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Constipation, Impaction and Dual


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Top of Page Overview

The DADS Quality Assurance and Improvement vision for reducing episodes of constipation, impaction, fecal incontinence and dual incontinence in LTC is

Improved bowel function through appropriate diet, hydration and activity.

Scope

Normal bowel function includes voluntary control of defecation - the ability to empty the rectum completely at will. This framework addresses disordered bowel emptying focusing on the symptoms of constipation, impaction, fecal incontinence (FI) and dual incontinence (DI). Bowel emptying dysfunction is a source of increased morbidity, decreased quality of life and psychosocial distress for long term care residents.[1,2,3,4,5]

Because as many as 50% of elderly persons in long term care experience fecal incontinence, symptoms such as constipation, impaction, FI and DI are often regarded as inevitable signs of aging. However, because these symptoms typically stem from remediable causes rather than age itself, simply cleaning up after incontinence episodes cannot be regarded as best practice.[1] Residents that experience symptoms of bowel emptying dysfunctions deserve prompt evaluation and appropriate treatment.

Definitions

  • Constipation: Difficulty passing stools or passing stools infrequently. In daily practice constipation can be considered as having fewer than 3 stools per week.[30] A diagnosis of clinical constipation includes identifying a large amount of feces in the rectum upon digital examination or excessive fecal loading in the colon, rectum or both as shown by an abdominal radiograph (e.g., KUB).[6,7]
  • Fecal impaction: Prolonged constipation and the presence of a hard, dry fecal mass in the rectum.[8]
  • Fecal incontinence: Passive leaking of mucus, liquid stools and feces.[8,9] This can be either a primary continence problem or can occur as a secondary manifestation  (overflow diarrhea) of impaction.
  • Dual incontinence: Both fecal and urinary incontinence.

Role of Constipation in Causing Fecal Incontinence

Constipation is the initial disorder in a series of events leading to FI. [8,10,11,12,13,14,15] Difficulty passing stools or passing stools infrequently leads to an increased fecal load in the rectum that, if not treated, can lead to fecal impaction. Despite the absence of effective bowel emptying, the rectum will continue to fill with feces. Overflow diarrhea, often manifesting as fecal incontinence, then occurs because the rectum cannot hold an ever increasing fecal load. Diarrhea in combination with fecal impaction indicates failure to treat constipation.[8]

Signs of Aging

Constipation and its subsequent complications are not a part of the normal aging process. There is no correlation between bowel movement frequency and age.[6] Yet the elderly tend to be more preoccupied with their bowel habits, complain of constipation and are more likely to use laxatives.[6]

Causes, Symptoms and Risk Factors for Developing Constipation

Because constipation precedes impaction and fecal incontinence, it is essential to identify and treat constipation in order to prevent impaction and fecal incontinence. See Table 1 for causes, symptoms and risk factors of constipation.

Treatment

Medications With Little or No Evidence Basis

Do not use docusate or magnesium hydroxide to treat constipation in the elderly.

  • Docusate is a stool softener that has no laxative action [16,17,18] and does not reduce constipation.
  • Magnesium hydroxide has only "minimal data" to support its use as a laxative in the elderly.[18,19]

Medications With an Evidence Basis

Bulk laxatives, lactulose and senna with fiber have an evidence basis.

  • Bulk laxatives are the preferred agents, but they may be ineffective in residents who are bedridden. In addition, the use of bulk laxatives requires that residents drink sufficient quantities of water daily.[11,20] In the absence of sufficient fluid intake, the use of bulk laxatives risks fecal impaction or intestinal obstruction due to the bulk forming agent itself.[11]
  • Lactulose appears to be an effective laxative in the elderly, but its effect on treating constipation may diminish over time.[10]
  • Senna plus fiber is more effective in treating constipation than lactulose.[20,21]

See Table 2 for a description of laxative agents, their actions and precautions.

