Constipation in Elderly

1. CONSTIPATION IN EDLERLY
Present by :
EN Jacqueline , EN Maybelline
Villa Francis Home for the Aged

2. OBJECTIVE
 Case study
 Anatomy and Physiology
 Definition
 Causes of Constipation
 Signs and Symptoms
 Complications
 Evaluation
 Nursing intervention
 Types of Laxatives
 Summary

3. Case Study
Name : Mdm WWS
Age : 90 yrs
Race : Chinese
Dialect : Cantonese
Religion : Catholism
Marital Status : Single
Date of admission : 15.08.2016
Mobility status : Wheelchair Bound
RAF status : Category III
Drug Allergy : NKDA

4. Medical History
Medical Conditions
2005 Hypertension
Hyperlipidemia
Fracture neck of femur s/p Bilopar Hemiatroplasty done
2006 Right Breast surgery done
2009 Subactue left frontal lobe infarct – Excessive Dysphagia residual
2010 NCNC anemia
2012 Vitamin D deficiency with Osteoporosis
Right Knee Pseudogout
2013 IHD – NSTEMI
2016 Prominent Intra and extrahepatic billary tree and gall bladder
Constipation colic
• CT Scan Abdomen – showed no acute intraabdominal pathology or
intestinal obstruction

5. Current Medications
Oral
 Aspirin 100 mg OM
 Amlodipine 2.5 mg ON
 Enalapril 10 mg OM
 Enalapril 5 mg ON
 Carvedilol 6.25 mg BD
 Isosorbide Mononitrate 30 mg OM
 Sangobion one capsule OM
 Omeprazole 20 mg OM
 Colecalciferol 1,000 unit one tablet OM
 Sennoside 15 mg ON
Topical
 Miconazole 2% cream BD to rashes (Buttock)

6. Social History
Resident
(90 yrs)
Resident’s
brother (Mr
Wong)

7. Anatomy& Physiology
The Gastrointestinal Tract
 30 Ft long
 Function: To take in food and liquids, extract
useful nutrients and expel waste
 Many Enzymes, proteins, hormones, organs
and muscle involve
 The GI Tract communicates with the other
organs (including the brain)

8. GI Tract
 Dentition: critical in tearing food and grinding
food.
 Oropharynx: salivary glans produce digestive
enzymes that begin digestive process
 Esophagus: First muscular tubular structures
that propels food along the GI tract
(esophagus 1 ft long). Transit time 13 seconds.
 Stomach: Acids to dissolve food and continue
digestion. Strong muscular organ that mixes
and threshes food. Time: 2-4 Hrs.
 Duodenal bulb next

9. GI Tract
The Small Intestine
 20 -24 ft long
 Food moves via wave like contractions
 Transit 1-3 hours
 The stuff is still liquid as it is delivered

10. GI Tract
The large intestine
 ileocecal valve to anal sphincter: 4 ft long
 Roles :
1. To extract water
2. To lubricate stool
3. To pass water to rectum to be expelled from
body

11. GI Tract
The colon
 Material is transported via segmenting
contraction and propagating contraction
 By 24 hours stool has made it to transverse
colon
 By 48 hours stool made it to descending colon
and sigmoid colon

12. GI Tract
Rectum and Anus
 Defecation is evacuation of fecal material from
rectum. Combination of voluntary and involuntary
action :
 stool fills rectum, causing distention.
 straightening of anorectal angle (90 degree)
 involuntary relaxation on internal anal sphincter
 to pass stool, puborectalis muscle holds angle
and external
 sphincter relax

13. Feces
What composes feces?
 Feces is composed primarily water (75%)
 Remainder: 1/3 dead bacteria, 1/3 residue
(fiber), balance: sloughed cells from intestine,
bilirubin, fats, salts

14. : Guess What ?
Type 2 : Sausage-shaped but
Lumpy
* Mild Constipation
Type 6 : Fluffy pieces with
ragged edges, Mushy stools
* Mild Diarrhea

15. Type 1 : Separate hard
lumps, like nuts (hard to
pass)
* Severe constipation
Type 5 : Soft blobs with
clear cut edges (Passed
easily)
* Lacking Fiber
Type 4 : Soft sausage or
snake like, smooth and
soft
* Normal
: Guess What ?

16. Type 3 : Sausage-shaped but
with cracks on surface
* Normal
Type 7 : Watery, no solid pieces
(Entirely liquid)
* Severe Diarrhea
: Guess What ?

17. Bristol Stool Chart

18. Definition
 Constipation is a decrease in the frequency of
defecation and/or physical difficulty in emptying the
rectum effectively. The feces are usually hard;
defecation is painful and requires straining. A
sensation of abdominal fullness is often present,
and there may also be intestinal colic. (WHO)
 It is fundamentally defined by the patient. If the
patient complains of constipation or defecates less
than three times per week, assessment of bowel
habits is warranted. (Constipation in palliative care
Jan 18, 2017)

19. Constipation
 Frequent problem in elderly in NH
 50% of residents in VF using laxative regularly
 Untreated can lead to: fecal impaction
 Obstruction (megacolon)
 Volvulus (ischemia)
 Painful experience

20. Constipation
Basic problem :
 Obstructed defecation
 Slow transit time

21. Constipation
Obstructed Defecation
Outlet obstruction Cystocele, Rectocele, Anal stricture, Tumor
Pelvis floor dys-
synergy
• Muscular hypertonicity and spasm
• Incomplete relaxation to pelvis floor
• Paradoxical contraction
(This patients needs to manually help or when laxatives are
ineffective)
Anal Pathology • Painful condition
• Patient reluctant to pass stool, even if able
o Anal fissure
o Other anal lesions
o Hemorrhoids
Colon Cancer • A feeling that bowel doesn’t empty completely
• Rectal bleeding
• Constipation occurs when digested food spends too much
time in colon
• Colon absorb too much water and making the stools hard

