older people and laxative use: literature review and pilot study report

Older people and laxative use: literature review and pilot study

report

TINATINA KOCHKOCH BA, PhD, RGN

Royal District Nursing Service of South Australia Inc., Chair in Domiciliary Nursing,

School of Nursing, Flinders University of South Australia, GPO Box 2100, Adelaide 5001,

South Australia, Australia

SALLYSALLY HUDSONHUDSON BAppSSci , Adv Nurs (NEd), BN, RGN, RMN

Research Associate, RDNS Business Centre, PO Box 247, Glenside 5065,

South Australia, Australia

Accepted for publication 29 July 1999

Summary

· This study explored older adults' perceptions of constipation, and the

measures taken if they believed themselves to be af¯icted by this condition.

· The paper provides an overview of the current literature surrounding laxative

use, followed by a discussion of the pilot study and its ®ndings.

· The objectives of the pilot study were to establish older people's de®nitions of

the term `constipation'; identify prescribed laxatives, over-the-counter laxatives,

and home remedies used by older people to manage constipation; produce a

detailed account of when these products are used; identify the older person's

belief system underpinning their concepts of constipation, and their consequent

use of laxative products; and produce information which will inform nursing

practice, with a particular focus on nurses in community practice.

· People who identi®ed themselves as being constipated were interviewed on a

one to one basis.

· Participants shared their stories of loneliness, social isolation and anxiety

related to constipation and the need to use laxatives on a daily basis, and

described persistent unpleasant and often painful physical symptoms such as

bloating, urges, excessive ¯atus, nausea and cramps, commonly associated with

laxative ingestion.

· Nurses are challenged to work with older people within a `wellness'

framework, helping clients to maintain their bowel function, rather than fall

back on short-term options, which provide only brief relief of symptoms, while

ignoring the underlying causes.

Correspondence to: Tina Koch, Royal District Nursing Service of SouthAustralia Inc., Chair in Domiciliary Nursing, School of Nursing,Flinders University of South Australia, GPO Box 2100, Adelaide5001, South Australia, Australia.

Journal of Clinical Nursing 2000; 9: 516±525

516 Ó 2000 Blackwell Science Ltd

Keywords: constipation, community nursing, in-depth interviews, laxative use,

older people, research.

Introduction

It is widely believed in the community of healthcare

professionals that a high percentage of older people are

laxative-dependent. It is also widely believed in the

general community that constipation is one of the

consequences of ageing. However, minimal research exists

which addresses the problem of laxative overuse. Indeed,

much of what is believed as `facts' about individuals'

attempts to self-manage what they believe to be consti-

pation is, in the main, assumption.

Estimates of use vary widely in discussions about

laxative intake. It is clear, however, from a cursory check

of South Australian supermarkets, health food shops and

pharmacy shelves that a lucrative market exists for these

products, which are often displayed prominently. Informal

discussion with the owners of smaller businesses indicates

that bowel stimulant products such as senna pods and

leaves, and coloxyl with senna are favoured products

among elderly purchasers.

While it can be accepted that there is a percentage of

people in the community who regularly consume some

form of laxative product, there is minimal evidence about

what is being taken, by whom, and when. Most importantly,

the reasons and belief systems underpinning this consump-

tion have never been explored. This gap in a largely under-

researched area has the potential to underscore yet again the

ageist attitudes and prejudices that still exist in the wider

community and among many healthcare providers.

Given the lack of knowledge in this basic area of

healthcare, the assumption that professionals know best

how to manage these problems cannot be sustained. The

researchers in this pilot study listened to the voices of

those most affected by constipation and laxative use in

order to discover the consequences of this behaviour.

This study will make a contribution to the health of

older adults in this area by adopting a different focus.

Literature review

This review will discuss some of the published research

literature available in the last 15 years in the areas of

constipation, diarrhoea and ¯atus. Integral to these issues

is the use (and possible abuse) of laxatives and enemas,

whether prescribed or obtained `over-the-counter' (OTC

medications).

