20
12
Bo
w
el
H
ea
lth
Bowel Dysfunction in the Elderly –
Constipation
an
d
Dr Rachel Bradley
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
Consultant Geriatrician University Hospitals Bristol NHS Trust
& St Martins Continence Promotion Unit, Bath
10th October 2012
20
12
G
S
Bl
ad
de
rs
an
d
Bo
w
Prevalence and impact
Presentation concentrates on Functional/Primary causes
Normal and abnormal bowel function
Assessment & working diagnosis
Practical management advice
dl
ey
-B
•
•
•
•
•
el
H
ea
lth
Presentation
R
ac
he
lB
ra
Declaration of interest: member of constipation in the
elderly advisory board for Shire
20
12
ea
lth
Introduction
w
el
H
• Bowel dysfunction in the elderly is common (C & FI)
Bo
• Significant impact on QOL of an individual
de
• depression & social isolation
ad
– Financial
he
lB
ra
• Carer stress
ey
-B
G
S
Bl
cost of pads, healthcare time & drug costs
placement decisions
laxatives £46 million per year England
½ per week of district nurse time
dl
•
•
•
•
rs
an
d
– Physical
– Psychosocial
ac
O’Keefe EA, et al.Bowel disorders impair functional status and quality of life in the elderly: a population-based study. Journals of Gerontology Series A-Biological Sciences & Medical Sciences.
Jul 1995. 50;4:M184-9
R
Stenzelius K et al. Bowel function among people 75+ reporting faecal incontinence in relation to help seeking, dependency and quality of life. Journal of Clinical Nursing. Mar 2007 16;3:458-68
Health Technology Assessment (HTA). Systemic review of the effectiveness of laxatives in the elderly. 1997;vol1:No13
ea
lth
20
12
Prevalence of Bowel Dysfunction
in the Elderly
el
w
Bo
an
d
– 20% community dwelling elderly
– Up to 50% hospitals
– 2/3rds nursing home residence
H
• Constipation
de
rs
• Faecal Incontinence
-B
G
S
Bl
ad
– Estimated 1% community adults, 3-5% >65yr olds
– 10% Residential homes
– 30% Nursing home, up 60% EMI
ey
• Irritable Bowel Syndrome
he
lB
ra
dl
– Prevalence 14-24% women & 5-19% men
– 2% GP visits per year
ac
Donald IP et al. A study of constipation in the elderly living at home. Gerontology. 1985. 31/2(112-8)
R
Bowel Care in Older People: Research into practice. Clinical Effectiveness & Evaluation Unit. Royal College of Physicians. 2002
Stenzelius K et al. Bowel function among people 75+ reporting faecal incontinence in relation to help seeking, dependency and quality of life. Journal of Clinical Nursing. Mar 2007 16;3:458-68
Tobin GW, Brocklehurst JC. Faecal incontinence in residential homes for the elderly: prevalence, aetiology and management. Age and Ageing. 1986. 15:41-46
NHS. Faecal incontinence. NICE clinical guidance 49. June 2007
ea
lth
20
12
Consequences of Constipation
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
an
d
Bo
w
el
H
• Feeling of incomplete evacuation
• Faecal loading/ impaction in rectum or colon
• REMEMBER this can occur with soft stool!
