Best s Using Volume 3, Issue y Myth 2 e Fogg m Care ugh th ng Ter Thro in Lo February-Marc utting delines h C ce Gui 2008 Practi Inside this issue:

Myth 1: 1 Constipation is BP Blogger not serious Myth 2: 1 Myth Busting: The Bowel Issue Fecal incontinence is diarrhea Myth 1: What is constipation? Myth 3: 2 Constipation The Rome II criteria (2004), global consensus of gastroenterological experts, Fecal impaction is not serious define constipation as the presence of 2 or more doesn't cause symptoms during the past 12 months: fecal impaction The most common bowel management problem in older people is constipation 1. straining for more than 25% of BMs Myth 4: 2 2. hardened stools with more than 25% of BMs but it’s not a problem that results from Bowel programs 3. sensation of incomplete evacuation of stool more don’t work aging. Older people can have normal than 25% of bowel movements bowel function but many are exposed to 4. sensation of blockage or obstruction with more medical conditions such as , diabetes, than 25% of bowel movements BPGs and 2 depression, dementia, and stroke; and 5. need to use manual maneuvers to facilitate Resources medications, low calorie/fibre intake, evacuation of stool with more than 25% of BMs, and immobility and ignoring the urge to 6. less than 3 bowel movements per week. Contacts for 1 & Information 2 defecate that increases the risk for immobile, had Parkinson’s disease or diabetes constipation. Constipation is a common mellitus, or took iron supplements, calcium problem in LTC with up to 50% of channel antagonists, or antidepressants. Chronic More information residents experiencing this condition constipation not only affects older persons’ on This and Other and 58-75% receiving at least one type quality of life but sometimes it can lead to Best Practices of laxative. Half of these residents serious complications such as fecal impaction, took a daily laxative, yet only 62% of bowel obstruction, bowel perforation/ ulcers, • Contact your Regional them met the Rome II criteria for megacolon, volvulus, incontinence, rectal LTC Best Practices constipation. Laxative use was more prolapse, hemorrhoids, laxative abuse and Coordinator. They can common in those who were cardiac and/or cerebrovascular dysfunction. help you with Best Practices Info for LTC. Myth 2: Find them at: • www.rgpc.ca Fecal incontinence is diarrhea Click on Long Term Care

Fecal incontinence (FI) occurs in up to 21% of for formed stool but it can’t cope with liquid or • www.shrtn.on.ca older people living at home and over 50% of irritant substances. FI varies from mere soiling of Click on Seniors Health LTC residents. FI increases with age, is higher undergarments by liquid stools to loss of control in older men than women and can be permanent of even solid stools. FI isn’t diarrhea. Residents • Check out the or temporary. Double incontinence (fecal and may complain of diarrhea when in fact, it’s FI. Hamilton Long Term urinary) occurs 12 times more often than fecal The most common cause of FI is constipation Care Resource Centre incontinence alone, with 50% to 70% of followed by anorectal muscle weakness due to www.rgpc.ca residents experiencing both. The combination constant strain- ing , post surgery, childbirth, of urinary and fecal incontinence is the second severe diarrhea, infection, laxative abuse, stroke, • Surf the Web for most common reason for LTC placement. medications, colorectal diseases, diabetes, BPGs Some …… .What is it? FI is the involuntary Parkinson’s, MS, spinal injury, dementia, sites and passage of fecal material through the anus. immobility and/or functional problems. resources are The function of the listed on pg 2. rectum is to act Centres of Excellence in Inter-professional Prac- Hamilton LTC as a reservoir tice and Collaborative Geriatric Care and The Resource Centre ©MLvanderHorst The Long Term Care Resource Centre Hamilton CuttingCutting Through Through the the Myth 3: A major problem associated FoggyFoggy Myths Myths Using Using Best Best with constipation Cutting Through the is the development of fe PracticePractice Guidelines Guidelines in in Fecal cal impaction. Fecal Foggy Myths Using Best impaction impaction n LongLong Term Term Care Care eeds special management which Practice Guidelines in often CONTACTS doesn't ca involves using enemas to clear the Long Term Care use EditorEditor bowel; in addition to stimulant l CONTACTS axatives. Mary-LouMary-Lou vanvan derder HorstHorst fecal incontinen When normal bowel fun Editor ce ction is restored, it’s GeriatricGeriatric Nursing Nursing /Knowledge /Knowledge important to Mary-Lou van der Horst resume constipation prevent TranslationTranslation Consultant Consultant (GIIC) (GIIC) strategies and discontinue ion as many laxatives as possible. Fecal RegionalGeriatric Geriatric Nursing /KnowledgeProgram - bowel