Constipation and diarrhoea are often considered com-

mon among older people (Gibson et al. 1995; Neal, 1995)

yet there is little research addressing these, and the related

problems of excessive ¯atus and laxative use. It can be

suggested that many consumers of laxative products

develop a cycle of perceived constipation followed by

stimulant laxative intake followed by diarrhoea. However,

Petticrew et al. (1997) conclude that there have been so

few comparative studies, and the trials have been so small,

that it is dif®cult to determine what constitutes effective

treatment of constipation with older people.

A CD-ROM search using CINAHL and MEDLINE

was undertaken, using various combinations of the

keywords constipation, diarrhoea, laxative use, elderly,

research and clinical implications. The literature extracted

using these terms is limited and generally has an acute or

extended care focus. Of over 300 articles dealing with

constipation, less than 10% was research-based, while a

search relating to laxative usage produced only four

articles. Two of these dealt with older people's use of

OTC medications. The other two focused on young

women's use of laxative preparations as part of their

bulimic syndrome. Similarly, of 88 articles dealing with

diarrhoea, only 17 were research-based, and only nine

dealt speci®cally with older people. Flatus, a condition

commonly associated with constipation and diarrhoea, is

only mentioned by Annells (1997), who has studied this

phenomenon extensively. She maintains that the biomed-

ical literature has a

¼ preoccupation to research the pharmacological/

medical/surgical treatment rather than studying the

impact and consequences of problems [while]¼ the

discourse of science¼ has dominated nursing dis-

course on the topic, with just glimpses of caring

discourse able to be discerned (Annells, 1997; p. 51).

While these remarks refer to the problem of ¯atus, they

are equally valid when considering other colo-rectal

dysfunction. No extensive studies of this phenomenon

have been conducted in Australia. Hence the statistics

presented here were located in a UK report of randomized

control trials (RCTs) of the treatment or prevention of

constipation and a systematic review of the effectiveness of

laxatives in the elderly (Petticrew et al., 1997).

DEFINITIONDEFINITION

According to Petticrew et al. (1997), the term constipation

is used primarily to refer to dif®culty in defecation

(straining) and/or infrequency, which is not secondary to

Issues in care for longer-term patients Older people and laxative use 517

Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 516±525

some underlying cause (Moriarty & Irving, 1992). Asso-

ciated complaints include bloating and abdominal pain

(Lennard-Jones, 1993). As an objective criterion for

de®ning constipation, defecation less than three times

per week has been widely used (Whitehead et al. 1989;

Wolfsen et al. 1993).

PREVALENCEPREVALENCE

Constipation appears to be a greater problem in older

people. Based on surveys in the UK and USA, possibly

20% of older people living in the community have

symptoms of constipation. Not only does the prevalence

appear to be much higher in this age group but also the

impact on quality of life is greater. The prevalence of

constipation has been consistently estimated to be higher

in women than in men (Petticrew et al., 1997). Harari

et al. (1996) also report that laxative use increased with

age, and was more common among women than men.

CONTRIBUTING FACTORSCONTRIBUTING FACTORS

The biomedical literature is based on a predictable model

of patho-physiology and intervention, in a linear cause/

effect progression. A number of pathological conditions

are implicated as causes of constipation and diarrhoea, and

therefore it is essential ®rst to determine the aetiology of

the constipation. In the absence of disease, constipation

and diarrhoea are generally considered a consequence of:

· dietary indiscretion, e.g. highly spiced or rich foods;

· low-®bre diet;

· dehydration ± often as a result of diuretics, but also as a

result of inadequate ¯uid intake or of climatic condi-

tions;

· prescription drug ingestion;

· chronic laxative abuse: some adults use laxatives even in

the absence of constipation.

