Constipation in the Elderly: What Every CRMA Needs to Know

As Certified Residential Medication Aides (CRMAs), a significant part of our role involves ensuring the comfort and well-being of our elderly clients, and a common challenge we encounter is constipation. While it might seem like a minor issue, understanding the complexities of constipation, its medications, and when to intervene (or hold) is vital. This week, let's dive into the details to empower you with the knowledge to provide the best possible care.

The Dangers of Untreated Constipation

Constipation is more than just an inconvenience; for elderly clients, it can lead to a cascade of problems. Initially, clients may experience discomfort, bloating, decreased appetite, and irritability. Left unaddressed, these symptoms can escalate. Imagine the pain of straining, which can exacerbate conditions like hemorrhoids or even contribute to rectal prolapse. In clients with cardiac conditions, straining can even increase the risk of a cardiovascular event due to increased abdominal pressure.

The most severe complication, and one we absolutely want to prevent, is fecal impaction. This occurs when a large, hard mass of stool gets stuck in the rectum or colon, making it impossible to pass normally. Symptoms can include abdominal pain, nausea, vomiting, a sense of fullness, and paradoxically, sometimes even the leakage of watery stool around the impaction (known as overflow diarrhea). Fecal impaction is not only incredibly uncomfortable and distressing for the client, but it can also lead to serious medical emergencies if not managed promptly, including bowel obstruction or even perforation.

Fecal Impaction: If you see "leaking" liquid stool but the resident feels full/constipated, report it immediately—it could be an impaction.

Recognizing the signs early and reporting them to the nurse immediately is paramount.

Is the Medication Working? Assessing Effectiveness

One of the most common questions you might have when administering a medication for constipation is, "Is it effective?" This is where your keen observation skills come in. Effectiveness is measured by the client having a soft, formed bowel movement within the expected timeframe for the particular medication.

It's important to understand that "normal" bowel habits can vary greatly from person to person. For some, it might be daily, for others, every two or three days. The key is consistency for that individual and the absence of straining or discomfort. Always refer to the client's care plan and baseline bowel habits.

If a client consistently has hard, infrequent stools despite medication, or if they are complaining of significant discomfort, it's a sign that the medication regimen might need adjustment. This should always be reported to the nurse. Don't wait for impaction to occur; proactive communication is key.

Diarrhea and Holding Medications

This is a critical point: If your client has diarrhea, you must hold any prescribed laxative or stool softener and report it to the nurse immediately.

Administering a medication for constipation when the client is experiencing diarrhea can worsen their condition, leading to dehydration, electrolyte imbalances, skin breakdown, and increased discomfort. Diarrhea could also be a symptom of a more serious underlying issue, such as an infection (like C. difficile) or even overflow diarrhea around a fecal impaction. Always err on the side of caution. When in doubt, hold the medication and notify the nurse.

Categories of Constipation Medications

Let's break down the common types of medications you'll encounter for constipation, along with administration guidelines and typical side effects. Remember, always follow the specific instructions on the medication administration record (MAR) and the client's care plan.

1. Bulk-Forming Agents (e.g., Metamucil, FiberCon, Citrucel)

How they work: These act like dietary fiber, absorbing water in the intestines to form a bulky, soft stool that is easier to pass. Administration:

• Crucial: Must be mixed with a full glass (at least 8 ounces) of water or juice and followed by another full glass of fluid.

• Administer promptly after mixing as they can thicken quickly.

• Do not administer dry. Most Common Side Effects: Bloating, gas, abdominal cramping. Key Point: Adequate fluid intake is essential to prevent these from worsening constipation or causing an obstruction.

2. Stool Softeners (Emollients) (e.g., Docusate Sodium - Colace)

How they work: These medications allow water and fats to penetrate the stool, making it softer and easier to pass. They don't stimulate bowel movements but rather prevent them from becoming hard. Administration:

• Can be given with or without food.

• Often prescribed as a preventative measure to avoid constipation, especially when clients are on medications that can cause it (e.g., opioids). Most Common Side Effects: Generally well-tolerated; mild abdominal cramping can occur.

  
  

  3. Osmotic Laxatives (e.g., Milk of Magnesia, Miralax, Lactulose)

How they work: These draw water into the intestines from other body tissues, softening the stool and promoting bowel movements. Administration:

• Milk of Magnesia: Shake well before administering.

• Miralax: Usually mixed in a beverage (water, juice, coffee, tea). Dissolves completely.

• Often takes 1-3 days for Miralax to produce a bowel movement. Most Common Side Effects: Bloating, gas, abdominal cramping, nausea, diarrhea (if too much is taken). Key Point: Adequate hydration is important with these medications.

4. Stimulant Laxatives (e.g., Senna - Senokot, Bisacodyl - Dulcolax)

How they work: These directly stimulate the nerves in the intestinal wall, causing the muscles to contract and move stool through the bowel. Administration:

• Often work within 6-12 hours for oral forms, and much quicker (15-60 minutes) for suppositories.

• Oral forms are often given at bedtime to produce a morning bowel movement.

• Bisacodyl tablets should not be chewed or crushed and should not be taken within an hour of antacids or milk. Most Common Side Effects: Strong abdominal cramping, nausea, diarrhea, electrolyte imbalances with prolonged use. Key Point: Due to their strong action, these are generally not for long-term daily use unless specifically ordered by a physician, as the bowel can become dependent on them.

5. Rectal Suppositories and Enemas (e.g., Glycerin Suppository, Bisacodyl Suppository, Fleet Enema)

How they work:

• Suppositories: Melt or dissolve in the rectum, either lubricating the stool (glycerin) or stimulating a bowel movemen

• Enemas: Introduce fluid into the rectum to soften stool and stimulate evacuation. Administration:

• Always ensure client privacy.

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  Suppositories: Insert gently into the rectum, past the internal sphincter. Encourage the client to hold it for 15-30 minutes if possible.

• Enemas: Position the client appropriately (usually left side-lying with right knee flexed). Lubricate the tip. Insert gently and slowly instill the fluid. Encourage the client to hold the fluid for the recommended time (e.g., 5-10 minutes for a Fleet enema). Most Common Side Effects: Rectal irritation, cramping, urgency to defecate. Key Point: These are often used for immediate relief or when oral medications are ineffective or contraindicated. Always wear gloves and maintain client dignity.

Your Role is Vital

As CRMAs, your role in managing constipation is incredibly important. You are on the front lines, observing changes, administering medications correctly, and communicating effectively with the nursing staff. By understanding the causes, complications, different medication categories, and especially when to hold a medication, you contribute significantly to the comfort, health, and dignity of our elderly clients.

Stay vigilant, ask questions when unsure, and remember that proactive care is always the best approach!