Non-drug Treatments With an Evidence Basis

Immobility is a significant risk factor for laxative use, constipation and fecal incontinence. [22,23,24,25] Colonic transit time in chair-bound or bedridden long-term care residents can be as slow as two weeks (compared to the normal transit time of less than three days).[26] Regular exercise and abdominal massage can reduce episodes of fecal incontinence and increase the number of bowel movements.[27] Changing posture from lying down to sitting up can speed colonic transit time.[25]

Other treatment options involve removing causes of constipation. For example, certain classes of drugs (e.g., anticholinergics) depress colonic motility and thus should be considered for removal.

See Table 1 for causes, symptoms and risk factors for constipation.

Complications

Constipation can lead to at least four types of complications of which caregivers in long-term care should be aware.[6]

  1. Non-obstructive GI effects due to straining at defecation include hernias, anorexia, inappropriate fullness and worsening of GI reflux symptoms.
  2. Cardiovascular effects due to straining at defecation include a decrease in coronary, cerebral and peripheral arterial circulation due to changes in intrathoracic pressure.
  3. Psychological effects include restlessness and confusion that are attributed to constipation.
  4. Obstructive GI effects such as fecal impaction, fecal incontinence, intestinal obstruction, megacolon and urinary complications.

Top of Page Resident Evaluation

When evaluating a resident for constipation do the following:[6,7,28,29]

  1. Conduct a complete and thorough history. Does the resident:
    1. Have sufficient fiber and fluid intake? Is intake measured properly?
    2. Suffer from immobility? If so, to what degree?
    3. Have trouble chewing or dental problems that would keep him from chewing his food properly? If so, is dental care or a dental device indicated?
    4. Fail to respond to the urge to defecate? If so, is this due to a physical, medical, or social reason? When possible, address the reason and encourage the resident to use the toilet when the urge to defecate presents.
    5. Strain on defecation? Is this of new onset? If not, does the resident strain harder now than in the past?
    6. Have abdominal or rectal pain when defecating? Is this of new onset? If not, is it worse than before? Note: rectal pain on defecation should alert the physician to such conditions as rectal ischemia, anal fissure, or anorectal tumor.
    7. Have fecal and/or urinary incontinence?
    8. Have fecal soiling on underclothes, pajamas, or in bed?
    9. Have overflow diarrhea (i.e., diarrhea not associated with a specific illness or clinical pathogen)?
    10. Use or abuse laxatives?
    11. Have constipation that presents with additional bowel symptoms (e.g., megacolon, bleeding, or obstruction)?
    12. Have any disease or ailment that may cause constipation (e.g., intrinsic bowel lesions, neurologic disorders, psychiatric diseases, endocrine or metabolic disorders, collagen disease, of infiltrative disease)? See Table 1 for secondary causes of constipation and examples of specific diseases.
    13. Have dementia or Parkinson's? Both conditions may predispose to constipation.
  2. Identify residents who have rectal dyschezia. Such residents may have constipation despite regular bowel movements because rectal sensation is impaired even in the presence of impaction.
  3. Review all current and recently discontinued medications. Discontinue any non-essential medications, especially anticholinergics, which contribute to constipation.
  4. Conduct a complete and thorough physical examination.
    1. Perform a digital rectal examination. This can reveal impaction, hemorrhoids, anorectal disease and perianal fecal soiling.
    2. A plain film of the abdomen (KUB) can be helpful in determining the extent and distribution of feces in the colon particularly when there is an empty ampulla on digital rectal examination.
    3. In women, pelvic examinations should be performed to rule out gynecological reasons for constipation.

Top of Page Care Planning

The following section outlines processes in resident assessment and care planning for the prevention, early detection  and treatment of bowel emptying dysfunction. The foundation of bowel care planning is attention to adequate resident hydration, dietary fiber and activity. If symptoms persist despite thorough resident evaluation, optimal hydration and diet, the next step is medication review in order to eliminate agents that are producing constipation as a side-effect. When all of these measures are insufficient to relieve the symptoms, then medications are warranted.

