q 2000, British Geriatrics Society
Age and Ageing 2000; 29: 159–164
Does treatment of constipation
improve faecal incontinence in
institutionalized elderly patients?
PHILIPPE CHASSAGNE, ALAIN JEGO, PHILIPPE GLOC , CORINNE CAPET, CHRISTOPHE TRIVALLE, JEAN DOUCET,
PHILIPPE DENIS1, ERIC BERCOFF
Service de Médecine Gériatrique and 1Service de Physiologie Digestive et Urinaire et Groupe de Recherche sur
l’Appareil Digestif (GRAD), Centre Hospitalier et Universitaire de Rouen, 76031 Rouen Cedex, France
Address correspondence to: P. Chassagne. Fax: (+33) 2 32 88 91 30. Email: [email protected]
Abstract
Objective: to evaluate whether faecal incontinence can be improved by treatment of constipation in elderly
patients with faecal incontinence associated with impairment of rectal emptying.
Design: a prospective randomized study with a 2-month follow-up.
Setting: five long-term care units.
Subjects: 206 patients with daily faecal incontinence associated with chronic rectal emptying impairments such as
faecal impaction received either a single osmotic laxative (group I) or an osmotic agent along with a rectal stimulant
and weekly enemas (group II).
Measurements: episodes of faecal incontinence and associated details of soiled laundry (used as indicators of the
workload for caregivers). We performed periodic digital rectal examinations on group II patients to evaluate
whether treatment resulted in complete and long-lasting rectal emptying. We compared data between groups and
in group II between persistently constipated patients and patients with complete rectal emptying.
Results: the frequency of faecal incontinence did not significantly differ between the two groups. The 23 patients
in group II who had complete rectal emptying had 35% fewer episodes of faecal incontinence and 42% fewer
incidents of soiled laundry than the rest of the group.
Conclusions: when long-lasting and complete rectal emptying is achieved by laxatives, the number of episodes of
faecal incontinence as well as the workload for caregivers is reduced.
Keywords: constipation, elderly, faecal incontinence, institutional care
Introduction
Faecal incontinence is a common cause of institutionalization [1–3] with important psychological consequences [4–6] and economic impact [6, 7]. Its
prevalence ranges from to 30% in long-term care
units [8, 9] to 47% in psychogeriatric units [10].
Faecal impaction [11–14] is a major cause of faecal
incontinence in this population and its prevalence is
about 30% [15–17]. In institutions faecal impaction is
particularly common in demented patients [13] and
those with severe mobility impairments [17, 18].
Although faecal impaction is frequent, recurrent
and a cause of faecal incontinence, little has been
published on its treatment, especially as a way to
reduce the occurrence of faecal incontinence. Theoretically, patients with overflow incontinence [13] could
benefit from treatment of constipation if complete and
long-lasting rectal emptying could be achieved [19].
The aim of this study was to evaluate whether the
treatment of constipation in elderly patients with faecal
incontinence, secondary to rectal emptying impairments, is effective in decreasing the frequency of faecal
incontinence and, as a result, the workload of their
caregivers.
Methods
Subjects
From 751 residents of five long-term care units between
March and May 1998, we selected 206 patients aged 65
years or older with faecal incontinence and impaired
159
P. Chassagne et al.
rectal emptying. Faecal incontinence was defined as at
least one involuntary loss of faeces per week [3].
Impaired rectal emptying was based on at least one
episode of faecal impaction diagnosed in the past 2
months (n = 58) or on a history of functional
obstructed defecation. The diagnosis of faecal impaction was based on a digital rectal examination, while
functional obstructed defecation was defined [18] as a
difficulty in defecating requiring manual disimpaction
of stools (n = 21), a feeling of anal blockage (n = 45) for
at least 12 months or the identification of a rectum that
was persistently full of faeces on digital rectal
examination (n = 82).
We questioned patients and consulted their medical
records. We noted data suggesting cognitive impairment (e.g. patients with moderate to severe but daily
cognitive impairment with disorientation and memory
defects). We assessed patients for mobility using a
functional scale [20] and then stratified them into
two groups: those who were unable to get out of bed
or to walk alone and those who were completely
ambulatory.
A digital rectal examination was performed on each
patient to check and, if necessary, achieve rectal
emptying. All laxatives were stopped 48 h before the
beginning of the study.
