Association between Anticholinergic Burden and Constipation: A Systematic Review

The association between anticholinergic burden and constipation is not well defined and documented; for this reason, a systematic review was carried out in five databases (Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus), including studies assessing the correlation between anticholinergic burden, and constipation between January 2006 and December 2020. Data extraction was conducted independently by two researchers. Abstracts and titles were reviewed to determine eligibility for review with eligible articles read in full. From 2507 identified articles, 11 were selected for this review: six cross-sectional studies, four retrospective cohort studies, and a post hoc analysis of a randomized clinical trial. Overall, nine studies reported at least one statistical association between anticholinergic burden and constipation, finding 13 positive results out of 24 association measurements. A total of 211,921 patients were studied. The association between constipation and anticholinergic burden could be demonstrated in studies including 207,795 patients. Most studies were not designed to find differences in constipation prevalence and did not adjust the results by confounding factors. Our findings suggest that a correlation between anticholinergic burden and constipation exists. Higher quality-evidence studies are needed, including analysis that considers confounding factors, such as other non-pharmacological causes of constipation.

Potentially Inappropriate Prescriptions for Anticholinergic Medications for Patients with Constipation

INTRODUCTION

Constipation is a very common functional gastrointestinal disorder in the general population and can be primary or secondary.

OBJECTIVE

The aim of this study was to estimate the anticholinergic burden of prescribed drugs in a population diagnosed with constipation in Colombia.

METHODS

This was a cross-sectional study that used a population database of 6.5 million people to identify the prescription of cholinergic antagonists and drugs for the management of constipation in outpatient services. The anticholinergic burden was evaluated using the Anticholinergic Drug Scale. Potentially inappropriate prescriptions that increased the risk of constipation were identified.

RESULTS

A total of 3,887 patients with constipation were identified; the identified patients had a mean age of 54.4 ± 21.9 years, and 69.4% were women. Eighty percent received at least one laxative, and the most prescribed laxative was bisacodyl (50.5%). Forty-one percent (n = 1,586) of all patients received drugs with cholinergic antagonist activity, in particular codeine (6.5%) and valproic acid (6.5%). Being over 30 years of age (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.24-2.57), being treated in the cities of Manizales (OR: 2.20; 95% CI: 1.50-3.21) and Pereira (OR: 1.49; 95% CI: 1.07-2.09), and having hypothyroidism as a comorbidity (OR: 1.37; 95% CI: 1.08-1.73) were associated with a greater probability of receiving medications with an anticholinergic burden of 3 or more points.

CONCLUSIONS

The majority of patients with constipation were women and were using laxatives to manage constipation. A large proportion of patients were prescribed at least one cholinergic antagonist drug, with an increased probability of use after 30 years of age.

Is Fibre an Effective Strategy to Improve Laxation in Long-Term Care Residents?

The high prevalence of constipation in long-term care (LTC) residents has been a long-standing issue for caregivers, attending health professionals, and the residents themselves. The traditional medical response has been to utilize pharmaceutical laxatives, enemas, and suppositories for treatment. The purpose of this review was to determine if fibre supplementation (including fibre added to foods) is effective in increasing stool frequency, improving stool consistency, and decreasing laxative use in LTC residents. A systematic search was conducted using PubMed and CINAHL databases, inclusive to March 2017. Search terms included: "long-term care" or "nursing home" AND "fiber (fibre)," "bran," "psyllium," "inulin," or "prebiotic." Intervention trials of fibre supplementation with ≥5 LTC residents were included. The search generated 456 articles following removal of duplicates; 8 studies met the inclusion criteria. Three additional trials were identified through a hand search of references of pertinent articles. Current evidence suggests that added fibre may be effective in increasing stool frequency and/or decreasing laxative use in LTC residents and, thus, may lessen the burden of constipation. However, randomized controlled trials are needed to clearly demonstrate the effects of adding fibre to foods, particularly insoluble and less fermentable sources, on constipation in LTC residents.

Constipation and Laxative Use among Nursing Home Patients: Prevalence and Associations Derived from the Residents Assessment Instrument for Long-Term Care Facilities (interRAI LTCF)

Introduction. Constipation is a common, bothersome, and potentially dangerous condition among nursing home (NH) patients. Between 50 and 74% of NH patients use laxatives. Objective. To study prevalence and associations of laxative use and constipation using the comprehensive Norwegian version of the Resident Assessment Instrument for Long-Term Care Facilities. Methods. Cross-sectional study. Patients from 20 NH units were included. Logistic regression was used to analyze the results. Data collected in NHs might be clustered. Consequently, the multivariable models were tested against a mixed effects regression model to investigate variance both on the level of patients and on the level of NH units. Results. In all, 261 patients were included. The prevalence of constipation was 23.4%, and 67.1% used laxatives regularly. Balance problems, urinary incontinence, hypothyroidism, and Parkinson's disease were associated with constipation. Reduced ability to communicate and number of drugs were associated with laxative use. Antidementia-drugs and being involved in activities 1/3 to 2/3 of daytime were protective factors for laxative use. Mixed effects analyses identified variance on the level of NH units as nonsignificant. Conclusion. Constipation and laxative use are common. Variance is mainly explained by different patient characteristics/health deficiencies. Hence, patients might benefit from individualized care to compensate for deficiencies.

Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review

OBJECTIVE

The objective of the study was to investigate the prevalence of, and factors associated with, polypharmacy in long-term care facilities (LTCFs).

METHODS

MEDLINE, EMBASE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library were searched from January 2000 to September 2014. Primary research studies in English were eligible for inclusion if they fulfilled the following criteria: (1) polypharmacy was quantitatively defined, (2) the prevalence of polypharmacy was reported or could be extracted from tables or figures, and (3) the study was conducted in a LTCF. Methodological quality was assessed using an adapted version of the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

Forty-four studies met the inclusion criteria and were included. Polypharmacy was most often defined as 5 or more (n = 11 studies), 9 (n = 13), or 10 (n = 11) medications. Prevalence varied widely between studies, with up to 91%, 74%, and 65% of residents taking more than 5, 9, and 10 medications, respectively. Seven studies performed multivariate analyses for factors associated with polypharmacy. Positive associations were found for recent hospital discharge (n = 2 studies), number of prescribers (n = 2), and comorbidity including circulatory diseases (n = 3), endocrine and metabolic disorders (n = 3), and neurological motor dysfunctioning (n = 3). Older age (n = 5), cognitive impairment (n = 3), disability in activities of daily living (n = 3), and length of stay in the LTCF (n = 3) were inversely associated with polypharmacy.

CONCLUSIONS

The prevalence of polypharmacy in LTCFs is high, varying widely between facilities, geographical locations and the definitions used. Greater use of multivariate analysis to investigate factors associated with polypharmacy across a range of settings is required. Longitudinal research is needed to explore how polypharmacy has evolved over time.

Managing constipation: implementing a protocol in a geriatric rehabilitation setting

This study examined the effect of implementing a constipation management protocol (CMP) within a geriatric rehabilitation setting. A convergent mixed-methods research design was used. Quantitative data on bowel activity, laxative use, opiate drug use, and nursing documentation regarding bowel care were gathered through a review of health records for 305 patients admitted to three geriatric rehabilitation units before (n = 137) and after (n = 168) protocol implementation over two 3-month periods. Focus groups were conducted examining nursing staff's experiences with such a protocol. Findings revealed that although implementation of the CMP did not reduce constipation rates among older patients, the average number of incidences of constipation per patient was reduced after implementation of the protocol. More importantly, it resulted in more due diligence by staff regarding patients' bowel patterns as well as improved bowel care documentation. Findings and recommendations extend current literature and have practical implications for nurses interested in improving management of patients' bowel care.

Prevalence and Effectiveness of Laxative Use Among Elderly Residents in a Regional Hospital Affiliated Nursing Home in Hsinchu County

Background:

Long-term care residents are susceptible to constipation and one-half to three quarter of older nursing home residents receive laxatives regularly.

Objectives:

The purpose of this study was to evaluate the factors related to abnormal bowel function and explore the effectiveness of laxative treatment among the elderly residents of a nursing home.

Patients and Methods:

A total of 110 residents older than 65 years old was enrolled in this study. The following variables were gathered: age, gender, body mass index (BMI), length of stay, daily fluid intake, type of food, functional level, cognitive ability, physical therapy status, somatic and psychiatric diseases, number of medications, and medication use. The use and dosage of laxatives were recorded by means of Anatomical Therapeutic Chemical (ATC) classification system. Normal bowel function was defined as defecation frequency from three defecations per day to three defecations per week and stool consistency score of three to five on Bristol Stool Form Scale. A comparison between groups with normal and abnormal bowel function was drawn.

Results:

Low BMI, increased fluid intake, liquid food intake, poor functional level, poor cognition, and a history of stroke were significantly associated with altered bowel function (P < 0.05). The most frequently used laxatives were glycerol, senna glycoside, and magnesium oxide. There were significant differences in laxative regimens between residents with normal and altered bowel function; those with altered bowel function tended to take more laxatives than those with normal bowel function.

Conclusions:

This study suggested that treatment of constipation in the nursing home was unsatisfactory. To improve treatment outcomes in those susceptible to altered bowel function, a coordinated approach with involvement of physicians, nursing staff, and other professionals including dieticians and pharmacists seems necessary.