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Assessment and treatment of older
patients with constipation
Kyle G (2006) Assessment and treatment of older patients with constipation. Nursing Standard. 21, 8,
41-46. Date of acceptance: February 14 2006.
Summary
This article examines the experiences of an older patient with
constipation to illustrate the importance of thorough assessment.
The interaction between another medical condition and constipation
is discussed, and indications for laxative use are outlined. The
current evidence base for bowel care is limited. Tools for risk
assessment are required and further research is needed to improve
patient care in this area.
Author
Gaye Kyle is senior lecturer, Faculty of Health and Human Science,
Thames Valley University, Slough, Berkshire. Email: gaye.kyle@tvu.ac.uk
Keywords
Bowel management; Constipation; Suppositories
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For related articles and author guidelines visit our online archive at
www.nursing-standard.co.uk and search using the keywords.
CONSTIPATION IS a problem that can affect
any person at any time in life. Those who are ill, in
hospital or in an institution are particularly at risk
of developing constipation. It is rarely
life-threatening, but the distress it causes can lead
to reduced patient comfort and diminished
quality of life (Sweeney 1997).
Constipation affects the patients physical,
psychological and social wellbeing, yet there
is a reluctance by patients and healthcare
professionals to discuss bowel function until it
has become a significant problem. Successful
treatment of constipation depends on defining the
patients symptoms following careful assessment.
The case study described in this article enables
the examination of variables that resulted in the
patients distressing situation. The contributing
factors are identified and discussed. A short
interview with the patient and a review of her
medical and nursing notes supplied the details for
the article. Permission has been given to publish
this case study and a pseudonym is used to
maintain confidentiality (Nursing and Midwifery
Council 2004).
NURSING STANDARD
art & science continence focus
Case study
Day one Mary, a healthy and active 83-year-old,
had a fall at her great-grandsons third birthday.
As a consequence of the fall Mary experienced
pain in her back, however, she was still able to
mobilise independently. Her family took Mary
home because she was adamant that she would be
best equipped to cope there.
Day two Mary had difficulties overnight with
pain in her back and was taken to her local
accident and emergency department in the
morning. Mary was diagnosed with a crush
fracture of the second lumbar vertebra, caused by
the trauma of her fall, and osteoporosis which
was previously undiagnosed.
She was commenced on two tablets of
co-dydramol four times a day, which she agreed
to take because of the considerable pain she was
experiencing. Mary was also given calcium
supplements and prescribed alendronic acid
(as sodium alendronate) 70mg once weekly for
osteoporosis.
Her mobility became greatly diminished and
her appetite was poor because of the pain. She
asked a neighbour to purchase some senna at the
local chemist, because Mary worries if she does
not open her bowels daily.
Day three Mary was in great distress because of
severe back pain. She contacted the GP who
prescribed an opioid analgesic, tramadol, 50mg
three times a day, and advised her to discontinue
taking co-dydramol.
Day four Mary was unable to move and sat all day
with a heat pad behind her back. She continued to
take tramadol and was also taking two senna
tablets each night. She informed her family that
her stomach was swollen and bloated, and that
she had not opened her bowels since the day
before her fall.
Lack of exercise, inability to prepare food
and abdominal discomfort resulting from
constipation contributed to Marys poor food
intake. However, Mary made every effort to keep
her fluid intake as usual. She knew from past
experience when she was on holiday that any
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art & science continence focus glycerine suppositories were administered.
Mary tried to keep the suppositories in her
rectum, but after one hour she had to urinate
and, to use Marys words, the suppositories just
reduction in her usual fluid intake could result blew out.
in constipation, and she was anxious to prevent Day seven Marys stomach was now distended
this reoccurring. and hard, her mobility was greatly reduced and
Day five Mary contacted the surgery to say that her feeling of nausea was increasing. Despite the
her pain was no better and that she was finding fracture in her back, Mary was now primarily
it difficult to get out of bed. When the GP concerned about her worsening constipation,
visited, Mary mentioned that she had not which made her feel isolated and low in mood.
opened her bowels since before her fall, despite She was no longer trying to mobilise, which is
taking two senna every night. She was given a important in the initial stage of rehabilitation for
prescription changing her analgesia to patients with back fractures. She also
tramadol-modified release 100mg twice daily. experienced fullness in her rectum and a feeling
She was also given a prescription for lactulose that faeces was pushing against her anus.
15ml at night. Mary tried to take the lactulose Mary contacted the surgery again. Another
but the sweetness of the medication exacerbated GP visited and undertook an abdominal
her feelings of nausea. examination revealing a constipated sigmoid
Day six Mary telephoned the surgery and asked colon. A full digital rectal examination was not
to speak to the district nurse. Mary requested conducted because the GP observed that
an enema because it was seven days since her last Mary had a gaping anus full of impacted faeces.
bowel action. Mary was told that there were no Mary was prescribed Movicol and an
enemas available at the surgery but that the anti-emetic. She was initially prescribed four
district nurse or community staff nurse would sachets of Movicol to take immediately, and a
visit her. further four sachets to take that evening.
The district nurse visited Mary but no Day eight Mary had a successful bowel
physical examination was undertaken. Two evacuation. She felt much relieved and started
to rehabilitate successfully. Her appetite returned
FIGURE 1 and she began preparing her own food again.
The Bristol Stool Form Scale She continued to take one sachet of Movicol
twice a day until her bowels were consistently
Separate hard lumps between types 3 and 4 on the Bristol Stool Form
Type 1 Scale (Figure 1). She now takes one sachet of
like nuts (hard to pass)
Movicol if she goes more than one day without
opening her bowels.
Type 2 Sausage-shaped but lumpy
Discussion
Constipation can be influenced by physical,
Type 3 Like a sausage but with psychological, physiological, emotional and
cracks on its surface environmental factors. It is largely a subjective
sensation and has many interrelated causes.
Constipation can be clinically classified into
Like a sausage or
Type 4 three categories, and may result from one or
snake, smooth and soft
more of these:

Primary.
Type 5 Soft blobs with clear-cut
edges (passed easily)
Secondary.

Iatrogenic.
Type 6 Fluffy pieces with ragged Primary constipation, also referred to as simple
edges, a mushy stool or idiopathic, is associated mainly with lifestyle
changes and where there is no underlying
pathophysiology causing the constipation.
Type 7 Watery, no solid pieces, Secondary constipation results from
entirely liquid physiological diseases or conditions that affect
bowel function. Iatrogenic-induced
Reproduced by kind permission of Dr KW Heaton, reader in medicine at the
University of Bristol. 2000 Norgine Ltd
constipation results from medication or
treatment (Box 1).

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There continues to be much debate in the
literature as to what constitutes a clear definition
of constipation (Richmond 2003). The British
National Formulary (BNF) (2006) states that
constipation is: the passage of hard stools less
frequently than the patients own normal
pattern. This definition is open to great variation
in bowel habits. Most definitions now include
symptoms such as frequency of defecation,
hardness of stools, abdominal fullness or
bloating and feelings of incomplete evacuation,
although patients tend to emphasise symptoms
such as pain and straining rather than frequency
(Romero et al 1996).
The Rome II criteria (Box 2) are frequently
used to define constipation (Thompson et al
1999). However, they are mainly used as
inclusion criteria for research purposes and have
limited use in practice, as demonstrated in the
case study where they could not be applied.
The American College of Gastroenterology
Chronic Constipation Task Force (2005) states
that the widespread use of Rome II criteria is
impractical because observation studies indicate
that most patients who report constipation do
not fulfil these criteria. Nevertheless, a
definition in terms of bowel frequency alone is
imprecise, because bowel habits vary from one
individual to another. This lack of clarity of
what constitutes constipation could limit
treatment strategies.
In the case study, Mary knew she was
constipated, so any confusion about what
BOX 1
Drugs that commonly cause constipation

Antacids (containing aluminium hydroxide or
calcium carbonate).