Although many studies have found that constipation is a

greater problem for older people, it has also been

emphasized that there is nothing about ageing per se that

causes constipation (Abyad & Mourad, 1996; Harari et al.,

1996; Petticrew et al., 1997). Yet there is general agree-

ment that older patients commonly report that they are

constipated (Abyad & Mourad, 1996; Harari et al., 1997;

Petticrew et al., 1997; Stoehr et al. 1997). Old people who

are healthy and active often have normal defecation

(Merkus, 1984). More accurately other known risk factors,

in particular ¯uid intake, diet and mobility, may confound

the association between age and constipation. These

contributing factors are discussed in the report by

Petticrew et al. (1997). Lack of ¯uid has been cited as a

risk factor for constipation (Richards-Hall et al., 1995;

Maestri-Banks & Burns, 1996), with the suggestion that

older people may drink less in an attempt to control

urinary incontinence. Physical mobility problems are more

likely in older people, and constipation has been found to

be more prevalent in those who take little exercise or are

relatively inactive (Sandler et al., 1990). Signi®cantly, one

large population survey (Sandler et al., 1990) has also

found that constipated adults reported lower consumption

of fruit, beans, peas, and other vegetables (Petticrew et al.,

1997).

Clearly, accurate assessment of the aetiology of consti-

pation is the crucial ®rst response in the formulation of a

plan of care based on the range of treatment options

available and underpinned by a social health framework of

care.

INTERVENTIONSINTERVENTIONS

A major issue in any discussion of constipation and

diarrhoea is that of laxative use which is either self-

prescribed or recommended by healthcare professionals. It

is generally accepted that there are four categories of

laxatives available, although some would argue that bran is

a component of a healthy diet:

· bulking agents: bran, fybogel, ispaghula husk, psyllium,

calcium polycarbophil, Normacol, Metamucil;

· osmotic agents: magnesium hydroxide, lactulose;

· stimulant laxatives: senna, senna tablets, cascara,

bisacodyl, danthron, sodium picosulphate;

· faecal softeners: liquid paraf®n, arachis oil, Coloxyl.

Stoehr et al. (1997) found in a sample of over 1000

individuals with a mean age of 74.5 years that 10% of

older people reported taking laxatives as a self-prescribed

OTC item. Despite this ®nding, and contrary to fre-

quently held opinion, there is no evidence that a change in

bowel motility is an inevitable consequence of ageing. Yet

there is general agreement that older patients commonly

report that they are constipated (Abyad & Mourad, 1996;

Harari et al., 1997; Stoehr et al., 1997). A study by

Rodrigues-Fisher et al. (1993) identi®ed that up to 30% of

older adults use laxatives at least once weekly. Laxative use

has also been associated with greater use of a range of

services such as medical practitioners and domiciliary

nursing care services (Stoehr et al., 1997).

MANAGEMENT AND COSTSMANAGEMENT AND COSTS

The nursing literature generally takes a broader view of

constipation and diarrhoea. While recognizing that the

aetiology of both these symptoms can be multifactorial and


518 T. Koch and S. Hudson

therefore a thorough assessment is needed prior to

implementing a treatment regime (Wright & Staats,

1986; Taylor 1991; Williams & Roe 1995), there is also

recognition of the role of prevention and non-pharmaco-

logical intervention (Gibson et al., 1995; Neal, 1995;

Bentsen & Braun, 1996; Nazarko, 1996). Wright &

Thomas (1995; p. 289) label constipation and diarrhoea

`the neglected symptoms', and suggest that a great deal of

money is spent annually in the attempt to manage these

disorders.

All these authors also point out that both constipation

and diarrhoea are often sources of major discomfort and

concern, while preventative strategies and treatments are

extremely important. More consistent nursing assessments

and interventions are necessary to prevent serious dis-

comfort for patients, according to Williams & Roe (1995).

They maintain that laxatives are commonly prescribed for

older people, although there have been few advances in

laxative treatment in the last 50 years, and that overpre-

scribing of laxatives is common. In 1993, over 10 million

prescriptions for laxatives were written in the UK. This is

despite the fact that non-pharmacological strategies such

as changes to dietary and ¯uid intake habits, increased

exercise and, most importantly, education about what

constitutes `normal' bowel habits have been shown to be

effective symptom management strategies for most people

(Williams & Roe, 1995).

Despite the large sums spent on laxatives, and millions

of prescriptions written to manage the problems of

constipation and diarrhoea, there is minimal research

addressing these problems in the general community,

although it is claimed that these colo-rectal complaints are

common.

