H.Gage et al (2010) 18 conducted a study to investigate the correlation of constipation in people with Parkinson’s disease, which showed that 50 % to over 70% of people with Parkinson’s suffer from constipation. The cause include anorectal outlet dysfunction causing straining & slow colonic transit. The stool diary analysis revealed that Parkinson’s patients were more constipated nearly 5 times more. Number of medication taken is an independent predictor of constipation. The study suggests that constipation is a disease related rather than a life style issue.
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Bee Wee et al (2010)9 carried out a study with an aim to evaluate the burden of managing constipation in patients receiving opiods within specialist palliative care. Patients those enrolled in the study were already on opiods treatment on admission or during admission and they had to be constipated during admission. Of 58 patients, 53.4% were females in the median age of 70.The cost of managing constipation mainly shed light on the staff time and consumable items required to carry out a range of tasks related to constipation. Approximately 20% of time in nursing & doctor handover meeting is spent discussing laxative prescribing & bowel function management although the cost is considered relatively modest it remains a clinical prescription.
Gulsah Gurol Arslan and Ismet Eser (2010) 4 conducted a study to examine the effect of castor oil pack administration in elderly with constipation. Study included 35 residents of age above 65 years residing at rest home in the province of Turkey. It was observed that castor oil administration had an advantage over laxatives and purgatives as it caused feces of normal consistency. It did not cause diarrhea, incontinence or a problem of not reaching the toilet in time. COP did not affect the bowel movement or amount of feces but reduced the subjects symptom of constipation in terms of fecal consistency , straining while defecation & feeling of incomplete evacuation after defecation.
Fabrizo cardian et al (2009) 7 conducted a study to establish the factors that determine the onset of constipation in acutely hospitalized older patients. The study involved 192 patients over 67 years of age, British stool form scale was used to define consistency of feces and all clinical and physical data were collected. The study statistically found higher prevalence of laxatives use in elderly before their hospital admission itself. Conditions that functionally associated with fewer bowel movements include aesthesia, depression, restricted mobility, and neurological diseases and above all constipation inducing drugs. The study focused the point that significant risk of need to use the laxatives during the hospital stay was having use them before hand.
Paul Gallagher MB,MRCPI & Denis O Mohany MD 16 reviewed about the constipation in old age and found that constipation is common in older people but it is not a consequence of normal ageing but the aetiology of constipation is multifactorial. Detailed physical and history examination is essential to determine the exact cause of constipation and to establish effective treatment. Regular toileting schedule should be encouraged and adequate privacy should be provided. Judicious use of laxative is necessary when general measures become unsuccessful. Polyethylene glycol & lactulose are generally safe and well tolerated.
Antonia Paulo Nassar Jr.MO et al(2009) 21 carried out an observation trial to evaluate the incidence & risk factors of constipation in intensive care unit. The Study enrolled 106 patients fulfilling the criteria of staying in ICU for not less than 3 days and had not undergone bowel surgery. The study demonstrated that constipation was associated with failure to wean from mechanical ventilation, increased length of stay, higher sensitivity of illness, higher mean doses of vasopressors but not associated with antibiotic therapy or the use of fentanyl, the common opioid used in the study site.
Daniel Pohl et al (2008) 22 carried out an investigational study to determine new pharmacologic treatment for constipation. Chloride channel activator lubiprostone (16 mcg) bid is found to be the optimal dose to treat irritable bowel syndrome Patient thought it is got adverse effect of diarrhoea and abdominal pain. Tegaserod was meant for chronic idiopathic constipation in both men & women but due to increased cardio-vascular events it had been withdrawn. Other investigational agents include Renzapride 5-77t4 receptor agonist used to treat idiopathatic bowel syndrome in female patients. Granylate cyclise agonist linaclutide developed to treat functional constipation, selective neurotroponins for spinal injury constipation. Pre-biotics have also taken up their place in the treatment chart of constipation.
George Peppas et al (2008) 2 carried out a work based on literatures to evaluate the epidemiology of constipation in Europe & Oceania. Articles based on studies conducted on constipation were collected from PubMed & other hand research references. Only small proportion of patients suffering from constipation seek medical advice thus the exact prevalence was difficult. All studies involving cases of functional constipation regardless of the diagnostic criteria used were considered for inclusion. The receiving system consisted of 8 questions on the validity of study design & maximum quality the study could achieve was 8.The lowest prevalence among elderly was observed in New Zealand and the highest prevalence in general population of Sydney Australia (30.77%).Among studies conducted in Oceania the mean value of constipation prevalence is 15.3%. Female gender is associated with elevated constipation prevalence rates in North America which are 2.2 times more likely than males.
