mixed opioid agonist and noradrenaline reuptake inhibitor , as well as the combined preparation oxyco- |
Box 4 . Drugs commonly associated with constipation |
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done / naloxone are newer opioids associated with less constipation . 35 Transdermal opioids ( fentanyl and buprenorphine ) are also less constipating . Rotating between hydrophilic opioids ( such as morphine , oxycodone or hydromorphone ) and lipophilic ones ( such as fentanyl , buprenorphine or methadone ) is commonly tried , but the practice lacks concrete supporting evidence . 35 Peripherally acting μ-receptor opioid antagonists are novel medications that have an increasing role in treating opioid-induced constipation ; an example of this is methylnaltrexone |
ACID mnemonic :
• Analgesics : opiates , NSAIDs .
• Antacids : aluminium-containing antacids .
• Anticholinergic agents .
• Antidepressants .
• Antipsychotics .
• Anticonvulsants .
• Calcium-channel antagonists .
• Calcium supplements .
• Iron supplements .
• Dopamine agonists , levodopa .
• Diuretics .
Adapted from Chan ’ s Practical Geriatrics 4th edition with permission 25
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Figure 4 . Taking a medication history is crucial . |
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bromide , which is TGA approved . 36
Lifestyle and dietary
Adequate fluids , and dietary and
|
Bowel retraining
Bowel retraining includes advising
patients to implement a regular daily
|
constipation . 32 This approach entails instructing those with the cognitive capacity to relax instead of tens- |
meet the increased fluid requirements of bulk-forming laxatives . 37 , 45 The consensus statement also recommended |
and may result in bloating and flatulence . Other osmotic laxatives are not broken down by gut bacteria but |
lifestyle modifications such as |
routine that involves opening their |
ing their pelvic floor and abdominal |
that a suitable alternative to these |
are more likely to cause dehydra- |
|
active lifestyle ( avoidance of sedentary lifestyle ) can be trialled , although these are not always feasible in older patients . Guidelines recommend trialling these before
32 , 37 pharmacological interventions . Adequate hydration is impor-
|
bowels either within 30 minutes after meals to take advantage of the gastrocolic reflex or early in the morning when colonic activity is peaking . 37 , 40 It is also important to educate patients about promptly responding to the urge to defecate , refraining from pro- |
muscles during straining , aided by visual or auditory cues that offer feedback to the patient . A Cochrane review found that 40-100 % of patients report improvement with biofeedback ; however , the evidence supporting this was of low quality . 42 |
for softening the stool is docusate sodium . 38 If stools are soft yet difficult to pass , a stimulant laxative , suppository or enema should be considered .
OSMOTIC These agents include lactulose , sorb-
|
tion . Polyethylene glycol is overall superior to lactulose in increasing stool frequency , relieving abdominal pain and preventing reliance on additional products . 46 There is insufficient research to establish the effectiveness and safety of magne- |
tant but the recommended daily |
longed pushing , and ensuring con- |
Consider the cognitive func- |
itol , polyethylene glycol ( macro- |
sium salts , specifically in older indi- |
fluid intake may need to be bal- |
venient access to the toilet . 16 |
tion , physical status and degree of |
gol ), various magnesium salts and |
viduals . It is therefore not advisable |
anced against conditions that require |
For physically capable patients , |
co-operation the patient is capable |
sodium phosphate . They are osmot- |
to use these for prolonged periods |
restriction , for example , cardiac or |
appropriate defecation posture can |
of when recommending or imple- |
ically active and obligate diffusion |
because of concerns about potential |
renal failure , so the recommended |
optimise defecation mechanics . This |
menting behavioural management |
of water into the lumen to maintain |
magnesium toxicity . Note that mag- |
volume may vary . If immobility is |
involves incorporating a footstool |
therapies . 16 |
isotonicity with plasma . Lactulose is |
nesium salts are contraindicated in |
a contributing factor , patients can be encouraged to mobilise if able . A diet rich in fibre ( unprocessed grains , |
to ensure the knees are elevated higher than the hips , leaning forward and placing the elbows on the |
Laxatives
Laxatives are used as second-line
|
a synthetic disaccharide commonly used in older persons . Sorbitol is an effective and cheaper alternative . |
older patients with renal failure . 47
BULK-FORMING
|
fruits and vegetables , see figure 9 ) is encouraged to help alleviate constipation . 38 The side effects of bloating , cramping and flatulence associated with a high-fibre diet can be avoided by titrating dietary fibre slowly |
knees , bulging out the abdomen , and straightening the spine . 41
Biofeedback
Biofeedback is a viable alternative , particularly for older indi-
|
treatment and are administered on a prn basis . Educate the patient and caregiver on proper use , as laxative dependence and abuse are common among older persons . 43 , 44 Osmotic laxatives are preferred over bulk-forming |
Polyethylene glycol or macrogol is a biologically inert , non-absorbable osmotic laxative . Its powder preparation is mixed with sodium chloride , potassium chloride and sodium bicarbonate to be dissolved in solu- |
Natural fibre ( psyllium , bran ), semi-synthetic fibre ( methyl cellulose ) and synthetic fibre ( polycarbophil ) hold additional water in the stool and avoid digestion and absorption in the small intestine , thus increas- |
upwards to the recommended daily |
viduals experiencing dyssynergic |
laxatives in older patients because of |
tion for use . Lactulose and sorbi- |
ing stool frequency , stool weight and |
intake of 20-35g per day . 39 |
defecation rather than slow-transit |
the inability of some older people to |
tol are fermented by gut bacteria |
reducing colon transit time . Patients |