Evidence-based management of constipation in the oncology patient

Healthcare Professionals' Experiences of Assessing, Treating and Preventing Constipation Among Older Patients During Hospitalization: An Interview Study

PURPOSE

Constipation is a common and troublesome condition among older patients and can result in a variety of negative health consequences. It is often undiagnosed or undertreated. Healthcare professionals have a responsibility to understand and address patients' overall healthcare needs; so exploring their experiences is, therefore, highly relevant. The purpose of the study was to explore healthcare professionals' experiences of assessing, treating and preventing constipation among older patients.

METHODS

A qualitative design with an exploratory approach was used. The participants (registered nurses and physicians) were purposively sampled from three wards in a geriatric department in a medium-sized hospital in Sweden. Data were collected through focus group discussions and individual interviews, and analyzed using content analysis.

RESULTS

Three categories were generated: Reasons for suboptimal management of constipation, Strategies for management, and Approaching the patients' needs. In the care of older patients at risk of or with constipation, decisions were made based on personal knowledge, personal experience and clinical reasoning. A person-centered approach was highlighted but was not always possible to incorporate.

CONCLUSION

Different strategies for preventing and treating constipation were believed to be important, as was person-centered care, but were found to be challenging in the complexity of the care situation. It is important that healthcare professionals reflect on their own knowledge and clinical practice. There is a need for more support, information and specific guidance for healthcare professionals caring for older patients during hospitalization. Overall, this study underscores the importance of adequate access to resources and education in constipation management and that clinical guidelines, such as the Swedish Handbook for Healthcare, could be used as a guide for delivering high-quality care in hospitals.

The course of sexual interest and enjoyment in head and neck cancer patients treated with primary (chemo)radiotherapy

INTRODUCTION

The aim of this prospective study was to investigate the course of sexual interest and enjoyment in relation to sociodemographic and clinical factors, health-related quality of life (HRQOL), and symptoms of psychological distress in head and neck cancer (HNC) patients treated with primary (chemo)radiotherapy.

METHODS

HNC patients (n = 354) completed patient-reported outcome measures (PROMs) on HRQOL (EORTC QLQ-C30 and QLQ-H&N35, including the sexuality subscale covering less sexual interest and enjoyment), and psychological distress (HADS) pretreatment, at 6-week follow-up and at 3-, 6-, 12-, 18-, and 24-month follow-up (i.e., after treatment). Linear mixed models were used to analyze the course of sexuality from pretreatment to 24-month follow-up, and to investigate its relation to sociodemographic and clinical factors, HRQOL, and psychological distress as measured at baseline, and to investigate the course of sexuality from 6- to 24-month follow-up in relation to these factors measured at 6-month follow-up.

RESULTS

Before start of treatment, 37% of patients reported having less sexuality, which increased to 60% at 6-week follow-up, and returned to baseline level from 12-month follow-up onwards. Older age (p = 0.037) and trouble with social contact (p < 0.001), weight loss (p = 0.013), and constipation (p = 0.041) before treatment were associated with less sexuality over time. Female gender (p = 0.021) and poor social functioning (p < 0.001) at 6-month follow-up were associated with less sexuality from 6- to 24-month follow-up.

DISCUSSION

Less sexuality is often reported in HNC patients treated with (chemo)radiotherapy. Using PROMs in clinical practice may help identify patients who might benefit from supportive care targeting sexuality.

Constipation prophylaxis in children undergoing orthopedic surgery: A quasi-experimental study

PURPOSE

This study evaluated the effectiveness of constipation prophylaxis administered with the support of an advanced practice nurse.

DESIGN

A quasi-experimental study with a historical control group of 112 pediatric (age 1-18) orthopedic patients and an intervention group of 59 patients was conducted in a surgical ward in Switzerland.

RESULTS

The implementation of a standardized constipation prophylaxis led to an absolute risk reduction (27%) of constipation. Fisher's exact test showed a significant difference in the prevalence of constipation in the two samples, p = .001.

PRACTICE IMPLICATIONS

Constipation prophylaxis is a necessity in pediatric orthopedics.

