Constipation: cause and control in an acute hospital setting

Nonrandomized Clinical Trial of the Effectiveness of a Laxative Treatment Protocol to Time of First Bowel Movement After Uterine Artery Embolization Procedure: A Pilot Study

PURPOSE

The purpose of this pilot study was to determine the efficacy of a proactive laxative protocol for constipation prevention in patients undergoing uterine artery embolization (UAE).

DESIGN

A nonrandomized clinical trial.

METHODS

A nonrandomized trial study design was piloted using a convenience sample of 35 patients undergoing UAE in the course of 1 year.

FINDINGS

There was a statistically significant difference (P < .0001) in time of first bowel movement after UAE when patients followed a proactive laxative protocol. A combination of senna and stool softener taken twice a day for 2 days preoperatively was associated with a shorter time to first bowel movement postoperatively.

CONCLUSIONS

This pilot study supports the benefits of a proactive laxative protocol in helping achieve procedural recovery uncomplicated by constipation in patients undergoing UAE.

Prevalence of constipation among persons living in institutional geriatric-care settings - a cross-sectional study

RATIONAL

The current state of knowledge about the prevalence of constipation among persons living in institutional geriatric-care settings is limited.

AIM

The aim was to investigate the prevalence of constipation among institutional geriatric-care residents and identify resident characteristics related to constipation.

METHODOLOGICAL DESIGN

In a cross-sectional study of all the institutional geriatric-care settings in a county in northern Sweden, 2970 residents were assessed. The member of staff who knew each resident best used the Multi-Dimensional Dementia Assessment Scale and the resident's records of prescribed medication to monitor cognitive function, activities in daily life, behavioural and psychological symptoms, physical restraints, speech ability, nutrition and pharmacologic agents. The study was approved by the Regional Ethical Review Board.

RESULT

The prevalence of constipation was 67%. The mean age was higher among those with constipation. A significantly higher proportion of the constipated had cognitive and/or physical impairments, physical restraints, impaired speech, problems with nutrition, and higher numbers of drugs for regular use. Of those with constipation, 68% were prescribed laxatives for regular use. Twenty-three per cent of the constipated residents were prescribed opioid analgesics (n = 465), and 29% (n = 134) of these were not prescribed any laxatives.

STUDY LIMITATION

Due to the cross-sectional design, the results should be interpreted with caution in terms of causal reasoning, generalisation and conclusions about risk factors. Another limitation is the use of proxy assessments of constipation.

CONCLUSION

The results show that constipation is common among residents in institutional geriatric-care settings in Sweden, which is in line with previous studies from other Western countries. Despite being constipated when having prescribed opioid analgesics, a large number did not have prescribed laxatives. The results indicate the urgency of finding strategies and implementing suitable interventions to improve bowel management in residents in institutional geriatric-care settings.

Constipation and Botanical Medicines: An Overview

Constipation affects 14% of the adult population globally, mainly women, and significantly impacts on health-related quality of life. The causes of constipation are mainly three: lifestyle related (functional constipation), disease related, and drug induced. Constipation can generate considerable suffering, including abdominal pain and distension, anorexia, and nausea. The value of some therapeutic measures such as increased fluid intake, physical activity, diet rich in fiber, and nutritional supplements recommended for the relief of constipation is still questionable. The treatment of constipation can be carried out not only with traditional drugs but also with herbal medicines or with nutraceuticals, which are used to prevent or treat the disorder. We have reviewed the most common botanical laxatives such as senna, cascara, frangula, aloe, and rhubarb and their use in the treatment of constipation.

Risk assessment and management tools for constipation

Constipation is a distressing condition that can happen to anyone, but is of particular concern in the elderly and less mobile, people with neurological impairments, and those in institutional care. The causes of constipation are multifactorial, and can be influenced by physical, psychological, physiological, emotional and environmental factors. This article discusses definitions, symptoms and types of constipation, and provides guidance on risk factors and assessment using the Norgine Risk Assessment Tool for Constipation.