We randomized patients who fulfilled the criteria
into two groups in each centre. Those in group I
received of 30 g per day of lactulose by mouth. Those
in group II received 30 g of lactulose, a daily glycerine
suppository (Eductyl) and a tap-water enema once a
week.
The appropriate local committee for human
research approved the study.
Follow-up and measurements
Follow-up was performed by the nursing staff of each
institution for 2 months. We investigated the frequency
(defined as the number of episodes of loss of faeces per
patient per day) and consequences of faecal incontinence, and the effectiveness of the treatment.
The assessment of the consequences of faecal
incontinence was based on details of soiled laundry
(including the number of times that clothes and/or bed
linen were changed) and on time that the nursing staff
spent managing patients (either treating them or
checking information).
We assessed the effectiveness of the treatment in
achieving complete and lasting rectal emptying by
carrying out rectal digital examinations every 10 days
in group II patients. Patients were classified as
‘responders’ when at least three consecutive digital
rectal examinations showed complete rectal emptying
and as ‘non-responders’ if the examinations showed
persistent rectal loading with faeces.
We excluded patients who missed treatment or
follow-up for more than 48 h. Each institution was
160
visited twice a week by a physician from the coordination study group who did not work at the
institution, to check all registered information. Nonlaxative therapeutic management of constipation by
usual nursing staff practices such as physical exercise,
daily fibre supplementation (given to two patients in
group I and three patients in group II) or use of pads
was left to the discretion of the staff.
Statistical analysis
Characteristics of the two groups were compared
using the x2 test for categorical variables and student’s
t-test for continuously measured variables. To make
sure that the treatment was the same for both groups
and had the same duration, individual information was
checked, starting 7 days after treatment had begun. We
performed statistical analysis of data after 5 and 8
weeks of treatment using the Mann–Whitney nonparametric test on the sample sizes of patients still
included in the study. We performed analyses on a
Macintosh computer using Stat Graphics statistical
software package.
Results
Patient characteristics
Of 206 patients selected, data from 178 were available
for analysis after the first week of treatment. The
following were excluded: 19 with severe diarrhoea,
one who had died and eight who refused to participate.
Among the 28 excluded patients, nine were in group I
and 19 in group II (P < 0.05). In group II diarrhoea was
directly attributable to laxatives.
Characteristics of the 178 remaining patients are
shown in Table 1. There was no statistical difference in
the percentages of patients in each group with altered
mobility or cognitive decline.
Cohort characteristics of constipation and faecal
incontinence are shown in Table 2. Twenty-eight
patients in group I and 30 in group II had had at least
one incident of faecal impaction in the last 2 months
(P > 0.05). In both groups 40% of patients had had daily
faecal incontinence for more than 2 years.
Comparison of the study groups after 5 and 8
weeks of treatment
After 5 weeks of treatment, 123 of the original 178
subjects remained in the study. Sixty-one of these were
in group I and 62 in group II. We excluded 55 patients
due to death (n = 10), diarrhoea (n = 10) or because
they had missed follow-up (n = 35). The number of
patients excluded due to an incomplete follow-up was
significantly (P < 0.01) higher in group I (n = 25) than
in group II (n = 10).
Faecal incontinence in institutional care
Table 1. Baseline characteristics of patients (n = 178)
Table 2. Characteristics of faecal incontinence and constipation in the studied population (n = 178) at the beginning of
the statistical analysis
a
Group
..............................................
I
(n = 93)
Variable
II
(n = 85)
n (and %), by groupa
P value
..................................
.......................................................................................................
Age, years
Mean 6 SD
85.9 6 6.1
84.7 6 6.6
Range
(66–99)
(69–98)
I
(n = 93)
Variable
II
(n = 85)
P value
.......................................................................................................
History of faecal impaction
Yes
58 (62)
59 (69)
No
25 (27)
20 (23)
Not reported
10 (11)
6 (7)
Gender (female), n (and %)
77 (83)
68 (80)
0.54
0.77
Cognitive impairment, n (and %)
Duration of faecal incontinence (months)
Yes
67 (72)
63 (75)
No
18 (19)
17 (20)
Not reported
8 (9)
5 (5)
<6
24 (26)
24 (28)
6–24
19 (20)
18 (21)
> 24
50 (54)
43 (51)
0.78
Mobility, n (and %)b
0.90
Frequency of faecal incontinence
Altered
80 (86)
77 (91)
Preserved
13 (14)
8 (9)
0.47
a
All subjects received 30 g/day lactulose. Those in group II also
received daily glycerine suppositories and weekly enemas.
b
Patients with altered mobility were unable to get out of bed or walk
alone; those whose mobility was preserved remained completely
ambulatory.