ATTITUDES AND BELIEFSATTITUDES AND BELIEFS

While research indicates that laxative use increases with

age, there is little evidence to explain this. Ebersole &

Hess (1990) suggest a cascade of factors including

advertising of laxatives directed at older people, and

cultural habits deriving from weekly doses of cathartics in

childhood, in the belief that `cleaning out' the colon is

essential for good health. In a study of over 300 older

adults and a comparison group of middle-aged adults,

Ross (1993) found that more than twice as many older

people believed that `regular' bowel habits were important

for good health.

These views are consistent with Lawler's thesis that `the

body is the primary source of dirt ¼ especially dirt

associated with the margins of the body ± excrement'

(Lawler, 1991; p. 76). Elsewhere she notes that the idea of

the body as dirty (impure) has a long history in Judeo±

Christian philosophy. Robinson (1997; p. 26), who states

that many societies consider faeces `the most profane of

substances', also explores this concept. Arguably, these

notions are the basis for much of the reported laxative use

by older people. By eliminating body impurities, `inner

cleanliness' can be achieved and health can be maintained.

This is also a basic premise of many complementary

healthcare schools, e.g. naturopathy, herbalism, etc., that

is, optimization of bowel function is a prerequisite for

good health (Turner, 1996).

QUALITY OF LIFE AND SOCIAL IMPLICATIONSQUALITY OF LIFE AND SOCIAL IMPLICATIONS

Petticrew et al. (1997) state that little research has been

conducted into the effect of constipation on quality of life

of older people. Little attention has been paid to exploring

the relationship between effects of constipation and the

social engagement of older people. How constipation

interferes with activities of daily living and how these

people cope with the pain and discomfort is also under-

researched. However one random sample of 704 older

people (aged over 65 years) living in the community found

that functional disorders of the bowel (a group of disorders

which included constipation) interfered with daily living

and impaired well-being (O'Keefe et al., 1995).

CONCLUSIONCONCLUSION

Research to explore the problems of diarrhoea, constipa-

tion, faecal incontinence, ¯atus and laxative usage in the

community has become increasingly necessary. The

management of increasing numbers of older people with

constipation in the community is an expanding commu-

nity health issue because of increasing numbers in this

population and little is actually being done to address this

common problem. This is a crucial issue for nurses

working in the community in a partnership of care with

older people.

Exploration of the psychological and social implications

for those af¯icted, and the burden placed on spouse and/

or caregiver, are warranted if the consequences of these

conditions ± social isolation, carer burnout and break-

down of care in the community ± are to be avoided

(Norton, 1994; Addison, 1996; Gray & Burns, 1996).

The study

The aim of this pilot study was to explore older people's

experiences and understanding of constipation, the mea-

sures they take to deal with the problems and their



knowledge of the products they use. The study was

supported by a small grant. The constraints of the grant

meant that we were only able to interview six participants,

but we are seeking further funding to continue the study.

METHODOLOGYMETHODOLOGY

Ethical considerations

The research proposal was approved by Royal District

Nursing Service (RDNS) Ethics Advisory Committee.

The conduct of the research followed the National Health

and Medical Research Council (NHMRC) Guidelines on

Research Practice (NHMRC, 1997). These include

con®dentiality, anonymity, informed consent, ensuring

free participation, and withdrawal at any time without

compromise. Participants were offered the opportunity to

receive a copy of the research report if they indicated an

interest in receiving feedback about the study. Indeed all

participants wanted feedback and so the actual report was

written in simple language using the words of participants

themselves so that they would have easy access to the

®ndings.

Study criteria for selection of participants

Sampling in qualitative research is directed at ®nding

information-rich cases rather than at randomization and

generalizability (Koch, 1994, 1996). Participants were

selected to ensure a cohort who had experiences relevant

to the central study phenomenon, that is, constipation and

use of laxatives by people aged 65 and older. The criteria

for selection of participants in this study were:

· RDNS clients aged 65 years and older;

· a medical diagnosis of constipation related to laxative

use;

· a nursing action of bowel management on the care plan.

The exclusion criteria were any RDNS client who also

had a diagnosis of dementia, was seriously ill or in any

acute treatment phase.