Amiodarone.

Anticholinergics (tricyclic antidepressants,
antihistamines and antipsychotics).

Antidiarrhoeal agents.

Antiparkinsonian agents.

Calcium-channel blockers.

Calcium supplements.

Clonidine.

Disopyramide.

Diuretics.

Iron preparations.

Lithium.

Non-steroidal anti-inflammatory drugs.

Opioids, analgesics and cough suppressants
(Prodigy Guidance 2005)
NURSING STANDARD
BOX 2
Rome II criteria for definition of constipation
For definition of constipation, two or more of the
following symptoms should be present for at least
12 weeks out of the preceding 12 months.

Straining at defecation for at least a quarter of
the time.

Lumpy and or hard stools for at least a quarter
of the time.

A sensation of incomplete evacuation for at least
a quarter of the time.

Three or fewer bowel movements per week.
(Thompson et al 1999)
constitutes constipation did not affect Marys
outcome. Initially, Mary tried to treat herself by
asking a neighbour to purchase over-the-counter
laxatives for her. Harari et al (1996) state that
constipation is common in older people and is
often treated with numerous prescriptions and
over-the-counter laxatives.
Management Prodigy Guidance (2005) advises
a stepped approach to the management of
constipation. After excluding any underlying
medical conditions, the first step is dietary advice
and the second is the use of laxatives. The
National Prescribing Centre (NPC) (2004)
reviewed trials on the effectiveness of laxatives in
adults. They concluded that there is insufficient
clinical evidence to assess objectively the relative
effectiveness and tolerability of laxatives
(Petticrew 1997, Tramonte et al 1997, Petticrew
et al 2001, Jones et al 2002). However, there are
seven indications for when laxatives should be
used (Prodigy Guidance 2005):

No response to adequate non-drug treatment
(after one month of dietary advice).

Faecal impaction.

Constipation or painful defecation associated
with illness, surgery or pregnancy.

Older age and poor diet.

Drug-induced (iatrogenic) constipation.

Medical conditions in which bowel strain is
undesirable, for example, haemorrhoids or
rectal prolapse.

Preparation for an operation or investigation.
Mary fulfilled four of these criteria: faecal
impaction, constipation associated with illness,
poor diet because of nausea and immobility, and
drug-induced constipation from opioids and
calcium supplements. Laxatives are the obvious
treatment when these criteria are present.
However, it is important to adopt a proactive
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approach when assessing older patients with
constipation. A prompt and comprehensive
patient assessment would have resulted in earlier
identification and treatment of the risk factors
involved, thereby relieving Marys constipation
sooner and minimising any distress and
discomfort.
Numerous studies support the benefit of a
high fibre diet to prevent constipation (NPC
2004). Therefore, the first step of giving dietary
advice to address constipation would have been
appropriate for Mary if given concurrently with
laxative advice (Prodigy Guidance 2005).
Constipation is a common side effect of opioid
analgesia. Even compound analgesic
preparations, such as co-dydramol, contain
sufficient opioid to cause constipation
(BNF 2006). This raises the question of why the
healthcare team did not advise Mary about the
BOX 3
Assessment of bowel function
When assessing a patients bowel habits, a careful history should be taken
and the following points noted:

Description of problem, sensation, wind, feelings of discomfort or
incomplete evacuation.

Frequency of normal and current bowel movement.

Description of normal diet and fluid intake.

Any changes to normal diet or fluid intake.

Any change in mobility.

Whether the patient is able to prepare food, and whether the patient is
reliant on others for shopping and preparation of food.

Check condition of tongue and breath for signs of dehydration.

Check for poorly fitting dentures or decayed teeth.

