Chances are good that the care plan meeting you attended this week discussed two of the most common, even ominous conditions of elderly residents. Problems with elimination are quite prevalent; the estimates are that 50–80% of nursing home patients experience a significant change (eg, constipation and diarrhea) in bowel habits.1,2 These challenges also exist with community-dwelling seniors and carry into the home care setting. Early recognition and intervention are critical to provide patient comfort and prevent accompanying distress to the resident.
Traditional care plans tend to address management strategies that are medical in nature, especially for acute conditions that present the risk of serious complications. A nutritional evaluation and focus on dietary components in the care plan can optimize treatment.
Diarrhea Takes a Quick Toll
Reported as one of the most frequent illnesses in the United States,3 diarrhea is broadly defined as an alteration in normal bowel habits resulting in frequent loose or watery stools. Although diarrhea is usually caused by bacterial, parasitic, or viral infections, many patients on antibiotics will have this side effect. Non-infectious causes include medication, drugs containing magnesium compounds, laxatives, antihypertensives, antiarrhythmics, and chemotherapy agents. Also, intestinal diseases (eg, inflammatory bowel disease), intolerance to food, and certain endocrine disorders can be the culprit.
Acute diarrhea occurs suddenly and lasts less than two weeks. Serious complications include dehydration, anemia, and renal failure. Primary focus should be the identification and treatment of an underlying cause, which should include a good medical history and a physical exam with stool and blood samples. Personal hygiene, especially with foods and daily care, must be impeccable during the recovery phase to prevent recontamination.
The incidence of Clostidium difficile (C. difficile) is currently rising4 and sends up the red flag when dealing with a late onset diarrhea (after 7–14 days or up to six months) following a course of antiinfectives. The organism’s pathology presents a significant risk to elders, especially the immunocompromised and those with poor nutritional health at the onset. Twenty percent or more of these cases can be fatal. Again, hygiene and environmental sanitation are very important in the treatment, as the C. difficile spores are passed in stool.
Chronic diarrhea points to elevated concerns with fecal incontinence, impaction, or inflammatory bowel disease. Endoscopic examination and further diagnostic testing will be needed to shed light on the cause and effect of this condition. Treatment recommendations include medication review, dietary changes for intolerances and malabsorption, and stool-bulking agents. Of most concern, however, is the affect of chronic diarrhea on the nutritional status. Prolonged malabsorption will generate a rapid overall decline, protein calorie malnutrition, and deficiencies of key nutrients that are important to healthy skin, immune response, bone strength, and neurological functions. The senior individual is of course at high risk in this situation as well. **probiotics403.jpg**
Nutritional Support
Managing symptoms is the top goal to replace lost fluids and electrolytes in the elderly. It becomes quite a challenge to entice an ill person to drink fluid; use creative ideas like Italian ice or popsicles, small diluted portions of juice, warm broths in a hand mug, clear juice spritzers, and slushy shakes. Plain warm water in the bedside pitcher is usually resisted. Commercial rehydation solutions contain a balanced profile of key nutrients and carbohydrates. Some have even added small amounts of protein to enhance the nutritional contribution. Intravenous solutions are indicated with severe dehydration. Fluid needs are typically calculated on body weight. General guidelines for replenishing losses from diarrhea are 40–50 cc/kg/day.
Offer easily digested foods that prompt bowel rest and recovery. Simple, low-fiber, low-carbohydrate foods (eg, toast, crackers, oatmeal, plain pasta, and unseasoned rice) can help start the oral intakes back to solid food. Broiled, lean meats can be introduced gradually as tolerance improves. Avoidance of caffeinated, acidic, or high-fat foods is also recommended. Fresh fruits and vegetables (other than a ripe banana) should be added as the diet is elevated to regular. Evaluation for lactose intolerance may be helpful in treating patients, since enteric infections often cause a transient lactase deficiency. Fermented dairy foods and supplements with probiotics have, however, been shown to bring about a better recovery in diarrhea.