Identi®cation of RDNS clients meeting the study criteria

Two options for identifying RDNS clients meeting the

study criteria were detailed in the proposal. In Option

One, the RDNS Continence Nurse Advisers were asked to

provide the research associate with the names of clients

referred to them for education and assistance about

constipation, diarrhoea and laxative use. Option Two

proposed that the research associate would access the

RDNS client database and extract names of RDNS clients

meeting the study criteria. Due to recruitment dif®culties,

the latter option became the preferred alternative. The

research associate then visited the Regional Of®ces to seek

out the nurses responsible for the care of clients identi®ed

to determine if any exclusion criteria existed. One

participant was identi®ed using this process. Another

client was identi®ed when the research nurse spoke with

®eld staff at random, asking if they had any clients meeting

the study criteria.

Recruitment of participants

The research associate mailed the documentation which

had been approved by the RDNS Ethics Advisory

Committee to the nine RDNS clients meeting the study

criteria. She then telephoned each client, asking if they

were willing to participate in the study and if so,

negotiated a suitable interview time and venue. Two

clients chose not to participate. Any RDNS client's

decision not to participate was taken as ®nal and nursing

care and service delivery from RDNS was not affected in

any way. If any client spoke a language other than English,

there was provision in the study to contact the South

Australian Migrant Health Service interpreting service to

organize for an appropriate interpreter to join the

interviewer, and assist with transcribing and interpretation

of data. However, this was not required.

Research process

Eventually, six community-dwelling people, three male

and three female, with a mean age of 84 years, volunteered

to participate in the study. They all had a medical

diagnosis of constipation related to laxative use and/or a

nursing action of bowel management.

The issues of constipation, diarrhoea, ¯atulence and

laxative use are considered sensitive topics for discussion.

Questions were developed based on the Continence

Assessment form used by RDNS nurses and RDNS

Continence Nurse Advisers. The RDNS Continence

Nurse Advisers were consulted in the tool design to elicit

information about the topics being studied. A semi-

structured approach is well suited to exploring topics, in

that participants can be encouraged to talk freely about the

issues of interest. Semi-structured interviews also provide

the opportunity for participants to articulate their own

understanding and experiences. Generative questions to

guide the interviews were developed from the existing

research literature and moved from less to more sensitive

issues. The central questions revolved around partici-

pants' self-diagnosis and self-care strategies within a



framework of their own perceptions of acceptable symp-

tom management. The following is a sample of the

interview questions:

· Can you tell me how your bowels have been over the

years?

· When you say that you're constipated, what exactly do

you mean?

· What is your normal pattern for having your bowels

open?

· What symptoms do you have if/when you are consti-

pated?

· Do you take any medicines or use any remedies to have

your bowels open?

· Who recommended this product or remedy to you?

· Does this product/remedy have any side-effects?

· Do you eat any particular foods to help with your

bowels?

· How much ¯uid would you drink in a day?

· What happens to you when your bowels don't work as

often as you'd like?

· Do you think constipation affects your health, your life,

social constraints?

The interview process

The interviews were conducted between March and May

1998 as RDNS clients meeting the study criteria were

identi®ed. The interviews were akin to natural informal

conversation, which allows the participants to speak freely

about their most salient experiences and perceptions in

relation to the experience of constipation. The duration of

each interview was ¯exible, depending upon the quality of

the discussion, ranging from 45 min to 80 min. Interviews

were tape-recorded and the data transcribed. Data collec-

tion and analysis were concurrent as this enabled emerging

themes and issues from early data to guide subsequent

interviews.

Each interview transcript was read a number of times to

gain a sense of the whole story of each participant. The

transcripts were re-examined to select exemplars of signi-

®cant statements to illustrate the themes (Koch, 1993; p.

221±224) and we compared similarities and dissimilarities

with the literature on constipation and use of laxatives.

Ethical concerns

Clients are often admitted to the district nursing service

for `an enema'. While it is recognized that every client

should be offered a full nursing assessment within 24 h of

admission, it was often the case that the assessment

process was incomplete for these clients. An ethical

dilemma arose part way through the research, when we

discovered that not only was a full assessment not carried

out for some of the participants but also that one district

nursing visit was inadequate for some clients. In listening

to the stories from clients and their carers, we made a

professional judgement that in some instances care and

follow-up was inappropriate. We considered it necessary

to approach the Ethics Advisory Committee for further

guidance. We sought their approval for the research

associate to approach the nurse responsible for the

de®cient care, and discuss our concerns. After consider-

able discussion, this request was approved.

