Medical Management of Constipation in Elderly Patients: Systematic Review

Cost drivers and feasibility of a hospital-at-home programme for geriatric care in northeastern Mexico: a retrospective observational study

OBJECTIVE

The primary objective was to evaluate factors influencing the cost of a 'hospital at home' (HAH) for geriatric patients in a Northeastern Mexican hospital. Secondarily to evaluate the per capita global cost-effectiveness compared with traditional hospital care.

DESIGN

This retrospective analysis examined the costs incurred by geriatric patients in an HAH programme from February to December 2022 SETTING: We collected data from clinical records and assessed medication and procedure costs through the hospital's financial department. Costs for traditionally hospitalised patients were reviewed for comparison.

PARTICIPANTS

Subjects of both genders aged 70 and older who were treated in HAH during 2022 and hospitalised subjects with the same age and gender treated in the same period.

INTERVENTION

NA PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: factors that influence costs in HAH. Secondary, global per capita cost comparison between HAH and hospital care.

RESULTS

We examined the expenses associated with 416 home visits to 49 patients in the HAH programme. The main factors influencing the programme's overall cost were medical care and procedure-related disorders (β=0.333, p=0.002), sleep-regulators (β=0.561, p<0.001), laxatives (β=0.330, p=0.001) and anticoagulants (β=0.228, p=0.025). The HAH programme's per capita cost was three times lower compared with that of traditional hospital care and resulted in a 40% reduction in hospitalisation days.

CONCLUSIONS

This study highlights that the main factors influencing the HAH programme's costs include medical care and procedure-related disorders, as well as medication extensively used in the elderly population. Additionally, we demonstrated the cost-effectiveness of the HAH programme, which produces substantial savings and is a financially viable alternative to traditional hospital care.

Association between dietary index of gut microbiota and constipation in a female population: a cross-sectional study

Objective

To examine the potential association between dietary index of gut microbiota (DI-GM) scores and constipation in adult women in the United States.

Methods

This cross-sectional study used data from adult participants in the 2005-2010 US National Health Survey (NHANES). The missing values in the covariables were filled by multiple interpolation. Multivariate logistic regression models were used to determine the odds ratios (OR) and 95% confidence intervals (CI) for the association between DI-GM and constipation. Subgroup analyses were also performed to examine the possible interactions between DI-GM and constipation.

Results

Of the 7,325 subjects, 887 reported constipations, with a prevalence of 12.1%. After adjustment for multivariate modeling, the DI-GM score was significantly associated with constipation (0.92 [95% CI 0.87-0.96]; p = 0.001). Similar results were found for the association of beneficial gut microbiota score with constipation (OR 0.89 [95% CI 0.84 to 0.95]; p = 0. 001). Subgroup analyses revealed that the relationship between DI-GM scores and constipation remained stable (p > 0.05).

Conclusion

DI-GM was negatively associated with the incidence of constipation in the female population. Clinicians should consider the influence of dietary structure on the treatment of constipation in women. Dietary intervention can be an important strategy for the comprehensive treatment of constipation.

Understanding constipation as a geriatric syndrome

Constipation is common among older adults and significantly impacts their quality of life (QoL). Prior studies have extensively detailed constipation, but conceptualization of constipation as a geriatric syndrome is lacking. In this review, we provide an overview of constipation in the geriatric population and conceptualize constipation as a geriatric syndrome given its high prevalence, under-recognized status, and association with poor QoL and adverse outcomes among older adults. The conceptualization of constipation as a geriatric syndrome, as with frailty and delirium, highlights its importance and need for a multi-faceted approach. Future research is needed to 1) better define constipation, 2) explore the multifactorial nature of constipation in older adults and relationship with other geriatric syndromes, 3) include more older adults in pharmacological and non-pharmacological interventions for constipation, and 4) curate multidisciplinary care models. Appreciating constipation as a geriatric syndrome will yield tailored management strategies, ensure timely intervention, and avoid adverse outcomes.

