Normal-Transit Primary Constipation
|Mr. Jones is a 75-year-old nursing home resident who has been transferred to a new primary care physician. The nurses reporting on his condition to the new physician believe that his chronic constipation has been poorly controlled. They report that he passes hard stools only every 4-6 days with great difficulty, unless he receives a Fleets enema every three days. They also note that he is incontinent of small amounts of soft stool 1-2 times per week. Mr. Jones reports a persistent sense of incomplete evacuation (even with the enemas), and complains of bloating and "crampy" abdominal pain after taking the "medicine they make me drink." He has struggled with constipation for 8-10 years, and his medical history also includes degenerative joint disease, hypertension, and diabetes mellitus. Mr. Jones takes the following medications:
-Acetaminophen 625 mg, QID
-Lisinopril 10 mg, QD
-Insulin glargine 30 units, HS
-Docusate 100 mg, BID
-Lactulose 15 cc, QD
-Senna 2 tabs, HS
-Fleets Enema, PRN (if no BM for 3 days)
Findings from Mr. Jones's examination and evaluation include the following:
Physical examination: Normal
Rectal examination: Hard stool; heme negative
Lab results, including TSH, CBC, complete metabolic profile: all normal
Note: Mr. Jones has refused a colonoscopy in past.
It appears to the primary care physician that Mr. Jones suffers from normal-transit primary constipation--constipation unrelated to a secondary cause such as a medication or other disease process (see "Ask the Experts: Functional Subtypes of Chronic Constipation").
About 50% of long-term care residents suffer from constipation, while 59-78% use laxitives regularly.(1-4) Anything that can be done to simplify and improve the efficacy of treatment will not only benefit the resident but may also benefit the facility's bottom line. According to one study examining the management of constipation in the nursing home, the average cost per "task occurrence" ranged from $0.72 for enema administration to $1.74 for oral medication administration. Average nursing staff costs per patient per year were $1,577 for oral medication administration, $215 for dietary supplement administration, $39 for constipation assessment, $17 for suppository administration, and $6 for enema administration. Based on estimates of frequency of occurrence, the total annual labor and supply cost per long-term care resident with constipation was $2,253.(5)
Stool softeners can cause fecal incontinence. They are most appropriately used on a short term basis to help manage anal fissures and hemorrhoids. Lactulose can cause bloating, cramping, and diarrhea. Fleets enemas contain sodium phosphate salts and should be used with caution in residents with renal and heart failure. Inorganic phosphate salts are readily absorbed from the gastrointestinal tract and can cause hyperphosphatemia, even in individuals with normal-functioning kidneys. Severe hyperphosphatemia results in acute hypocalcemia and hypomagnesemia. Tetany, seizures, bradycardia, prolonged QT interval, dysrhythmias, coma, and cardiac arrest are possible serious consequences.
The physician prescribes lubiprostone (one 24 mcg capsule, bid) for Mr. Jones. It is the only readily available FDA-approved medication for management of chronic constipation in adults over 65. It is generally reserved for patients like Mr. Jones who fail or are intolerant to standard therapy. The physician discontinues Mr. Jones's docusate and lactulose, but continues his senna. Within 24 hours, Mr. Jones reports having a large bowel movement with a sense of complete evacuation. He subsequently asked to limit treatment with lubiprostone to once every other day.
Case contributed by:
Mario Cornacchione, DO, CMD, FAAFP
Geriatric Research & Consulting Group
Northeastern PA Memory & Alzheimer's Center
Wilkes Barre, PA
Clinical Associate Professor
The Commonwealth Medical College
Clinical Assistant Professor
Institute for Successful Aging
University of Medicine & Dentistry of NJ
School of Osteopathic Medicine
(1) Tariq SH. Constipation in long-term care. J Am Med Dir Assoc. 2007;8(4):209-18.
(2) Lamy PP, Krug BH. Review of laxative utilization in a skilled nursing facility. J Am Geriatr Soc. 1978;26(12):544-9.
(3) Primrose WR, Capewell AE, Simpson GK, et al. Prescribing patterns observed in registered nursing homes and long-stay geriatric wards. Age Ageing. 1987;16:25-28.
(4) Petticrew M, Watt I, Sheldon T. Systematic review of the effectiveness of laxatives in the elderly. Health Technol Assess. 1997;1(13):i-iv, 1-52.
(5) Frank L, Schmier J, Kleinman L, et al. Time and economic cost of constipation care in nursing homes. J Am Med Dir Assoc. 2002;3(4):215-23.