Guideline for the Prevention and Management of Constipation in Long-Term Care Residents

Constipation is a highly prevalent disorder with discomfort and privacy issues that impact quality of life.¹ The prevalence of constipation in long-term care (LTC) residents ranges from 10% to 71%.^2-4 Over 50% of all LTC residents are prescribed scheduled laxatives.^4,5 Unfortunately, LTC residents find the treatment of constipation unsatisfactory.⁶ Additionally, the economic burden amounts to billions of health care dollars nationwide.⁷ 

Typical physical effects from constipation include abdominal pain, cramps, excessive flatulence, and rectal bleeding.⁸ Serious complications include fecal impaction, volvulus, lower gastrointestinal bleeding, toxic megacolon, anal fissures, rectal ulcerations, and fluid and electrolyte depletion.⁹  

Constipation is clinically defined using Rome IV criteria and/or subjective patient reports of difficulty with bowel emptying.^1,10 The etiology and pathophysiology of constipation is complex.¹¹ Primary causes of constipation are intrinsic, such as dysmotility and pelvic floor dysfunction.¹² Secondary constipation is the result of dietary habits, immobility, medications, and disease. 

An unpopular topic among LTC residents and health care providers, constipation is rarely life-threatening.^1,13 However, fecal impaction and treatment with enemas and/or saline laxatives is correlated with significant morbidity and mortality.^14-17 Unfortunately, some providers consider constipation a problem more imagined than real.¹¹ LTC residents are especially vulnerable to such dismissals because they may have a limited ability to express needs and advocate for themselves.¹⁸ Often, constipation is not addressed until the resident is in a state of crisis.¹⁴ Consequently, treatment can cause diarrhea, fecal incontinence, and subsequent social isolation.^1,18-20 

Clinical practice guidelines are an important tool to inform evidence-based practice decisions and provide quality care.²¹ Several guidelines are available for preventing and managing constipation in older adults.^12,13,22 However, recommendations do not specifically address LTC residents. This population possesses the most risk factors for constipation, which include: (1) older age; (2) immobility; (3) comorbidities; (4) polypharmacy; (5) poor or fair self-rated health; and (6) moderate or severe depression.^6,23

We developed a tailored guideline to assist interdisciplinary team members to make evidence-based practice decisions for the prevention and management of constipation in long-term care residents. Treating constipation can improve their quality of life, enhance appetite, reduce distress, lower health care costs, and prevent hospitalization and/or emergency department visits.^1,5,7,8,14 

Guideline development and evaluation occurred from December 2018 through February 2020. First, a thorough evidence review was completed, followed by three phases to evaluate for rigor, clinical applicability, and quality of the guideline. 

Phase 1 involved creating a clinical guideline using the Delphi method. Phase 2 included assessment for clinical applicability by surveying interdisciplinary team members who care for LTC residents. Finally, phase 3 was completed by appraisers who used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to evaluate the guideline for quality. 

Approval from the associated Charles George VA Medical Center and East Tennessee State University internal review boards was granted before initiation. Recruitment occurred via email and flyers. Informed consents were obtained from each of the three participating groups, and participation was voluntary.  

An initial literature review was conducted in PubMed and using the search terms constipation, long-term care, and nursing home. An expanded review included the terms bowel training, exercise, nutrition, prunes, fiber, laxatives, medications, stool softeners, prevention, management, pharmacological, nonpharmacological, enemas, suppositories, fecal impaction, older adult, and institutionalized. Limited studies were available concerning constipation in LTC residents. Therefore, many studies used to create the guideline focused on older adults, regardless of setting. 

The development of the guideline included a literature review of 44 articles. Inclusion criteria were articles written in English and published within the last 10 years. Reference lists of quality articles were also reviewed. The following were included: (1) evidence regarding older adults and/or LTC residents (13 articles); (2) information on management of acute and chronic constipation; and (3) information on pharmacologic and nonpharmacologic interventions for constipation. Only evidence rated level I through level III per the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide was reviewed (Table 1).²⁴ In addition, each recommendation was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method (Table 2).²⁵ Exclusion criteria included study participants who were children and young adults and lower-quality evidence.

Phase 1 occurred from December 2019 to February 2020. The first draft of the guideline was completed using the Delphi method, which involves reaching consensus among a diverse group of content experts.²⁶ The Delphi committee consisted of one gastroenterologist, two geriatricians, and one pharmacist. The clinical experts were emailed the guideline and met with the guideline developer to provide feedback. Recommendations were updated to incorporate the comments provided by the content experts and then resubmitted for further review and evaluation. Changes were made until consensus was reached by all members of the Delphi committee.  