Top of Page Practical Guide to Quality Improvement

Part I. Systems Related to Prevention and Early Detection of Constipation

  1. Does your facility have a system in place that promotes prevention, early detection and treatment of constipation and related disorders?
  2. If not, develop a system that includes:
    1. A mechanism to evaluate all residents upon admission for signs and symptoms of constipation.
    2. A careful review of the medication list of all new admissions to identify medications that can cause constipation.
    3. Actions to decrease risk of constipation. For example, develop procedures and programs that promote mobility (e.g., an exercise program) to reduce the risk of constipation.
    4. A means for identifying constipation in current residents by documenting changes in bowel habit, resident complaints of straining or inability to defecate and looking for evidence of fecal incontinence such as soiled clothing or linen.
    5. Training for nursing assistants to help them understand the roles of hydration, diet and activity in maintaining normal bowel function as well as the importance of recognizing and reporting signs of bowel emptying problems.
    6. A means to identify residents who take laxatives on a chronic basis. Laxative abuse is associated with bowel emptying problems.
    7. Diets that include adequate amounts of fluid and natural fiber to promote normal bowel function.

Part II. Identify Residents Who Experience Constipation [6,7,28,29]

Perform a history and physical (H & P) to evaluate residents with signs or symptoms of constipation.

  1. If the H & P is not consistent with symptoms of constipation, determine the nature of the resident's symptoms.
    1. What is the resident describing when s/he says constipation?
    2. Does the resident have increased sensation in the rectum that gives a feeling of fecal loading?
    3. Is there another potential cause (e.g., tumor)?
    4. If the resident does not have constipation, but takes laxatives regularly, the laxative may be the cause of the symptoms.
  2. If the H & P is consistent with the symptom of constipation:
    1. Discontinue medications having anticholinergic effects that may be responsible for the symptoms.
    2. Determine whether the resident needs disimpaction. Note: If disimpaction is indicated and not performed, future interventions will be ineffective and lead to worsening abdominal pain and increased risk of bowel perforation.
  3. Implement the following interventions to improve bowel function.
    1. Assess the resident's toileting habits.
      1. Emphasize comfort and privacy of toileting activities.
      2. Provide convenient, bedside toilets if necessary. Toilets should be cleaned as soon as possible after defecation, but no longer than 30 minutes after use. Failure to provide this basic attention may prevent residents from using a bedside toilet.
      3. Encourage toileting 30 minutes after breakfast and other meals to take advantage of the gastrocolic reflex.
      4. Evaluate residents that strain at stool for hemorrhoids and other anorectal conditions.
      5. Having the resident elevate the legs while seated on the toilet can assist weakened abdominal and pelvic floor muscles function more effectively.
    2. Provide adequate fluid intake:
      1. 1.5 liters of fluid intake per day is recommended to avoid constipation.
      2. Water is preferred, but juices are equally beneficial.
      3. Avoid diuretic medications as well as coffee, tea and alcohol as these increase the risk of dehydration and result in hard stools.
    3. Provide adequate dietary fiber:
      1. Encourage intake of 25 to 30 grams of dietary fiber per day with a fluid intake of at least 1.5 liters per day. Make sure that residents on increased fiber receive additional fluids.[30]
      2. A high fiber diet is not recommended for residents who are immobile or who are unable to take in at least 1.5 liters of fluid per day.
      3. Recognize that bloating, flatulence and irregular bowel movements are side effects of increased fiber intake, especially during the first 2 to 3 weeks. Increasing fiber intake can be done gradually (i.e., 1 tablespoonful per day over a few weeks) to minimize those side effects.[30]
    4. Provide a program of regular exercise in order to increase intestinal mobility.
      1. Residents who are fully mobile should walk 15-20 minutes once or twice a day.
      2. Residents with limited mobility should walk at least 50 feet twice a day with assistance.
      3. Residents who are unable to walk can perform pelvic tilt exercises, low trunk rotation and single leg lifts 15 to 20 minutes at least twice a day.
      4. For residents unable to tolerate even a simple exercise program, sitting up in a chair rather than lying in bed can improve intestinal mobility.
  4. Even when pharmacological treatment is necessary, proper diet, hydration and activity remain the foundation of constipation prevention and treatment.
    1. Anticipate the need for laxatives when a resident is prescribed narcotic pain medications. Ideally, physicians should prescribe a laxative at the same time that a narcotic is prescribed.
    2. Pharmacological treatments include: stimulant laxatives, bulk laxatives, saline laxatives, hyperosmolar laxatives, fecal softeners and enemas. See Table 2  for a description of laxative agents, their actions and recommended precautions.
    3. Consider using a laxative only if a resident does not have a bowel movement for more than three days. If laxatives must be used, proceed stepwise beginning with the bulk forming laxatives.
    4. Use suppositories for bowel retraining purposes. Because the rectal sphincter weakens with age, the use of a suppository can be therapeutic and is relatively harmless.[36] Bisacodyl suppositories are usually more effective than glycerin suppositories.
    5. When enemas are used to treat fecal impaction or intermittent chronic constipation, do not use soap suds or hydrogen peroxide enemas. These can cause severe colonic irritation.
    6. Whole gut irritation is an option as a single treatment for treating severe constipation or fecal impaction. This option should be used cautiously and should not be used in residents with heart failure.
  5. Develop individualized bowel regimen based on the above assessment components, possible interventions, and consideration of the resident's cultural background, preferences, and individual expectations of what is normal for that person.[30]

