RESPONSI ENDOCRINOLOGY CONSTIPATION IN ELDERLY

Oleh: Tennyson Kwan Chong Chuen Vishnu Varathan A/L Moganadass Rachmi Mirna Putrianti Prasilia Ramadhani 0810714036 0810714045 0810713079 0810713033

Pembimbing: Dr. Sri Sunarti, SpPD

LABORATORIUM / SMF ILMU PENYAKIT DALAM FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA RUMAH SAKIT UMUM DAERAH DR. SAIFUL ANWAR MALANG 2012

Constipation in Elderly An 88 years old male came with difficulty in defecation accompanied by painful sensation, also decreased of appetite since one month ago. He came to our emergency unit on 18th of July 2012. Hereby, I would like to report a case study.

Vignette Anamnesis Male/ 88 years old /W24A Chief complain: Difficulty in defecation Patient complains of difficulty in defecation since one month ago, about 2 times in a week, the amount of defecation is little; consistency is hard, and not bloody. Patient complains of pain during defecation, straining during defecation and sometimes need help to facilitate the defecation, before this the patient has smoothly bowel movement every day. Patient complains of decreased of appetite since one month ago. Patient's family has claimed that patient reduce appetite because afraid of the painful sensation during defecation, each meal with only two scoops of rice and sometimes patient refuse to eat. Patient drinks water about 1 liter/day. Before this, patient has a good appetite. Patient has difficulty in urinating since 2 months ago, with the sensation of pain during urination and peeing a little by little (anyang-anyangan), and he feels not satisfied after each urination. The time for urination is more than 3 minutes each time. Patient has no history of increase frequency in urination, 2-3 times in one day. Patient's family claimed that the patient having difficulty in doing daily activities such as wearing clothes, go washroom, eating a meal and so on by himself since one month ago. The body of the patient is weak and lack of strength. Before this, patient can able to do all the daily activities alone independently. Right now, Patient has difficulty in mobilization, difficult to walk because his body is weak. Patient's family reported that the patients had impaired of hearing since 2 months ago. According to patients family, they have to increase their voice when talking to the patient, because the patient will not hear if the voice is too soft. Patient has not check to Polyclinic ENT yet. Patients family claimed that patient has slight memory impairment. The patient always forgets to eat on time, need to remind him to eat. But patient still can remember the time to pray. He will follow every single pray although he has difficulty in walking. Patient does not have history of Diabetes Mellitus, Heart Disease, and Hypertension. Patient had done right eye cataract surgery in the RSSA hospital since 2 years ago. After the operation, Patient control to the ophthalmology clinic and put the eye drop on the operated eye routinely.

Past Illness History: The patient has history of illness in Lawang hospital since 3 months ago with chief complain of stomach discomfort and diarrhea, more than 3 times in a day, color is yellow, and quantity is 1-2 aqua glass cup, not with mucus, blood and fat. At that time, Patient did not hospitalize, after taking the medication that prescript by the doctor there, the patient went back home. The patient does not remember the name of the medication. Past Medication history: Patient has no history of taking medication in a long period. Each time when patient was sick, then only he will drink medication. No history of taking laxative medication energy drink, and jamu-jamuan. Family history: Patient has no family history of difficult in defecation. Both parents of the patient had passed away, and patient does not know the cause of the death. Patients son and daughter are all healthy, and they always have their body checkup routine annually to the nearby hospital or laboratory. Personal history: History of allergic: Patient has no allergic to food and medication. History of immunization: Patient does not remember. Hobby: Watching TV and Playing with his grandchildren Exercise: Jogging, but stop since 1 month ago because body is weak and no strength. Eating habit: Decreased of appetite since 1 month (3 times 2 scoops, with rice, vegetables, kale / cabbage / spinach, tofu and tempeh), patients drank water 1 large bottle of mineral water (1 liters). Smoking: Patient do not smoke Drinking alcohol: Patient do not drink Sex history: Didnt ask to the patient Physical examination General appearance looked moderately ill GCS 456 BP = 160/100 mmHg PR =96 tpm RR = 20 tpm tax : 36.8 C Head No abnormality found Thorax Cor : No abnormality found Lung : No abnormality found Abdomen Extremities : Bowel sound + , Flank tenderness, Trobes space dullness : No abnormality found