The mean number of episodes of faecal incontinence and soiled laundry did not differ statistically
between the groups (Table 3). Comparison of groups
for the study variables such as the number of episodes
of faecal incontinence according to baseline patient
characteristics (for example the number of patients
with cognitive and/or mobility impairments) showed
no significant differences.
After 8 weeks of treatment, 101 patients remained
(39 in group I and 62 in group II). All exclusions
occurred in group I, mainly because of missing
$ 1 episode per day
38 (41)
38 (45)
$ 1 episode per week
47 (51)
44 (52)
8 (9)
3 (4)
Not reported
0.36
a
All subjects received 30 g/day lactulose. Those in group II also
received daily glycerine suppositories and weekly enemas.
follow-up. Comparison of the two groups did not
show a statistical difference in the number of
episodes of faecal incontinence or in the amounts
of soiled laundry.
Comparison of treatment effectiveness after 5
weeks
We performed a periodic digital rectal examination in
59 of the 62 patients in group II (96.7%). Twenty-three
of these 59 patients (40%) were ‘responders’ (Table 4).
Table 3. Comparison of the number of episodes of faecal incontinence and soiled laundry between groups
Groupa
..............................................................................................
I
(n = 61)
Variable
II
(n = 62)
P value
........................................................................................................................................................................................................................
No. of episodes, (n)/mean 6 SD
(1461)/24 6 11.5
(1492)/24 6 10.8
0.9
Faecal incontinence (soiling)
(702)/12 6 9.9
(766)/12 6 12.7
0.63
b
(4881)/80 6 16.1
(4843)/78 6 20.7
0.55
0.85
0.84
2.9
2.8
Faecal incontinence (loss of faeces)
Soiled laundry
Incidents/per day/per patient
Faecal incontinence (loss of faeces)
b
Soiled laundry
a
All subjects received 30 g/day lactulose. Those in group II also received daily glycerine suppositories and weekly enemas.
Number of changes per day (of bedding and or clothing) due to faecal incontinence.
b
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P. Chassagne et al.
Table 4. Comparison of numbers of episodes of faecal incontinence and soiled laundry between patients who did and did not
responda after 5 weeks of treatment with lactulose, glycerine suppositories and enemas
Responders
(n = 23)
Variable
Non-responders
(n = 39)
P value
........................................................................................................................................................................................................................
No. of episodes, (n)/mean 6 SD
Faecal incontinence (loss of faeces)
(331)/14 6 9.1
(795)/22 6 11.7
< 0.02
Faecal incontinence (soiling)
(103)/4 6 7.1
Soiled laundryb
(948)/41 6 19.4
(295)/8 6 6.2
> 0.05
(2593)/72 + 28.3
< 0.001
0.51
0.78
1.5
2.6
Incidents/per day/per patient
Faecal incontinence (loss of faeces)
b
Soiled laundry
a
Patients were classified as ‘responders’ when at least three consecutive digital rectal examinations showed complete rectal emptying and as
‘non-responders’ if the examinations showed persistent rectal loading with faeces.
b
Number of changes per day (of bedding and or clothing) due to faecal incontinence.
Among ‘responder’ patients, 331 episodes of faecal
incontinence were registered compared with 795 in
‘non-responders’ (P < 0.02). The responders showed a
35% reduction in frequency of faecal incontinence and
a 42% reduction in incidents of soiled laundry.
After 8 weeks of treatment, 13 (30%) of the 62
patients remaining in group II were still responders.
Among these patients, 504 episodes of faecal incontinence were reported, significantly fewer (P < 0.05)
than the 1272 episodes recorded among the nonresponders. There was no significant difference
between responders and non-responders in the
number of incidents of soiled laundry.
The time necessary for nurses to complete the
standardized individual questionnaire was 5 min per
day. The time spent in administering an enema ranged
from 10 to 20 min and for bathing and dressing from 5
to 20 min (mean 15 min).
Discussion
In this study we selected a cohort of elderly institutionalized patients with daily faecal incontinence
associated with impaired rectal emptying.
Our purpose was to evaluate whether the treatment
of constipation could improve incontinence in these
patients. Because participating patients had chronic
constipation, they all received at least an oral laxative
agent which had been previously tested in these
clinical circumstances [21–23].
