Review of the literature on constipation to enable development of a constipation risk assessment scale

The Korean medicine for aging cohort (KoMAC) study: A protocol for a prospective, multicenter cohort study on healthy aging in the population entering old age in South Korea

BACKGROUND

South Korea is anticipated to enter a super-aged society by 2025, necessitating a focus on healthy aging. In Korean medicine (KM), aging and disease susceptibility are individual specific, emphasizing personalized treatments, and many Korean local governments have integrated KM services for elderly people into the public sector. However, there is a notable absence of research incorporating KM to treat older adults.

AIM

The proposed study aims to examine the comprehensive health profiles of individuals entering old age in rural and urban areas and explore the significant correlations between healthy aging and four key factors: biological, psychological, social, and KM-based phenotype factors. It will also establish a database and blood biobank, serving as a platform for future research to develop a traditional KM-based healthy aging model.

METHODS

A multiple randomized controlled trial design will be adopted in this prospective, multicenter cohort study for the clinical investigation of the markers associated with KM-based healthy aging. The aim is to recruit 1,000 participants who are entering old age from both urban and rural settings for this study, and recruitment began in August 2023 with follow-up surveys planned at one-year intervals. Comprehensive health profiles, including biological, psychological, social, and KM-based phenotype factors, will be developed through the creation of a database, a blood biobank, and multi-omics data.

RESULTS

In the baseline phase of this study, we will focus on identifying markers for KM-based phenotypes and examining how these phenotypes relate to aging and associated diseases. In the next phase, we will implement interventions tailored to KM-based phenotypes to verify the effects of KM on healthy aging. Ultimately, we intend to develop a KM-based integrated health management model, with further substudies aiming to explore factors related to healthy aging. This protocol was approved by the institutional review board of Wonkwang University Korean Medicine Hospital, Iksan, Republic of Korea (approval number: WKUIOMH-IRB-2023-05) on August 16, 2023 and Jangheung Integrative Medical Hospital (approval number: WKUJIM-202307-001) on August 21, 2023. Recruitment started on August 16, 2023.

CONCLUSION

The anticipated results of our study aim to establish personalized preventive and therapeutic interventions for individuals entering old age. Additionally, we seek to offer an KM-based integrated health management model that incorporates comprehensive diagnosis and an integrative medical treatment strategy for healthy aging.

TRIAL REGISTRATION

Clinical Research Information Service: KCT0008863 (registered on October 11, 2023, https://cris.nih.go.kr/cris/search/detailSearch.do/25718).

A single-centre observational study of delayed defaecation in brain-injured patients in an adult intensive care unit

BACKGROUND

The incidence of delayed defaecation is high in enterally fed ventilated patients in intensive care units (ICUs). Those with brain injury may be harmed by increased intracranial pressure if delayed defaecation leads to abdominal distension. There are no studies evaluating a bowel guideline in the treatment of delayed defaecation in ventilated brain-injured ICU patients.

OBJECTIVE

The objective of this study was to assess the incidence and clinical associations of delayed defaecation and level of compliance to an ICU bowel guideline.

METHODS

Data were collected on ventilated adult patients with brain injury admitted for more than 3 days to one New Zealand ICU over a 2-year period.

RESULTS

Data were analysed for 117 patients; 56 (48%) who defaecated within 3 days of ICU admission (Group one) and 61 (52%) with delayed defaecation after 3 days (Group two). Compliance with the bowel guideline was low. Only 1 of 61 patients who should have had a rectal examination did so, and only 7 of 61 patients who should have had an aperient on day 3 did so. All seven received Movicol®, which was not part of the guideline. Use of aperients and enemas was found to be associated with stool passage (odds ratio: 93; 95% confidence interval: 5.2-1668; p = 0.002). Patients with delayed defaecation had longer ICU stays (mean 7.1 ± 4 SD vs 5.9 ± 3 days, p = 0.07) and more often had high gastric residual volumes after day 4 (27/61 vs 14/56; p = 0.003). No differences were seen between the groups in the incidence of ventilator-associated pneumonia, bacterial infections, diarrhoea, vomiting, duration of mechanical ventilation, or mortality.