Rectal Touche : Tonus , Feces +(Brown color), Pain +

Laboratory Finding 18/7/2012 Hematology Leukocyte Neutrophil Liver functional test Random blood glucose Kidney functional test Ureum Creatinine Electrolyte Potassium 19/7/2012 Electrolyte Potassium 20/7/2012 Electrolyte BJ Plasma Immunoserology (CEA,CA19-9) 22/7/2012 Immunoserology (PSA total) Cholesterol Uric acid

: 10.760 : 77% : No abnormality found : No abnormality found : 76.70 : 1.23 : 5.40

: 5.98 (~Lysis)

: No abnormality found : 1.026 : No abnormality found

: No abnormality found : No abnormality found : No abnormality found

CXR (18/July/2012) Conclusion: No abnormality found EKG (18/July/2012) Conclusion: Sinus rhythm with heart rate of 100 beats per minute USG (18/July/2012) Conclusion: No appendix antecaecal structure and Cyst at the right kidney Problems found in this patient 1. Immobilization (Score ADL:2) 2. Cognitive Disturbance (MMSE: 16) 3. Malnutrition (MNA: 4.5) 4. Hearing Disturbance 5. Constipation 6. Vision Disturbance 7. Insomnia 8. Digestive Disturbance

Therapy Non-pharmacology 1. Education the patient Educate how constipation happens, avoid the risk factor, and explain to them how to have a healthy bowel movement. 2. Diet dietary fiber/fruit mixtures Give soft diet 1900kcal/day and high fiber food 3. Fluids 1.5-2L/daily IVFD NS 0.9% 20dpm 4. Physical activity(30 min brisk walk and 11 min home exercise a day) Patient is weak and unable to walk 5. Regular toileting habits Educate patient to have regular toileting habit Pharmacology 1. Laxative and Enema use 1.1 Stimulant- Senna/Cascara/Bisacodyl Laxadine is chosen for this patient because it is a safe agent to use in elderly people with functional constipation, Bisacodyl 10mg daily is useful alternative stimulant laxative to senna. 1.2 Bulk- Psyllium/Methyl cellulose/Calcium polycarbophil 1.3 Magnesium salt- Magnesium hydroxide(milk of the magnesia) 1.4 Hyperosmolar- Lactulose/sorbitol 1.5 Hyperosmolar- Polyethylene glycol 1.6 Softener- Docusate sodium 1.7 Phosphate, Sodium citrate, Arachis oil, Tap water, Enemas

Introduction In 2000, approximately 10% of the worlds people were 60 years old or older. According to the United Nations Medium Variant population projection, falling fertility and mortality rates will cause this figure to rise to over 20% by 2050. This means that 400 million older people will be living in the developed countries and over one and a half billion in the less-developed world (Philip, 2003). United Nations (2002) data predict that the percentage of Indonesians over the age of 60 will rise from 7 to 8 per cent of the population today to 13 per cent in 2025. Comparable shifts in Europe took fifty years in the case of Britain and over a century in France. Not only is the speed of change remarkable, the scale of the Indonesian situation is mind-boggling. Due to a still rapidly growing national population, in absolute terms elderly numbers will increase by 300 to 400 per cent, while the approximately 16 million people over 60 already constitute the seventh largest elderly population in the world today (John et al, 2011). Constipation is a frequent health concern in elderly people. People older than 60 years have became the primary care visits for constipation, as well as regular use of laxatives (Halter, 2009). There is lack of agreement on the definition of constipation regarding what patients perceive as constipation and what physicians traditionally see as constipation. Constipation is related to multiple factors, and when left untreated or not properly treated, results in complications, such as impaction, even perforation and death. There is a need for a large-scale trial examining an appropriate cost-effective approach to the management of constipation in the nursing home (Anonymous, 2003). This study will focus on the epidemiology, etiology, differential diagnosis, diagnosis approach and management approach of chronic constipation in elderly. Epidermiology The prevalence of self-reported constipation, physician visits, and laxative use increase with aging, while the prevalence of stool frequency dosent change with age. One older community-based study of 3166 persons aged 65 years and older asked the question, Do you have recurrent constipation? and found a prevalence of 26% in women and 16% in men; in the 84+ years age group, prevelance was 34% and 26%, respectively (Juan et al, 2011). Age was a strong independent risk factor for selfreported constipation. Other community studies support this relationship with age and show prevalence rates of up to 34% of women and 30% of men older than age 65 years.