FINDINGSFINDINGS

Bowels open every day

All the participants believed that it was important and

ideal to have their bowels open every day. They consid-

ered themselves constipated if this did not occur and

usually took a laxative. Participants de®ned constipation

for themselves. Here is what they had to say:

Dan: I was quite happy to have a motion once every

two days, over the last ®ve days it has been regular

between say 8 and 9 in the morning.

Ethel: I like to have them once a day if possible so I

take the real old thing and it's genuine, I have Epsom

Salts, I've got to watch myself and I do have bother. I

like relief. If I didn't go to the toilet every day I

would have a problem and it would bother me.

Larry: My bowels are the best now today that they've

been for 30 years, every day is regular for about the

last three months. You don't seem so heavy and so

bloated, you just seem more refreshed and more

light, not lighter, but more light in yourself.

Doris: It is pretty terrible and worrying and serious

and I just have to have a real good bowel motion

every day with no effort. It is such an effort if I miss a

day and I am straining too much. I have two or three

motions and I don't mind it that way because I know

it clears out properly and that is how I have got to

keep it every day.

Frank: Once a day, yes that would be a normal

routine. I like to go every day, be regular, but I can't

get too upset about it. I always have Normacol on the

desk and if I think it's getting too near the time I

ought to be having one, I take a spoonful, I think it

helps a bit.

Ross (1993) supports this ®nding in the previously cited

study of over 300 older adults and a comparison group of

middle-aged adults. He found that more than twice as



many older people believed that a `regular' bowel habit

was an important practice with health-related bene®ts.

Compromised health and wellness

All participants described feelings of bloating, cramps,

excessive ¯atus, abdominal tightness and generalized

aching when constipated. Three described experiencing

ùrges' and having `long tries' when constipated. These

participants reported compromised health and wellness

due to unrelieved symptoms of constipation. However, for

all participants the experience of constipation, and the

active pursuit of strategies to achieve some minimization

of symptoms and satisfactory quality of life, were central

to their existence.

Preoccupied with bowels

One participant's wife saw preoccupation with bowels and

their movement as anxiety or `paranoia'. This preoccupa-

tion in¯uenced lifestyle and limited participation in social

activities, particularly those involving bus and overnight

travel. One participant stated, `Your life revolves around

your bowels and being close to a toilet at all times'. Another

participant said, `Constipation is one of those things I wish

to avoid for the rest of time'. A third participant, aged 66,

who is deeply depressed by the unrelenting and devastat-

ing symptoms of constipation said, Ìt's just fate'.

Cultural habit

Three participants described laxative use since early

childhood, recounting a lifelong pattern of laxative abuse

and compromised health and well-being. According to

Ebersole & Hess (1990), the advertising of laxatives, with

strong messages for the need to be `regular', is often

directed at older people, therefore lifelong laxative use

could be viewed as a cultural habit.

Arguably this can be traced to weekly doses of cathartics

such as castor oil, rhubarb and Epsom salts (magnesium

sulphate) in childhood in the belief that à good clean out'

of the colon was an essential practice to prevent ill-health.

Two of the participants also described their siblings'

experiences with chronic constipation and laxative use as

similar to their own. One of these participants said, Ì

thought it was normal to take laxatives'.

Diet and ¯uid intake

Although four participants were aware of the need for

adequate dietary ®bre and ¯uid intake, they described a

diet that was low in ®bre. Two of these received Meals on

Wheels each day. The remaining two clients believed that

it was very important for them to have a high-®bre diet in

the management of their constipation. One participant's

daughter provided a supply of pea soup for lunch each

day, while the other participant, who is 98, obtained a

recipe book using Metamucil, and now makes Metamucil

patties and burgers. (Metamucil is a widely advertised

proprietary brand of powdered psyllium husks, sweetened

with sucrose or aspartame. It is available as a plain or

orange-¯avoured product from supermarkets and phar-

macies.) Notably, the four participants eating a low-®bre

diet also reported a poor ¯uid intake during the day.