CONCLUSION

Delayed defaecation was common, and compliance with the guideline was low. Movicol® and phosphate enemas were effective in stool production.

Development and validation of a clinical score for early diagnosis of constipation in critically ill children

Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.

Risk and main contributing factors for constipation in patients with gastrointestinal cancer: a multicenter cross-sectional study in China

BACKGROUND AND OBJECTIVES

The purpose of this study is to determine the risk of constipation and to identify the significant risk factors for constipation in patients with gastrointestinal cancer using the Chinese version of the constipation risk assessment scale (CRAS-C), as well as to explore the complementary constipation risk factors in patients with gastrointestinal cancer, to improve the specificity of the CRAS-C in this population, and finally to provide a theoretical basis for constipation prevention.

RESEARCH DESIGN AND METHODS

A cross-sectional study involving multiple centers was conducted. A total of 190 patients with gastrointestinal cancer completed surveys that included demographic information, defecation habits, and the CRAS-C. The mean, SD, median, maximum, minimum, frequency, and percentage were used as indicators for the constipation risk and significant risk factors. The t test and Chi-square tests were used to analyze constipation indicators in patients with gastrointestinal cancer.

RESULTS

The mean (SD) age of the 190 participants was 61.68 (12.35) years. The total CRAS-C mean (SD) score was 13.22 (4.69). Fifty-one patients (26.8%) scored lower than 11, who were at the low-risk level of constipation. One hundred thirty-nine patients (73.2%) scored 11 or above, who were at the high-risk level of constipation. The top 10 factors were insufficient liquid intake (81.1%), failure to consume bran products daily (78.9%), insufficient fiber intake (77.9%), antiemetics (74.7%), cytotoxic chemotherapy (52.6%), colorectal/abdominal diseases (42.6%), female (35.3%), opioid analgesics(26.8%), calcium channel blockers (16.3%), and endocrine disorders (14.2%). Chi-square test showed that constipating for most of the past 3 months, ascites and ECOG score were complementary constipation risk factors in gastrointestinal cancer patients.

CONCLUSION

The findings indicate that most gastrointestinal cancer patients were at a high risk of constipation. There are also several complementary constipation risk factors, and CRAS-C can be further revised in future studies to make it more specific in gastrointestinal cancer patients. Integrating CRAS into the pathway of constipation management, carrying out constipation risk screening for hospitalized cancer patients, and building systematic constipation prevention plan based on risk assessment are important to reduce the incidence of constipation in patients with gastrointestinal cancer and improve the quality of life.

[Consensus approach: Prior to the construction of an evaluation scale of risk constipation patients hospitalized for nursing practice]

BACKGROUND

Constipation is a frequent issue during hospitalization. Multiple causes such as the existence of irregular habits, lack of exercise as well as medical history have been identified. Drugs such as strong painkillers, central nervous system therapies and treatments of the digestive tract are a major cause of constipation. Additionally, unbalanced diet, fluid deficiency, and anxiety may aggravate constipation. The consideration of all these risk factors being under the responsibility of nurses. The difficulty to take into account such a multifactorial aetiology in nursing practice and the fact that there is no easy to use and validated tool to assess the risk of constipation in current nurse practice has led us to consider the development of a Risk Assessment scale of Constipation in Patient Hospitalized (ERCoPH) to facilitate preventive management of this trouble. We present here the first step of the elaboration of this scale, the identification of risk factors through a consensus approach after a systematic literature review.

METHODS

The key informants consensus-based approach proposed by Pineault and Daveluy is based on five steps: (1) a literature review to identify risk factors for constipation; (2) the elaboration of a questionnaire containing the factors identified in the first step; (3) pre-select a panel of experts; (4) submission the questionnaire to the panel; (5) analysis the results of the consensus survey. Only factors that received a rating>6 by at least 80 % of the experts were retained.