Constipation is more common in elderly, blacks, women, and persons of lower socioeconomic class. The prevalence of constipation varies from 20-25% in older people in the United Kingdom and is more common in women then in men. There is some evidence suggesting that lack of fiber, inactivity, and lack of fluid may contribute to constipation in otherwise healthy older people. Frailty is a major problem in older persons and, in frail elders, up to 45% reported constipation as a health issue (Philip, 2003). Risk factor Many risk factors particular to the elderly population have been identified as contributing to constipation, such as use of polymedications, impaired mobility, neurological conditions, low dietary fiber, depression, dan metabolic disturbances. Risk of constipation increase in older patients with polypharmacy, average of six prescribed medication per day (Ness et al, 2006). Example of the medications are anticholinergic drugs (tricyclics, antipyschotics, antihistamines, antiemetics), opiates, iron supplements, calcium channel antagonists dan Nonsteroidal anti-inflammatory drugs. Anticholinergic drugs reduce intestinal smooth-muscle contractility and have been associated with daily laxative use in nursing home redisents and community-dwelling elderly person (Christine, 2005). Calcium-channel antagonists impair lower gut motility, associated with rectosigmoid dysmotility, by inhibiting calcium uptake into smooth muscle cells and altering intraluminal electrolyte and water transportation, result in severe constipation, especially patients taking nidedipine and verapamil. All types of iron supplements (sulphate, fumarate, and gluconate) cause constipation in adults, the constipating factor being the amount of elemental iron absorbed. Nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of constipation in older people, most likely through prostagladin inhibition (Halter, 2009). Common risk factor for constipation in older people is impairement of mobility. Greater physical activity (including regular walking) is associated with less self-reported and symptom-specific constipation in older people living both at home and in long-term care. Reduced mobility was found to be the strongest independent correlate of heavy laxative use among nursing home residents, following adjustment for age, comorbility, and other relevant clinical factors (Halter, 2009). Neurological conditions such as dementia, parkinson disease, diabetes mellitus, autonomic neuropathy, stroke and spinal cord injury are pathologies that lead to

constipation. Dementia predipose individuals to rectal dysmotility,

partly through

ignoring the urge of defecate. Patients with Parkinson disease suffer from primary degeneration of dopaminergic neurons in the myenteric plexus resulting in prolonged colorectal transit, besides, pelvic dyssynergia causing rectal outlet delay and small increases in intra-abdominal pressure prolonged straining. Diabetic patients with autonomic neuropathy are more likely to be constipated because of markedly slowed transit throughout the colon and impairment of gastrocolic reflex. Colonic transit time in frail and immobile older people with diabetes is etremely prolonged at 200144 hours. An Israeli study showed that this very long transit time in long-term care residents with diabetes can be significantly reduced by administering acarbose, an alpha-glucosidase inhibitor with a pontential adverse effect of causing diarrhea. Constipation affects 60% of those recovering from stroke on rehabilitation wards, and a high number of these have combined rectal outlet delay and slow transit constipation. For stroke survivors living in the community, problems relating to bowel evacuation are greatly worsened by difficulties accessing the toilet owing to functional impairment (Juan, 2011). Low consumption of wheat bran, fiber, vegetables, fruit, rice, and calories can all predipose toward constipation. A U.K. survey showed that consumption of fruit, vegetables, and bread decreases with advancing age. It has been suggested that the prevalence of constipation is rising because modern food processing produces redined food with low roughage. Low fluid intake in older adults has been related to symptomatic constipation in epidemiologic surveys and to slow colonic transit. Withholding fluids over a 1-week period in young male volunteers significantly reduced stool output. Elderly people are at greater risk of dehydration because of impaired thirst sensation, less effective hormonal responses to hypertonicity, limited access to drinks, and voluntary fluid restriction in an attempt to control urinary incontinence (Halter, 2009). Depression, physiological distress, and anxiety are all associated with increased self-reporting of constipation in older persons. Hypokalemia produces neuronal dysfunction that minimizes acetylcholine stimulation of gut smooth muscle and so prolongs transit through the gut. Hypercalcemia cause conduction delay within the extrinsic and intrinsic innervation of the gut. Patients with myxedema have been observed to have edema of the gut wall with mucopolysaccharide deposition, although whether this contributes to the colonic hypomobility seen commonly in clinical