Randomized controlled trial protocol to analyze the effects of rice with different contents of resistant starch on chronic constipation

The trend of the aging population worldwide is becoming increasingly severe. As people age, constipation becomes increasingly common in older adults, causing varying degrees of physical and psychological harm to them. Dietary intervention is a common nonpharmacological therapy. Resistant starch is a type of dietary fiber that can regulate the gut microbiota and alleviate chronic constipation. However, few studies have explored the effects of different types of rice on chronic constipation in older adults. This protocol aims to evaluate the effects of rice with different contents of resistant starch on chronic constipation in old adults. This trial is a double-blind, two-arm randomized controlled trial. Older adults with chronic constipation residing in long-term care facilities will be recruited. Participants will be randomly assigned to receive A rice (resistant starch: 11-20%) or receive B rice (resistant starch: 0.1-0.5%). Both groups will adopt the serving of individual dishes, and the nutrition experts calculated the consumption of rice in the two groups according to the different conditions of each older person to ensure that the number of calories in the meal remained unchanged and that the other dietary components remained unchanged. The intervention will last for a total of 24 weeks. Participants will undergo follow-up via questionnaires at 6, 12, and 24 weeks during the intervention. The primary outcome will be constipation symptoms assessed by the Wexner questionnaire. The secondary outcomes will be quality of life, depression, anxiety and sleep quality. This is the first randomized controlled trial on the effects of rice with different contents of resistant starch on chronic constipation in older adults. It is expected that this study, if proven effective in relieving constipation symptoms in older adults, will provide evidence-based constipation care for medical staff.Trial registration number: retrospectively registered on Chinese Clinical Trial Registry.

Analysis of the efficacy of lactulose combined with polyethylene glycol in the treatment of functional constipation

OBJECTIVES

This study focuses on analyzing the efficacy of lactulose oral solution combined with Macrogol 4000 Powder in the treatment of functional constipation (FC).

METHODS

A total of 125 FC patients were selected, with 60 cases in a control group, who were treated with lactulose oral solution alone, and 65 cases in a research group, who were treated with lactulose oral solution combined with Macrogol 4000 Powder. The two groups were analyzed and compared in terms of efficacy, symptom recovery, Bristol Stool Form Scale (BSFS) and Wexner Constipation Scale (WCS) scores, adverse effects, serum indices, and Patient Assessment of Constipation Quality of Life (PAC-QOL). Univariate and multivariate analyses were performed to identify risk factors affecting the efficacy.

RESULTS

The total response rate of treatment in the research group was higher than that in the control group, and the symptom recovery was significantly better in the research group. In addition, the research group showed markedly elevated BSFS scores and reduced WCS scores after treatment as compared to the control group. Furthermore, significantly better improvements in various serum indices were determined in the research group. There was no remarkable difference in the incidence of total adverse reactions between groups. Finally, the course of disease, hypertension, diabetes, hyperlipidemia, and therapeutic method were identified to be factors affecting treatment efficacy in patients with FC.

CONCLUSIONS

The efficacy therapeutic of lactulose oral solution combined with Macrogol 4000 Powder in the treatment of FC is promising.

Study on the chemical stability of β-lactam antibiotics in concomitant simple suspensions with magnesium oxide

BACKGROUND

A simple suspension method, where solid formulations are disintegrated and suspended by being soaked in warm water followed by tube administration, is widely used, especially for elderly patients with dysphagia in Japanese clinical settings. However, there is insufficient information on drug stability in the simple co-suspension of multiple formulations especially including acidic or alkaline ones. The influence of occasional prolonged soakage on drug stability is also of concern. In this study, the chemical stability of typical β-lactam antibiotics, amoxicillin, and cefcapene pivoxil hydrochloride, was investigated in simple co-suspensions with magnesium oxide (MgO), which is frequently used as an alkaline laxative for the elderly.

