MALAYSIA: Gutsy ageing

Face to face with disturbing bowel problems in the elderly – constipation and incontinence. PENANG, Malaysia (The Star), June 15, 2008: AGE WELL By Dr TAN SOON SENG NOBEL laureate in literature Doris Lessing once said about ageing: “The greatest secret that all old people share is that you really haven’t changed in 70 or 80! Your body changes, but you don’t change at all, and that, of course, causes great confusion.” When it comes to the bowel, if I may add, the bodily changes cause embarrassment and depression. Faecal incontinence and constipation are two common gastrointestinal problems faced by the elderly. There are, on average, 2.5 million physician visits per year for constipation among those more than 65 years old in the US and Europe, and at the same time, 7% to 30% of this same demographic group of population are suffering from faecal incontinence. Yet these problems are often under-reported, undiagnosed and untreated. The social stigma attached to the disorders makes many patients, their families and even their physicians, reluctant to admit and face them. Many patients suffer in silence and isolation; this in turn may lead to anxiety and depression, and greatly impair the quality of their lives. Constipation Constipation is defined as two or fewer bowel movements in a week, associated with straining at defecation, hard stools, or a feeling of incomplete evacuation. Many elderly, however, perceive constipation as straining during defecation rather than a decreased bowel frequency, resulting in a large number of elderly who wrongly self-treat with laxatives. Medications are a common offender of constipation. Many prescribed drugs such as antidepressants, anti-Parkinson drugs and certain anti-hypertensives cause constipation, as well as many over-the counter medications such as painkillers (NSAIDs), antacids, antihistamines, iron and calcium. Diet plays an important role in constipation, especially those with poor fibre and fluid intake. In general, most elderly consume lower amounts of fibre than recommended. Dehydration may also lead to increased absorption of salt and water from the colon, leading to constipation. Immobility among the elderly is an important contributing factor to constipation. It causes reduction of colonic mass movement, inability to use abdominal musculature to defecate, poor diet, dehydration, hypercalcaemia (high calcium levels in the blood stream), and difficulty using toilet facilities. All these have the tendency to cause constipation. It is important to realise that constipation of sudden or acute onset often signals a potential or impending abdominal emergency. Obstruction or ileus is the common cause of acute-onset constipation – it often requires immediate medical attention. Constipation of chronic-onset which is associated with certain symptoms such as weight loss, anaemia, abdominal pain and rectal bleeding may be due to a sinister cause such as colon cancer, and therefore warrants referral to a gastroenterologist for more extensive investigations. Treatment of constipation consists firstly of conservative measures with the addition of dietary fibre in the diet. Supplementary fibre may be given, but its tendency to cause bloating, flatulence and its poor taste often make it intolerable for the elderly. In addition, adequate fluid intake is essential for constipated patients taking fibre. Mobilisation and toilet training, especially using the gastro-colic reflex after a meal, should be encouraged. Laxatives often are necessary to relieve constipation in the elderly. However, the use of laxatives has to be medically supervised as chronic abuse of laxative often leads to dependency. Stimulant laxatives such as bisacodyl, senna, and phenolphthalein are effective and safe for short-term use, but long-term usage in the elderly can cause dehydration, malabsorption, escalating doses and potentially damaging colonic function. Saline laxatives such as magnesium-containing compounds should be used with care in the elderly with renal or cardiovascular disease as these patients may not tolerate a salt load. This may lead to worsening of their kidney and heart conditions. Osmotic agents such as lactulose or sorbitol are the safest agents for longer term use in the elderly, although abdominal distension and bloating may not be well tolerated by some elderly patients. Suppositories or enemas are fairly safe in the long-term treatment of constipation. Rare complications include perforation and rectal injury and ulcer. Faecal impaction Faecal impaction may sometimes complicate chronic constipation in elderly patients. In this case, hardened stool causes obstruction in the distal colon resulting in abdominal distension, pain, and faecal incontinence. The treatment involves manual removal of the hardened faeces, enema, and laxatives. Faecal incontinence Faecal incontinence is defined as continuous or recurrent un-intentional passage of stools. It is a common problem in the elderly, estimated to affect 3% to 7% of people age 65 and above. It is even more prevalent in institutionalised individuals, affecting about 30% of the elderly in nursing homes. Continence and controlled defecation depend on the coordinated sensory and motor innervations of the rectum, anal sphincter and the muscles of the pelvic floor. When the rectum is filled with stool and a threshold volume is reached, stretch receptors in the wall of the rectum and along the pelvic floor are activated, leading to a sensation of urge and relaxation of the internal anal sphincter, allowing the contents of the rectum to pass into the anus. However, rectal distension also leads to a reflexive contraction of the external anal sphincter, allowing for continence. Disturbance of this normal physiological mechanism may result in faecal continence in older people. In addition, an intact mental function is needed to sense the need to defecate. Many elderly patients with declining mental function cannot sense rectal distension, or they may ignore the urge to defecate, resulting in stool impaction and subsequent intermittent leakage incontinence. Repetitive damage to the pudendal nerve associated with vaginal deliveries and chronic defecation straining are two common causes of faecal incontinence seen among elderly females It is also important to realise that diarrhoea is a common and preventable factor of faecal incontinence as a high volume of watery stool can lead to leakage even if the recto-sphincter is intact. Treating the diarrhoea leads to resolution or improvement of the incontinence. On the other hand, as mentioned above, obstruction of the colon by a tumour or an impacted stool could lead to constipation and overflow-incontinence. Treatment of faecal incontinence should start with simple measures such as stool bulking and elimination of food that may cause diarrhoea. Faecal impaction or colitis, if present, should be removed and treated. Anti-diarrhoeals such as loperamide and opiate derivatives are useful if there is no obvious cause. Biofeedback may be useful in many patients regardless of the aetiology. Patients are trained using visual clues on a tracing to stimulate contraction of external anal sphincter to balloon distension of the rectum. Surgery, which includes sphincter repair and colostomy, may be necessary in intractable cases who have failed medical therapy. Constipation and faecal incontinence are disturbing but common problems one faces in one’s golden age. Instead of shying away from them and pretending that they are not there, as we slowly become a part of this demographic subpopulation, we might as well face it and age with guts. As Maurice Chevalier aptly stated: “Old age isn’t so bad when you consider the alternative”. I dedicate this article to my late parents, who until their death in old age, were free of bowel problems. That, from my own experience of managing so many unfortunate elderly patients with such problems, was a true blessing to themselves and their family. Dr Tan Soon Seng is a consultant gastroenterologist. For more information, e-mail starhealth@thestar.com.my Copyright © 1995-2008 Star Publications (M) Bhd