Constipation: Assessment and Management in an Institutionalized Elderly Population

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Abstract
OBJECTIVES: To examine prescribing and utilization patterns of laxatives, stool softeners, and enemas in a large, long‐term care facility, to compare self‐reports of constipation with specific, bowel‐related symptoms in residents of this facility, and to examine concordance between bowel symptoms reported by residents and the assessments of the nursing staff. DESIGN: Cross‐sectional study. SETTING AND SUBJECTS: All individuals residing in an academically oriented long‐term care facility in the United States for at least 1 month (n = 694). MEASUREMENTS: Clinical, functional, and medication data were abstracted from the medical and nursing records. Individual interviews regarding bowel‐related symptoms were conducted with all able participants (n = 456 (66%)) and their respective primary nurses, and concordance was determined. The study definition of symptom‐specific constipation was no more than 2 bowel movements per week and/or straining on more than 1 in 4 bowel movements. RESULTS: Fifty percent (n = 367) of all residents used at least 1 daily laxative, stool softener or enema during a 1‐month study period. Over half of all laxative users (n = 200) took more than 60 doses per month. Stool softeners were most commonly prescribed, followed by saline laxatives, stimulant laxatives, hyperosmolar laxatives, and bulk laxatives. Forty‐seven percent (n = 213) of the 456 interview responders reported constipation (“self‐reporters”), but only 62% of self‐reporters met the study criteria for symptom‐specific constipation. Concordance between resident's and nurse's report regarding specific bowel symptoms was only fair to slight (kappa 0.12–0.38). Self‐reporters of constipation took almost twice as many laxatives, stool softeners, and enemas as residents who did not report constipation. CONCLUSION: Our findings emphasize the need for a more systematic approach to the assessment of constipation in the long‐term care setting, particularly when pharmacologic treatment is being considered.