GERIATRIC UPDATE

CONSTIPATION AND THE GERIATRIC PATIENT:

TREATMENT IN THE EMERGENCY DEPARTMENT
Authors: Joan Somes, RNC, PhD, CEN, CPEN, FAEN, and Nancy Stephens Donatelli, RN, MS, CEN, NE-BC,
St Paul, MN, and New Wilmington, PA
Section Editors: Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, and Joan Somes, RNC, PhD, CEN, CPEN, FAEN

Earn Up to 8.0 CE Hours. See page 413.

t is not uncommon for an older adult to present to the

emergency department with a complaint of abdominal
pain related to constipation. In fact, 24% to 50% of
independent living adults have constipation, and 74% of
residents in long-term care facilities require laxatives daily
to keep the bowels functioning at an optimal level. 1-3
Even though ED staff question whether constipation is
an emergency, constipation in the adult patient is not only
painful and distressing, it can also be life-threatening should
it progress to fecal impaction. It should be noted that if an
older adult presents with a sudden change in mental status,
the differential diagnosis should include constipation and
impaction, in addition to all the other factors than can cause
mental status changes. 1-3 Other symptoms associated with
constipation include lack of passing stool on a regular basis
(with each person having his or her own denition of
regular), passage of liquid stool while still having a sense of
fullness in the colon, having to strain to pass stool, or
having to use laxatives, enemas, or suppositories to maintain
regularity. Patients may also have crampy abdominal pain
and blood-tinged stool from straining and tearing of rectal
tissue. Straining during a bowel movement has been
associated with syncopal episodes as noted by ambulance
personnel who have to extricate the man down from the
bathroom on a fairly frequent basis. 1-4
There are 4 typical reasons the older adult may present
with constipation. The most common is functional

Joan Somes, Member, Greater Twin Cities Chapter, is Staff Nurse/Department

Educator, St Josephs Hospital, St Paul, MN.
Nancy Stephens Donatelli, Member, CODE Chapter, is Project Coordinator,
Shenango Presbyterian SeniorCare, New Wilmington, PA.
For correspondence, write: Joan Somes, RNC, PhD, CEN, CPEN, FAEN,
5718 Upper 135 St Ct, Apple Valley, MN 55124; E-mail: somes@blackhole.com.
J Emerg Nurs 2013;39:372-5.
0099-1767/$36.00
Copyright 2013 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.04.002

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JOURNAL OF EMERGENCY NURSING

constipation. The patient will present with hard stool that is

difcult and painful to pass. The pain and discomfort
associated with functional constipation are generally relieved
with passage of the stool.
A second reason for constipation is pelvic oor
constipationwhere evacuation of stool is compromised
because of faulty coordination of the pelvic oor muscle,
anorectal structural abnormalities, or impaired perianal
descent innervation. A third reason for constipation is
slow-transit constipation. This type of constipation is
related to partial paralysis in the colon leading to decreased
peristalsis. Finally, constipation may be the symptom of a
variety of bowel issues, including irritable bowel syndrome,
Crohns disease, adhesions, ruptured diverticulum, intestinal
cancer, hernia, volvulus, or prolapsed rectum. Before one just
assumes that the pain or lack of a bowel movement is related
to stool, it will be important to ensure that there is not a
specic intestinal issue that is the cause and especially a
condition that could be made worse, or even life-threatening,
by treating the patient with classic constipation therapies.
In general, functional constipation is the most common
type and should be addressed rst. If a thorough history and
physical, including a digital examination, and use of
standard therapies are unsuccessful, then the patient should
be referred for testing to rule out the other causes
mentioned earlier. 3-6 Although it may not specically be
the role of the emergency department to perform a workup
related to chronic constipation, some critical thinking and
diagnostics by the emergency department may lay the
groundwork for the primary care provider.
In the emergency department, it often seems that the goal
is to x the immediate problem, but in reality education
focused on preventing this issue could be more effective in the
long run. Generic instructions teaching the patient about diet,
exercise, bowel techniques, timing of going to the bathroom,
breathing, and positioning on the toilet should be given to
anyone who is at risk of having, or currently having,
constipation. In addition, if a patient is discharged with a
prescription that adds a constipating medication to his or her
regimen of pills, the prescription should be accompanied by