Check medication. Bowel habit may change as a result of taking
medication for the alleviation or prevention of another
pathophysiological condition. Five or more medications are a particular
risk for constipation (Potter et al 2002).

Description of stool: colour, mucous, consistency (use Bristol Stool Form
Scale, Figure 1).

Any unusually offensive odour to stool (may be due to diet or
malabsorption).

Pain or bleeding on defecation (may suggest local injury, for example,
haemorrhoids, anal fissure or underlying pathology such as colorectal
cancer).

Unexplained change in bowel habit (may suggest underlying pathology
such as colorectal cancer).

Ask the patient how he or she usually copes with the problem. It may be
that the patient uses digital rectal stimulation.
(Adapted from Norton and Chelvanayagam 2000)
44 november 1 :: vol 21 no 8 :: 2006
possibility of constipation, especially as her usual
level of mobility was greatly reduced.
Immobility is a primary risk factor in
constipation (Harari 2004). Marys diminished
mobility resulted in reduced colonic motor
activity and eventual weakening of the
abdominal wall muscles. This led to difficulty in
raising intra-abdominal pressure sufficiently for
defecation which would have been exacerbated
by Marys back pain.
The decision to prescribe lactulose 15ml at
night to an older patient who is already
constipated and feeling nauseous may not have
been the best treatment option because lactulose
may take up to two to three days to have an effect
and is not suitable for rapid relief of constipation
(NPC 2004). It should not be regarded as first-
choice therapy in the management of patients
with constipation (Prodigy Guidance 2005).
Macrogols, such as Movicol and Idrolax,
are inert polymers of ethylene glycol. There is
limited evidence from several trials that
polyethylene glycol is a safe and effective
alternative to lactulose in the management of
patients with constipation (Attar et al 1999,
Corazziari et al 2000).
Movicol is the only laxative recommended
in the treatment of faecal impaction, so it was an
appropriate laxative for Mary when it was
prescribed (BNF 2006). However, when Mary
first consulted the GP she may not have been
impacted, although this was not confirmed
because a comprehensive bowel assessment was
not undertaken.
Assessment Assessment is important for the
effective management of any distressing
symptom. Mary should have received an initial
assessment to ascertain the possible causes of her
constipation, for example, medication, poor diet
and reduced mobility. Accurate assessment of the
cause of constipation is the first crucial stage in
developing a treatment plan (Koch and Hudson
2000). Points to consider during assessment have
been outlined by Norton and Chelvanayagam
(2000) and adapted in Box 3.
There is no conclusive evidence that one laxative
is more effective than another in treating older
patients (Petticrew et al 1999). The appropriate
laxative should be chosen according to the
individual patients needs and circumstances.
Glycerine suppositories act as a rectal
stimulant because of the mildly irritant action of
glycerol (BNF 2006). A stimulant laxative is a
suitable choice for short-term use to allow usual
bowel function to be restored (NPC 2004).
Despite a lack of assessment, the use of
suppositories appears to have been appropriate
for Mary. However, as the suppositories remained
intact after one hour in the rectum, they may not
have been appropriately administered.
NURSING STANDARD
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Glycerine suppositories should be moistened
before insertion and then placed alongside the
bowel wall. Suppositories need body heat to
dissolve so that the glycerol can act as a bowel
irritant. If suppositories are placed in the middle
of faecal matter they remain intact and serve no
purpose. There are conflicting
recommendations about the administration of
suppositories. Baxter et al (2004) advocate
insertion of the blunt end of suppositories first,
using previous research to substantiate this
viewpoint (Abd-el-Maeboud et al 1991).
However, Abd-el-Maeboud et al (1991) make
no reference to the insertion of suppositories for
bowel care, so their research could be
interpreted for systemic or local action of
suppositories or both.
The application of research that is reported in
clinical textbooks, such as The Royal Marsden
Hospital Manual of Clinical Nursing Procedures
(Dougherty and Lister 2004), can be problematic
if the research has used simple descriptive
statistics. The findings of Abd-el-Maeboud et al
(1991) suggest that although the apex foremost
mode of insertion is common sense, base
foremost insertion is preferable for administering
rectal suppositories (Abd-el-Maeboud 1992).
This conflicting advice can mean that healthcare
professionals are unsure about what constitutes
best practice in the administration of
suppositories.
It is often assumed that constipation is an
inevitable consequence of older age. However,
Koch and Hudson (2000) found no evidence that
a change in bowel motility is an inevitable
consequence of ageing. Nevertheless, the rate
of regular laxative use among older people is
reported to be between 7 and 10 per cent (Harari
et al 1994, Pahor et al 1995). This rate rises to
between 50 and 75 per cent in nursing homes
(Harari et al 1994, 1995).
The apparent reduction in bowel movement
frequency observed in older people appears to be
related to contributory factors associated with
ageing, such as reduced mobility, polypharmacy,
chronic disease and poor diet, rather than ageing
itself (Harari 2004).
Risk assessment data are not yet available
to assist healthcare professionals with
interpretation of contributing factors to
constipation (Richmond and Wright 2004).
The use of such data or a risk assessment tool
may have prevented the exacerbation of
Marys constipation. If Marys constipation
had persisted or continued to be inappropriately
managed, certain complications could
have ensued, including haemorrhoids,
urinary incontinence, urinary tract infection,
rectal bleeding and possible hospitalisation.
Any of these complications would have
adversely affected Marys quality of life and
would have had cost implications for the NHS.
It is estimated that 10 per cent of district
nursing time is spent on bowel management
(Poulton and Thomas 1999). In 2001, more than
12 million prescriptions for laxatives were