Laxatives or methylnaltrexone for the management of constipation in palliative care patients

BACKGROUND

Constipation is common in palliative care; it can generate considerable suffering due to the unpleasant physical symptoms. In the first Cochrane Review on effectiveness of laxatives for the management of constipation in palliative care patients, published in 2006, no conclusions could be drawn because of the limited number of evaluations. This article describes the first update of this review.

OBJECTIVES

To determine the effectiveness of laxatives or methylnaltrexone for the management of constipation in palliative care patients.

SEARCH STRATEGY

We searched databases including MEDLINE and CENTRAL (The Cochrane Library) in 2005 and in the update to August 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating laxatives for constipation in palliative care patients. In the update we also included RCTs on subcutaneous methylnaltrexone; an opioid-receptor antagonist that is now licensed for the treatment of opioid-induced constipation in palliative care when response to usual laxative therapy is insufficient.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity.

MAIN RESULTS

We included seven studies involving 616 participants; all under-reported methodological features. In four studies the laxatives lactulose, senna, co-danthramer, misrakasneham, and magnesium hydroxide with liquid paraffin were evaluated. In three methylnaltrexone.In studies comparing the different laxatives evidence was inconclusive. Evidence on subcutaneous methylnaltrexone was clearer; in combined analysis (287 participants) methylnaltrexone, in comparison with a placebo, significantly induced laxation at 4 hours (odds ratio 6.95; 95% confidence interval 3.83 to 12.61). In combined analyses there was no difference in the proportion experiencing side effects, although participants on methylnaltrexone suffered more flatulence and dizziness. No evidence of opioid withdrawal was found. In one study severe adverse events, commonly abdominal pain, were reported that were possibly related to methylnaltrexone. A serious adverse event considered to be related to the methylnaltrexone also occurred; this involved a participant having severe diarrhoea, subsequent dehydration and cardiovascular collapse.

AUTHORS' CONCLUSIONS

The 2010 update found evidence on laxatives for management of constipation remains limited due to insufficient RCTs. However, the conclusions of this update have changed since the original review publication in that it now includes evidence on methylnaltrexone. Here it found that subcutaneous methylnaltrexone is effective in inducing laxation in palliative care patients with opioid-induced constipation and where conventional laxatives have failed. However, the safety of this product is not fully evaluated. Large, rigorous, independent trials are needed.

The older person: management of constipation

Despite being a major concern for the older person, constipation is not given the attention it needs as other conditions are often deemed as more pressing. This article explores the symptom of constipation in the older patient; established management and treatment options are discussed within the context of available evidence together with new constipation management modalities.

Constipation in the acutely hospitalized older patients

The aim of this work was to establish the factors that determine the onset of constipation in acutely hospitalized older patients with a view to contributing towards an evidence-based identification of which patients warrant early, specific preventive measures. To evade the problem posed by the definition of constipation, we have considered parameters that are part of the daily routine in the hospital ward, such as the prescription of laxatives, also paying attention to how the co-operative older person subjectively interpret this condition. One thirds of the 192 hospitalized older patients needed a laxative at least once every 3 days. Multivariate analysis identified the use of laxatives at home as the only risk factor for objective constipation while in hospital (odds ratio (OR)=3.0). A significant risk of being dissatisfied with their bowel emptying emerged among patients who were bedridden for more than 2 weeks (OR=6.0), and in those who experienced cerebrovascular events (OR=3.1). The use of laxatives at home and awareness that satisfaction with bowel movements drops in patients obliged to stay in bed for lengthy periods of time and in those who have suffered cerebrovascular damage, should provide the grounds for a screening program to establish rational guidelines on bowel movement therapy.

Constipation and palliative care - where are we now?

