Management of constipation in residents with dementia: sorbitol effectiveness and cost

Association of laxatives use with incident dementia and modifying effect of genetic susceptibility: a population-based cohort study with propensity score matching

BACKGROUND

Constipation was associated with incidence of dementia and cognitive decline. Laxatives are the mainstay of constipation management and are commonly used among older populations for both treatment and prevention of constipation. However, the association between use of laxatives and incident dementia, and whether laxatives use may modify the effect of genetic predisposition on dementia remains unclear.

METHODS

We applied 1:3 propensity score matching to balance the baseline characteristics of the laxative users versus non-users and to reduce potential confounders using multi-variates adjusted Cox hazards regression models. We categorized genetic risk into three groups (low, middle, and high) through a genetic risk score of common genetic variants. Information on laxatives use was assessed at baseline and categories into four varieties, including bulk forming laxatives, softeners and emollients, osmotic laxatives, and stimulant laxatives.

RESULTS

Of 486,994 participants, there were 14,422 laxatives users in UK Biobank. After propensity score matching, participants with use of laxatives (n = 14,422) and matched non-laxative (n = 43,266) exposed individuals were enrolled. Over follow-up to 15 years, there were 1377 participants developed dementia (539 for Alzheimer's disease, and 343 for vascular dementia). The use of laxatives had greater risk of dementia (HR, 1.72; 95% CI:1.54-1.92), Alzheimer's disease (HR, 1.36; 95% CI: 1.13-1.63), and vascular dementia (HR, 1.53; 95% CI: 1.23-1.92). Compared to non-laxative exposed participants, those with use of softeners and emollients drugs, stimulant laxatives, and osmotic laxatives were associated with 96% (HR, 1.96; 95 CI: 1.23-3.12; P = 0.005), 80% (HR, 1.80; 95% CI: 1.37-2.37; P < 0.001), and 107% (HR, 2.07; 95% CI: 1.47-2.92; P < 0.001) higher risk of developed incident dementia, respectively. In joint effect analysis, compared to participants with low/middle genetic susceptibility and non-laxatives use, the HR (95% CIs) of dementia was 4.10 (3.49-4.81) for those with high genetic susceptibility plus use of laxatives. There was an additive interaction between laxatives use and genetic susceptibility on dementia (RERI: 0.736, 95% CI: 0.127 to 1.246; AP: 0.180, 95% CI: 0.047 to 0.312).

CONCLUSIONS

Use of laxatives was associated with higher risk of dementia and modify the effect of genetic susceptibility on dementia. Our findings suggested that attention should be paid to the relationship between laxatives use and dementia, especially in people at high genetic susceptibility.

Use of sorbitol as pharmaceutical excipient in the present day formulations - issues and challenges for drug absorption and bioavailability

Sorbitol is a popular sugar alcohol which has been used as an excipient in formulations of various drugs. Although from a safety perspective the presence of sorbitol in drug formulations does not raise a concern, reports have emerged and these suggest that sorbitol in drug formulations may alter oral absorption and bioavailability of certain drugs. The focus of this article was to review the published literature of various drugs where pharmacokinetic data has been reported for the drug alone versus drug administered with sorbitol and provide perspectives on the pharmacokinetic findings. Interestingly, for BCS class I drugs such as theophylline, metoprolol, the oral absorption, and bioavailability were generally not affected by sorbitol. However, theophylline oral absorption and bioavailability were decreased when sustained release formulation was used in place of immediate release formulation. For drugs such as risperidone (BCS class II) and lamivudine and ranitidine (BCS class III), the solution formulations showed diminished oral bioavailability in presence of sorbitol, whereas cimetidine and acyclovir (BCS class III), did not show any changes in pharmacokinetic profiles due to sorbitol. Finally, the presence of activated charcoal with sorbitol showed different pharmacokinetic outcome for BCS class I and II drugs.

A controlled trial of an intervention to improve urinary and fecal incontinence and constipation

OBJECTIVES

To evaluate effects of a multicomponent intervention on fecal incontinence (FI) and urinary incontinence (UI) outcomes.

DESIGN

Randomized controlled trial.

SETTING

Six nursing homes (NHs).

PARTICIPANTS

One hundred twelve NH residents.

INTERVENTION

Intervention subjects were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months.

MEASUREMENTS

Frequency of UI and FI and rate of appropriate toileting as determined by direct checks from research staff. Anorectal assessments were completed on a subset of 29 residents.

RESULTS

The intervention significantly increased physical activity, frequency of toileting, and food and fluid intake. UI improved (P=.049), as did frequency of bowel movements (P<.001) and percentage of bowel movements (P<.001) in the toilet. The frequency of FI did not change. Eighty-nine percent of subjects who underwent anorectal testing showed a dyssynergic voiding pattern, which could explain the lack of efficacy of this intervention program alone on FI.

CONCLUSION

This multicomponent intervention significantly changed multiple risk factors associated with FI and increased bowel movements without decreasing FI. The dyssynergic voiding pattern and rectal hyposensitivity suggest that future interventions may have to be supplemented with bulking agents (fiber), biofeedback therapy, or both to improve bowel function.

Evidence rocks in long-term care, but does it roll?

This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation). In many cases, the treatments used have only marginal efficacy and increased potential for side effects. This article makes recommendations for improving the approach to evidence-based care in long-term care and strongly urges the FDA to require drug studies in nursing homes.

Constipation in Long-Term Care

Constipation is more common in older adults and accounts for increased physician office visits and hospital admissions. There is lack of agreement on the definition of constipation regarding what patients perceive as constipation and what physicians traditionally see as constipation. Constipation is related to multiple factors, and when left untreated or not properly treated, results in complications, such as impaction, even perforation and death. Laxative use increases with age and at times multiple agents are used to relieve symptoms of constipation. Currently the most commonly used laxative is stool softener but it lacks efficacy. From the review of literature, osmotic laxatives are effective in older adults and well tolerated. Psyllium, a bulk laxative, is also effective in the treatment of constipation, while there is limited evidence for stimulants, dioctyl sulfosuccinate, and other bulk laxatives such as calcium polycarbophil and methylcellulose. A new drug, lubiprostone, is a type 2-chloride channel activator and is shown to be effective, safe, and well tolerated in older adults treated for chronic constipation in studies up to a year. It appears to be particularly useful in persons who have recurrent fecal impaction and in those with severe chronic constipation. There is a need for a large-scale trial examining an appropriate cost-effective approach to the management of constipation in the nursing home.