Bowel Elimination Among Older Adults And Nursing Care

Geriatric Nursing Bowel Elimination Issues

Three major bowel elimination problems In Adult Elders , Constipation ,Fecal Incontinence ,Colorectal Cancer

Bowel Elimination Among Older Adults

        Bowel elimination is the end process of digestion resulting from interactions of the central and autonomic nervous systems, and endocrine, gastrointestinal and musculoskeletal systems. 

Three major bowel elimination problems have been studied and consistently have been shown to affect the older population: constipation, incontinence, and colorectal cancer (American Cancer Society, 2003a; Hogstel , 2001; Memorial Sloan-Kettering Cancer Center, 2003; Vogelzang , 1999) .

1:Constipation: 

    Constipation defined as the accumulation of feces in the lower intestines with difficulty evacuating this waste, is the most common complaint among older adults (Abrams, Beers, Berkow , & Fletcher, 1995). According to Annells and Koch (2002), laxatives have become the most commonly sought treatment for constipation.
     More than one third of older adults use weekly laxatives to reduce strain and enhance fecal elimination (Reiss & Ev ans , 2002). Research findings demonstrate that increasing fiber and fluid in the diet significantly decreases the need for laxative use and stool softeners (Howard, West, & Ossip -Klein, 2000; Robinson & Rosher , 2002).

    Vogelzang (1999) cited seven reasons for constipation in the elderly. Multiple medications ( polypharmacy ) had been identified as a primary reason for constipation, especially in nursing home residents. Six or more medications have been shown to adversely effect motility of the digestive tract ( Vogelzang ). 

    Older adults living at home may be at an even higher risk for overdose related to self-medication with over-the-counter drugs ( Vogelzang ). In addition, limited income influences the quality of food purchased and the degree of fiber-rich foods incorporated into the older adult's diet. Annual income is less than $6,000 in 40% of older Americans, leaving them limited funds for groceries. 

    Most do not take advantage of funded food programs. Selection of the same foods is common, leading to a poorly balanced diet ( Vogelzang ). Non-healthy snacking throughout the day also counteracts appetite as well as bowel regularity. 

    Lack of social interaction, physical inactivity, nausea caused by contaminated food due to unclean food preparation, and inadequate cooking skills have also been identified as contributing factors to risk for constipation ( Vogelzang ). 

    Constipation can he controlled by a well-balanced diet high in fiber, adequate hydration (at least 6-8 eight-ounce glasses of water/day), along with in-creased activity (Hinrichs, Huschoc , Tang, & Tirler , 20011.

2:Fecal Incontinence 

    It has been shown to contribute to decreased social activity ( Giebel . Lefering , Troidl , & Blochl , 1998). Older adults are embarrassed that incontinence may occur in public, so they tend to limit outside activity with friends and family. 
    There exists a strong correlation between urinary and fecal incontinence (Chassagne et al., 1999). In a survey conducted by Giebel and colleagues, 500 randomly selected older adults in Germany responded to a questionnaire about bowel habits. It was found that 4.8% were unable to control solid stool, whereas 19.6% experienced at least one type of incontinence. 
    Women had more of a problem with pasty or liquid stools. They also experienced an urgent sensation to quickly reach the toilet. Men described soiling their underwear as most problematic. Controlling flatus was also described as a concern. 
    Findings suggest that the lack of control associated with bowel habits plus the reduction in activities necessitate interventions aimed at education about intestinal health and dietary change. Another study done on fecal incontinence enrolling 1,186 older adults 60 years of age and older in a long-term care setting identified five risk factors associated with fecal incontinence: 
(1) history of urinary incontinence
(2) neurological disease 
(3 ) poor mobility
(4) severe cognitive decline
(5) age greater than 70 
    Fecal incontinence associated with impaction and diarrhea occurred in 234 (20%) of the sample. The study showed an association between permanent fecal incontinence and overall poor health in older adults.

    Approximately 90% of individuals with colorectal cancer are over 50 years of age (American Cancer Society, 2003a). 

    The United States Preventive Task Force recommends individuals beginning at age 50 be screened for colorectal cancer as follows: (a) yearly fecal occult blood test, (b) flexible sigmoidoscopy every 5 years, (c) colonoscopy every 5-10 years (American Cancer Society; Donovan & Syngal , 1998). Screening can reduce risk by up to 75% (Donovan, & Syngal ). Those with a family history of colon cancer and/or polyps should be screened at a younger age and more frequently.

    Borum (1998) evaluated the relationship of age with screening for colorectal cancer. A retrospective chart review of 200 patients over 50 years old in an ambulatory clinic showed that more rectal exams were done on 50-60 year olds than on 60-70 year olds . These results indicate that less screening is done in the older elderly than the younger elderly. As aggressive screening decreases, risk for colorectal cancer increases ( Borum ).

3:Colorectal Cancer:

    Diet plays an important role in the prevention of colorectal cancer. Negri, Franceschi , Parpinel , and La Vecchia (1998) investigated fiber intake and the risk of colorectal cancer. Dietary habits of patients (1,225 with colon cancers, 728 with rectal cancers, and 4,154 with no history of cancer) were studied. 
    The data indicated that dietary fiber has a protective effect against colorectal cancer. High fiber diets may protect against colorectal cancer by allowing brief mucosal exposure to carcinogens. The longer stool remains in the intestine, the more likely the chance of cancer.

    Caygill , Charlett , and Hill (1998) investigated the relationship between intake of high fiber and risk of breast and bowel cancer. The study showed cereal and vegetables protect against both colorectal and breast cancer, Fruit had no protective effect on colorectal or breast cancer. However, fruit was shown to be more protective against cancers of the upper digestive tract ( Caygill , Charlett , & Hill).

Conclusion

    In summary, older adults are at risk for developing bowel elimination complications, which may be associated with the physiological changes occurring with advancing age and lack of screening. Screening for cancer needs to be done on all the elderly, regardless of advanced age. Diets high in fiber, adequate hydration, increased activity, and education programs encourage prevention of complications.