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art & science continence focus
written in England in general practice
(Department of Health (DH) 2001).
Conclusion
Discussion of the issues raised in the case study
highlights the lack of agreement on what
constitutes a working definition of constipation.
Poor understanding of the use of laxatives and
limited assessment protocols indicate the need
for a national consensus on bowel management.
The introduction of bowel assessment pathways
will provide healthcare professionals with a clear
structure for assessing patients with constipation
(Bayliss et al 2000).
The response of NHS trusts to the Essence
of Care document (DH 2003) will help to ensure
the development of benchmarks on bowel
management that are based on best patient-
focused practice. Continual improvement of
these benchmarks will be maintained by
comparison and sharing of knowledge and
expertise from similar clinical areas.
Digital rectal examination courses are now
run throughout the UK. They provide an ideal
forum for enhancing education on all aspects
of bowel management. However, bowel
management remains an underfunded and
under-researched area of health care (Kyle
2005). Constipation rarely receives attention
until it has become a significant problem for the
patient (Ross 1998). The problems associated
with a reactive approach to constipation are
compounded by ongoing reference to
management of constipation, rather than
prevention, in the literature (Harari et al 1994,
Powell and Rigby 2000, NPC 2004). The case
study demonstrates that, despite Marys
awareness of her constipation, healthcare
professionals did not respond effectively until
Marys constipation was affecting her general
wellbeing and quality of life.
Evidence-based health care is an NHS priority
(DH 2000). There is increasing emphasis on
supporting all clinical practices with quality
evidence. However, the common nursing
procedure of inserting rectal suppositories for
bowel care is not supported by quality evidence.
This highlights the need for more rigorous bowel
care research.
An emerging theme from much of the nursing
literature is the importance of assessing patients
to identify those at risk of constipation
(Richmond 2003, Richmond and Wright 2004).
Assessment strategies are necessary to prevent
the development of this distressing condition.
Risk assessment tools have been described as the
backbone of prevention (Thompson 2005),
therefore a prerequisite for the prevention of
constipation is the development of such a tool.
To date no such risk assessment tool exists. Once
healthcare professionals can easily identify
patients at risk, they can institute preventive
measures to meet each patients needs NS

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