Constipation is an unpleasant and distressing symptom that many palliative care patients may experience, often having a profound effect on their quality of life. The many management options available reflect the multifactorial nature of constipation. The article explores the complexity of constipation in palliative care and highlights the challenge of managing opioid-induced constipation. Advances in the pharmacological and non-pharmacological management of constipation are reviewed and discussed in the light of relevant research. Further discussion includes definitions, incidence and causes of constipation in palliative care.

Laxatives for the management of constipation in palliative care patients

BACKGROUND

Constipation is a common problem for palliative care patients which can generate considerable suffering for patients due to both the unpleasant physical symptoms and psychological preoccupations that can arise. There is uncertainty about the 'best' management of constipation in palliative care patients and variation in practice between palliative care settings.

OBJECTIVES

To determine the effectiveness of laxative administration for the management of constipation in palliative care patients, and the differential efficacy of the laxatives used to manage constipation.

SEARCH STRATEGY

We searched The Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue four, 2005), MEDLINE (1966 to January 2005), EMBASE (1980 to January 2005), CANCERLIT, PUBMED, Science Citation Index, CINAHL, The Cochrane Library, SIGLE, NTIS, DHSS-DATA, Dissertation Abstracts, Index to Scientific and Technical Proceedings and NHS-NRR and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing laxatives for constipation in palliative care patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted patient-reported data measuring changes in stool frequency and ease of passing stools, using objective and validated scales. Tolerance or adverse effects of laxatives used were also sought. The appropriateness of synthesizing data from the controlled trials depended upon the clinical and statistical homogeneity of studies identified. If the controlled trials were homogeneous, a meta-analysis would be attempted.

MAIN RESULTS

Four trials involving 280 people were included. Between these trials, the laxatives lactulose; senna; danthron combined with poloxamer (Co-danthramer); Misrakasneham; magnesium hydroxide combined with liquid paraffin (Milpar) were evaluated. All four trials included number and frequency of bowel movements and relative ease of defecation as part of the assessment of laxative efficacy. All of the laxatives demonstrated a limited level of efficacy, although a significant number of participants required rescue laxatives in each of the studies. The only significantly different treatments were in the trial where lactulose plus senna were more effective than danthron combined with poloxamer. Patient preference did not favour either treatment option. Other related systematic reviews have similarly identified that there is a lack of evidence to support the use of one laxative, or combination of laxatives, over another.

AUTHORS' CONCLUSIONS

The treatment of constipation in palliative care is based on inadequate experimental evidence, such that there are insufficient RCT data. Recommendations for laxative use can be related to costs as much as to efficacy. There have been few comparative studies, equally there have been few direct comparisons between different classes of laxative and between different combinations of laxatives. There persists an uncertainty about the 'best' management of constipation in this group of patients.

Pharmacoeconomic Impact of Low-Dose Macrogol 3350 plus Electrolytes Compared with Lactulose in the Management of Chronic Idiopathic Constipation among Ambulant Patients in Belgium

OBJECTIVE

To estimate the economic impact of using low-dose macrogol 3350 plus electrolytes (macrogol 3350; Movicol((R))) compared with lactulose in the treatment of chronic idiopathic constipation among ambulant patients in Belgium, from the perspectives of the Sick Fund and patients. The analysis considered separately the economic impact of (a) a specialist and (b) a general practitioner (GP) initiating treatment.

DESIGN AND SETTING

This was a modelling study performed from the perspective of Belgium's Sick Fund and patients.

METHODS

Estimates of healthcare resource utilisation in a previously reported UK model depicting the management of chronic idiopathic constipation with either macrogol 3350 and lactulose over 3 months were replaced with Belgian estimates derived from a panel of 11 gastroenterologists and 11 GPs. The model was used to estimate the expected 3-monthly Sick Fund cost and direct cost to patients of using either laxative to manage chronic idiopathic constipation in Belgium.