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instructions about how to prevent constipation. Sometimes, it

is as simple as recommending mild physical activity rst thing
in the morning, a warm beverage, some ber, and some more
warm uid to initiate bowel contractions. The patient then
needs to take the time to go and sit in the bathroom and let
nature take its course. Some of this education is appropriate
even as one xes the problem, because many ED actions
involve stimulating the bowel. 1-5
The process of xing the bowel requires some serious
thought. Before proceeding, the nurse should ensure that
the following factors are considered, evaluated, and
managed. First, the nurse should determine whether the
patient needs to undergo disimpaction. Stool that is packed
hard in the rectum will not pass. Breaking up the impacted
stool is necessary before the patient will be able to expel the
blockage. Simply giving medication to stimulate bowel
spasm will not push the stool through. 1,2,4
A second consideration is related to concern that digital
manipulation may stimulate the vagal nerve and could
potentially lead to bradycardia. One should have knowledge
of the underlying risks related to cardiac rhythm, in addition
to the recognition that attempts to stimulate the bowel may
lead to an increased risk of dysrhythmias, necessitating
placement of a monitor during disimpaction, or at least have
backup easily available should bradycardia occur. The safety
of the practice of administering a Fleet (sodium phosphate)
enema to older adults is being questioned more and more.
Electrolyte imbalances tend to occur as the gut pulls uid into
it. Fluid loss, dehydration, decreases in blood pressure, and
extreme increases in phosphate levels and decreases in calcium
levels have been seen. In addition, renal function has been
noted to deteriorate, acid-base imbalances have been seen, and
several deaths have followed administration of sodium
phosphate enemas. The current recommendation is to use
this type of uid cautiously, if at all, in the older adult. 1,4,6-8
Before instilling any uids into the rectum, many
practitioners recommend obtaining a radiograph or computed tomography scan of the abdomen to ensure that there
is no free air or indications of a bowel perforation or
rupture. A thorough abdominal examination searching for
any masses or discomfort is essential before one instills uid
into a leaky gut, which can lead to peritonitis. 4-6
Finally, one must consider the patients mobility. Can the
patient safely make it to a bathroom, or will he or she need a
bedside commode? Can the patient even make it to the
commode to have the bowel movement? Will he or she be able
to safely sit to pass the stool without falling off the commode?
A thorough medication review focused on medications
that may lead to constipation often may be facilitated by a
pharmacist. However, this responsibility does not eliminate
the need for a review by the emergency physician and nursing

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staff. Antacids with aluminum hydroxide and calcium

carbonate are two medications that are notoriously known
for leading to constipation. Antispasmodics, antidepressants,
iron, anticonvulsants, diuretics, caffeine, alcohol, and narcotic
medications are commonly linked to slow bowel motility,
hard stool, and constipation. Traveling, the use of public
restrooms, and smoking cessation have also been linked to
constipation. 1 Obtaining a history of recent travel, current
diet habits, uid intake history, and recent smoking cessation
and asking the question How much time do you actually
spend sitting on the toilet? are important bits of information
that can help sort out and identify potential causes of
constipation and may help develop a teaching and discharge
plan for the patient.
General physiological functioning may also need to be
evaluated. Thyroid function testing may identify the patient
with hypothyroidism, which has been connected with
constipation. Checking lead levels could identify lead
poisoning as an unusual but real cause of constipation. 3,4
EDoriented therapies for constipation can range from
disimpaction and cleansing enemas to medication or
admission for surgical intervention or medical treatment.
Some tricks to consider include the following: An oil
retention enema will soften the stool if given a half hour before
any attempt is made to break up the hard stool with a doublegloved nger. A good examination to ensure that there are no
painful hemorrhoids, anal ssures, or an anal stenosis that has
contributed to the issue is needed. Pretreating the rectal area
with a local pain-reducing product typically used for
hemorrhoids, including Proctofoam-HC (Duchesnay, Inc,
Blainville, Quebec, Canada; hydrocortisone acetate 1% and
pramoxine hydrochloride 1%), lidocaine jelly, witch hazel,
Preparation H, and other similar products, can make passage
of hard stool easier as well. The purpose of the enema is to
administer enough uid to stretch the rectum so that a reux
squeeze is generated. Use of 500 to 2,000 mL of warm saline
solution or tap water will stretch the bowel, leading to a reux
spasm that should lead to bowel evacuation. It should be
noted that the various additives used over the years (sugar,
soap, baking soda, and others) are discouraged because of the
irritation that they cause to the bowel and risk of electrolyte
imbalance and bowel perforation. It is also recommended that
the traditional triple H enema (high, hot, and heck of a lot)
be avoided and that the water should be lukewarm.
The well-lubricated tip of the catheter is placed no
more than 4 inches into the rectum. Cramping is generally a
good indication that bowel stretching is taking place and the
uid administration should be stopped or at least slowed to
allow the bowel to stretch in a gradual manner. In addition
to stretching the bowel, the uid makes it easier to pass the
stool. Distention of the bowel by uids used during enema

