Constipation and palliative care - where are we now?

Management of Opioid-induced Constipation in Older Adults

Opioid-induced constipation (OIC) is a common condition in older adults who may not be responsive to traditional laxative therapy. OIC is defined as new or worsening constipation symptoms that occur with initiation of or altering the dose of opioid analgesia. For adult patients with OIC and noncancer pain, we recommend considering nonpharmacologic interventions (eg, dietary measures, increased physical activity, and biofeedback training) and over-the-counter laxatives, followed by prescription opioid receptor antagonists (methylnaltrexone, naloxegol, and naldemedine) if traditional over-the-counter laxatives fail. Other options may include lubiprostone, linaclotide, plecanatide, and prucalopride; however, these are not indicated for OIC specifically or studied in older adults. Because of the complex nature of absorption, distribution, metabolism, and excretion in the aging population, all agents used to treat OIC must be evaluated individually and reevaluated as patients continue to age. This review will serve as a guide to managing OIC in older adults.

Solihull constipation pathway

Constipation management is in need of improvement. This improvement is more likely to be achieved with a thorough initial assessment and ongoing daily monitoring with evaluation. A practical, user-friendly documentation system that facilitates this has been developed at Marie Curie Hospice, Solihull. It is currently being used with great success in a hospice inpatient setting and is transferable to hospitals. With some modification it could be used by district nurses and general practitioners in the community. It is an important step towards improving the management of constipation.

Consensus Recommendations on Initiating Prescription Therapies for Opioid-Induced Constipation

Objective

Aims of this consensus panel were to determine (1) an optimal symptom‐based method for assessing opioid‐induced constipation in clinical practice and (2) a threshold of symptom severity to prompt consideration of prescription therapy.

Methods

A multidisciplinary panel of 10 experts with extensive knowledge/experience with opioid‐associated adverse events convened to discuss the literature on assessment methods used for opioid‐induced constipation and reach consensus on each objective using the nominal group technique.

Results

Five validated assessment tools were evaluated: the Patient Assessment of Constipation–Symptoms (PAC‐SYM), Patient Assessment of Constipation–Quality of Life (PAC‐QOL), Stool Symptom Screener (SSS), Bowel Function Index (BFI), and Bowel Function Diary (BF‐Diary). The 3‐item BFI and 4‐item SSS, both clinician administered, are the shortest tools. In published trials, the BFI and 12‐item PAC‐SYM are most commonly used. The 11‐item BF‐Diary is highly relevant in opioid‐induced constipation and was developed and validated in accordance with US Food and Drug Administration guidelines. However, the panel believes that the complex scoring for this tool and the SSS, PAC‐SYM, and 28‐item PAC‐QOL may be unfeasible for clinical practice. The BFI is psychometrically validated and responsive to changes in symptom severity; scores range from 0 to 100, with higher scores indicating greater severity and scores >28.8 points indicating constipation.

Conclusions

The BFI is a simple assessment tool with a validated threshold of clinically significant constipation. Prescription treatments for opioid‐induced constipation should be considered for patients who have a BFI score of ≥30 points and an inadequate response to first‐line interventions.

Managing constipation: a focus on care and treatment in the palliative setting

Constipation can cause unnecessary discomfort and suffering for patients, and there appears to be a lack of awareness among nurses and doctors about its cause, impact and management. A large proportion of the evidence for the assessment and management of constipation in the context of palliative care is derived from the perspective of advanced cancer and from guidelines developed at a European level. Although constipation remains a problem for palliative care patients, early intervention combined with continuous and impeccable assessment can assist in its management and improve patient comfort at the end of life.

Comparison of the Constipation Assessment Scale and plain abdominal radiography in the assessment of constipation in advanced cancer patients

CONTEXT

Constipation is a distressing condition for advanced cancer patients and is frequently underdiagnosed.

OBJECTIVES

The primary objective of this study was to determine if a strong correlation existed between the use of the Constipation Assessment Scale (CAS) and a plain abdominal radiograph in the interpretation of constipation in patients with advanced cancer. The secondary aim of the study was to compare the plain film radiographic constipation scores among three palliative medicine physicians.

METHODS

The study was a prospective cross-sectional study of 50 advanced cancer patients admitted to a tertiary palliative care unit. These patients completed the CAS shortly after their admission to the unit. Around the same time, they underwent a flat plate of abdomen that was scored from 0 to 12, based on the amount of stool in the colon, by three palliative medicine physicians who were blinded to the CAS results and each other's radiographic interpretations. Kendall Tau correlation coefficient was used to estimate and test the correlations between the CAS and radiographic constipation scores.

RESULTS

There was no concordant correlation between the CAS scores and each physician's radiographic constipation score. There also was no concordant correlation between the CAS score and the combined radiographic constipation scores of the three palliative medicine physicians (Kendall Tau coefficient=0.04; P=0.72). The degree of correlation between the radiographic constipation scores from the three palliative medicine physicians was moderate.

CONCLUSION

Our study failed to yield a strong correlation between the CAS and the plain abdominal radiographic scores for constipation completed by three palliative medicine physicians. It is advisable that constipation in advanced cancer patients be assessed both clinically and radiographically.

