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Chronic Constipation Management for Institutionalized Older Adults
CE Article Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on the inside back cover. On completion of this article, the reader should be able to: 1. Discuss existing literature related to the effects of bran on constipation in older adults 2. Identify the effects of bran on chronic constipation of institutionalized adults 3. Describe the research design used to test the effects of bran on older adults
Chronic Constipation Management for Institutionalized Older Adults Lois V. Howard, RN, MS, NP, Diane West, RN, MSN, and Deborah J. Ossip-Klein, PhD
Abstract: Bran’s effectiveness in reducing the need for bowel medication for intermediate care patients was examined at a VA medical center in New York. Twelve older men with chronic constipation and bowel medication use were matched and randomized to receive either bran treatment or usual care (controls). After baseline assessment, six patients were given gradually increasing daily doses of a bran mixture. Results over a 4-month period showed that these patients completely discontinued oral laxative use and had an 80% reduction in total bowel medication use without adversely affecting bowel frequency. The six men who received usual care (controls) experienced no changes. (Geriatr Nurs 2000;21:78-82)
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Geriatric Nursing 2000 • Volume 21 • Number 2
C
onstipation—defined as two or fewer stools per week, straining at stool, or hard feces often with fecal impaction—is a chronic, recurrent concern that affects approximately 50% to 73% of nursing home residents.1-5 The most common interventions are laxatives, enemas, and other invasive procedures, such as manual removal of fecal impaction. These interventions are not without risk and may produce such undesired side effects as cramping, bloating, dehydration, anal irritation, fecal incontinence,1,3 and defecation syncope. They are unpleasant for both caregivers and patients and incur pharmacologic and nursing time costs. A small body of research, primarily case studies, recommends dietary fiber to manage constipation in institutionalized older patients.6 For example, Hope and Down7 followed 30 nursing home patients for 12 months in a pre/post design using fiber biscuits with 1500 mL fluid. Results showed that bowel medications could be discontinued when bran intake reached 25 g daily. Behm8 reported a recipe for an inexpensive, easily formulated bran mixture that significantly reduced oral laxative use in a nonrandomized test group using 2 tablespoons/day of this mixture. Several additional studies reported success with this or similar bran mixtures. For example, Smith and Newman9 reported a pre/post trial of 11 patients whose intake of the bran mixture gradually was increased to 6 tablespoons/day over 6 weeks; laxative/enema use was decreased by 80%, and regular bowel function improved. In addition, habit training for fecal incontinence was facilitated because bowel movement timing was more easily predictable. Karam and Nies 10 found decreased laxative use in nine of 10 patients given 1 to 3 ounces of this mixture per day for 4 weeks. In a randomized, controlled trial, Brown and Everett11 followed 41 patients for 12 weeks using a lower dose of 2 to 4 tablespoons of a similar bran mixture, which decreased laxative use in the treatment group. The two other randomized, controlled trials in the literature, however, found no significant reductions in bowel medication use.12,13 Benton and colleagues14 developed a bowel care program for 30 continuing care patients on a pilot unit. The program consisted of increased fiber in meals, increased fluid intake, timely toileting, and regular activity or exercise combined with staff training and clear expectations that performance standards would be met. During the 3 years of program implementation, the use of as-needed laxatives decreased from 91.2% to 40% and regularly prescribed laxatives decreased from 23.5% to 15.8%. These results appeared to compare favorably with data for a retrospective comparison unit, although statistical analyses of results were not provided. Overall, the data support the potential role of bran/fiber in the treatment of constipation in institutionalized long-term care (LTC). In general, more fa-
Geriatric Nursing 2000 • Volume 21 • Number 2
TABLE 1. Bran Treatment Protocol Bran Mixture* 3 cups unsweetened applesauce 2 cups unprocessed coarse wheat bran 1-1/2 cups unsweetened prune juice
Bran Dosing (Bran-Treatment Subjects Only) Give 1 tablespoon of bran mixture/day for 1 week. Increase weekly by 1 tablespoon/day until ≥ 3 tablespoons/day are tolerated (dosing is increased gradually to avoid abdominal discomfort). When a dosage of 3 tablespoons/day is achieved, discontinue all routine stool softeners and oral laxatives. Administer laxatives and enemas only if the patient has no bowel movement for 3 consecutive days. Continue to increase bran dose as needed, up to 6 tablespoons/day, in 1 tablespoon increments. Monitor the patient to ensure minimum fluid intake of 1500 mL/day.