RESULTS

The systematic literature review identified 69 risk factors submitted to the 23 experts of the panel. Fifteen risk factors were retained after analyzing the answers of the experts. The Scientific Committee added eight risk factors because of their importance in the literature and decided to group together some factors of the same domain.

CONCLUSION

A total of 19 risk factors were selected and grouped by major class (age, physical activity, medication, social data, food/hydration, medical and surgical history and environmental data). These factors have been tested among 300 patients enrolled in different clinical settings as part of the construction and validation of ERCoPH.

Supporting patients in reducing postoperative constipation: fundamental nursing care - a quasi-experimental study

BACKGROUND

The prevalence of constipation in the general population is 2-28%. Patients with constipation report symptoms of abdominal pain, bloating, nausea, straining to defecate and general discomfort. Strategies for preventing constipation include laxatives, exercise and increased fluid and fibre intake, but life style adjustments, such as exercise, eating more fibres and drinking more fluids, were not considered a solution by older patients. Previous studies have shown that actively involving patients through individualised care and support increases patients' outcome.

AIM

To test the efficacy of a nursing intervention based on active patient involvement including individualised nursing care plans and daily dialogues for patients with hip fractures in preventing constipation after surgery.

METHODS

A quasi-experimental design was applied. Inclusion criteria hip fracture needing surgery, understand Danish. Exclusion criteria dementia, gastrointestinal disease. A total of 186 patients were included and 155 completed. An admission interview including Constipation Risk Assessment Scale was undertaken. On that basis an individualised nursing care plan was made. At admission, discharge and 30 days after surgery constipation, intake of fibres and fluid were measured. The Bristol Stool Scale and Rasmussen's scale were used to measure constipation. Patients in the control group received standard care of the ward.

RESULTS

After 30 days constipation rates for patients in the intervention group were significantly lower than for patients in the control group (p = 0.042). The fibre intakes and fluid intakes were significantly higher in the intervention group (p ≤ 0.001). The effect of liquid intake was statistically significant (OR = 1.1, 95% CI: 1.0-1.2). Likewise, the effect of fibre intake was statistically significant; the odds of constipation decreased with increasing fibre intake (OR = 0.4, 95% CI: 0.2-0.8).

CONCLUSION

Patients with hip fractures that were actively involved in their own care in preventing constipation were significantly less constipated 30 days after surgery than control patients. Increases in fluid and fibre intakes had significant effects on reducing the risk of developing constipation.

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.

Holistic Approach to Functional Constipation: Perspective of Traditional Persian Medicine

Traditional Persian medicine (TPM) proposes a different viewpoint to the chronic diseases. Diagnosis and implemented treatment are based on individual differences among patients. Constipation or Ea'teghal-e-batn is a condition in which the patient develops difficult or painful defecation. Based on TPM concepts, the fifirst digestion step starts from halq (oral cavity), and ends via defecation from the maq'ad (anus). Avicenna believed that four faculties, ha'zemeh (digestive), ja'zebeh (absorptive), ma'sekeh (retentive) and da'fe'eh (propulsive), are involved in the process of digestion and absorption of the ingested food and expelling the waste materials. The bowel movement and appearance of the stool is a measure for evaluating the gastrointestinal healthy function. Defecation should be with no pain and fecal material should have no burning and acuity. Low food intake or foods with dry temperament, dryness of gastrointestinal tract, diaphoresis and heavy exercise as well as intestine sensory loss were discussed as main causes of constipation. Management of constipation in TPM includes dietary schemes, oil massages and subsequently simple herbal medicines. According to TPM theories, the fifirst step in treating a disease is the elimination of disease causes (asbabe- maraz) and also providing the causes of health (asbab-e-sehhat). Health care providers should know the proper condition which the herbal medicines should be administered in and be able to guide the patients about the benefifits and hazards of herbal remedies, commonly used in their living origin.