Top of Page Related Licensure and Certification Tags

The following deficiencies may be cited for failure to provide appropriate management of constipation, impaction, fecal incontinence and dual incontinence. The deficiency list is representative rather than exhaustive.

Program Licensure Tags (State) Certification Tags (Federal)
Nursing Facilities
19.407(1) F164 Personal Privacy
19.601(c) F224 Neglect
19.701(5)(A) F246 Accommodation of Needs
19.801 (1) F271 Admission Orders
19.801(2)(A)(B)(ix) F272 Comprehensive Assessments
19.801(2)(C)(i) F273 Comprehensive Assessment within 14 days of admission
19.801(2)(C)(ii) F274 Assessment following Significant Change in Condition
19.801(3) F276 Quarterly Review
19.801(7) F278 Accuracy of Assessment
19.802 (a)(1)(2) F279 Comprehensive Care Plans
19.802(b)(3) F280 Review and Revising the Care Plan
19.802((d)(1) F281 Services Meet Professional Standards of Quality
19.802(d)((2) F282 Implementation of Care Plan
19.802(e) F514 Care Plan available to all direct care staff (Readily Accessible)
19.901 F309 Quality of Care
19.901(1)(A)(iii) F310 Activities of Daily Living Decline
19.901(1)(B) F311 Treatment and Services
19.901(1)(C) F312 Activities of Daily Living
19.901(7)(B) F322 G tube appropriate treatment
19.901(9)(A) F325 Nutrition/Body Weight and Protein
19.901(9)(B) F326 Therapeutic Diet
19.901(10) F327 Hydration
19.901(12)(A)(i-vi) F329 Unnecessary drugs
19.1001(1)(A)(ii) F353 Sufficient Staff
19.1107(a)(1) F363 Menus and Nutritional Adequacy
19.1501(2) F426 Pharmacy Services
19.1501(4)(A) F428 Drug Regimen Review
19.1501(4)(B) F429 Irregularities reported by the Pharmacist
19.1701(4)(A)(iv) F460 Full Visual Privacy
19.1701(5) F462 Toilet Facilities room proximity
ICFs/MR
M0015 90.42 (c) W242 Training In Personal Skills
M0015 90.42 (c) W322 Preventive and general health care
Assisted Living
92.41(a)(3)(C)(v) Sufficient Staff to meet resident needs
92.41(a)(3)(D)(i)(ii) Availability of Staff
92.41(c)(1)(G) Resident assessment for ADLs
92.41(c)(1)(K) Resident Assessment for Physical Functioning
92.41(c)(1)(L) Resident Assessment for Nutritional Status
92.41(e)(1)(A) Admission and Retention of Resident whose needs cannot be met by the facility
92.41(j) Medications
92.41(k)(3) Medical Services due to Temporary Illness
92.41(j)(3) Self Administration of medications
92.41(m)(3) Nutritious Diet
92.41(m)(4) Therapeutic Diet
92.53 (c) Sufficient Staff (Alzheimer's Certified Unit)
92.62(m)(2)(A) Resident toilet and bathing facilities
92.101 Neglect of a Resident

Top of Page Additional Resources (including online resources)

The resources listed below are provided solely as a convenience to our users. These may include publications from government, professional, for-profit and non-profit sources. Some of these sources may have financial ties to industry. DADS does not control the content of these resources, and the opinions and recommendations provided there are those of the authors and do not necessarily reflect the position of QAI or DADS.