However, they all said that they knew they should be

increasing their daily intake of liquid. It was interesting

that all participants in the study acknowledged the link

between their ®bre and ¯uid intake, their persistent

constipation problems and the ongoing need for laxatives.

Naming the laxatives

Participants were asked to name the laxatives prescribed

for them by their doctor and those purchased over the

counter, and to indicate the quantities of laxatives they

consumed. They were also asked how often they used these

products, and whether they experienced any side-effects

attributed to laxative use. They were asked which laxatives

they had taken in the past, and what they favoured now.

However, this became confusing because they tended to

change laxatives when the product seemed ineffective, so it

was impossible to gain an accurate picture of which

laxatives had been used over the decades. Table 1 lists all

the laxatives used by each of the participants, although not

all these laxatives are used concurrently.

The following combinations of laxatives were described:

Ethel: I try all sorts myself but I ®nd Epsom Salts

is the best, two teaspoons in a glass mix up with

water and drink that down before breakfast, in the

morning when you get up, I like relief.

Maria (who remains constipated): At the present

moment I have a bowel washout and take magnesium

three times a day, and a senna leaf that you boil,

sit for a minute and drink, also take Metamucil,

senna, coloxyl and senna and Aculax, Herbalax.

Larry: I was taking Senokot granules. While I was

in hospital that's what they used to give me, so

when I come out of hospital, I've always taken

something. I'd take tablets and if I got a bit bound up

I'd take the granules and they'd clean you out. And

you don't feel well in yourself. Nulax ®lls me full

of wind, senna does the same thing, ®lls you full of

wind. Metamucil is working for me now.



Health resources

The problem of constipation is clearly resource

intensive. It has been noted that laxative use is also

associated with greater use of a range of services such as

medical practitioners and community nursing care

(Stoehr et al., 1997). Contact with community nursing

seemed to occur when an enema was required to relieve

the acute symptoms of constipation. All participants

reported regular contact with their general practitioner

and four reported regular contact with medical special-

ists at their local hospital. Of the six participants in this

study, four reported having exploratory tests such as

abdominal X-rays, endoscopy, colonoscopy or a barium

meal.

Maria was taken to the Accident and Emergency (A &

E) department at the local hospital because of severe lower

abdominal pain. However, the doctor would not listen to

her daughter telling him about Maria's history of bowel

problems. Instead, he ordered tests to be carried out. In

the interview, the daughter related her discussion with the

A & E doctor. She said:

Look, please don't do an endoscopy, because her

problem is constipation and I can explain. He says

`No.' He wouldn't listen to me, he gave her the X-ray

and just wasted so much time and money, which

there's not much around, and that's why I got really

agitated with him, and then when he came back he

says, Òh she's full.' I said, Ì told you that before!'

Maria's daughter also made the following comment

about hospital staff:

From a doctor seeing a patient there for two minutes,

they don't know what she or he has got, and as far

as I am concerned, I mean I might be wrong, but I

think it's just wasting time and money, and time is

money in the hospital system.

Table 1 Laxatives used by the participants

Laxatives Dan Maria Ethel Larry Doris Frank

Coloxyl Ćoloxyl and senna ´ ´ ´ Ćoloxyl and danthron ´Senekot granules ´Lactulose

Durolax ´Biscodyl Ágarol ´ ´Microlax ´ Ńulax ´ ´Mucilax Áculax ´Herbalax ´Metamucil ´ ´ Épsom Salts ´ ´ Ćascara ´Magnesium ´Pelagrino Ńormacol ´ Ćastor oil ´Paraf®n oil ´ ´ Ólive oil ´Glycerine ´Boiled senna leaf ´Boiled senna beans Ćharcoal tabs ´Suppositories ´ ´Mini enemas ´ ´ ´Soap and water enema ´ ´Bowel washouts ´Go lightly ´



LIMITATIONS OF THE STUDYLIMITATIONS OF THE STUDY

A major limitation of this study is clearly the small

number of clients who agreed to participate. This was, in

part, due to the constraints imposed by the available

funding. More importantly, there was considerable dif®-

culty accessing RDNS clients meeting the study criteria.