hypothyroidism is uncertain. Patients on long-term renal dialysis have prolonged age-

adjusted transit-time, more so in hemo- than peritoneal dialysis. In a questionnaire study from Japan, 63% of hemodialysis patients complained of constipation (Tariq, 2007). A large japanese survey of constipation symptoms found that alcohol consumption was a preventive factor in men. A population survey of middle-aged women in the United States showed that daily alcohol consumption (exceeding 12g/d) and low moderate caffeine intake were independently inversely related to infrequent bowel movements. Black coffee has been shown to increase colonic motility specifically in the rectosigmoid within 4 minutes of ingestion in young healthy volunteers, implying that caffein triggers the gastrocolic reflex (Juan, 2011). Causes of constipation can be divided into primary and secondary cause (FoxxOrenstein et al, 2008). Primary causes of constipation could be classified into 3 group: normal transit constipation, slow transit constipation, and anorectal dysfunction. Normal transit constipation, also known as functional constipation, is the most common. In patients with functional constipation, stool passes through the colon at a normal colonic transit time of about 72 hours. Slow transit constipation is characterized by prolonged delay in passage of stool through the colon. Patients may complain of abdominal bloating and infrequent bowel movements. Anorectal dysfunction is the inefficient coordination of the pelvic musculature in the evacuation mechanism. These patients are more likely to complain of a feeling of incomplete evacuation, a sense of obstruction, or a need for digital manipulation. Secondary cause of constipation is the use of medications, especially those that affect the central nervous system, nerve conduction, and smooth muscle function (Juan, 2011).

Diagnosis Based on Rome III diagnostic criteria, fuctional constipation is diagnosed by two or more of the following: straining during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, sensation of the incomplete evacuation for at least 25% of defecations, sensation of anorectal obstruction/blockage for at least 25% oof defecation, manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor) and fewer than three defecation per week. Loose stools are rarely present without the use of laxatives and insufficient criteria for irritable bowel syndrome are also a diagnostic criteria for functional constipation according to Rome III diagnostic criteria (Drossman, 2006)(Longstreth, 2006). Hence, functional