METHODS

Amoxicillin (capsule) or cefcapene pivoxil hydrochloride (tablet) was placed with or without MgO (tablet) in a centrifuge tube containing warm water (55 °C). The tube was allowed to stand for 10 min or 5 h at room temperature and simple suspensions were prepared. The suspensions were then treated with large amounts of solvents and neutralized using a weakly acidic cation exchange resin. The resulting solutions were analyzed by high-performance liquid chromatography. The degradation products were identified by mass spectrometry and nuclear magnetic resonance spectroscopy.

RESULTS

Amoxicillin was found to be partially degraded to amoxicilloic acid and amoxicillin diketopiperazine by the co-suspension with MgO. The degree of degradation increased with the prolonged soaking. The recovery rates of cefcapene pivoxil decreased due to the poor solubility in the co-suspensions with MgO and no degradation product of the drug was observed.

CONCLUSIONS

Amoxicillin and MgO should be independently suspended because of the chemical instability of amoxicillin. This study has also indicated there is a degradation risk after prolonged soaking. It should be noted that the poor water solubility of cefcapene pivoxil under alkaline conditions may affect the absorption process as well as tube passability.

Constipation: a neglected condition in older emergency department patients

Constipation and fecal impaction are common issues with the potential for significant morbidity in older people presenting to the Emergency Department (ED). While many of these patients present with classical symptoms of constipation or fecal impaction, atypical presentations are also frequent. These atypical presentations may include paradoxical diarrhea, fecal incontinence, urinary retention or overflow incontinence, hyperactive or hypoactive delirium, anorexia/dysphagia, and syncope. In addition, various clinical conditions (such as dementia, Parkinson's disease, dehydration, and hypothyroidism) and medications (such as opiate analgesics, anticholinergics, diuretics, calcium channel blockers, anti-parkinsonian drugs, and oral iron supplements) are associated with constipation and should be considered during the diagnostic process in the ED. This narrative review specifically focuses on the prevalence, presentation, diagnoses, and management of constipation in older ED patients.

Methodological Guidelines of the Scientific Community for Human Microbiome Research (CHMR) and the Russian Gastroenterology Association (RGA) on the Use of Probiotics, Prebiotics, Synbiotics, Metabiotics and Functional Foods Enriched with Them for the Treatment and Prevention of Gastrointestinal Diseases in Adults and Children

   Aim: to optimize outcomes of the treatment and prevention of gastrointestinal diseases in adults and children.

   Key points. The Methodological Guidelines contain sections on the terminology, classification, mechanisms of action, requirements for sale in the Russian Federation, requirements for proving the efficacy and safety of probiotics, prebiotics, synbiotics and metabiotics, as well as functional foods enriched with them. An overview of relevant data allowing to include these drugs and products in the treatment an d prevention of gastrointestinal diseases in adults and children is presented.

   Conclusion. The clinical efficacy of probiotics, prebiotics, synbiotics and metabiotics depends on the specificity and quantity of their components, the dosage form, the regimen and duration of treatment. Products and functional foods with proven efficacy and safety are recommended for the treatment and prevention of gastrointestinal diseases in adults and children.

Polyethylene Glycol Misuse Causing Acute Renal Failure and Metabolic Acidosis Requiring Dialysis: A Case Report

Laxative misuse is a well-known occurrence, most often identified in patients struggling with eating disorders. Polyethylene glycol (PEG) 3350 is a readily available, well-tolerated osmotic laxative. High doses of PEG 3350 may cause gastrointestinal upset, diarrhea, dehydration, and electrolyte imbalance, although systemic toxicity is infrequently reported. This case report highlights the exceedingly rare metabolic derangements associated with profound levels of protracted PEG misuse. A 60-year-old female presented to the emergency department with altered mental status. She was found to have acute renal failure (ARF), anion gap metabolic acidosis (AGMA), and rhabdomyolysis secondary to excessive PEG 3350 use, requiring continuous renal replacement therapy (CRRT). Renal function improved after three days of CRRT, and no alternative causes beyond PEG ingestion were found to account for her mental status changes or metabolic anomalies. This report illustrates the importance of considering osmotic laxative misuse in the setting of pre-renal and intrinsic renal failure.

