disturbances 
Kidney
Disturbances
Complications
(Roerig, Cummings, Copeland)

12. Diagnosis
 Practitioner’s suspicion
 Melanosis Coli
 GI symptoms
 Serum hypokalemia
 Fecal electrolytes
 Stool osmotic gap : 290 – 2* (Stool Na + Stool K)
(Roerig)

13. Role of the Registered Dietitian
 Identify patient’s bowel
patterns.
 Identify type and frequency of
laxative use.

Be specific – patients will not always
willingly offer this information.
 Check labs, electrolytes, and
fluid status.
 Monitor for disordered eating
patterns or disordered bowel
regimens.

14. Treatment/Monitoring
 Education
 Appropriate treatment for eating disorders
 Risks?
 Goals of treatment:
 Stop laxative abuse
 Maintain healthy GI Function
 Weight trends
 Labs and other nutritional parameters

15. Is this patient abusing laxatives?
YES. But, is it an eating disorder, or is she just
an older adult with constipation?
 Anxiety/depression issues
 Rigid bowel regimen
 Renal failure
 Aging
 Poor appetite

16. References
Copeland PM. Renal failure associated with laxative abuse. Psychother
Psychosom. 1994;62:200-202.
Cummings JH, Sladen GE, James OF et al. Laxative-induced diarrhoea: a
continuing clinical problem. BMJ. 1974;23:537-541.
Escott-Stump S. Nutrition and Diagnosis Related Care Seventh Edition.
2012. Baltimore: Lippincott, Williams, and Wilkins.
Fruit-Eze. Laxative Abuse and the Laxative Habit. 2003. Retrieved on May
7, 2013 from http://web.pdx.edu/~sujata/FruitEzeWeb/education/
laxative/habit.html
Harari D, Gurwitz JH, Avor J et al. Constipation: assessment and
management in an institutionalized elderly population. J Am
Geriatric Soc. 1994;42:947-952.
Mahan LK, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition
Care Process Thirteenth Edition. 2010. St. Louis: Elsevier Saunders.
Mikrut R, Groetsma C et al. Clinical Dietetic Reference Pocket Guide. 2010.
Hines: Edward Hines Jr. Hospital Department of Veterans Affairs
Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference
Tenth Edition. 2011. St. Louis: Elsevier Mosby.

17. References
Pronsky ZM, Crowe JP. Food Medication Interactions Seventeenth Edition.
2012. Birchrunville: Food Medication Interactions.
Pryor T, Widerman MW, McGilly B. Laxative Abuse Among Women With
Eating Disorders: An Indication of Pathophysiology? Int J Eat Disord.
1996;20(1):13-18.
Roerig JL, Steffen KJ, Mitchell JE, Zunker C. Laxative Abuse: Epidemiology,
Diagnosis, and Management. Drugs. 2010;70(12):1487-1503.
Steffen KJ, Mitchell JE, Roerig JL. The eating disorders medicine cabinet
revisited: a clinician’s guide to ipecac and laxatives. Int J Eat Disord
2007;40:360-368.
Surgenor LJ, Maguire S, Russel J, et al. Self-liking and aself-competence:
relationship to symptoms of anorexia nervosa. Eur Eat Disord Rev.
2007;15:139-145.
Weltzin TE, Bulik CM, McConaha CW et al. Laxative withdrawal and anxiety in
bulimia nervosa. Int J Eat Disord. 1995;17:141-146.
Wilson BA, Shannon MT, Shields KM. Pearson Nurse’s Drug Guide. 2013.
Upper Saddle River: Pearson Education.