22. Constipation
Delayed / Slow Transit time
Main causes: Inactivity, spinal cord pathology,
colonic myopathy
Metabolic causes Hypercalcemia, Diabetes Mellitus,
Hypothyroidism
Drugs: Analgesia, Anti-inflammatories,
Antidepressant, Antipsychotic, Anti-
Parkinsonian, Antihypertensive,
antihistamine, anticonvulsant

23. Common Causes of Constipation
in Elderly
 Not being active
 Eating disorders / Poor diet
 Overuse of laxatives
 Inadequate fluid intake
 Low fiber in diet
 Tumor or other obstructing mass (e.g. Colon cancer)
 Irritable bowel syndrome
 Neurological conditions such as Parkinson's disease or multiple
sclerosis, spinal cord lesions, stroke
 Depression, Dementia
 General disability
 Lack of Privacy

24. Common Causes of Constipation
in Elderly
 Medications
 Analgesics (opiates, tramadol, NSAIDs)
 Calcium channel blockers (e.g. Amlodipine, Nifedipine,
Diltiazem)
 Antacids (calcium and aluminum)

Calcium supplements

Iron supplements

Antihistamines

Diuretics (furosemide, hydrochlorothiazide)

Anti-parkinsonian drugs (e.g. Madopar, Sinemet)

25. Signs and Symptoms
 Passage of dry, hard stool
 Passage of liquid faecal seepage / spurious diarrhoea
 Infrequent passage of stool
 Frequent but nonproductive desire to defecate
 Straining at stools
 Nausea and vomiting
 Anorexia
 Abdominal pain or tenderness
 Abdominal distension
 Dull headache
 Pain with defecation

26. Complications
 If neglected or inadequately treated, constipation soon leads to
other symptoms and complications -
o Anorexia, nausea
o Overflow diarrhea or spurious diarrhea
o Faecal incontinence
o Retention of urine
o UTI
o Functional intestinal obstruction
o Delirium
o Rectal Prolapse
o Anal Fissure
o Chronic back pain
o Hernia
o Haemorrhoids

27. Evaluation for Constipation
 History of bowel movements
 Drug review
 Physical exam of:
→ Mouth
→ Abdomen
→ Rectum e.g. DRE
 Look at environment and functional status for
clues

28. Nursing Intervention
1. Assess usual pattern of
elimination:

29. Nursing Intervention – cont
2. Fluid intake at least 1.5 – 2
L/day (if not contraindicated)
3. Dietary fiber
4. Regular period of
Elimination / Toilet training
5. Provide privacy
during elimination

30. Nursing Intervention – cont
6. Physical
activities and
rehab program
7. Evaluate pattern of
laxative and enema use,
type and frequency
8. Provide laxatives,
suppositories and
enemas only as
needed

31. 9. Evaluate and review current medications
Nursing Intervention – cont

32. Nursing Intervention – cont
10. Proper monitoring and documentation in daily bowel
chart
3. Amount
2. Color
1.
Types
4. Supp
5. Continence /
Incontinence
Chart - 1

33. Nursing Intervention – cont
• Bisacodyl suppository
• inserted
3 days
BNO
• Bisacodyl suppository
inserted
3 days BNO
Chart -

34. Nursing Intervention:
11. Highlight to staff to report abnormalities
12. If there is a sudden change of behavior /
mood in resident, to rule out constipation

35. Villa Francis : BNO Protocol
 Follow the BNO Protocol (Bowel
management)
 Administration of laxatives as ordered by
Doctor
 If BNO for 2 days - administer Lactulose syrup as
ordered
 If BNO for 3 days - inserted Bisocodyl Suppository
 If still BNO - Administer Fleet enema (normal or high)
may need to add olive oil for high fleet
 If still BNO - Perform manual evacuation if needed and
no contraindications then review with Doctor

36. Types of Laxatives
Types of Laxatives Indications Examples
Bulk-Forming
Laxative (Fiber)
• Normal and slow
transit constipation
• Increases water
content and bulk of
the stool
Fybogel
* Not common use in elderly as
they need to drink more fluid.
Lubricant Laxatives
* Not common use
• Make stools slippery Mineral oil (liquid
petroleum)
Emollient Laxatives
(Stool Softener)
• Helps to “wet” and
soften the stool
Lactulose syrup
Stimulant Laxatives • Prolonged bedrest or
poor dietary habits.
• Increase gut motility
by nerve stimulation
Dulcolax, Senokot
* Not commonly use in Singapore

37. Types of Laxatives
Types of
Laxatives
Indications Examples
Suppository
Laxatives
• Draws water into the
intestines ( 15 – 60
minutes )
Bisacodyl / Dulcolax
Osmotic • Stimulate the
intestines to absorb
excessive amounts of
water from the body
Forlax
Saline Laxatives or
Enema
• Stimulate stool
evacuation
• The process helps
push waste out of the
rectum when you
Fleet (Sodium-
Phosphate), Milk of
Magnesium (MOM)

38. Summary
 Constipation is complicated but prevention
is simple
 If neglected or inadequately treated,
constipation soon leads to other
symptoms and complications
 May lead to medical emergency (e.g.
Intestinal obstruction)
 Do not abuse of laxatives
 Evaluate and review of medications is
needed

39. Any Question
for us ?