Nursing Research Bowel Elimination Among Elder 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).

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 & Evans, 2002). Research findings demonstrate that increasing fiber and fluid in the diet significantly decreases the need for laxative use and stool softeners (Howard, West, & OssipKlein, 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 olderAmericans, 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 also have been identified as contributing factors to risk for constipation (Vogelzang). Constipation can be controlled by a well-balanced diet high in fiber, adequate hydration (at least 6–8 eight ounce glasses of water/day), along with increased activity (Hinrichs, Huseboe, Tang, & Titler, 2001).

Fecal incontinence 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 associatedwith fecal incontinence: (1) history of urinary incontinence, (2) neurological disease, (3) poor mobility, (4) severe cognitive decline, and (5) age greater than 70 (Chassagne et al.). 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.

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