Efficacy and safety of galacto-oligosaccharide in the treatment of functional constipation: randomized clinical trial

The efficacy and safety of galacto-oligosaccharides (GOS) in treating functional constipation were evaluated in a four-week randomized, double-blind clinical trial on 63 patients who met Rome IV criteria (34 GOS, 29 placebo group). The number of bowel movements per day and changes in the shape of bowel movements in the treatment group significantly improved compared to those in the control group after four weeks. The Patient Assessment Constipation Quality of Life questionnaire showed that satisfaction with constipation significantly increased in the treatment group. The levels of Bifidobacterium sp. and Lactobacillus sp. significantly increased after four weeks of GOS treatment compared to those measured at baseline. No significant adverse drug reactions were identified in any indicator except for pulse rate. Thus, the prebiotic GOS can be safely used in foods and pharmaceuticals to alleviate symptoms of functional constipation by improving the intestinal flora.

Factors associated with gastrointestinal dysmotility in critically ill patients

Critical illness may disrupt nutritional, protective, immune, and endocrine functions of the gastrointestinal tract, leading to a state of gastrointestinal dysmotility. We aimed to identify factors associated with the occurrence of gastrointestinal dysmotility in critically ill patients. A cross-sectional retrospective study was conducted, using patient files as a source of data. The study included 185 critically ill patients treated in the intensive care unit of the University Clinical Center, Kragujevac, Serbia, from January 1, 2016, to January 1, 2022. Significant risk factors associated with some form of gastrointestinal dysmotility were acute kidney injury (with paralytic ileus, nausea, vomiting, and constipation), recent abdominal surgery (with ileus, nausea, vomiting, and constipation), mechanical ventilation (with ileus, and nausea), age (with ileus and constipation), and use of certain medication such as opioids (with ileus, gastro-esophageal reflux, nausea, vomiting, and constipation), antidepressants (with ileus, nausea, and vomiting), and antidiabetics (with ileus). On the other hand, Charlson comorbidity index had divergent effects, depending on the form of gastrointestinal dysmotility: it increased the risk of gastro-esophageal reflux but protected against ileus, nausea, and vomiting. In clonclusion, recognition of factors associated with gastrointestinal dysmotility should initiate preventative measures and, thus, accelerate the recovery of critically ill.

Effectiveness and safety of lubiprostone after switching from stimulant laxatives in elderly patients with chronic constipation

Background and Aim

Stimulant laxatives may cause electrolyte abnormalities, dehydration, and abdominal pain; their long-term use can lead to tolerance and subsequent refractory constipation. We investigated the effectiveness, safety, and quality of life after switching from stimulant laxatives to lubiprostone in elderly patients with chronic constipation (CC).

Methods

This multicenter, interventional, open-label, single-arm, before-and-after comparison study enrolled 99 Japanese patients aged 65-90 years with CC who took stimulant laxatives for ≥2 weeks prior to switching to lubiprostone monotherapy.

Results

The mean ± SD spontaneous defecations at Week 1 of 7.8 ± 6.2 times/week was not significantly different from that at baseline (8.3 ± 4.7). Spontaneous defecations were significantly reduced at Weeks 2 (-1.5 ± 4.0, P < 0.001) and 4 (-1.5 ± 3.7, P < 0.001). The Bristol Stool Form Scale score did not change from baseline (4.7 ± 0.9) at Weeks 1 (4.5 ± 1.3) or 4 (4.3 ± 1.3), but it did at Week 2 (4.3 ± 1.5, P < 0.05). The Patient Assessment of Constipation Quality of Life questionnaire score increased (0.36 ± 0.07, P < 0.001) after 28 days. Nausea was the only symptom that worsened from baseline and was the most frequently reported adverse drug reaction (15.2%).