Earlie Mc claim Hale et al (2007) 23 conducted a randomized controlled trial to evaluate the effectiveness & feasibility of natural laxatives which includes food resources high in dietary fibres to prescribed laxatives. Study was carried out in a 200 bedded Mid-Western hospital with affiliated skilled LTC facility. 45 patients were enrolled with 34 completing the 8 week study period, patients were in the age group of 65 to 100 years. Ease of administration was found in the subjects receiving the natural laxative mixture. Data were analyzed in SPSS & ANOVA was used to measure differences in bowel movement frequency among treatment and control groups thus it was found that Beverly – Travis natural mixture given at 2 tablespoon twice daily is cost effective and more effective.
Virginia B Kalish MD &Bridget Loven (2007) 24 conducted various RCTs to identify best treatment for constipation in elderly. They compared the effectiveness of fibers, laxatives VS placebos & effect of exercise on 246 institutionalized patients. These studies varied in reported outcome measures including stool frequencies, stool consistency, straining, decrease in laxative use and symptom scores and in some reports it has shown slight improvement for patient’s with laxatives VS placebo. Tegaserod found no difference in outcome with placebo but lubiprostone offers promise in a total of 220 elderly patients of 65 years of age and older.
Ronald and Hedva (2007) 25 evaluated the efficacy of Tegaserod for treating chronic constipation in elderly patients. In this study 331 elderly patients were enrolled and found that tegaserod was effective in improving constipation and no significant adverse effects were noted but older adults have risk of diarrhoea with tegaserod in higher dose.
Jose J Hernande (et al) (2007) 27 conducted a study to determine the prophylaxis of opioid induced constipation in elderly long term care residents. 867 patients from both black and white were enrolled in the study and the analysis proved that white female and concurrently married patients spend 27%, 52%, and 39% respectively, more months with at least one administration of laxative and opioids than their counter part non-white male, unmarried patients co morbidities were not associated with laxative prophylaxis. In elderly receiving chronic opioids the prevalence of concurrent laxatives and opioid administration was 56%. The common interventions noticed with opioid and identified to prescribers regarding the importance of laxative has enabled to give a rise from 35% in 1998 to 42% in 2002 in the number of patients receiving concurrent laxative with opioid.
Richards( 2006) 28 demonstrated a different approach to treat constipation .He used a type of message using tennis ball to provide circular movements along the path of colon for 10 minutes per day to improve bowel function and decrease the use of laxatives. Based on the findings of Richards, Physical therapy was done on an 85 yr old woman with slow transit constipation. It focussed on increasing faecal transit within colon, training and electro galvanic stimulation of pelvic floor dysnergia. Abdominal massage is safe, non invasive and can be independently performed & no known side effects are reported & limited contraindications exist.
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Christine Hsichm, MD (2005)17 studied about the cause and treatment of constipation in elderly. He analyzed that the constipation is a common problem of elderly accounting for 2.5 million physician visit annually, he categorized constipation in to primary and secondary and determined various causes of both the conditions. A treatment pattern was made including both pharmacological and non-pharmacological methods in addition to that an algorithm was prepared to treat the functional non-transit constipation. A cost effective study of various classes of laxatives were made and compared regarding their outcomes and drawbacks.
Virginia B Khalish& Bridget Loven (2004)28 reviewed several studies to analyze the best ttreatment for chronic constipation in elderly. Considering results from several RCT trials, it was determined that Polyethylene glycol and Tegaserod are effective in all ages but Tegaserod overdose leads to diarrhea and certain times linked to ischaemic events. Lubiprostone offers promise and was found to be the effective in a total of 220 elderly patients above 65 years of age, evidences also suggest that the use of psyllium and lactulose. Dietary and exercise modifications are also recommended as first line treatment followed by laxatives.
Brain E Lacy & Mathew S. Cole (2004) 10 carried out a research to understand the prevalence, history of chronic constipation & to review common etiologies of this symptom. The prevalence rate of constipation in elderly range from 19-40% & significantly increases over 65 years, the causes includes anatomical obstruction slow-transit constipation, pelvic floor irritable bowel syndrome, medications & metabolic disorders. Prevalence of laxative use in the elderly is reported to be as highly as 50%, the use of stimulants & bulk- laxatives are common, enemas (tap water, soap water, mineral oil & phosphate) are often used along with laxatives.