MAIN OUTCOME MEASURES AND RESULTS

According to our model, 53% and 24% of patients are expected to be successfully treated with macrogol 3350 and lactulose, respectively. Additionally, using macrogol 3350 instead of lactulose is expected to reduce the 3-monthly Sick Fund cost in approximately 55% of patients and afford a cost-effective treatment in the remaining patients. Furthermore, the 3-monthly Sick Fund cost of managing chronic idiopathic constipation among ambulant patients is expected to be reduced by approximately 50% if patients were initially treated by a GP instead of a specialist. In Belgium, laxatives are paid for by patients. Despite the difference in their acquisition cost, treating chronic idiopathic constipation with either macrogol 3350 or lactulose was found to be cost neutral from a patient's perspective.

CONCLUSIONS

The true cost of managing chronic idiopathic constipation is impacted on by a broad range of resources and not only laxative acquisition costs. This study indicated that managing ambulant patients with chronic idiopathic constipation with macrogol 3350 instead of lactulose is a cost-effective treatment from the Sick Fund's perspective and cost neutral from a patient's perspective.

Adverse events and complications among patients admitted to hospital in the home directly from the emergency department

INTRODUCTION

The nature and incidence of adverse events and complications among patients admitted from the emergency department to hospital in the home has not been investigated. This study aimed to investigate this problem and make recommendations for prevention strategies.

METHODS

This was an explicit retrospective chart review of patients admitted from the emergency department directly to hospital in the home between 22 February 1995 and 1 September 2000. A data extraction document was designed specifically for the study and used to extract data relating to patient demographics, diagnosis, past medical history and outcome. The outcomes of interest include adverse events, complications and death. An adverse effect is defined as an unintended injury or complication that results in disability, death or prolonged hospital stay and is caused by health care management. These adverse events may occur prior to or during the index admission and may be noted during or after the index admission. A complication is defined as an undesirable outcome that occurs during the management but not causing disability, death or prolonged hospital stay.

RESULTS

Three hundred and fifty-seven patients were enrolled (51.3% male; median age 52 years, range 16-96 years). Fifty-five adverse events were identified: 49 adverse events (89%) were due to management prior to hospital in the home admission and six adverse events (10.9%) were directly attributable to hospital in the home management. This represents a rate of 1.7 adverse events per 100 hospital in the home admissions directly attributable to hospital in the home management. One hundred and eighteen complications were identified. Most complications were easily managed. Thirty-one patients had unplanned re-admissions and two patients died within 28 days of hospital in the home admission.

CONCLUSION

Most patients admitted to hospital in the home from the emergency department were managed successfully. Few adverse events arose from hospital in the home treatment. Complications were common but minor in nature. Strategies for the prevention of phlebitis and constipation are recommended.

Economic impact of low dose polyethylene glycol 3350 plus electrolytes compared with lactulose in the management of idiopathic constipation in the UK

OBJECTIVE

To estimate the economic impact of using low dose polyethyene glycol 3350 (PEG 3350) plus electrolytes (PEG+E) compared with lactulose in the treatment of idiopathic constipation in ambulant patients. DESIGN AND PERSPECTIVE: This was a decision analytic modelling study performed from the perspective of the UK's National Health Service (NHS).

METHODS

The clinical outcomes from a previously reported single-blind, randomised, multicentre trial were used as the clinical basis for the analysis. These data were combined with resource utilisation estimates derived from a panel of six general practitioners (GPs) and four nurses enabling a decision model to be constructed depicting the management of idiopathic constipation with either PEG+E or lactulose over 3 months. The model was used to estimate the expected 3-monthly NHS cost of using either laxative to manage idiopathic constipation.