Consensus recommendations for the management of constipation in patients with advanced, progressive illness

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

Bowel and bladder care at the end of life

This article discusses the management of end of life continence care under the headings of four end of life core competencies. Management modalities are identified and explored within the context of evidence based practice.

Management of gastrointestinal symptoms in advanced cancer patients: the rapid learning cancer clinic model

PURPOSE OF REVIEW

Gastrointestinal symptoms are prevalent, often persistent, and detrimental to patients' quality of life. This review discusses evaluation of gastrointestinal symptoms as patient-reported outcomes (PROs) and presents an information technology-based system for symptom monitoring and management. The electronic PRO (ePRO) system is then placed within the larger context of rapid learning healthcare, a concept currently under development in which data obtained through both research and clinical care continuously build large datasets for analysis, seed future research, fuel expansion of the evidence base, and support clinical decision-making.

RECENT FINDINGS

PROs are increasingly recognized as valid measures of symptoms, functional status, and quality of life. They have demonstrated prognostic significance and are being developed as a component of toxicity reporting in clinical trials. Recent studies have validated an information technology-based approach for collecting ePROs in routine clinical care. The system is feasible and acceptable; electronic and paper-based data, collected on validated assessment instruments, are equivalent; ePRO collection supports real-time symptom monitoring and management. The ePRO system represents a first step toward implementing rapid learning healthcare at the clinic level.

SUMMARY

ePROs provide a rich source of information to support monitoring and clinical management of troubling symptoms such as gastrointestinal complaints.

Detailing of gastrointestinal symptoms in cancer patients with advanced disease: new methodologies, new insights, and a proposed approach

PURPOSE OF REVIEW

This review summarizes recent developments in the palliative management of gastrointestinal symptoms experienced by advanced cancer patients and provides a framework for detailing that encompasses education, assessment and monitoring, and treatment.

RECENT FINDINGS

Although many viable treatment options exist, gastrointestinal symptoms, particularly nausea and vomiting, constipation, and diarrhea, continue to challenge both patients and clinicians. New medications, such as skin patch delivery of granisetron for nausea or methylnaltrexone for constipation, show promise of better symptom management, and are advancing alongside an increasing emphasis on prevention. The integration into care plans of complementary and alternative therapies, such as relaxation techniques and electroacupuncture, may also assist with symptom relief. Accurate assessment is essential but often problematic, especially as the patient's experience of gastrointestinal distress is often incommensurate with objective measures. New methodologies that harness technology to collect patient-reported outcomes may improve the accuracy of assessment, better capture the patient's experience of gastrointestinal symptoms, and provide a means to simultaneously monitor symptoms, educate patients, and collect longitudinal data.

SUMMARY

Palliative management of gastrointestinal symptoms in advanced cancer patients requires a multipronged approach that entails effective assessment, judicious use of latest evidence-based approaches, and monitoring that incorporates both clinical measures and patient-reported outcomes. In combination with refinements in the overall clinical approach to symptom management, the deployment of standardized instruments that streamline data collection and enable data warehousing will support better symptom management.

[Opioid-induced bowel dysfunction: a literature analysis on pathophysiology and treatment]

Bowel dysfunction is a frequent and serious side effect of opioid analgetics. In spite of its common occurrence, in the course of clinical routine, it is frequently ignored or underestimated. Authors of the analysed literature widely agree that a prophylactic and routine pharmacotherapy is necessary. For this purpose, laxatives, enemas and suppositories, prokinetic agents and opioid antagonists can be considered. Bulk-forming laxatives did not prove to be effective, since the quantity of fluid intake required for the action usually cannot be provided. Furthermore, the benefit of emollient agents is doubted. As a monotherapy they are not sufficient. By contrast, stimulant and osmotic laxatives proved to be active. Prokinetic drugs are not recommended because of their serious side effects. Effective abatement of opioid-induced obstipation by opioid antagonists has been proven in numerous studies. However, the loss of analgesia and opioid withdrawal symptoms were described as adverse effects. Development of quaternary opioid antagonists such as methylnaltrexone was allowed for mitigating these adverse effects.

Holistic assessment of cancer patients' pain: reflections on current practice

This article explores the holistic assessment and management of pain for palliative care patients through the use of a case study. Using literature searching and reflection on current local practice, issues within pain assessment and management for cancer patients are identified. These issues include communication, opioid misconceptions, disease progression associated with increased pain, and the need to address all components of cancer patients' total pain. Reflection on practice has highlighted that education, effective communication and multidisciplinary collaboration, and adaptation of an existing assessment tool to develop a multidimensional holistic approach to assessing pain, have the potential to improve quality of life for palliative care patients and their families.

Nutrition in palliative care: online information and resources

Following revelations that almost 40% of hospital patients are at risk of malnutrition and the total annual cost to the country of treating this condition is over £7 billion, recent guidelines from the UK National Institute for Health and Clinical Excellence (NICE) suggest that all hospital patients should be routinely screened for malnutrition and offered specialist support. Patients with cancer may be at an increased risk because of the peculiarities of the disease process, and suffer additional serious effects such as reduced response to treatments. It has also been estimated that 20% of all cancer deaths could be attributed to malnourishment. This month’s Web Words looks at aspects of nutritional assessment and how this feature of care could be enhanced.