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

PURPOSE OF REVIEW

This review summarizes recent developments in the management of gastrointestinal symptoms experienced by cancer patients and provides a framework for 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. Current clinical guidelines now recommend that patients treated with moderate emetic risk chemotherapy regimens be preferentially treated with the 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, palonosetron, in combination with dexamethasone. A large randomized trial has also recently validated that single-dose fosaprepitant is equivalent to the standard 3-day, aprepitant regimen. New medications, such as skin patch delivery of granisetron for nausea or methylnaltrexone for constipation, show promise in both the management of symptoms and as preventive agents. The integration of complementary and alternative therapies, such as relaxation techniques, ginger, 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 disproportionate with objective measures. New methodologies that harness technology to collect patient-reported outcomes may improve the accuracy of assessment, provide a better picture of the patient's experience of gastrointestinal symptoms, and deliver 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. When combined with refinements in the overall clinical approach to symptom management, standardized instruments that streamline data collection and enable data warehousing will support better symptom management.

A review of laxative therapies for treatment of chronic constipation in older adults

BACKGROUND

Multiple studies have addressed the treatment of chronic constipation in adults in general; however, less guidance is available for treating this condition in older patients.

OBJECTIVE

The aim of this paper was to review the effectiveness of laxatives for chronic constipation in the elderly.

METHODS

Medline, Web of Science, international Pharmaceutical Abstracts, and the Cochrane database of Systematic Reviews were searched for english-language articles evaluating the treatment of chronic constipation in older individuals from the inception of the databases until October 2010. Search terms included constipation, treatment, laxative, elderly, and geriatric. Articles were excluded if the mean age was <65 years.

RESULTS

Thirty-one trials were identified. These studies varied widely in terms of methodology, quality, sample size, efficacy end points, and duration. Mean stool frequency was 9.08 bowel movements per week with psyllium and 8.29 per week with calcium polycarbophil (P = 0.04). docusate sodium daily, docusate sodium q12h, and docusate calcium daily for 3 weeks produced a mean stool frequency of 1.95 bowel movements per week versus 1.50 for placebo (P = NS), 2.29 versus 1.76 (P = NS), and 2.83 versus 1.75 (P<0.02), respectively. Mean stool frequency with lactulose versus placebo was 0.7 and 0.5 bowel movements per day (P<0.02). in patients receiving polyethylene glycol or lactulose, mean stool frequency was 1.3 and 0.9 bowel movements per day (P = 0.005). in a study comparing senna plus a bulking agent with lactulose, mean stool frequency was 4.5 per week for the combination product versus 2.2 per week for lactulose (P<0.001). A study comparing sodium picosulfate with senna reported a mean stool frequency of 0.71 and 0.63 per day (P value not reported). Lubiprostone was associated with 5.69 spontaneous bowel movements per week versus 3.46 per week for placebo (P = 0.001).

CONCLUSIONS

Higher-quality trials evaluating the treatment of constipation in older patients are needed to create a basis for more definitive recommendations in this population. The approach to older adults with constipation should be individualized.

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.

Nutritional needs of patients with malignancies of the head and neck

OBJECTIVES

To provide strategies to manage nutrition in patients with head and neck cancer.

DATA SOURCES

Empirical articles, reviews, books, and anecdotal evidence.

CONCLUSION

Major nutrition issues include sore mouth/throat, difficulty swallowing, taste changes, dry mouth/thick saliva, constipation, nausea/vomiting, and decreased appetite.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are one of the main providers for patients with head and neck cancer and may be the first to recognize a nutritional issue. The oncology dietitian and nurse work closely together to manage the nutritional care of the patient.

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.

A systematic review of treatments for constipation in children and young adults undergoing cancer treatment

Constipation is a common problem in children and young people with cancer. Treatment of this complication is subject to wide variation in practice. We undertook a systematic review of randomized controlled trials to build a rational approach to prophylaxis and treatment of this complication. Randomized controlled trials of any intervention (pharmacologic, physical, complementary, or alternative) to prevent or treat constipation were to be included if they included children and young people 16 years old and younger who were undergoing treatment for malignancy. Of the 1336 abstracts retrieved from the searches, only 3 papers were identified for further assessment, and no studies were suitable for inclusion. There are no good data on which to base the management of constipation in children and young people with cancer. This is not to say that we do not know if laxatives work-they are clearly effective. Our ignorance is of the comparative value of different agents. The practical problems with undertaking specific trials of supportive care measures are large, and integration of such questions into treatment trials is essential.

