It is well known that constipation is a common problem among the elderly and that serious mechanical problems, such as bowel perforation or bowel obstruction, can result from constipation. Also well known is the association of fecal impaction with diarrhea and even incontinence. Less well known is how subtle the presentation of fecal impaction can be and how it can lead to other events that result in severe morbidity, even when mechanical catastrophes do not occur.
In a long-term care or general hospital setting, constipation can be easily overlooked as a significant clinical problem when other more apparently pressing issues exist. Physicians often tend to relegate the problems of bowel routine to nursing staff. The Geriatric and Long Term Care Review Committee to the Chief Coroner for the Province of Ontario is composed of specialists in geriatric medicine, a family physician with a particular interest in geriatrics, and a representative from the Coroner’s office.
The committee’s mandate is to improve the quality of medical care for the elderly in Ontario, by reviewing deaths that cause concern. Cases are referred to the committee from many sources, including local coroners, regional coroners, long-term care institutions, government ministries, and concerned citizens. The committee has reviewed cluster deaths in institutions as well.
The committee conducts a review of the available records relevant to the case and then sends recommendations back to the local community for discussion and implementation, with the aim of preventing future deaths in similar circumstances. Recently, the committee reviewed two cases where death occurred because caregivers failed to recognize the potential dangers of constipation in elderly patients.
A 79-year-old woman had a long history of trigeminal neuralgia and suffered a relapse in June 1990. She required hospitalization, and her symptoms were brought under control only with difficulty. She fractured her hip after a fall in hospital and, rather than return home, she was discharged to a nursing home. Her medications included phenytoin, amitriptyline, and acetaminophen tablets containing 30 mg of codeine. She did well until January 1991 when her neuralgic pain intensified, necessitating more frequent doses of acetaminophen with codeine.
Decreasing daily bowel movements were noted and treated with docusate sodium and occasional phosphate enemas, with mixed results. She was hospitalized for 1 week in February, but still did not obtain adequate pain relief for her neuralgia. She had no bowel movements during that week, and no bowel regimen was prescribed. A neurosurgical consultation was arranged for the beginning of April, but the patient was readmitted to hospital and missed her appointment. Once again, over a prolonged hospital stay (April 4 to 16) she had no bowel movements. Although one of the admission diagnoses was bowel obstruction, she was treated only with daily sennocides and one phosphate enema, with no effect. She continued to do poorly at her nursing home, and was readmitted to hospital on April 24.
Once again, bowel obstruction was one of the admission diagnoses. She was dehydrated at this time and, despite a rectal examination revealing soft stool and an abdominal x-ray examination that commented on “lots of stool,” no definitive efforts were made to clean the bowel of stool. She died April 30, 1991, and an autopsy revealed a bowel obstruction secondary to fecal impaction as well as terminal pneumonia.
An 88-year-old woman with mild dementia and chronic congestive heart failure was a resident in a nursing home. She used a wheelchair, but was independent in several aspects of basic activities of daily living and able to participate in some of the home’s activities. She developed an upper respiratory tract infection in March 1991 and went on to develop pleuritic chest pain and tenderness localized over one rib. After consultation in the local emergency department on March 15, she was referred back to the nursing home and treated for musculoskeletal pain. She was given frequent doses of acetaminophen with 30 mg of codeine for the pain and dimenhydrinate (Gravol) for nausea.
Starting on March 18, her functional level declined and she had little interest in getting out of bed or drinking and eating. On March 21, she was disimpacted of a “fair amount of hard stool,” but no vigorous attempts to clean her bowel of stool were made. On the next day she complained of abdominal cramps, her rectum was found to be empty of stool, and a phosphate enema was administered, without results. Later that day her abdomen became more distended and painful, and she was transferred to an acute hospital. In consultation with the family, aggressive measures were not undertaken and she died shortly thereafter. Autopsy was not performed.
Constipation played an important part in the deaths of these two women and contributed to severe morbidity. In both cases, it led to avoidable hospitalizations. In retrospect, it is easy to say that prophylactic bowel regimens should have been introduced at the same time that narcotic analgesics were first started because they are a well-known cause of constipation and fecal impaction.
Perhaps the attending physician and nurses in the first case believed that a fecal impaction could occur only in the presence of hard stool in the rectum, which was checked for and not found. However, massive fecal loading can occur with soft stool, or no stool, in the rectum.
In the second case, the physician and nurses might have incorrectly believed that manual disimpaction was sufficient therapy for fecal impaction. Treating established fecal loading or fecal impaction usually requires, in addition to possible manual disimpaction, vigorous use of enemas, and eventually laxatives or osmotic agents taken orally.
Severe constipation can result in severe morbidity and even death in the elderly, particularly those in institutions. Attempts should be made to prevent this complication by instituting prophylactic bowel regimens and carefully monitoring bowel status. Methods of preventing severe constipation include increasing fiber in the diet, ensuring adequate fluid intake, encouraging mobility, and using bulk-forming laxatives and stool softeners (Table I).
|Table 1. Managing Fecal Impaction:Sample therapeutic regimens|
|Lactulose as needed (on days without a bowel movement)|
|Avoid aggravating medications|
|Gastrointestinal lavage solution|
|Lactulose (30 mL twice daily)|
|Stop offending medications|
|Ensure adequate hydration|
If severe constipation occurs, it should be treated vigorously. Contrary to the belief of many physicians, the condition is very difficult to treat. Failure has been documented even with the standard regimens of daily phosphate enemas and osmotic laxatives, such as lactulose. Better results have been obtained by using 2 L of gastrointestinal lavage solution daily for 2 days, followed by daily enemas and lactulose (30 mL twice a day), than by using enemas and lactulose alone.
Rectal examination, although crucial, is not always diagnostic; abdominal flat plates can be used for diagnosis and to ensure adequacy of treatment. Removing aggravating factors, such as drugs, and assessing the diet for adequate fiber content and fluid intake should be addressed at the same time that treatment is instituted. Bulk-forming laxatives are generally not helpful until the bowel is cleared of stool.