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administration will lead to an evacuation reux. One should

remember that there is a risk of bowel perforation with the
enema tip or an excessive amount of or too rapid uid
instillation. Perforation may have been present before the
enema and part of the reason for the constipation. A small
tear in the bowel is especially a risk for the older adult,
whose gastrointestinal mucosa tends to be thinner and easier
to penetrate and tear. Pain during insertion or instillation of
the uid or after uid administration should lead to
suspicion of a perforation. In addition, one should
remember that the actions of the enema administration
equipment may be enough to produce vagal stimulation and
resultant bradycardia. 1,4,7-9
In addition to enemas, there are other options that will
stimulate the bowels to move. Osmotic agentspolyethylene
glycol electrolyte solutions, such as GoLYTELY (Braintree
Laboratories, Braintree, MA); the powdered preparations
without electrolytes (MiraLAX; Merck & Co, Whitehouse
Station, NJ); or synthetic disaccharides, lactulose, magnesium
citrate, or milk of magnesiawill all pull water into the bowel
and encourage stool movement. Most of these are taken orally
and take up to a day to work. If there is a fecal impaction, these
products will not be sufcient to yield passage of the stool but
will only cause pain and more packing of the stool into the
rectum. Sometimes, diarrhea that ows around the impaction
will develop because of liquefaction of the stool in the colon
but not in the rectal area. This can lead to difculties in
making the diagnosis. 1,4,6,7 A staff member recently noted
that eating a large number of dietary hard candies could lead
to an effect similar to polyethylene glycol electrolyte solutions.
Stimulant laxativessuch as bisacodyl, senna, and
sodium picosulfate (Dulcolax Drops; Boehringer Ingelheim, Ridgeeld, CT)typically are taken orally to
stimulate bowel spasm and stool movement. Suppositories
containing glycerin or bisacodyl will also stimulate bowel
contraction. They also pull liquid into the gut, and the waxy
carrier for the medication contained in the suppositories
helps to liquefy the stool, providing a secondary benet of
the suppository. Suppositories tend to have an effect in 1 or
2 hours versus waiting several hours to days for the oral
laxatives to take effect. 1,4,6,7
Recently, a new type of drug has been introduced to the
market that, though not specically a laxative, does assist in
emptying the bowel of slowly moving stool, especially if the
patient is taking a narcotic that is leading to slow bowel
function. Methylnaltrexone works on the receptors of the
gut. A single subcutaneously injected dose of this
medication works similarly to naloxone by displacing the
opioid from the receptor sites that affect bowel motility.
Alvimopan is an oral medication that works in a similar
manner. The good news is that these drugs do not affect the

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TABLE 1

Preventing constipation: Education for ED patients

Medications that can lead to decreased bowel motility
and constipation include the following: aluminum
antacids, anticholinergics, anticonvulsants, antidepressants, antihistamines, barium, calcium antacids, calcium
channel blockers, calcium supplements, diuretics, iron
supplements, levodopa, opioids, and psychotropics.
Foods that can lead to decreased bowel motility and
constipation include the following: caffeine, alcohol,
rened sugar and processed foods, and animal fats
(dairy, meat, and eggs).
Actions that can lead to decreased motility and constipation include the following:
Increased intake of uids, especially warm uids, and
increased intake of fruits and vegetables.
Increase in exercise.
Increase in time sitting on the toilet when the urge strikes.
There is a need for more bulktaking a daily dose of a
dietary ber or bulk-forming laxative such as psyllium
or methylcellulose with extra uid will assist in
preventing constipation. In one study, prunes were
actually found to be just as effective as psyllium. 10 The
recommended dose of ber each day is 20-35 g/d. Bran,
2-6 tablespoons per day with a glass of water, may also
prevent constipation.
An over-the-counter stimulant laxative can be taken,
especially if patients have just been given a prescription
for a constipation-causing medication. It is recommended that patients not rely on laxatives, and if they
do, they should taper off of them and attempt to keep
the bowels regular with uid, bulk, and exercise.