Conclusion

Switching to lubiprostone monotherapy for CC was not associated with significant concerns in short-term spontaneous defecation frequency and safety, but it might affect the efficacy and patient quality of life over 2 weeks. Careful treatment strategies facilitating gradual switching to lubiprostone monotherapy may be needed in patients using stimulant laxatives.

The Effect of Chronic Laxative Use on Lipid Profile and HbA1c: A Hospital-Based Retrospective Study

BACKGROUND

Laxatives are over-the-counter medications used as a treatment for constipation. The lipid-lowering effect of the long-term use of laxatives has been proposed.

AIM

To investigate the possible impact of the chronic use of laxatives on serum lipid profile, body mass index (BMI), and hemoglobin A1c (HbA1c).

METHODS

An observational retrospective cohort study was conducted to analyze data related to patients who received laxatives for six or 12 months or more in the KAUH database system. BMI, weight, cholesterol, triglycerides, low-density lipoprotein (LDL), high-density lipoprotein (HDL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and HbA1c data were collected retrospectively from hospital records for three time points: baseline, six months, and 12 months of laxative treatment from the starting date for each patient.

RESULTS

A total of 106 patients' records fulfilled the inclusion criteria, 46 (43%) males with a mean age of 66 and 60 (57%) females with a mean age of 63. A significant decrease in plasma cholesterol and low-density lipoprotein-cholesterol (LDL-C) levels was observed in those who used laxatives for 12 months. Furthermore, an overall BMI and ALT reduction was seen in the combined. On the other hand, HbA1c levels appeared to improve in the combined group but not statistically significant. The change in the cholesterol level could be observed in patients receiving statin treatment and those without, with no statistical significance between the two groups.

CONCLUSION

Chronic laxative use for 12 months or more is associated with a decreased total and LDL-C level with no significant effect on high-density lipoprotein-cholesterol (HDL-C) levels. Additionally, there was a significant reduction in BMI and ALT. This effect is more prominent with combined therapy. Further multicentric studies on larger sample sizes are recommended to confirm our findings.

A study on the chemical stability of cholesterol-lowering drugs in concomitant simple suspensions with magnesium oxide

BACKGROUND

Difficulty in taking solid medicines is a common issue particularly for the elderly because of a decline in swallowing function, also known as dysphagia. For patients with such a dysfunction, a simple suspension method, in which solid medicines are disintegrated and suspended using warm water, has been developed and widely used in Japanese clinical settings. However, there is little information on drug stability in the simple co-suspension of multiple formulations especially including acidic or alkaline ones. In this study, the chemical stability of typical cholesterol-lowering drugs was investigated in a simple co-suspension with alkaline magnesium oxide (MgO) which is frequently used as a laxative or antacid in Japan.

METHODS

A cholesterol-lowering drug (one tablet) was soaked with or without MgO in warm water (55°C), and the vessel was left at room temperature for 10 min or 5 h. The suspensions prepared were then analyzed by high-performance liquid chromatography. Degradation products were analyzed by nuclear magnetic resonance spectroscopy and mass spectrometry for the structural elucidation.

RESULTS

In the simple co-suspension with MgO, no significant degradation was observed for atorvastatin or pravastatin, while a significant decrease of the recovery from the co-suspension was observed for rosuvastatin after 5 h. On the other hand, simvastatin and ezetimibe co-suspended with MgO were partially degraded to simvastatin acid and a pyran compound, respectively.

CONCLUSIONS

A simple co-suspension with MgO is feasible for atorvastatin, pravastatin, and rosuvastatin, although the rosuvastatin tablet should not be left soaking for a long time. Further it is inadvisable to suspend simvastatin or ezetimibe together with MgO because of their partial degradation.