Constipation and Diarrhea in Patients with Cancer

Constipation and diarrhea are both common problems in patients with advanced cancer. They are source of major morbidity and distress. Constipation is, overall, more common that diarrhea. Diarrhea may be severe and, in some cases, associated with life-threatening dehydration and electrolyte abnormalities. Indeed, with some of the newer chemotherapy agents, this is a problem seen with increasing frequency. Oncologists must be familiar with the common causes of constipation and diarrhea in cancer patients and the strategies to evaluate and manage these common and distressing symptoms. Both with constipation and diarrhea, there is a differential diagnosis. In many cases, management can be complex and challenging. Approaches to diagnosis, evaluation, and management are reviewed.

A constipation assessment scale for use in pediatric oncology

Constipation is prevalent in pediatric oncology patients because of treatment with vinca alkaloids and/or narcotics and lifestyle changes secondary to disease process. Sequelae of constipation include anorexia, nausea, vomiting, abdominal pain, emergency department visits, and a decrease in quality of life. There are no reliable instruments to measure constipation in children. A pilot study (N = 21) evaluating the presence and severity of constipation and the reliability and validity of a modified version of the adult Constipation Assessment Scale (CAS) in children with cancer was conducted. Patients receiving weekly vinca alkaloids and/or narcotics = 2 times per day were recruited. Initial bowel function assessments included standardized nursing and nutrition assessments, history/physical review, and baseline CAS score repeated at 1 hour to assess test-retest reliability. Subsequent assessments included CAS administered 3 times per week and daily patient bowel diaries. Test-retest reliability was evident (r = .93; P = .000). Acceptable construct validity was indicated by a difference in mean CAS scores (t = 4.4, P <.001). Patients reported difficulty with CAS questions and response selections. Symptoms asked on CAS were often not viewed as a problem.

Constipation in paediatric oncology

Constipation is a common problem encountered by many children during treatment for childhood cancer. It can be distressing and impact on the quality of life for the child. However, the advice and information they and their families receive can vary enormously. The clinical practice group (a subgroup of the paediatric oncology nurses forum (PONF)) decided to examine the management of constipation throughout the paediatric oncology units in the UK. This paper presents the findings and the subsequent action taken and highlights the need for further work.

The treatment of chronic constipation in elderly people: an update

Constipation is a common problem in elderly persons, with prevalence ranging from 15% to 20% in the community-dwelling elderly population and up to 50% in some studies of nursing home residents. In these patients, constipation results from a combination of risk factors, such as reduced fibre and fluid intake, decreased physical activity resulting from chronic diseases and multiple medications. Despite the high prevalence of constipation, there is surprisingly little evidence available on which to base management decisions of this common condition. Increased fluid intake, regular physical activity and high fibre intake are usually proposed as first step nonpharmacological measures. However, adherence to these measures is limited and pharmacological treatment is frequently required. Data are too limited, especially in elderly persons, to formally recommend one class of laxatives over another or one agent over another within each class. However, bulk-forming and osmotic laxatives are usually recommended as first-line agents, even though data on their effectiveness are limited. The need to maintain good hydration is a limitation in the use of bulk-forming laxatives, in particular, in frail elderly patients. In these patients, polyethylene glycol, an osmotic agent, is an attractive alternative. In addition, it has been shown to relieve faecal impaction in frail patients with neurological disease. Its cost and potential danger in patients at high risk for aspiration is, however, a limitation. Stimulant laxatives are considered mainly as an intermittent treatment in patients who do not respond to bulk-forming or osmotic laxatives. Several promising compounds such as the new serotonin 5-HT4 receptor agonists (tegaserod, prucalopride) and neurotrophin-3 (NT3) have not been adequately tested in older individuals. They are not routinely used and their role in the management of constipation in these patients will be more precisely defined in the future. Other treatment options are available (acupuncture, biofeedback, botulinum toxin and surgery), but experience with these interventions in elderly patients is limited and their indications in this population remain to be clarified. Management of constipation in elderly persons depends largely on experience and beliefs. Several new compounds seem promising but will need to be specifically tested in this population before being recommended.

Nurses' knowledge of prevention and management of constipation

Constipation is often a preventable problem in health care; therefore health professionals must have the appropriate knowledge to help patients prevent this common complaint occurring. The purpose of this study was to assess nurses' knowledge of constipation in a teaching hospital in Northern Ireland. A knowledge questionnaire on constipation was obtained and adapted for use in this study using a non-experimental survey design to assess a convenience sample of nurses (n = 131) within various hospital specialities. The results demonstrated gaps in nurses' knowledge of constipation and also indicated that knowledge varied between specialties and between nursing grades. Educational initiatives must not allow bowel care, often labelled 'basic nursing care', to be neglected in postregistration education and training.