• Abdominal pain / low back pain
• Flatulence / abdominal distension
• Nausea / vomiting / headache
• Bladder dysfunction
• Confusion/Agitation
• Poor appetite
• Malaise
• Prolapse – rectal / vaginal
• Haemorrhoids
• Is not proven to cause toxaemia
20
12
Classification of Constipation – Primary
Bo
w
el
H
ea
lth
 Functional constipation
 Normal colonic transit (most common) - Normal stool frequency but
symptoms suggestive of constipation, but different to IBS
 Slow colonic transit (common in frail elderly) - May develop megacolon
rs
an
d
 Irritable Bowel Syndrome IBS (C)
lB
ra
dl
ey
-B
G
S
Bl
ad
de
 Defaecation/ Pelvic Floor Disorders
 Pelvic floor dyssynergia (or anismus, outlet obstruction) – poor
coordination
 Rectal dyschezia – reduced rectal sensation & tone leading to impaction
 Rectocele & Enterocoele
 Rectal Prolapse
R
ac
he
 Dilated colon
 Idiopathic Megacolon/ Rectum
 Hirshsprung’s disease (rare)
20
12
Classification of Constipation – Secondary
Metabolic & Endocrine
 Diabetes Mellitus
(diabetic autonomic enteropathy)
 Coeliac
 Chronic kidney disease
 Hypothyroidism
 Hyperparathyroidism
 Addison’s disease
 Amyloid
 Scleroderma
 Connective tissue disorders
de
rs
an
d
Bo
w
el
H
ea
lth
Intrinsic
 Colorectal Cancer
 Diverticulosis
 Inflammatory Bowel Disease
 Anorectal disorders such as Anal
Fissures & Haemorrhoids
Bl
ad
Post surgical abnormalities
R
ac
he
lB
ra
dl
ey
-B
G
S
Neurological Conditions
 Spinal Cord Injury
 Multiple Sclerosis
 Parkinsons disease
 Stroke & cerebrovascular disease
 Dementia & frontal lobe injury
Electrolyte disturbances
 Hypercalcaemia
 Hypokalaemia
 Hypermagnesaemia
ea
lth
20
12
Classification of Constipation – Secondary
Dietary factors
 Such as irregular meals
 Fibre content
 Fluids
Bo
w
el
H
Psychological
 Depression & Anxiety
 Anorexia nervosa
 Bulimia
 Affective disorders
 Abuse
ad
Bl
S
Functional disability
 Due to age related co-morbidities
 Environment (common)
e.g. hospital admission
R
ac
he
lB
ra
dl
ey
-B
G
Behavioural
 Lack of privacy and dignity
 Ignoring the ‘call to stool’
 Learning disabilities
de
rs
an
d
Immobility & Frailty
 Causing weak abdominal & pelvic
muscles
Secondary causes increasingly
important with age
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
an
d
ea
lth
H
el
w
Bo
Polypharmacy & Drug Side Effects
 Laxative abuse
 Anticholinergic agents:
 Tricyclic antidepressants
 Antipsychotics
 Oxybutinin
 Diuretics:
 Furosemide
 Analgesics:
 Opiates, Tramadol, Codeine phosphate
 NSAIDS
 Iron & calcium supplements
 Calcium-channel blockers:
 Verapamil
 Aluminium-containing antacids
 Anti-parkinson’s drugs
 Anti-histamines
20
12
Classification of Constipation – Secondary
ea
lth
20
12
The Function of the Colon
an
d
Bo
Hepatic flexure
de
ad
Bl
S
ey
-B
G
Caecum
ra
dl
Sigmoid colon
lB
4. Stool arrives in
solid form in the
rectum
he
ac
R
Splenic flexure
rs
2. Stool passes
along the colon
by peristalsis
1. Stool in liquid
form as passes
through Ileocaecal valve
3. Colon absorbs
water (&salts)
w
el
H
Transverse colon
Appendix
Anal canal
20
12
Peristalsis
w
el
H
ea
lth
• Muscular contractions of the gut, secretion of acids
and enzymes are under autonomic control
Bl
ad
de
rs
an
d
Bo
• Enteric autonomic nervous system forms
ganglionated plexuses with complex
interconnections to smooth muscle, mucosa & blood
vessels
he
lB
ra
dl
ey
-B
G
S
• The ganglia receive extrinsic excitatory fibres from
the vagus nerve (parasympathetic) & inhibitory
fibres from the sympathetic fibres (ACh). There are
also reflex circuits that react to stimuli
R
ac