The second phase involved an education and survey completion from interdisciplinary members associate with LTC residents.  The survey was developed by the investigator to evaluate their perception of the clinical applicability of the guideline (Table 3). Interdisciplinary team members included providers (physicians, nurse practitioners, and physician assistants), nursing staff (registered/licensed practical nurses and nursing aides), pharmacists, physical therapists, occupational therapists, dietitians, and psychologists. Survey questions were asked on a 4-point Likert scale, with 1 representing strongly disagree, 2 representing disagree, 3 representing agree, and 4 representing strongly agree. A score of 3 or higher out 4 was defined as a perception of clinical applicability. 

Education sessions involved in phase 2 lasted approximately 30 minutes. Handouts included the draft guideline recommendations and algorithm. After each education session, a volunteer dispensed and collected the 12-question survey to maintain feedback anonymity. Again, a 4-point Likert scale was used. Survey data results were aggregated and described using descriptive statistics. After the second phase, the Delphi committee reviewed and updated the guideline and algorithm (Table 4 and Figure 1). 

During phase 3, doctorally prepared practicing nurse practitioners appraised the guideline using the AGREE II instrument. Developed to assist in the evaluation of practice guidelines, the AGREE II instrument is reliable and valid, and features 23 items separated into six domains and a mechanism to rate overall quality.²⁷ Domains include: (1) scope and purpose; (2) stakeholder involvement; (3) rigor of development; (4) clarity of presentation; (5) applicability; and (6) editorial independence. A 7-point scale was used to rate each domain, and scores were presented as a percentage. Appraiser scores were calculated by summing all the scores for individual items and scaling the total as a percentage of the maximum possible score. Each nurse practitioner was asked to complete the AGREE II evaluation individually. Results were aggregated and reported using descriptive statistics. 

The interdisciplinary team considered the survey results to be clinically applicable. A total of 31 interdisciplinary team members who care for LTC residents participated in five different education sessions. Surveys were received from 30 participants. The average participant age was 49. Most participants were female (3:1 ratio) and provided direct care to LTC residents through a nursing or provider role. 

Overall, participants reported they viewed the guideline as useful. The average score was 3.5 or higher, indicating participants agreed or strongly agreed the guideline was clinically applicable. Participants felt strongly that the guideline provided helpful information for the prevention and treatment of constipation, with an average score of 3.8. Participants agreed that the guideline information should be shared with others, with an average score of 3.8. The lowest score of 3.5 was in answer to the question of whether constipation is an important topic to the LTC resident. 

Finalized guidelines were found to be of high quality as evidenced by appraiser evaluation using the AGREE II instrument in phase 3. The AGREE II user’s manual recommends at least four appraisers to create aggregated data for each domain. A guideline is considered high in quality if domain scores are over 70%.²⁷ Aggregated scores in every domain were 85% or higher, with an overall quality score of 92% (Figure 2). Highest scores were noted in clarity of presentation and editorial independence, with scores of 94% and 96% respectively. The lowest score of 85% was in applicability. The algorithm was especially popular and found to be most beneficial. Overall, comments from the appraisers were positive. 

For many, constipation is an uncomfortable topic that, when ignored, can result in a crisis.¹ Becoming comfortable with the topic encourages proper prevention and management strategies. During the education session, participants were ambivalent about learning and discussing constipation. However, once they grew more comfortable, multiple issues were discussed.  

Participants discussed how constipation is often not addressed until an LTC resident is in an acute constipation situation that requires immediate attention. As a result, residents may attempt manual disimpaction. If a resident is cognitively impaired, fecal matter can end up along the bedside rails or table tray. Providers in particular discussed how this hygiene issue can lead to other complications, such as conjunctivitis from rubbing eyes with unclean hands. Several participants discussed how constipation is a common reason for contacting providers during nonbusiness hours. Others expressed frustration over not having an as needed (PRN) bowel order set for every resident.

Participants were surprised to learn several treatments typically used for constipation in LTC residents are not considered safe. Changing the practice of using these treatments can be difficult, however, because they have been used for years. Saline laxatives and enemas should be avoided in residents with: (1) renal impairment; (2) congestive heart failure; (3) electrolyte imbalances; (4) a risk for dehydration; and (5) hypertension.^8,15 Sodium phosphate and soap suds enemas may result in bowel perforation, electrolyte imbalances, renal failure, sepsis, and even death in some patients (<4%).¹⁵ Enemas should only be used in specific circumstances, such as for a patient with a spinal cord injury. Therefore, soap suds enemas should be removed from all LTC facilities. Furthermore, the prescribing of these treatments should only occur with consultation of a pharmacist and be an interdisciplinary team decision. 