Global prevalence of constipation in older adults: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Constipation is one of the most common functional disorders of the gastrointestinal tract in older adults. To date, no systematic review or previous meta-analysis has estimated the global prevalence of constipation in older adults. The prevalence of this disorder has been reported differently in different studies; therefore, this study aims to systematically review the publications and to perform a meta-analysis of the prevalence of constipation in older adults.

METHODS

The electronic databases PubMed, Google Scholar, Scopus, Web of Science, and ScienceDirect were systematically searched for studies reporting the prevalence of constipation in older adults up to February 2022. To perform the analysis, the random effects model was used, and heterogeneity was assessed by Cochran's Q test and expressed as I2.

RESULTS

Out of 5341 evaluated publications, 36 met the eligibility criteria. These studies included 58,405 older adults aged 60-93 years. The overall prevalence of constipation in older adults was 18.9% (95% confidence interval [95% CI]: 14.7-23.9%). The prevalence of constipation in older adults according to Rome II criteria was 16.2% (95% CI: 6.8-33.7), based on Rome III criteria was 19.2% (95% CI: 12.6-28.1), and based on Rome IV criteria was 10.3% (95% CI: 5.8-17.7). The highest prevalence of constipation was found in older adults in Africa at 32.3% (95% CI: 21.5-45.4), and the lowest in Asia at 13.6% (95% CI: 9.1-19.9). Concerning diagnostic tools, the highest prevalence of constipation was found if a self-reporting tool was applied with a value of 19.7% (95% CI: 15.8-24.3).

CONCLUSION

The results suggest that health policymakers should pay more attention to the prevention of constipation in older adults, including raising public awareness to the importance of nutrition and diet and physical activity in older adults.

Latilactobacillus sakei Furu2019 and stachyose as probiotics, prebiotics, and synbiotics alleviate constipation in mice

Introduction

Slow transit constipation (STC) is a common disorder in the digestive system. This study aimed to evaluate the effects of stachyose (ST) and Latilactobacillus sakei Furu 2019 (L. sakei) alone or combined on diphenoxylate-induced constipation and explore the underlying mechanisms using a mouse model.

Methods

ICR mice were randomly divided into five groups. The normal and constipation model groups were intragastrically administrated with PBS. The ST, L. sakei, and synbiotic groups were intragastrically administrated with ST (1.5 g/kg body weight), alive L. sakei (3 × 10⁹ CFU/mouse), or ST + L. sakei (1.5 g/kg plus 3 × 10⁹ CFU/mouse), respectively. After 21 days of intervention, all mice except the normal mice were intragastrically administrated with diphenoxylate (10 mg/kg body weight). Defecation indexes, constipation-related intestinal factors, serum neurotransmitters, hormone levels, short-chain fatty acids (SCFAs), and intestinal microbiota were measured.

Results

Our results showed that three interventions with ST, L. sakei, and synbiotic combination (ST + L. sakei) all alleviated constipation, and synbiotic intervention was superior to ST or L. sakei alone in some defecation indicators. The RT-PCR and immunohistochemical experiment showed that all three interventions relieved constipation by affecting aquaporins (AQP4 and AQP8), interstitial cells of Cajal (SCF and c-Kit), glial cell-derived neurotrophic factor (GDNF), and Nitric Oxide Synthase (NOS). The three interventions exhibited a different ability to increase the serum excitatory neurotransmitters and hormones (5-hydroxytryptamine, substance P, motilin), and reduce the serum inhibitory neurotransmitters (vasoactive intestinal peptide, endothelin). The result of 16S rDNA sequencing of feces showed that synbiotic intervention significantly increased the relative abundance of beneficial bacteria such as Akkermansia, and regulated the gut microbes of STC mice. In conclusion, oral administration of ST or L. sakei alone or combined are all effective to relieve constipation and the symbiotic use may have a promising preventive effect on STC.