• Other transmitters in include 5-hydroxytryptamine
(5HT), adenosine triphsphate (ATP), nitric oxide &
neuropeptide-Y
20
12
ea
lth
Bowel Control
Bo
w
el
H
• Normal average transit time 3days,
(variance x3/d to x3/wk)
S
Bl
ad
de
rs
an
d
• Requires intact cerebral & spinal reflexes
• Enteric autonomic nervous system &
proprioceptive sensation
R
ac
he
lB
ra
dl
ey
-B
G
• Two sphincters (internal & external)
in the anus supplied by
– Pudendal nerve & Hypogastric (autonomic)
nerves formed from 2nd, 3rd & 4th Sacral nerves
• Functioning pelvic floor muscles
ea
lth
20
12
The ‘Call to Stool’
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
an
d
Bo
w
el
H
• Stool distends into the rectum activating the sacral nerve reflex arc
• Sensation ‘Call to Stool’. Sensory discrimination between liquid, gas or solid
• The Pubo-rectalis muscle creates an angle of 60-105 degrees between the anal
canal and the rectum by pulling forwards, this relaxes and the stool passes
through to the external sphincter
• External sphincter relaxes creating funnel shape
• Strong waves of peristalsis from internal sphincter and lower bowel occur
• Assisted by raised intra-abdominal pressure
• Voluntary contraction of the external sphincter can also prevent leakage of
flatus & stool and stop a stool from passing
20
12
ea
lth
The Ageing Bowel
an
d
Bo
w
el
H
• Age-related reduction in mesenteric neurones, but
stool frequency unchanged in healthy ageing
S
Bl
ad
de
rs
• But more bowel evacuation
difficulties, straining
ac
he
lB
ra
dl
ey
-B
G
• Multiple co-morbidities
• Functional disabilities
• Medication
R
• Women > men
20
12
Assessment
H
el
w
Bo
Previous bowel habit
Associated symptoms
‘Bothersome factor’ & impact on QOL
Urinary symptoms
• Identify ‘Red Flag’ Symptoms
an
d
–
–
–
–
ea
lth
• History of presenting complaint
Bl
ad
de
rs
– Rectal bleeding, Wt loss, Nocturnal pain or
diarrhoea, anaemia & fever
ey
-B
G
S
• Relevant Past Medical Hitory, Obstetric,
Surgical & Cognition
• Detailed drug history including OTC
ra
dl
– Response to previous laxatives
lB
• Diet & Fluid intake
he
– Response to dietary changes
R
ac
• Toileting Regimes
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
an
d
Bo
w
el
H
ea
lth
20
12
Don’t forget to ask patients about
their over the counter remedies!
ea
lth
20
12
Take a Detailed Bowel History
• What is meant by ‘Constipation’?
Bo
w
el
H
– Variation in good health (x3/day to x3/week)
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
‘Call to Stool’ or urge frequency
Stool frequency
Stool type
Straining
Feeling of incomplete evacuation
Abdominal pain
Bloating
Rectal/ Vaginal digitation
Remember the commonest cause of FI is Constipation
R
–
–
–
–
–
–
–
–
–
an
d
• What are the most bothersome symptoms?
de
ad
G
S
Bl
• Keep a Stool diary
rs
an
d
ea
lth
H
el
w
Bo
• Objective evidence is useful
– Bristol Stool Form Scale
ey
-B
• Diet & Fluid diary
R
ac
he
lB
ra
dl
– 1-2 weeks
– Review fibre content
20
12
Assessment
lB
ra
dl
ey
-B
G
S
Bl
20
12
Consent
Chaparone
RCN competency
Assess for masses, stool consistency & colour,
anal tone, puborectalis movement, & prolapse
ac
he
–
–
–
–
ad
de
rs
an
d
Bo
w
el
H
Nutritional status
Neurological (S3/4 sensation)
Abdominal Examination
Digital Rectal Examination (DRE)
R
•
•
•
•
ea
lth
Examination
ey
dl
ra
lB
he
ac
R
-B
S
G
rs
de
ad
Bl
an
d
w
Bo
el
H
ea
lth
20
12
DRE - What you are looking for?
ea
lth
20
12
Form a Working Diagnosis based on history
and supported by examination
de
rs
an
d
Bo
w
el
H
• Remember that Constipation is a symptom not a
diagnosis look at predominant symptom profile.