Complications from tube feeding can also precipitate the onset of acute diarrhea, especially when such therapy is just beginning on a compromised patient. Isotonic formulas are preferred, and regimens should be started gradually to restore the gut integrity before full nutritional goals can be met. Formulas with added soluble fiber improve gastrointestinal tolerance and bowel function.5 It is critical to monitor the application process of feeding regimens to control for bacterial growth, cross contamination, and other factors that lead to intestinal infections.
Constipation in the Elderly
More than two million Americans visit their healthcare provider each year for constipation-related problems. Prevalence increases exponentially after the age of 65, affecting 60% to 80% in geriatric care centers.6 Older persons are at increased risk for primary constipation7 for the following reasons:
• Dentition issues: dentures or missing teeth promote low fiber intake
• Reduced fluid intake to control urinary incontinence
• Immobility and lack of regular exercise
• Reduced abdominal muscle tone
• Neurological conditions like Parkinson’s and stroke
• Endocrine disorders (eg, diabetes and hypothyroidism)
• Overuse of laxatives
• Changes in life routine or stress
• Decreased sensation of or ignoring the urge to defecate
• Medication affects: antidepressants, antacids with aluminum, diuretics
A change in bowel regularity to less than three times per week is the classic definition of constipation. Hardened stool (which is difficult to pass), lower stool volumes, stool retention, straining, or the feeling of incomplete evacuation are all signs of constipation that should be addressed in the care plan.
Monitoring the bowel records consistently compared with the dietary intakes of the resident should be the first step. Ideally, the documentation process should be systematic reviews of all residents to screen for this condition. Stool retention and ineffective bowel management can lead to complications with fecal impaction, which have such a negative affect for both residents and caregivers.2
Team Approach
Treatment plans need to be collaborative in the long-term care setting. Most cases of constipation in the elderly respond to non-pharmacological measures. Promoting recovery of optimal bowel functions is best as a gradual and consistent approach.
Introduce a balanced regimen of adequate fluid, fiber, and exercise. Rapid changes in this routine can, however, have adverse results, so plan out modifications in weekly goals. A minimum of 1500 ml of fluid each day is advisable. Intake amounts should be increased in the summer and in patients on diuretics with stable cardiac function. Regular exercise should also be considered; for the mobility-challenged, work on erect body posturing and strengthening core muscle tone. Toileting schedules must be closely managed to promote regularity and reconditioning of the neuromuscular reflexes.6
**nutrition fig1.jpg**
The American Gastroenterological Association advises a gradual increase in dietary fluid and fiber.6 Coarse bran is most effective in increasing stool weight. Six to ten grams per day is prudent in patients with adequate fluid. Ideas on increasing fluid intakes are reviewed above. Natural fiber is the most accessible and more cost-effective than commercial bulking agents. A special recipe (see Figure 1) of a wheat bran, applesauce, and prune juice mixture can yield good results with high patient acceptance.1,6 Another helpful bulk laxative is ground flaxseed, which contains insoluble fiber and Omega-3 fatty acids. This can be sprinkled on foods, mixed into yogurt or applesauce, and/or added into baked goods.
Figure 1 - Food Tips for Constipation
|  | |
Beyond these nutritional approaches, pharmacological management is sometimes indicated. Osmotic laxatives (eg, magnesium hydroxide or anthraquinone) can be tried if constipation persists, but they should be used judiciously. Stimulant laxatives are effective on occasion; long-term use should be avoided due to effects on cathartic colon and electrolyte imbalances. If there is still no response, bisacodyl and enemas may be indicated to achieve results.
Lifestyle modifications are important in dealing with and preventing constipation. To supplement nutrition and medication interventions, use resident cuing and create a positive environment for relaxed bowel habits. Encourage patients to take an active role in self-care. Individualize toilet routines to match a person’s natural history. Allow for privacy and time to respond to physiological urges. Family involvement and education is another aspect of resident care plans that should be incorporated.
It has been said that the center of wellness is the gut. Although scientific bodies continue to debate this theory, the management of elimination in the long-term care setting is surely one of the most challenging and costly approaches for both residents and care providers. Nutritional support can help reduce the complications, identify better interventions, utilize normal body processes, and promote a well-rounded approach to improved quality of life. |
Save the Date
Targeting the Science Within Wounds