We felt that a combination of laxatives and enemas
(as provided to group II) would be more likely to
decrease the frequency of faecal incontinence in these
patients. This was not confirmed by our results. This
study could be randomized but not blinded because
outcomes were measured daily and because the
treatment was provided by the nursing staff. To
162
minimize this potential bias we randomized patients
in each centre and ensured that information was
checked by an investigator from the co-ordination
group who did not work in the unit. This appears to
have been successful in that results did not vary
between centres.
The results may be explained by the baseline
characteristics of the population studied. Patients had
had chronic constipation and daily long-lasting faecal
incontinence for at least 2 years in 40% of cases. As
shown in Table 1, these patients also had severe
cognitive and mobility impairments, which are both
strongly associated with faecal incontinence [8, 10, 14,
24, 25]. In addition, only 40% of the patients in group II
were ‘responders’ according to our criteria. This
suggests that treatment with an association of laxatives
was not well suited to these frail, elderly patients.
Other therapeutic regimens that have been assessed for
constipation include stimulant laxatives [26] alone or
in association with fibre intake and laxative osmotic
agents [27] or bisacodyl [28]. However, administration
of these oral laxative stimulants should be carefully
monitored in elderly patients because of potential side
effects, such as malabsorption or dehydration [18].
Treatment of constipated patients with faecal
incontinence based on laxatives alone is unsatisfactory,
probably because mobility and cognitive impairments
may play an important role in faecal incontinence.
However, few studies have evaluated non-pharmacological approaches to faecal incontinence such as
physical exercise [29] or prompted voiding [30].
Our second objective was to assess whether rectal
emptying would be associated with a decrease in the
frequency of faecal incontinence in constipated
patients with functional chronic rectosigmoid delay.
We confirmed this hypothesis. We showed that the
number of episodes of faecal incontinence was
reduced by 35% when rectal emptying was achieved,
Faecal incontinence in institutional care
and that the workload for institutional staff (based on
details of soiled laundry) decreased by 42%. In a
previous study [30] the workload for care-givers was
assessed on the basis of cost: at this time (1974) the
daily cost of laundry for a patient with faecal
incontinence was £8.50.
Whatever the treatment of chronic rectal emptying
impairment used for patients with faecal incontinence,
these results emphasize the importance of carefully
defined follow-up techniques. Digital rectal examination is a simple method which should be used to ensure
that rectal emptying has been achieved. Rectal
examinations seem to be more effective than periodic
patient interviews in identifying early signs of recurrent faecal impaction. Indeed, in this population,
interviews are limited by cognitive decline and because
signs of constipation may not be noticed due to
impairment of rectal sensitivity [31, 32]. Patients with
faecal impaction have a decrease in the threshold of
rectal distension, and this impairment is considered to
be the mechanism responsible of overflow faecal
incontinence [14, 33]. In these patients, rectal
examination seems to be the most suitable method
for early detection of acquired faecal impaction and the
best adapted for its management.
In conclusion, treatment of chronic rectal emptying
impairment in patients with faecal incontinence is
difficult but effective in decreasing the frequency of
faecal incontinence and thus the workload of nursing
staff. This treatment can probably be achieved through
individually tailored therapeutic programmes associated with strict clinical evaluation based on periodic
rectal examinations.
Key points
• Chronic impairment of rectal emptying may lead to
faecal impaction, a common cause of faecal
incontinence in frail elderly subjects.
• Treatment of constipation in patients with rectal
emptying impairment is difficult but should be
attempted in order to achieve complete and longlasting rectal emptying.
• When complete rectal emptying is achieved, the
frequency of faecal incontinence decreases and the
workload for caregivers is reduced.
• Periodic digital rectal examination to check rectal
emptying is a suitable method of follow-up in
elderly patients with constipation and faecal
incontinence.
Acknowledgements
The authors are grateful for the assistance of M. Maquin
and D. Roche. We would like to thank the physicians
(N. D. Manchon, Y. Moynot, C. Neveu, T. Pesqué and V.
Ruette) and the nursing staffs of the institutions
(Centre Hospitalier Saint Julien, Hôpital de Oissel and
Maison de Retraite Boucicaut, Centre Hospitalier et
Universitaire de Rouen, and Centre Hospitalier
Général de Dieppe) who collected the data for this
paper, and Solvay Pharma laboratories for its financial
support.
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Received 3 November 1998; accepted in revised form 3 June
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