For example:
he
lB
ra
dl
ey
-B
G
S
Bl
ad
• IBS (C) – variability, abdominal pain
• Slow gut transit – very infrequent urge,
infrequent hard stools, straining, life long
• Rectocoele – straining, incomplete
evacuation, digitation
R
ac
However, in elderly often other confounding factors
H
ea
lth
20
12
Is there such a thing as the Goldilocks
Stool?
el
Stools of people aged 40–69 years
w
Stool type
Women (n=613)
%
1
2
3.8
13.4
8.5
16.9
Normal
*
3
4
23.2
38.6
20.5
36.1
Loose
5
6
7
9.2
11.9
Not reported
10.1
8.0
Not reported
an
d
Bo
Men (n=510)
%
ey
-B
G
S
Bl
ad
de
rs
Lumpy
Normal* stools account for 57–62% of all stools
*Those least likely to evoke symptoms (types 3 and 4)
R
ac
he
lB
ra
dl
•Agree individual realistic ‘Goals of Treatment’ based
on symptom relief, not just stool type
•Trial of treatment & reassess
Heaton et al. Gut 1992;33(6):818-824
O’Donnell et al. Br Med J. 1990;300(6722):439-40
20
12
Investigations
Bo
w
el
H
ea
lth
Very few investigations are required for Functional Constipation.
Only use if diagnostic uncertainty, refractory to treatment or if
Musculus sphincter
surgery is being considered
ani internus
Blood tests
AXR & Colonic Transit Studies
Proctoscopy & Sigmoidoscopy
Barium studies
Colonoscopy & CT Colonogram
Defaecating Proctograms
Neurophysiology: EMG &
anorectal manometry
• Endoanal Ultrasound
an
d
•
•
•
•
•
•
•
Musculus levator
ani
de
rs
Musculus sphincter
ani externus
Bearing down
Rectum
Anal
sphincter
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
Electromyograp
hy
(EMG)
Abnormal increase in anal pressure
with no relaxation on bearing down
Occuring in dyssinergic defaecation
Rao et al. Neurogastroenterology and Motility. 2011;23,8-23. Evaluation of Gastrointestinal Transit in Clinical Practice;
ea
lth
Typical radiopaque markers1
20
12
Investigations
H
w
Bo
16
14
el
20
18
an
d
Number of markers remaining
Slow transit constipation is characterized by prolonged
delay in the transit of stool through the colon2
rs
dl
ey
-B
G
S
Bl
ad
de
Possible transit time study outcomes
lB
ra
Normal Transit Time Slow transit Time
Majority of markers Markers scattered
passed by Day 5
throughout colon
Pelvic floor disorder
Most markers in rectum
or rectosigmoid*
he
*Note: this represents a possible scenario, but pelvic floor
ac
disorders are not always visible via transit study
Chatoor & Emmanuel. Best Pract Res Clin Gastroenterol. 2009;23(4):517-30
Evans et al. Int J Colorect Dis. 1992;7:15-17; Image developed for programme
R
1.
2.
12
10
8
6
4
2
0
0
24
48
72
96
120
144
168
Time after ingestion of markers (h)
Normal transit
Mean
±2 standard deviations
Slow transit
Remaining cubes
Remaining cylinders
Remaining rings
ea
lth
20
12
Management Principles
w
el
H
• Exclude an organic and secondary causes
G
S
Bl
ad
de
rs
Influence ‘what goes in’ (diet)
Bowel motility/ transit time
Consistency of what comes out (stool)
Evacuation problems
-B
–
–
–
–
an
d
Bo
• Primary Constipation Management
R
ac
he
lB
ra
dl
ey
• Despite the prevalence of functional bowel problems in the
elderly there remains a lack of good evidence based
research on this subject. Many studies have been small, ill
defined, relied on self-reporting of symptoms and have had
unclear outcome measures
w
el
H
• Diet & Fluids
-B
G
S
Bl
ad
de
rs
an
d
Bo
regular meals or snacks
improve fibre (insoluble v soluble)
12-25g/day F, 30-38g/day M
adequate fluid intake
Dietician review for specialist/exclusion diets
• e.g gluten free, lactose intolerance
ey
–
–
–
–
–
20
12
ea
lth
Dietary Advice
ra
dl
– other natural foods
R
ac
he
lB
• e.g. Aloe vera, prunes, kiwi, linseeds
• ORTIS fruit cubes
Johanson. MedGenMed. 2007;9(2):25
H
Bo
w
el
Establish a regular bowel routine &
re-educate the bowel
• Privacy & allow enough time
de
rs
an
d
‘Behind closed doors campaign 2006’