constipation can be diagnosed if criteria fulfilled for the last 3 months with symtom onset at least 6 months prior to diagnosis (Brandt et al, 2005). Constipation in older people is diagnosed by using bowel history, general history, specific physical examination, and radiology tests. For bowel history, patients have to keep a stool chart for 1 week to document frequency, characteristics of their bowel movements, stool consistency and associated symptoms. Besides that, bowel history also consist of rectal pain, bleeding, laxative use, fecal incontinence, irritable bowel syndrome symptoms, straining of rectal outlet delay and duration of constipation (Halter, 2009). A broad assessment should be undertaken in older patients with constipation, focusing on prediposing causes. History should include over the counter medications, diet, and fluid intake. Examination should include cognition, mood and function. Appropriate laboratory test include laboratory tests include complete blood count; plasma electrolytes; glucose; and bone, liver, and thyroid profiles (Juan, 2011). Digital rectal examination is required in all patients who report constipation to reveal rectal impaction, rectal dilatation, hemorrhoids, anorectal disease, and perianal fecal soiling (Tariq, 2007). Retained stool in rectal impaction dose not have to be hard; loading with soft stool is commonly seen in older people taking laxatives who have problems with rectal outlet delay. A dilated rectum with diminished sensation and retained stool suggests rectal dysmotility. External sphincter tone is accessed by asking the patient to squeeze and pull up around the examining finger. Indicators of reduced internal anal tone are easy insertion of the finger into the anal canal and gapping of the anus on applying gentle traction to the anal margin. Anal sphincter weakness should prompt careful prescribing to avoid causing fecal leakage though excessive laxativeinduced softness of stool, and instruction in anal sphincter stregnthening exercises (Christine, 2005). Clinical diagnosis can usually be made on the basis of a thorough history and examination. However, a plain abdominal radiograph is useful in patients without rectal impaction in whom colonic loading is suspected because of a high-risk profile, constipation-related symptoms, or fecal incontinence. Dilatation of the colon (>6.5 cm maximum diameter) in the absence of acute obstruction points to a neurogenic component to bowel dysfunction, and thus identifies patients at risk of recurrent colonic impaction. Rectal dilatation (>4cm) implies dysmotiity and evacuation problems. Chronic constipation alone is not an appropriate indication for colonscopy (Halter, 2009). Anorectal function tests are rarely required in assessment of constipation in older

people. This may be indicated in patients with severe and persistent rectal outlet delay, in order to diagnose pelvic dyssynergia, which is more effectively treated by biofeedback than laxatives (Juan, 2011). Complication Constipation is a common, treatable, preventable, and often overlooked cause of fecal incontinence in older people. If constipation left untreated, will appear few medical symptoms such as fecal incontinence, fecal impaction, urinary retention, stercoral perforation, sigmoid volvulus, colonic pseudo-obstruction, rectal prolapse and

diverticular disease. Fecal impaction is an important cause of comorbidity in older patients, by increasing the risk of stercoral perforation of the wall of the colon (usually sigmoid) secondary to ischemic necrosis. Chronic constipation in frail older people is the leading cause of sigmoid volvulus in the developed world. Volvolus is more likely in constipated patients with Parkinson disease and neuropathic colon. (Halter, 2009)

Management Nonpharmacological treatment Educating patients as to what constitutes normal bowel habit should be one of the first step in managing self-reported constipation. Patients with no or mild symptoms of constipation should be encouraged to discontinue chronic laxative therapy. (1) Educational interventions promoting lifestyle changes for patients with chronic constipation should focus on exercise and diet, and ideally be based on the cognitive Theory of Planned Behaviour. Pasiens are advised to consume high fibre food (ranging from bran to processed pea hull) or fruit mixtures (apple puree to fruit porridge) to the daily diet (Thomas et al, 2003)(Muller-Lisner, 2005). Upping fluid intake by two 8-ounce beverages a day for 5 weeks in dependent nursing home residents significantly increased bowel movement frequency and reduced laxative use (Annells, 2003). Few studies proved that regular physical activity (30 min brisk walk and 11-min home exercises a day) decreased colonic and rectosigmoid transit time and improved defecation pattern (Tuteja et al, 2005). Abdominal massage added to the standard bowel regimen in spinal cord patients has been shown to shorten colonic transit time and increase weekly bowel movement frequently. Pelvic floor retraining can help rectal outlet symptoms, while sphincter strengthening exercises should be taught to patients with fecal soiling and/or weak external sphincter. Regular toileting habits restores comfortable

