Explain faecal incontinence in the elderly.
Always abnormal and almost always curable.
It is less common that urinary incontinence but signficantly more distressing.
Why is faecal incontinence more common in the elderly?
As the body ages the rectum can become more vacuous and the anal sphincter can gape due to a number of factors including haemorrhoids and chornic constipation.
Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stools.
Causes of faecal incontinence.
Most common cause is faecal impaction with overflow diarrhoea. It accounts for 50%.
Second most common cause is neurogenic dysfunction.
Sphincter dysfunction due to vaginal delivery, following procedures for fistulas, haemorrhoids and fissures.
Impaired sensation due to diabetes, MS, dementia, any spinal cord lesion.
Assessment of faecal incontinence.
Do a PR to check overflow incontinence, poor tone. Check the rectum, prostate, anal tone and sensation as well as visual inspection.
Stool type should be assessed if in the rectum.
Also assess neurological function of legs and particularly sensation.
Treatment of faecal incontinence.
Treat according to cause.
Ensure that a toilet is in easy reach.
Obey call to stool impulses
Esnure access to altest continence aids and advice on use.
Pelvic floor rehabilitation.
Loperamide 2-4 mg 45 min before social engagements may prevent accidents.
If all fails;
Enemas to empty the rectum and codeine phosphate. This is not a cure but makes it manageable.
Management of chronic diarrhoea in the elderly.
All underlying causes must be excluded by bowel imaging and stool culture.
All potentially causative medication should be removed.
Faecal impaction must be excluded.
Low dose loperamide can be trialled and then constipating and enema regimes can be used.
Causes of constipation in the elderly.
Poor diet and lack of exercise
Hospital environment and lack of privacy
Anal or colorectal cancer
Pelvic muscle dysfunction
Drugs like opiates and iron etc...
Neuromuscular - spinal or pelvic nerve injury as well as diabetic neuropathy.
Chronic laxative abuse
History of constipation.
Blood or mucus in the stools?
Alternating with diarrhoea? (think faecal impaction)
Has there been any recent changes/When did it start?
Are they using their finger to help pass stool?
Also do a PR examination.
Investigations of constipation.
No investigations are done in minimally affected young patients.
Bloods - FBC, ESR, U&Es, Ca2, TFT
Colonscopy if suspected colorectal malignancy
Transit studies can be done
Biopsy if Hirschprung's disease is suspected
Non-pharma treatment of constipation.
Types of medication for constipation.
Explain bulking agents.
Increases the faecal mass to stimulate peristalsis.
They must be taken with plenty of fluid and may take a few days to act.
They should not be given in diffuculty in swallowing, GI obstruction, colonic atony, faecal impaction.
Examples of bulking agents.
Explain stimulant laxatives.
Increase intestinal motility, this means it should not be used in intestinal obstruction or acute colitis. Prolonged use should also be avoid as it can cause colonic atony.
They can also cause abdominal cramps and it is important to inform patients about this side effect.
E.g. stimulant laxatives are not going to work effectively in hard stools because they need softening before they can be passed, this means giving a stimulant can be dangerous if there is hard stool.
Examples of stimulant laxatives.
Docusate sodium and dantron are stimulant mixed with softening
Explain stool softeners.
Particularly useful when managing painful anal conditions like fissures.
They are used alone or in combination with other anti-constipatory treatments.
Arachis oils enemas lubricate and soften impacted faeces.
Liquid paraffin should not be used for a long period of time.
Explain osmotic laxatives.
They retain fluid in the bowel, they either retain the fluid that it's been administered with, or draws fluid in.
Examples of osmotic laxatives.
Lactulose producing osmotic diarrhoea of low faecal pH that discourages growth of ammonia producing organisms. It can be used in hepatic encephalopathy.
Macrogol is another example used.
Magnesium salts are useful when rapid bowel evacuation is needed.
Phosphate enemas can be used for rapid bowel evacuation prior to procedures.
Risks of manual evacuation.
This is only done in difficult cases and can cause perforation.
However this is outwieghed by the positive impact on patient symptoms and wellbeing.
What should older patients with prescribed drugs that can cause constipation alsobe prescribed?