Especially important in Hospital
G
S
Bl
ad
• Utilise gastro-colic reflex
-B
• Improve toileting access & labelling
dl
ey
– Especially for Dementia
R
ac
he
lB
ra
• Toilet seat height & position
• ‘Brace and bulge’ technique
1. Markwell S, Sapford R. 1995. Physiotherapy management of obstructed defaecation. Australian Journal of Physiotherapy.
41:29-83
20
12
ea
lth
Lifestyle Advice
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
an
d
Bo
w
el
H
ea
lth
20
12
Gut Motility in Healthy vs. Slow
Transit Constipation
Dinning et al. World J. Gastroenterol 2010;16(41):5162-5172.
S
Bl
ad
de
rs
an
d
Bo
w
el
H
ea
lth
20
12
Can suppression of Defaecation affect Colonic
Motility?
lB
ra
dl
ey
-B
G
• This study was done in 12 young males and showed that voluntary
suppression of the urge to defaecate can affect bowel transit time
over a 2 week period
ac
he
•Ask patients about toilet avoiding habits, response to urge
R
•What effect does toilet avoidance behaviour have in Dementia?
Klauser et al. Dig Dis Sci. 1990.35(10)1271-5
20
12
ea
lth
Physiotherapy
Bl
ad
de
rs
an
d
Bo
w
Beneficial in both FI & C
Restores sensation and better evacuation
Gives better ‘control’
Useful in dyssinergia
Less likely to be effective with neuro abnormality or 3rd
degree tear
-B
G
S
–
–
–
–
–
el
H
• Pelvic floor exercises (PFE) & Sphincter Exercises
dl
ey
• Biofeedback techniques
he
lB
ra
• Need more long-term follow up studies
R
ac
• Post-partum education
H
ea
lth
20
12
Digital Stimulation & Digital Removal
of Faeces (DRF)
rs
an
d
Bo
w
el
• Digital stimulation be required in patients with
chronic neurological conditions or a Rectocoele
ac
he
lB
ra
dl
ey
-B
G
Local damage
Autonomic dysreflexia
May require sedation or GA
RCN & ACA guidelines
Exceptions some chronic neurological diseases
R
–
–
–
–
–
S
Bl
ad
de
• DRF should NO longer be part of routine clinical
practice as recognised complications
ea
lth
20
12
Drug Treatment for Constipation
G
S
Bl
ad
de
rs
an
d
Bo
w
el
H
• Consider when lifestyle factors don’t work
• Treatment tailored to the individual
• Several drugs or dose adjustments may be
required
• Monitor effect using Bristol Stool Form Scale &
individual symptoms
R
ac
he
lB
ra
dl
ey
-B
Bulk laxatives
Stimulant laxatives
Osmotic/Softener laxatives
Suppositories & enemas
Petticrew M. HTA 1997; Vol 1:No13. Systemic review of the effectiveness of laxatives in the elderly
Bosshard W, Dreher R, Schnegg JF, Bula CJ. The treatment of chronic constipation in elderly people – An update. Drugs Aging. 2004. 21:911-930
ea
lth
20
12
Drug Treatment for Constipation
Bulk Laxatives
an
d
Bo
w
el
H
• Bran, Ispaghula (Fybogel, Regulan), methylcellulose
(Celevac) & sterculia (Normacol)
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
rs
• Action increase faecal mass which stimulates peristalsis via
stretch receptors in the mucosa
• Useful 1st line small, hard stools, diverticular disease & IBS
• Take several days to work
• Must be taken with plenty of water
• Well tolerated
• Except avoid in megacolon as can make slow gut transit worse
S
Bl
ad
de
rs
an
d
Bo
w
el
H
ea
lth
20
12
• Several small RCTs comparing Bulk laxitives in
elderly with placebo or normal diet.
