Title: Constipation
1Medications and Constipation in the Elderly
No organ in the body is so misunderstood, so
slandered and maltreated as the colon! Sir Arthur
Hurst, 1935
2What is Constipation?
- Patient Definition
- Hard Stools
- Infrequent stools (lt3 per week)
- Excessive straining
- Sense of incomplete bowel emptying
- Excessive, unsuccessful time spent on toilet
- Constipation is NOT a normal part of ageing.
3Other symptoms of constipation
- Nausea /- vomiting
- Abdominal and Rectal pain
- Flatulence
- Loss of appetite
- Lethargy
- Depression
Patients may not associate these with constipation
4What are some of the consequences of constipation
in the elderly?
- 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
5Increased prevalence of Secondary Causes..
Why does constipation become a problem in the
elderly?
- Immobility
- Improper Diet
- Endocrine Metabolic Disorders
- Neurological Disorders
- Psychological Conditions
- Structural Abnormalities
- Medications
6Some medications associated with constipation
- Aluminium and calcium containing antacids
- Anticholinergic agents
- Calcium supplements
- Antipsychotics
- Iron
- Opioids
7.
Reference Australian Journal of Hospital
Pharmacy, 1998
81. Exercise - Fibre in the diet - Fluid Intake
- 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
9The kitchen can help!
- 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
102. Bulk Forming Laxatives
- 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
113. Stool Softeners Lubricants
- 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
124. 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 -
13Some precautions with osmotic laxatives
- 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
14Movicol and Thickeners
- IMPORTANT Thicken the water as per the
manufacturers instructions BEFORE adding Movicol
1. Mix the required amount of thickened water.
For convenience, this can be made ahead of time
and stored in the refrigerator for up to 48
hours. 2. To prepare Movicol for administration,
spoon about ¼ cup thickened water into a glass
and add Movicol powder. Stir thoroughly with a
spoon. 3. When mixed, add more thickened water to
make up to ½ cup (125mL) and again stir
thoroughly. 4. The mixture will return to the
required thickened state within approximately one
minute.
155. Stimulant Laxatives
- 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
16Nulax - the all natural and all organic in
origin fruit laxative
BEWARE
- 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
176. Enemas Suppositories
- 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 -
18Helping to prevent constipation
- Patient education
- Diet and Fluid Intake
- Exercise
- Effective Bowel Habits
- Toileting Facilities
- Medication Review
- Ensure a laxative is prescribed with opioids
- Imaginative ways to increase fibre-
- Add dry, fresh or canned fruit to cereal
- Add legumes to soups and casseroles
- Include grated vegetables in rissoles soups
- Choose fruit desserts
- High fibre snacks eg raisin bread, date scones,
carrot muffins
- An Effective Fibre Supplement
- 3 TBS unsweetened apple puree
- 1 TBS unprocessed bran
- 2-3 TBS prune juice
- Add 1 TBS to breakfast cereal