Fecal impaction is a serious issue that needs to be identified and handled with care.^9,14,15 A digital rectal exam is useful for assessment.¹⁸ If a resident has a fecal impaction, an emergency department visit should be considered. Residents in a fragile condition or who require an enema can be more safely monitored in the emergency department. One study found 90% of those visiting the emergency department for fecal impaction were admitted to the hospital.¹⁴ During hospitalization, this population experienced significant morbidity (40.6%) and mortality (21.9%). Transferring LTC resident with fecal impaction to the emergency department is a change in practice that may be difficult to enact. However, it may be the only safe way to help residents through a constipation crisis. 

Participants agreed that LTC residents experience a delicate balance between constipation and diarrhea.^18,28 Treating constipation is especially difficult in residents with cognitive or mental health care issues.²⁹ New-onset fecal incontinence can occur due to diarrhea, which may be embarrassing for residents.²³ Also, diarrhea puts residents who are fragile at risk for complications. Nursing staff from the interdisciplinary team considered diarrhea a frustrating issue because it requires more staff time and health care resources. 

An appropriate environment to have regular bowel movements was also a concern.³⁰ Prevention of constipation is key to avoiding a constipation emergency.^12,13,22 Many residents have a roommate and may feel embarrassed to have a bowel movement in bed when a roommate is present. Furthermore, having a bowel movement in bed causes a lingering smell. Bowel training is generally found to improve bowel function, but it is time consuming and requires buy-in from all interdisciplinary team members.^28,30 

Participants from the interdisciplinary team expressed frustration that food served to residents is often deficient in fiber and overly processed.³¹ Limited availability of fresh fruits and vegetables,  as well as functional limitations such as poor dentition, also hinder the ability of residents to consume a high-fiber diet Consequently, high-fiber snacks should be made readily available. Cost is a major barrier to providing whole grains and fresh produce. Laxatives have been successfully discontinued in over 50% of residents on a scheduled bowel medicine when they consumed additional fiber.^32,33 Prunes and other dried fruits are natural laxatives that increase stool weight and frequency. Adding fiber and prunes may be a simple, effective strategy to prevent and manage constipation. 

Participants agreed that if nonpharmacological interventions are ineffective, pharmacological interventions should be pursued. The aim of chronic constipation treatment is to establish regular bowel habits.^1,12,13,22 Fiber bulking agents are effective for ambulatory LTC residents.^32,33 Osmotic (ie, polyethylene glycol) and stimulant laxatives (ie, senna, bisacodyl) are safe alternatives for those with limited mobility and treatment failure with fiber.^29,30,34-39 Lactulose and lubiprostone can be considered in special circumstances.^34,38,4

The guideline was developed using a rigorous process; however, it was not translated into practice. It would be beneficial to test the guideline in multiple LTC facilities and non-VA settings. Additionally, the guideline was developed with feedback from Delphi and interdisciplinary team members who are employed by the VA. Their experience is primarily with male residents, whereas 67.9% of non-VA LTC residents are female.^41,42 Furthermore, LTC residents who reside in VA facility have higher provider- and nursing-staff-to-patient ratios compared with private-sector facilities.⁴²

Other limitations of the guideline were identified. The lack of existing research forced clinical experts in the Delphi Committee to provide direction for non-pharmacological and pharmacological interventions. The recommendations were given the lowest GRADE rating to reflect this clinical expertise. Results of further research in the area of constipation in LTC residents will be incorporated into future guideline revisions.

Constipation is a highly prevalent condition that impacts overall health and quality of life. This clinical practice guideline reflects available evidence-based interventions for LTC residents experiencing constipation. The development of the guideline further highlights the need for research and improved care for this vulnerable population in topics that matter to their everyday lives. Future direction should include guideline implementation in multiple settings with larger numbers of participants and guideline revision as more LTC facilities use the guideline. Constipation in LTC residents is complex, multifactorial, and can easily be prevented and treated to improve overall health and quality of life.

Authors: Georgiana Hogan, DNP, FNP-BC^1,2 • Janice Lazear, DNP, CRNP, FNP, CDE² • Jean Hemphill, PhD, FNP-BC²

Affiliations:
¹Charles George VA Medical Center, Asheville, NC
²East Tennessee State University, Johnson City, TN

Disclosures: The authors report no relevant financial relationships.

Address correspondence to:
Dr Georgiana C. Hogan DNP, FNP
Nurse Practitioner
Home-Based Primary Care
(828) 337-3408, Ext 5703
Georgiana.Hogan@va.gov