G
Cheskin et al. JAGS. 1995; 43(6)666-9
R
ac
he
lB
ra
dl
ey
-B
• In this study 10 community dwelling elderly patients
• Reduced gut transit time, increased stool frequency
• However, no effect on pelvic floor dysinergesia
ea
lth
20
12
Drug Treatment for Constipation
Stimulant Laxatives
Bo
w
el
H
• Anthraquinones (Senna, Manevac, Dantron/Co-danthramer)
and diphenylmethane cathartics (Bisacodyl, Sodium Docusate)
ad
de
rs
an
d
• Stimulate colonic nerves (myenteric plexus)
• SEs abdominal cramps, diarrhoea, hypoK & urine discolouration
Bl
– Senna
-B
G
S
• Action 6-12hrs
• Useful short term/acute constipation
ey
– Danthron
dl
• Palliative care only (potentially carcinogenic)
ra
– Sodium docusate
lB
• Acts as a softener & stimulant
he
– Castor oil & cascara are no longer used
R
ac
• unpredictable & dramatic results
20
12
ea
lth
H
el
w
Bo
an
d
rs
de
ad
Bl
G
S
Kamm MA, Mueller-Lissner S, Wald A, et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin
Gastroenterol and Hepatol 2011;9:577–583.
lB
ra
dl
ey
-B
• Improved quality of life among patients given bisacodyl
for constipation, compared with those given placebo
R
ac
he
• Combination of softener and stimulant institutionalised
elderly beneficial
Kinnunen wt al. Pharmacology. 1993. Oct;47 Suppl 1:253-5
ea
lth
20
12
Drug Treatment for Constipation
Osmotic/Softener laxatives
w
el
H
• Sugars (Lactulose, Sorbitol), purgatives (Magnesium hydroxide,
Epsom salts) and macragols/ polyethylene glycols (Movicol)
rs
an
d
Bo
• Draw water into stool, increase bulk & stimulate colonic motility.
Require plenty of water
R
ac
he
lB
ra
dl
ey
-B
G
S
Bl
ad
de
– Lactulose
• Dissachardide, not absorbed, low faecal pH discourages growth of
ammonia-organisms, therefore useful in liver patients
• Not very effective & takes 2-3days to work
• SEs flatulence & cramps
– Movicol PEG+E
• Contain electrolytes, more balanced solution, less dehydrating
• Useful for more resistant cases
• ONLY oral lax recommended for faecal impaction
– Magnesium Hydroxide
• useful short term/rapid use only
1.5
0.9
1.0
1.2
anMedian daily score for
d straining
Bo
w
el
H
ea
lth
1.3
20
12
1.5
Less straining with PEG vs lactulose
after 1 month1
1.0
0.5
0.5
0.5
0.0
0.0
PEG (n=50)
Lactulose (n=49)
PEG (n=50)
de
Lactulose (n=49)
rs
Mean stool frequency
per day
Higher stool frequency with PEG vs
lactulose after 1 month1
he
lB
ra
dl
ey
-B
G
S
Bl
ad
• PEG trials in elderly showed increased stool frequency and
less straining versus lactulose
• Studied in community dwelling elderly, institutions
• Study in Parkinson’s Disease showed benefit
• Useful for slow gut transit
• Licenced orally for faecal impaction
R
ac
Attar et al. 1999. Gut. Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation
Gruss et al. 2004. Eur J Ger. 6 (3): 143-150
Culbert et al. 1998. Clin Drug Invest. 16 (5): 355-360
ea
lth
20
12
Rectal Enemas & Suppositories
Bo
w
el
H
• Enemas & Suppositories are absorbed well by rectal mucosa
• Administration can take time and requires dexterity
• Local & systemic SE
an
d
• Stool softeners
ad
Mendoza. 2007. Alim Pharm & Ther. 26, 9-20
de
rs
– Microlax enema (sodium citrate)
– Phosphate enemas
• AVOID in elderly/CKD as these cause electrolyte disturbances
he
• Stimulants
lB
ra
dl
ey
-B
G
S
Bl
– Arachis oil (groundnut, peanut oil) enema
• CAUTION in patients with nut allergy
• Needs to be warmed to body temperature
– Liquid Paraffin lubricant
• to be avoided because of SE (incl seepage, irritant, granulomatous reactions
& lipoid pneumonia, impair absorption of fat soluble Vits)
R
ac
– Glycerol suppositories – rectal stimulation by mildly irritant action
