Constipation in the long-term care setting.

Constipation is a common symptom that clinicians must consider when caring for older patients. In the long-term care population, it is the most common nonpain symptom which patients suffer from, with 8.8% of one study population reporting symptoms (Rodriguez, Hanlon, Perera, Jaffe, & Sevick, 2010). Of these, 26.4% of the patients were undertreated. A larger multicenter study estimated the prevalence as high as 28%, with more than 50% using laxatives (Phillips, Polakoff, Maue, & Mauch, 2001). In a retrospective study using the minimum data set, 12.5% of patients (n 5 21,012) had constipation as a symptom. Race, poor fluid intake, pneumonia, and parkinsonism were risk factors (Robson, Kiely, & Lembo, 2000). Constipation not only decreases quality of life but also is costly to long-term care facilities. A small study of 31 patients over a 6-week period estimated $2.11 per administration of medication, with 70% of the cost due to medication administration (Pekmezaris, Aversa, Wolf-Klein, Cedarbaum, & Reid-Durant, 2002), not the medication itself. This article uses a case-based approach with three common scenarios to highlight the approach to evaluation and treatment of long-term care patients with constipation.CASE PRESENTATION NO. 1The patient is an 85-year-old woman currently residing in a longterm care facility, complaining of hard stool which requires tremendous straining to pass. She is only able to move her bowels two to three times a week and occasionally removes stool manually. Most of the time, she feels as if she has stool in her rectum (tenesmus), and this makes her very uncomfortable. She has a history of hypertension, hypothyroidism, moderate dementia, depression, osteoporosis, and osteoarthritis. Her medications include verapamil, hydrochlorothiazide, Synthroid, Aricept, Celexa, Percocet, Fosamax, and calcium supplements. Functionally, she is limited by arthritis and moves around with a walker. She spends most of her day either in bed or sitting in a chair. Her appetite has decreased, and she has poor fluid and food intake.On examination, her abdomen was soft, nontender, and distended. Stool was felt throughout the abdomen. Bowel sounds were present. Rectal examination was consistent with several external hemorrhoids, hard stool in the vault, and good sphincter tone. A diagnosis of chronic constipation was made. It was recommended that the patient increase fiber-rich foods in her diet, increase her fluid intake, and be encouraged to walk around the nursing facility more often during the day. As treatment for the constipation, she was given polyethylene glycol daily, leading to considerable improvement. In due time, she was moving her bowels almost daily with ease and little discomfort.Issues at Hand in This CaseThere is a high prevalence of constipation problems in older adults, more so in women (Higgins & Johanson, 2004). Over the age of 65 years, 26% of women and 16% of men report constipation. This increases to 34% of women and 26% of men aged 84 years and older (Harris, 2005). However, in residents of long-term care facilities, this prevalence increases. A Finnish study demonstrated that 57% of community-dwelling women and 64% of men reported chronic constipation. This, however, increased to 79% and 81%, respectively, in those residing in nursing homes (Kinnunen, 1991). Many factors contribute to constipation in older adults. Medications such as anticholinergic agents, opioid analgesics, antidepressants, diuretics, calcium supplements, calcium channel blockers, nonsteroidal antiinflammatory drugs (NSAIDs), and anticonvulsants all play a role in increasing the incidence of constipation. Calcium supplementation is a frequent cause (Prince, Devine, Dhaliwal, & Dick, 2006). Calcium channel antagonists such as nifedipine and verapamil cause rectosigmoid dysmotility, resulting in severe constipation (Traube & McCallum, 1984). Antidepressants, through their anticholinergic effects, reduce intestinal smooth muscle contractility, thus increasing constipation (Ness, Hoth, Barnett, Shorr, & Kaboli, 2006). …