What is the next best step in managing constipation in a 95-year-old long-term care resident with no bowel movements for 7 days, currently on Percutaneous Endoscopic Gastrostomy (PEG) tube, lactulose, and suppositories?

From the Guidelines

The next best step in managing constipation in a 95-year-old long-term care resident with no bowel movements for 7 days, currently on Percutaneous Endoscopic Gastrostomy (PEG) tube, lactulose, and suppositories, is to consider a rectal examination to check for faecal impaction and potentially use an isotonic saline enema.

Current Management

The patient is already on lactulose, which is an osmotic laxative that can help promote peristalsis and increase bowel movement frequency 1. However, the patient has not had a bowel movement for 7 days, suggesting that the current management may not be effective.

Potential Next Steps

Given the patient's age and lack of bowel movements, it is essential to consider the risk of faecal impaction, which can be a common cause of constipation in elderly patients 1. A rectal examination can help identify faecal impaction, and if present, an isotonic saline enema can be used to help clear the impaction 1.

Considerations

When using laxatives, particularly in elderly patients, it is crucial to consider the risk of adverse events, such as dehydration and electrolyte imbalances 1. The patient's medical history, including any cardiac or renal comorbidities, should be taken into account when selecting a laxative regimen 1.

Additional Measures

In addition to the potential use of an isotonic saline enema, other measures can be taken to help manage the patient's constipation, such as:

• Ensuring access to toilets and optimizing toileting habits 1
• Providing dietetic support and managing any decrease in food intake 1
• Considering the use of stimulant laxatives, such as senna or bisacodyl, if the patient's constipation persists 1

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Oral Adult: The usual adult, oral dosage is 2 to 3 tablespoonfuls (30 mL to 45 mL, containing 20 grams to 30 grams of lactulose) three or four times daily. The dosage may be adjusted every day or two to produce 2 or 3 soft stools daily The next best step in managing constipation in a 95-year-old long-term care resident with no bowel movements for 7 days, currently on Percutaneous Endoscopic Gastrostomy (PEG) tube, lactulose, and suppositories is to adjust the lactulose dosage to produce 2 or 3 soft stools daily, as the current dosage may not be effective.

• The resident is already on lactulose, but the dosage may need to be adjusted to achieve the desired effect.
• The goal of treatment is to produce 2 or 3 soft stools daily. 2

From the Research

Managing Constipation in a 95-year-old Long-term Care Resident

The resident is currently on Percutaneous Endoscopic Gastrostomy (PEG) tube, lactulose, and suppositories, with no bowel movements for 7 days. The next best step in managing constipation would involve:

• Reviewing the current treatment plan and considering potential interactions or side effects of medications, as daily use of laxatives can be detrimental to the resident 3
• Assessing the resident's overall health and potential underlying causes of constipation, such as decreased physical activity, fluid intake, or dietary fiber 3, 4
• Considering non-pharmacological interventions, such as:
  • Increasing physical activity and fluid intake
  • Adding dietary fiber or bran to the resident's diet
  • Using probiotics or fermented oat drinks to improve stool form and constipation symptoms 5
  • Implementing a constipation risk assessment and management flow chart to guide care 4
• Ensuring proper care and management of the PEG tube, including daily tube care and administration of medications as prescribed, to prevent complications 6, 7
• Educating and training healthcare staff on the management of bowel care and constipation in long-term care settings to improve knowledge and practice 4