MAIN OUTCOME MEASURES AND RESULTS

The expected 3-monthly NHS cost of using PEG+E or lactulose to manage idiopathic constipation was estimated to be 85 pound sterling and 96 pound sterling per patient, respectively (1999/2000 values). However, significantly more patients were successfully treated with PEG+E than lactulose (53% versus 24%; p < 0.001) at 3 months. GP visits were the primary cost driver for both PEG+E- and lactulose-treated patients, accounting for 56% (2.9 visits) and 73% (4.4 visits), respectively, of the expected NHS cost per patient at 3 months. Among PEG+E-treated patients, the acquisition cost of PEG+E was the secondary cost driver, accounting for 30% of the expected NHS cost per patient at 3 months, whereas the acquisition cost of lactulose accounted for only 11% of the expected NHS cost per lactulose-treated patient. District nurse domiciliary visits accounted for 4% and thyroid function tests for 2%. The costs of switched laxatives, concomitant laxatives, and gastroenterologist and colorectal surgeon visits collectively accounted for up to 9% of the total.

CONCLUSIONS

The true cost of managing idiopathic constipation is impacted on by a broad range of resources and not only laxative acquisition costs. This study indicated that managing idiopathic constipation with PEG+E instead of lactulose reduces the expected 3-monthly NHS cost by 11 pound sterling per patient. Moreover, using PEG+E instead of lactulose is expected to double the percentage of patients successfully treated at 3 months. Hence, PEG+E is a dominant treatment compared with lactulose. This suggests that the decision to use either PEG+E or lactulose to treat idiopathic constipation should be based on efficacy, safety, patient preferences and total management costs, and not drug acquisition costs.

Patient care after discharge from the ambulatory surgical center

An important and often forgotten aspect of postoperative care occurs after the patient is discharged from the ambulatory surgical center. With more than 60% of all surgeries and procedures occurring on an ambulatory basis, what happens after the patient is no longer in continuous professional care is of concern to the ambulatory nurse. Numerous physical postoperative complaints are common and expected sequelae of anesthesia and surgery in the ambulatory patient. In this article, important postdischarge complications are reviewed and contemporary management options discussed. The information contained in this review article is valuable to the provider in educating patients regarding their anticipated course of postoperative recovery.

OBJECTIVES

-Based on the content of this article, the reader should be able to (1) identify important postdischarge complications to provide patients with comprehensive discharge instructions regarding their continued recovery at home; (2) discuss contemporary management options available to treat postdischarge complications; (3) realize the incidence of specific postdischarge complications and how that relates to patient satisfaction with the surgical experience; (4) recognize signs and symptoms of postdischarge complications; and (5) identify risk factors of patients for developing specific complications in the postoperative phase.

Evidence-based management of constipation in the oncology patient

Constipation is suffered by over 50% of cancer patients and is regarded as one of the most distressing symptoms causing both physical and emotional distress. A need to treat constipation is often due to a failure to prevent it. There is little literature in this area and research based on clinical trials as to best treatment is virtually non-existent. It is suggested that many health-care professionals dismiss constipation as a relatively trivial problem, resulting in a lack of attention to the subject. There is a lack of consensus on the definition of constipation and confusion regarding effective methods for prevention and treatment. It could be argued that health-care professionals are more intent on monitoring the direct effects rather than the secondary effects of treatment. Since constipation is largely preventable, there is a need to highlight the importance of prevention in addition to establishing effective treatment guidelines. Oncology nurses are in an ideal position to identify cancer patients in a high-risk category and utilize preventive strategies. The study described has led to the development of evidence-based drug guidelines to be used in the prevention of constipation and acute/chronic constipation to ensure that patients receive the best treatment possible.

A protocol for treating acute constipation in the community setting

Constipation is a distressing symptom, common in many patient groups and traditionally treated by nurses. Ambiguity concerning limits of the nurse's role in treating constipation exists and guidelines are scarce. Theoretically constipation is largely preventable, but acute episodes arise for a number of reasons and often need prompt treatment. This article describes the development of a local protocol which empowers appropriately trained community nurses to treat adult patients with acute constipation. A flow chart was used to define the guidelines. Implementation of the protocol is briefly discussed in relation to other current local initiatives.