– Picolax - bowel cleansing prep, stimulates nerves, act within 3hrs
20
12
ea
lth
Other Therapies
Bo
w
el
H
Prokinetic drugs
• Procalopride
dl
ey
-B
G
S
Bl
ad
de
rs
an
d
– Selective affinity for 5HT4 receptor agonists
– NICE approved 3rd line agent in women. However,
experienced prescriber and 4weeks follow up required
– SEs Headache & GI
– Caution if history of IHD & arrythmias
R
ac
he
lB
ra
• ?Cholinomimetic drugs (e.g. carbachol, neostigmine)
which increase motility
w
el
H
• Traditionally used by spinal patients
ea
lth
20
12
Rectal Irrigation Systems
rs
an
d
Bo
• Rectal irrigation systems increasingly popular as an
alternative to surgery for other patient groups
-B
G
S
Bl
ad
de
– Cardiomed
– Peristeen £70 + £122 accessory unit
R
ac
he
lB
ra
dl
ey
• Requires dexterity & cognitive function
• CI IBD, obstruction
• Risk of perforation estimated 0.002% per irrigation
Christensen P et al. Gastroenterology 2006; 131:738-747. A RCT of transanal irrigation versus conservative bowel management in spinal cord patients
Christensen P etal. Dis Colon Rectum 2009; 52:286-292. Long-term safety of transanal irrigation for constipation and faecal incontinence
ea
lth
20
12
Sacral Nerve Stimulation
w
el
H
• Useful for UI, FI & C
• Minimally invasive technique
he
lB
ra
dl
ey
-B
G
S
Bl
NICE approval FI, all ages
A few small trials in Constipation
But expensive ££
Specialist centres only
Careful selection
ac
•
•
•
•
•
ad
de
rs
an
d
Bo
• Mechanism: Afferent nerve stimulation. Down regulates
efferent nerves to pelvic floor, bladder & bowel via negative
feedback sacral loop
R
Cochrane Review 2008 SNS for FI & C ,
Kamm et al. 2010. Neurogastroenterology. 59:333-340. Sacral Nerve stimulation for Intractable Constipation
ea
lth
20
12
Surgery
an
d
Bo
w
el
H
• Only considered after conservative measures have
been tried – e.g. sphincter repair
• Failure rate up to 50%
G
S
Bl
ad
de
rs
– Careful selection & counselling required
– Trials in elderly lacking
– Co-morbidities affect outcomes
ey
dl
– rectoplexy
-B
• Management of rectal prolapse remains a challenge
lB
ra
• Rectocoele newer surgical techniques
he
– Laparoscopic Rectoplexy, ?STARR
R
ac
• Total colectomy & stoma formation last resort only
Bl
ad
de
rs
an
d
Bo
– Good childhood toilet training
– Post-partum Pelvic Floor Exercises
– Healthy ageing
w
el
• Promote healthy & active lifestyle
H
ea
lth
20
12
How to Avoid Bowel Dysfunction in Old
Age - Prevention is Better than Cure
ac
he
lB
ra
dl
ey
Care Homes
Immobility
Hospitalised patients – diet, mobility & illness
Simultaneous prescribing of laxs with opiates
R
–
–
–
–
-B
G
S
• Identify, assess & treat at risk groups early
20
12
H
ea
lth
A Multidisciplinary Approach
de
rs
an
d
Bo
w
el
• Causes of bowel dysfunction in the elderly are often
multi-factorial
-B
G
S
Bl
ad
• Patients present to many different health/social care
professionals
lB
ra
dl
ey
• A multidisciplinary approach is vital with fully
integrated services & clear referral pathway
R
ac
he
– ? via the continence service
20
12
Key Points for Clinical Practice
H
ea
lth
• Constipation is a symptom not a diagnosis
de
rs
an
d
Bo
w
el
• Use your clinical skills to obtain a working diagnosis
• The Bristol Stool Chart is useful
• Set realistic ‘Goals of Treatment’ based on symptoms
ey
-B
G
S
Bl
ad
• Address life-style factors
• Physiotherapy & biofeedback may be helpful
• Tailor medication to the individual
R
ac
he
lB
ra
dl
• Establishing a bowel management
program can improve or cure the
majority of patients
ey
dl
ra
lB
he
ac
R
-B
S
G
rs
de
ad
Bl
an
d
w
Bo
Thank you
for listening
el
H
ea
lth
20
12