Constipation and defecation pattern the first 30 days after hip fracture

Constipation is often an overlooked aspect of patient care and increases the risk of postoperative complications, can prolong hospital stay, increase financial cost and add to staff nursing care time. A prospective descriptive design was used. One hundred six patients with hip fracture participated. On admission, day of discharge and 30 days after surgery, patients' normal and actual defecation pattern, stool consistency and if they had experienced problems with defecation were assessed using Bristol Stool Scale and a scale composed by Rasmussen. There were 69.1% of the patients who developed constipation during the first postoperative days and 62.3% reported the same problems 30 days after surgery. Normal defecation pattern was re-established 9.5 days after surgery, though 22.7% of the patients did not re-establish normal defecation pattern within the first 30 days after surgery. The results imply that further studies are needed to prevent constipation and help patients to cope with this side-effect of surgery after discharge.

Development and clinical gains of nurse-led medication monitoring profiles

AIM

This paper reports on the development of an instrument for nurse-led medication monitoring, the West Wales Adverse Drug Reaction profile for respiratory medicines, as part of a strategy to reduce avoidable adverse drug reactions.

BACKGROUND

Preventable adverse drug reactions account for 3.7% hospital admissions. Nurse-led medication monitoring may reduce drug-related harm. However, development of medication monitoring strategies is not reported elsewhere.

METHODS

The profile was developed by: (1) cognitive interviews (n = 4), (2) the content validity index (n = 10) involving academics, clinicians and service users prescribed respiratory medicines, (3) inter-rater reliability (n = 48) and clinical gains in a nurse-led outpatient clinic.

RESULTS

Cognitive interviews prompted more profile changes than either the content validity index or inter-rater reliability testing. Cohen's κ for inter-rater reliability for each item ranged from 0.73-1.00 (good to complete agreement). The profile identified previously unsuspected problems in all participants, including muscular weakness, skin and mouth problems.

CONCLUSIONS

The West Wales Adverse Drug Reaction profile was valid and reliable, and helped to detect and ameliorate drug-related harm.

IMPLICATIONS FOR NURSING MANAGEMENT

The West Wales Adverse Drug Reaction profile offers opportunities to improve care. Medication monitoring provides the structure to concurrently monitor known adverse drug reactions. Practice-based adverse drug reaction profiles benefit from cognitive, content validity and inter-rater reliability testing.

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.

Bowel habit, diet and body weight in preadolescent children

BACKGROUND

The possible influence of diet and body weight on bowel habit in children is unknown. The present study aimed to investigate the inter-relationships between bowel function, excess body weight and dietary intake in a group of preadolescent children.

METHODS

Eighty-four preadolescent children aged 7-10 years were recruited [mean (SD) age 9.7 (1.0) years]. All children completed a bowel habit diary, examining specific parameters of bowel function and a weighed food inventory concurrently for seven consecutive days. Height and weight measurements were also taken. Children were grouped according to whether they met dietary recommendations and by overweight status; differences in bowel function between the groups were then analysed.

RESULTS

Children who exceeded reference values for fat were more likely to report an incidence of straining to start (P = 0.005) and pain during defaecation (P = 0.021). Subjects who met protein recommendations were less likely to report incomplete evacuation (P = 0.000) and those who met zinc recommendations were less likely to report pain during defaecation (P = 0.044). Excess body weight (according to International Obesity Task Force cut-offs) was also associated with poor bowel habit, with overweight and obese children reporting lower defaecation frequency and a higher incidence of straining and feelings of incomplete evacuation, although these findings were not statistically significant. Defaecation frequency in healthy children was 1.4 defaecations per day compared to 1.2 defaecations for overweight and obese children.

CONCLUSION

A poor diet that fails to meet dietary recommendations as well as being overweight and obese appears to be associated with increased defaecation problems in preadolescent children.

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 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.