Interestingly, there were 60 clients with a ®rst nursing

action of bowel management recorded on the RDNS

database in March 1998. This number does not include

those clients who had other, coexisting conditions, yet

recruitment of participants was a frustratingly complex

process. This is an issue requiring work on several fronts.

We need to persuade staff and clients that our research

motives derive from clearly stated aims. In addition, they

need to know we are constrained by the obligations

imposed by the various ethics committees to whom we

submit our proposals before beginning a project.

CONCLUSIONCONCLUSION

The aim of this study was to explore older people's

perceptions and experiences of constipation related to

laxative use, and to identify the measures they used to deal

with the problem. Six participants shared their stories of

persistent unpleasant symptoms related to constipation

and laxative use over a long period, and four described

experiences that had spanned many decades from their

childhood. The described feelings of being constipated

ranged from despair, hopelessness, and resignation to a

lifetime of constipation, to feelings of isolation, anxiety,

paranoia, and loneliness. The experiences of being

constipated ranged from bloating, cramps, excessive ¯atus,

nausea, abdominal tightness, urges, to generalized aching,

needing to be near a toilet at all times, and just not feeling

well.

All participants had contact with the medical profession

and four reported having tests to determine the aetiology

of their chronic constipation. Contact with RDNS seemed

to occur when they required an enema to relieve acute

symptoms of constipation. But it seems for many older

people, the problem of constipation is largely unresolved.

However, it is interesting to note that all participants

acknowledged the link between their diet and ¯uid intake

and their persistent constipation symptoms and ongoing

need for laxatives.

Participants in this study indicated that they were aware

of the importance of ®bre, fruit, vegetables and water in

their daily diet but, for various personal reasons, some chose

to have less than optimal intake each day. These choices and

behaviours maintained their constipation experience but

continuing dependence on laxatives to purge achieved some

degree of comfort and short-term relief.

What should be the community nursing response to the

evidence generated in this study? In what way can

community nurses seek to develop a partnership approach

with older people with persistent constipation related to a

lifetime of laxative use? The complexity of these issues is

compounded by the cost factors involved, both from an

organizational delivery of care viewpoint and the volumes

of laxatives consumed. A glance at Table 1 listing laxatives

used by the participants causes one to question the cost of

treating constipation by laxatives rather than seeking to

improve the dietary and ¯uid intake habits of older people.

However, an important issue is whether there is education

and support available for this population from community

health providers.

Clearly accurate assessment of the aetiology of consti-

pation is the crucial ®rst response in formulating a

treatment plan based on the range of options available,

underpinned by a social health framework of care.

Multiple strategies are needed to tackle this potentially

expanding health issue. It is, however, unclear if this is a

phenomenon of a particular cohort and whether the

behaviour will diminish over time. Nevertheless there is

at present a signi®cant proportion of the older population

requiring nursing intervention. Rather than just admin-

istering an enema to provide brief, symptomatic relief,

we urge nurses to work with older people in managing

their bowel function, and to work with them toward

wellness.

FURTHER RESEARCHFURTHER RESEARCH

Statistics of prevalence used in this study were from

British reports because no such data are available in

Australia. This is a signi®cant gap in the Australian

research arena. We believe that further research should be

undertaken to:

· identify the extent of constipation related to laxative use

experienced by older people in Australia. This research

should be collaborative and multidisciplinary;

· identify the social and ®nancial implications for this

population and the community.

More evidence is needed to illustrate and understand

this complex issue of older people's experiences of

constipation related to laxative use. Such evidence would

inform more responsive community nursing practice.

Other research is needed to:

· identify the attitudes and beliefs of community nurses

related to ageing and the elimination patterns of older

people;



· identify the attitudes and beliefs held by community

nurses related to older people experiencing the mor-

bidity of constipation related to laxative use.

Acknowledgements

We wish to acknowledge with thanks the contribution of

A. Hofmeyer, Research Associate, who undertook the

research for this project.

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