Online

National Guideline Clearinghouse. (Search the database using the keyword Constipation.)

In Print

Harari D, Gurwitz JH, Avorn J et al. Constipation: Assessment and management in an institutionalized elderly population. Journal of the American Geriatrics Society 1994;42(9):947-52.

Newman DK. Managing and Treating Urinary Incontinence.  Health Professions Press, Inc.: Baltimore, Maryland, 2002.

Top of Page Bibliography

[1] Borrie MJ and Davidson HA. Incontinence in institutions: costs and contributing factors. Canadian Medical Association Journal 1992;147(3):322-328.

[2] Chiang L, Ouslander J, Schnelle J, and Reuben DB. Dually incontinent nursing home residents: clinical characteristics and treatment differences. Journal of the American Geriatrics Society 2000;48(6):673-676.

[3] Wald A, Hinds JP, Caruana BJ. Psychological and physiological characteristics of patients with severe constipation. Gastroenterology 1989;97:932-937.

[4] Wald A. Constipation and fecal incontinence in the elderly. Gastroenterology Clinics of North America 1990;19(2):405-417.

[5] Hu T. The economic impact of incontinence. Clinics in Geriatric Medicine 1986;2(4):673-687.

[6] Alessi CA, Henderson CT. Constipation and fecal impaction in the long-term care patient. Clinics in Geriatric Medicine 1984;4(3):571-588.

[7] Harari D, Gurwitz JH, Minaker KL. Constipation in the elderly. Journal of the American Geriatrics Society 1993;41(10):1130-1140.

[8] Kinnunen O, Jauhonen P, Salokannel J, Kivelä S-L. Diarrhea and fecal impaction in elderly long-stay patients. Zeitschrift für Gerontologie 1989;22(6):321-323.

[9] Kamm MA. Faecal incontinence. British Medical Journal 1998;316(7130):528-532.

[10] Brocklehurst J, Dickinson E, and Windsor J. Laxatives and feacal incontinence in long term care. Elder Care 1998;10(4):22-25.

[11] Kinnunen O. Study of constipation in a geriatric hospital, day hospital, old people's home and at home. Aging 1991;3(2):161-170.

[12] Barrett JA, Brocklehurst JC, Kiff E, Ferguson G, Faragher EB. Anal function in geriatric patients with faecal incontinence. Gut 1989;30(9):1244-1251.

[13] Tobin GW, Brocklehhurst JC. Faecal incontinece in residential homes for the elderly: prevalence etiology and management. Age and Ageing 1986;15(1):41-46.

[14] Read NW, Abouzekry L. Why do patients with faecal impaction have faecal incontinence? Gut 1986;27(3):283-287.

[15] Robson KM, Kiely DK, and Lembo T. Development of constipation in nursing home residents. Diseases of the Colon and Rectum 2000;43(7):940-943.

[16] Pietrusko RG. Use and abuse of laxatives. American Journal of Hospital Pharmacists 1977;34(3):291-300.

[17] Castle SC, Cantrell M, Israel DS, et al. Constipation prevention: empiric use of stool softeners questioned. Geriatrics 1991;46(11):84-86.

[18] Harari D, Gurwitz JH, Avorn J, Choodnovskiy I, and Minaker KL. Constipation: assessment and management in an institutionalized elderly population. Journal of the American Geriatrics Society 1994;42(9):947-952.

[19] Kinnunen O, Salokannel J. Constipation in elderly long-stay patients: its treatment by magnesium hydroxide and bulk-laxative. Annals of Clinical Research 1987;19(5):321-323.