evacuation in stroke survivors and in older postoperative inpatients (Rao et al, 2001). Toileting access should be assessed and facilitated particularly in patients with mobility, visual, or dexterity impairments (Halter , 2009). Pharmacological treament Medications that use in constipation are laxative, suppository, and enema. Senna is a cheap and safe stimulant laxatives agent for use in elderly people with functional constipation. Administration of 20mg of senna daily for 6 months to patients older than 80 did not cause any significant losses of intestinal protein or electrolytes. Senne generally induces evacuation 8 to 12 hours following administration, and should therefore be taken at bedtime. Frail elderly patients may have even slower response times, and may also require seceral weeks of daily use before achieving reguler bowel habit. Maintenance therapy with senna is appropriate in patients with chronic constipation, and it can be used in high doses for short-term treatment of fecal impaction. Bisacodyl is a useful alternative stimulant laxative to senna. A recent treatment (Bisacodyl 10mg daily) with chronic constipation showed improved stool frequency and consistency without side effects. Phenolphtalein and castor oil should not be used in older people because of a high risk of side effects including malabsortion, dehydration, lipoid pneumonia, and, with heavy prolonged use, cathartic colon. (Tariq, 2007) Bulk laxatives are generally underprescribed to older people, despite evidence that they increase bowel movement frequency, and improve consistency and ease of evacuation. Psyllium has been associated with increased stool frequency in people with Parkinson disease, but was not shown to alter transit time. Bulking agents are generally useful in older individuals with mild to moderate constipation who are albe to tolerate them and who drink sufficient fluids. They have the additional benefit of reducing abdominal pain in patients with irritable bowel syndrome, limiting flare-ups of diverticulitis, and facilitating painful defecation associated with hemorrhoids. (Halter, 2009) Magnesium salts are the most commonly prescribed type to elderly in hospital. This laxative agent was more effective than a bulking agent in increasing bowel movement frequency and softening stool. Long term use of magnesium hydroxide is contraindicated in chronic kidney disease. Based on evidence and known side effects, there is no clear role for using magnesium salts in treatment of chronic constipation.

Lactulose and sorbitol are effective agents in treating chronic constipation in older people in all health care settings, with sorbitol being the cheaper option. In comparison to lactulose, polyethylene glycol produced a greater increase in bowel movement frequency and a greater reduction in straining, but at the expense of a higher mean number of liquid stools (Christine, 2005). Docusate sodium has been shown experimentally to have no effect on colonic motility, and little or no laxative action, even at doses of 300 mg/day. Nevertheless, docusate is frequently recommended and used in older people as a laxative as well as fecal softener (Christine, 2005). Enemas have a role in both acute disimpaction and in preventing recurrent impactions in susceptible patients. Reguler use of phsphate enemas should be avoided in patient with renal impairment (Christine, 2005). Altered serotonim(5-HT) signaling may predipose to chronic constipation, and 5HT4 agonist (tegaserod) have been shown to stimulate gastrointestinal motility and increase stool water content. Tegaserod improves symptoms of constipation in younger people, its side effect profile includes headache and diarrhea. The enterokinetic drug prucalopride proved disappointing in treating constipation in people with Parkinson disease. These agents are not recommended for routine use in older people (Halter, 2009). In ambulant elderly with functional constipation, a daily bulk laxative is appropriate for both rectal outlet delay and slow-transit constipation. If the bulking agent is not tolerated, or proves ineffective, then senna may be substituted (1-3 tablets at night) with prn sorbitol (or lactulose) if needed to achieve patient-centered goals of comfortable regular evacuations. In frailer, less mobile elderly people at higher risk of impaction, a combination of regular senna and sorbitol (or lactulose) should be used with dosage titration. In patients with colonic impaction, oil retention enemas should be administered daily until there are no clinical or radiologis signs of obstruction, and then tap water enemas continued regularly until they produce no further result (Halter, 2009). Conclusion Health care providers should routinely inquire about constipation symptoms in older people, and be alert to the presence of clinical constipation in individuals unable to communicate. In many older people with constipation symptoms, lifestyle advice (diet, fluids, exercise, toileting habits) will preempt the need for laxative therapy. In higher risk

patients, a stepwise approach to prescribing laxatives, suppositories, or enemas should be used, with the goal of achieving comfortable and regular evacuation. Rectal ecavuation difficulties should be specifically addressed in order to identify conditions that may require additional interventions.

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