Christine .M. Ruby et al (2003) 29 carried out a study to determine the prevalence of laxative use in elderly of 5221 elderly, 80%(4162) were black and 2875 were white and data’s were collected through interviews regarding their prescription &OTC drugs .The study observed that 10.2% were using laxatives & a small percentage of elderly persons were using 22 laxative concurrently & commonly used were stimulants & bulking agents. Women with difficulty in walking & using multiple OTC non-laxatives &multiple physician visits & those taking anti -cholinergic were more likely to use laxatives.
M. Petticrew et al (2001) 30 evaluated the effectiveness of laxatives in adults, the U.K National survey of Morbidity in General Practice in England &Wales found consultation for constipation were common among very young and very old and more in people residing at nursing home. Laxatives are required by 87% of terminally ill taking strong opioids and 74% on weak opiods and 64 % not receiving any analgesics. RCT suggests that bulk laxatives are associated with an increase in frequency of 1 to 2 bowel movements per week. A recent unblinded RCT compared isapghula (fybogel) with lactulose in 473 patients recruited by 65 GPs in UK. Isapghula was found to be more effective than latulose with greater tolerability and fewer adverse effects.
Virginia Hurdsonet al (2000) 31 conducted several studies to determine whether docusate sodium is useful for patients at risk for constipation. The study excluded chronically ill patients and patients with pre-existing constipation. Patients demographic details, stool frequency, consistency and dose of docuste were documented. Each of individual study showed a small trend towards impaired stool consistency and frequency of bowel with docusate and the effect of docusate on the use of other laxatives were not evaluable because placebo/control groups were not allowed to use any laxatives.
V.Hyde et al (1999) 11 conducted a study about constipation and laxative use in older community dwelling adults in U.K and Australia, the search strategy was based from CINAHIL and Medline over a period of 7 years. The 19 participants included in the trial were in the age range of 72-92 years. The participants personal experience due to constipation were taken down and the results suggested the state of unhappiness and worrying occurrence. The contributing factors for this symptom included pregnancy, parkinson’s disease, decreased fluid and fiber intake etc. Among the 19 participants 12 were taking lactulose and 11 were using more than one laxative and in some patients the use of several laxatives and enemas were also observed.
Mark Petticrew et al (1999) 32 reviewed several studies and trials conducted in order to determine the best try for treatment of constipation. The prevalence is more than 10% in UK general population; the participants were 55 years or older. The methodological quality of the trials were assessed using a six items scale assessing inclusion criteria, randomization method, standardized assessment of ADR, double-blind design, description of withdrawals and statistical analysis. Bowel movement frequency improved with stimulant and osmotic laxatives, Stool consistency improved with stimulant laxatives, stimulant and osmotic laxatives were all reported to improve other symptoms of constipation. The pooled frequency data revealed that Agiolax increased 1.9 bowel movements per week and osmotic laxative magnesium hydroxide was found to be more effective in improving frequency and consistency. NHS expenditure on stimulant laxatives are increasing due to expensive prescribing and suspension carts up to 2.63 pounds for week compared with 42 per less for senna.
David C.Sacharfer et al (1998) 5 studied about constipation in elderly. During the study they found that only 2 percent of non-elderly are affected by this symptom but nearly 26 percent of elderly men and 34 percent of elderly women are suffering from constipation and 75 percent of elderly hospitalized use laxatives for normal bowel regulation. The study evaluated the patients based on several questionnaires, various physiological examination and diagnostic procedures. Treatment included non-pharmacological methods such as bowel retraining& diet.Pharmacologically laxatives were used preferably stimulant laxatives. Special considerations were given to chronically constipated patients and even surgical procedures were undertaken in critical cases where constipation is caused by mass obstruction or recurrent volvulus.
P J Meiring & G Joubert (1998) 33 determined the prevalence and risk factors of constipation in elderly. The participants included both white and black patients, who were born before 1930, and seen by one doctor at clinics at National and Peionomi hospitals in Bloemfortien. The questionnaire used in the study consisted of closed questions to which the participants had to answer ‘yes or no’ and the questions were asked about the current medications and laxatives taken and about physical activities and bowel movements. A frequency of 3 or more bowel movements a week was reported by 81% of white and 88.2% of blacks. Of the white using laxatives, 14.35% used more than one laxatives compared to 22.2% of black laxative users. The more common laxatives were phenolphthalin in white and mineral salt in black group.
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