[20] Kinnunen O, Winblad J, Koistinen P, and Salokannel J. Safety and efficacy of a bulk laxative containing senna versus lactulose in the treatment of chronic constipation in geriatric patients. Pharmacology 1993;47(Suppl. 1):253-255.

[21] Passmore AP, Wilson-Davies K, Stoker C, and Scott ME. Chronic constipation in long stay elderly patients: a comparision of lactulose and a senna-fibre combination. British Medical Journal 1997;307(6907):769-771.

[22] Chassagne P, Landrin I, Nevue C, Czernichow P, Bouaniche M, Doucet J, Denis P, and Bercoff E. Fecal incontinence in the institutionalized elderly: incidence, risk factors, and prognosis. American Journal of Medicine 1999;106(2):185-190.

[23] Johanson JF, Irizarry F, and Doughty A. Risk factors for fecal incontinence in a nursing home population. Journal of Clinical Gastroenterology 1997;24(3):156-160.

[24] Nelson R, Furner S, and Jesudason V. Fecal incontinence in Wisconsin nursing homes. Disease of the Colon and Rectum 1998;41(10):1226-1229.

[25] Harari D, Gurwitz JH, Avorn J, Choodnovskiy I, and Minaker KL. Correlates of regular laxative use by frail elderly persons. American Journal of Medicine 1995;99(5):513-518.

[26] Brocklehurst JC, Kirkland JL, Martin J. Constipation in long-stay elderly patients: its treatment and prevention by lactulose, poloxalkol-dihydrooxyanthroquinnolone and phosphate enemas. Gerontology 1983;29(3):181-184.

[27] Resenda TL, Brocklehurst JC, and O'Neill PA. A pilot study on the effect of exercise and abdominal massage on bowel habit in continuing care patients. Clinical Rehabilitation 1993;7:204-209.

[28] Hert M, Huseboe J. Management of Constipation. University of Iowa Gerontological Nursing Interventions Research Center 1996. Guideline summary provided by the National Guideline Clearinghouse. Available: www.ngc.gov. Accessed: December 28, 2002.

[29] Monane M, Avorn J, Beers MH, and Everitt DE. Anticholinergic drug use and bowel function in nursing home patients. Archives of Internal Medicine 1993;153(5):633-638.

[30] Newman DK. Bowel dysfunction and its relationship to urinary incontinence.  In: Managing and Treating Urinary Incontinence.  Health Professions Press, Inc.: Baltimore, Maryland, 2002, pp. 53, 70-73, 205.

[31] Benton JM, O'Harra PA, Chen H, Harper DW, Johnston, SF.  Changing bowel hygiene practice successfully: a program to reduce laxative use in a chronic care hospital.  Geriatric Nursing 1997;18(1):12-17.

[32] Badiali D, Corazziari E, Habib FI, Tomei E, Bausano G, Magrini P, Anzini F, Torsoli A.  Effect of wheat bran in treatment of chronic nonorganic constipation-a double-blinded controlled trial.  Digestive Diseases and Sciences 1995;40(2):349-356.

[33] Smith DA, Newman DK.  The bran solution.  Contemporary Long Term Care 1989;12:66.

[34] Howard LV, West D, Ossip Klein DJ.  Chronic constipation management for institutionalized older adults.  Geriatric Nursing 2000;21(2):78-82.

[35] Beverley L, Travis I.  Constipation-proposed natural laxative mixtures.  Journal of Gerontological Nursing 1992;18(10):5-12.

[36] Venn MR, Taft L, Carpentier B, Applebaugh G.  The influence of timing and suppository use on efficiency and effectiveness of bowel training after stroke.  Rehabilitation Nursing 1992;17(3):116-120.

Literature Review Evidence Table

Top of Page Reviewers

Peer Reviewer: Diane Kaschak Newman, RNC, MSN, CRNP, FAAN
Review Date: May 11, 2003

Ms. Newman is an adult nurse practitioner and Co-Director of the Penn Center for Continence and Pelvic Health, Division of Urology, at the University of Pennsylvania Health System in Philadelphia. Her clinical practice focuses on the management of urinary and fecal incontinence.

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Last updated: May 13, 2003
Links updated December 1, 2004