pain-relieving properties of the opioid. Initially used in areas

that served patients with chronic painful illnesses, such as
cancer, these drugs have recently been introduced to ED
personnel to consider for patients presenting with constipation related to pain medication. Methylnaltrexone, in
particular, has been shown to have predictable and quick
results (a bowel movement within 1 hour!). One testimonial
regarding this stated, Once it workslook out! Its as if the
entire gut relaxes and the entire stool comes out in one big
rush! The caution was to be ready with a close commode or
bathroom. This drug can be readministered every other day
for chronic constipation but recently has been marketed to
the emergency department as a one-shot x. 1,6
Some older adults are so frail and so constipated that
the safest approach is to admit them to the hospital for a
gentle evacuation of the bowel. Constipation is generally
not an admittable diagnosis, but if the patient is having
signicant pain associated with the constipation or has other
underlying medical conditions, especially bowel issues such
as those noted earlier, he or she may meet criteria for

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admission. The risk of peritonitis is great with constipation,

particularly as the gut attempts to move stool and meets
resistance. Coordinating with the physician and case
manager is in the patients best interest. 1
The inspiration for this article came from an older adult
who frequently presents to the emergency department with
complaints of abdominal pain and constipation. Fortunately, this visit did not require disimpaction. It was determined
after the emergency physician did a complete examination
and testing that it was safe to administer a tap-water enema,
which produced satisfactory results. During this time, it was
also identied that the patient could use additional
education on how to keep his bowels moving regularly.
The nurse and the pharmacist spoke with the patient about
his medications and found that, indeed, he was taking
several medications that could lead to constipation. It was
also determined that the patient did not have the best diet
and did little exercise. Education related to improving bowel
motility took place, and the patient went home with a smile
on his face and a parting note to the nurse that he was
going to try the things suggested.
Educational information for the ED patient regarding
preventing constipation is presented in the Table 1.
REFERENCES
1. Toner F, Claros E. Preventing, assessing, and managing constipation in
older adults. Nursing. 2012;42(12):32-9.
2. McKay SL, Fravel M, Scanlon C. Management of constipation.
J Gerontol Nurs. 2012;38(7):9-15.

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3. Mayo Clinic. Chronic constipation in older patients. Mayo Clinic Briefs.

http://www.mayoclinic.org/medicalprofs/constipation-older-adultspudd0412.html. Accessed February 20, 2013.
4. Schaefer DC, Cheskin LJ. Constipation in the elderly. Am Fam Physician.
1998;15(4):907-14. http : //www.aafp.org/afp/1998/0915/p907.html.
Accessed February 20, 2013.
5. Basson M, Katz M, Anand BS. Constipation in adults. Emedicinehealth. http://emedicine.medscape.com/article/184704-overview. Accessed
February 20, 2013.
6. Gu M, Gonzalez CE, Todd KH. Emergent management of constipation
in cancer patients. Emerg Med. 2011;43(11):6-12.
7. Pray WS. Enema products: uses and cautions. US Pharmacist. http://
legacy.uspharmacist.com/oldformat.asp?url=newlook/les/Cons/feat.
cfm&pub_id=8%. Accessed March 10, 2013.
8. Ori Y, Rozen-Zvi B, Chagnac A. Fatalities and severe metabolic
disorders associated with use of sodium phosphate enemas. Arch Intern
Med. 2012;172(3):263-5.
9. Lippincott, William, and Wilkins on line procedure manual. http://
lippincottsolutions.com/solutions/lnps. Revised July 7, 2012. Accessed
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10. Wald A. Management of chronic constipation in adults. UpToDate.
http://www.uptodate.com/contents/management-of-chronic-constipationin-adults. Published 2013. Accessed February 20, 2013.

Submissions to this column are encouraged and may be sent to

Joan Somes, RNC, PhD, CEN, CPEN, FAEN
somes@black-hole.com
or
Nancy Stephens Donatelli, RN, MS, CEN, NE-BC
question4gene@gmail.com

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