impaction can lead to Regional Geriatric Program - Central obstruction. Most often, fecal inc Translation Consultant (GIIC) ontinence is due to fecal impaction St.Central Peter's Hospital is reported in 42% of older ad which Regional Geriatric Program - ults who have chronic constipation, 88St. Maplewood Peter's Ave, Hospital Hamilton, ON. L8M 1W9 doses of laxativ are receiving large Central es resulting in the seepage of sto [email protected] Maplewood Ave, Hamilton, ON. T ols around the bowel obstruction. St. Peter's Hospital his seepage or overflow fec L8M 1W9 al incontinence is very common in r cognitively impaired esidents who are [email protected] Maplewood Ave, Hamilton, ON. and/or bedridden. Risk factors for • overflow fecal incontinence include L8M 1W9 Medications – narcotics, antipsycho Library Support Services tics, antidepressants, calcium channe [email protected] • Metabolic a l blockers, diuretics Shannon Buckley bnormalities – hypothyroidism, high c • alcium, low potassium SHRTN Library Services-Hamilton Inadequate fiber and water intake Long Term Care Resource Centre • Immob ility and inadequate toileting RED FLA 88 Maplewood Ave , Hamilton ON L8M 1W9 Gs facilities in [email protected] persons with constipation ….. • Delirium While most older persons with constipat ion can be treated symptomatically, pe rsons who have any of the following at condition Find it on the Web s should have their causes of hrtn.on.ca constipation looked at more rigorou .rgpc.ca or www.s sly, for: www * Sudden onset * Rectal bleeding * Sudden involvement to develop change * Liquid stools * Abdominal pain * individualized care approaches No bowel sounds * No bowel movement in 3 or Myth 4: • Prevention: Modify factors more days * Change in vitals signs Bowel programs where possible including * Weig ht loss * Iron deficiency anemia increasing dietary fibre and * Fam don’t work ily/personal history of colon cancer fluid intake, laxative reductions, Bowel care programs do help to review medications, improve Constipation in Palliating Residents is a common prevent constipation, fecal activity levels, regular timing and troublesome side effect from opioid medica- impaction, incontinence and and positioning on the toilet. tions; ietary, motility and disease factors. It can bowel obstructions. Develop a •Assess regularly—do Bowel cause severe discomfort and ill health. Unfortu- workable proactive bowel assessments on admission, nately, there is insufficient research information management program that’s quarterly and with changes to determine the “best” management of constipa- tion in palliative care. Laxatives are used and opioid realistic with goals to . . . •Educate staff on bowel • rotation is recommended where laxatives fail. Improve residents’ quality of functioning and bowel care life and dignity as bowel •Document monitoring of diet, problems can cause decline in fluids, bowel/toileting habits, Check out these Best Practices & Guidelines. QOL, functional ability, social Answers to the Myths came from them. Find mobility/exercise, behaviours interactions, and pain out more! •Have acute and chronic bowel • Promote multidisciplinary Canadian: management strategies Registered Nurses Association of Ontario. (2005). TIPS *** •If no bowel movement on Prevention of constipation in the older adult population. *** Bowel Care Toronto, ON: RNAO. www.rnao.org ould not be day 3, laxatives are needed ATION-Fibre sh CONSTIP e or who Others: who are immobil •Avoid frequent or used in residents te fluid. American Medical Directors Association (2006). iving inadequa prolonged use of laxatives Gastrointestinal disorders in the long-term care setting. are rece dration – manage dehy •Minimize the use of Columbia, MD: AMDA.www.amda.com CONSTIPATION h E- Residents wit INCONTINENC stimulants such as Senna FECAL e most Hinrichs, M., Huseboe, J., & Titler, M.G. (1998). Evidence- rment benefit th cognitive impai on for long term use of based practice guideline. Management of constipation. rompting, redirecti habit training, p chronic constipation as it Iowa City, Iowa: University of Iowa Gerontological Nursing from on Interventions Research Center. www.nursing.uiowa.edu When constipati LAXATIVES can lead to diarrhea, to prevention resolves, return Gilding, M., Weedon, K., Schofield, S., et al. (1999). Best laxative use dehydration, and a egies and reduce practice: Management of constipation in older adults. strat cathartic bowel. Evidence based practice information sheets for health professionals. North Terrace, South Australia, Australia: Special thanks in Central Ontario Regional Geriatric Program-Central, The Joanna Briggs Institute for Evidence Based Nursing and Midwifery. www.joannabriggs.edu.au Seniors Health Research Transfer Network (SHRTN) , and The Village of Wentworth Heights LTC Home-Hamilton .©MLvanderHorst