Timing of Bran Dosing Up to 3 tablespoons/day: administer before breakfast. 4-plus tablespoons/day: administer split dose (before breakfast and before supper). *Smith DA, Newman DK. The bran solution. Contemp Long Term Care 1989;12:66.
vorable results appear to be obtained at higher doses of bran/fiber. However, most data came from uncontrolled studies. The current study was a controlled trial of bran’s effectiveness in reducing bowel medication use in institutionalized LTC patients.
METHODS Subjects. Twelve men on an intermediate care unit at the Canandaigua VA Medical Center who had chronic constipation (two or fewer stools per week) and average daily fluid intake of at least 1500 mL (necessary to increase bran intake) served as the subjects. Patient pairs were matched by age, bowel function, number of prescribed bowel medications (laxatives, enemas, and suppositories), and at least three of five areas of functional ability (basic hygiene, nutrition, and feeding; elimination; mobility; behavior; and orientation). The subjects gave their informed consent. One member of each pair was randomized to receive the bran mixture, and the other received usual care for a total of six patients per condition. Procedures. After a 3-week baseline assessment, subjects were added sequentially to the study during a 1-month period. The intervention was conducted for 5 months after baseline assessment; each subject was fol-
79
lowed for a minimum of 16 weeks. Each usual-care-control subject was followed during the identical interval as his paired bran-treatment subject. Bran-treatment subjects received the mixture using the protocol provided in Table 1. Usual-care subjects continued to receive their typical diet. Measures. Subjects were assessed at baseline (3week period before initiating bran mixture) and daily thereafter for number of bowel movements and bowel medications (laxatives, enemas, suppositories). No changes were predicted in bowel frequency because subjects who did not have a bowel movement for 3 days were given pharmacologic interventions regardless of study condition. Reduction was predicted in bowel medication use for subject in the bran-treatment group relative to usual-care controls. The number of tablespoons/day of bran mixture and fluid intake also were monitored for subjects in the bran group to ensure a minimum of 1500 mL fluid each day.
RESULTS Statistical analysis. Data analyses were conducted using SAS software. Wilcoxon signed-ranks tests were performed for the six matched pairs of subjects for number of bowel movements and number of bowel medications (laxatives + enemas). Bran-treatment and usualcare-control subjects were compared for changes in these variables from baseline to the middle 3 weeks of the intervention period and from baseline to the last 3 weeks of the intervention period, at which time subjects were at their maximum bran dose. Subject characteristics. Subjects were older, institutionalized men who chronically used laxatives or enemas. The men ranged in age from 61 to 80, with a mean age of 72.6 for bran subjects and 73.8 for control subjects. Both groups averaged five diagnoses, including dementia for five of six men in each group. Other diagnoses included the typical range for chronic geriatric populations— Parkinson’s disease, cerebrovascular accident, degenerative joint disease, hypertension, coronary artery disease, etc. Subjects took about nine medications per day, including two or three bowel prescription medications, and had 2.39 to 2.72 bowel movements per week. Although the number of prescribed bowel medications did not differ between groups, subjects in the control group actually used more of these medications per week; this difference was of borderline significance (13.22 ± 5.50 versus 7.06 ± 5.73, P = .052 for control versus bran subjects, respectively). Four of six subjects in the bran-treatment group and three of six subjects in the control group were on a high fiber diet when the study began. Bran dose. The bran dose ranged from 4.0 to 5.33 tablespoons/day of the bran mixture during the 3 midtreatment weeks (mean = 4.28) and from 4 to 6 tablespoons/ day during the last 3 weeks of treatment (mean = 5.17). Bowel movements. No treatment-control differ-
80
ences in number of bowel movements were found between baseline and midtreatment or baseline and maximum dose periods (W = .5, P = 1.00 and W = -1, P = .875, respectively). Mean bowel movements per week at baseline and end of treatment were 2.39 (SD = .53) and 2.28 (SD = .39), respectively, for bran-treatment subjects and 2.72 (SD = 1.18) and 2.67 (SD = .79), respectively, for usual-care-control subjects. Bowel medication use. At midtreatment, a mean reduction of 3.39 bowel medications/week was found for treatment versus control subjects. Five of six treatment subjects showed decreases in medication use relative to controls ranging from 1.33 to 7.33 medications/week; only one subject showed no change relative to controls. Although in the predicted direction, this difference was not statistically significant (W = -7.5, P = .063). At maximum bran dose, the reduction in medication use from baseline was significantly greater among treatment subjects than among controls, with a mean subject/control difference in reduction of 5.72 medications/week (W = -10.5, P = .03). The reduction in medication use was greater in all treatment subjects than in controls, with subject/control differences in reductions ranging from 1 to 14 fewer medications/week. Changes in medication use over time for the bran-treatment and control groups are presented in Figures 1 and 2. Overall, bowel medication use decreased by about 80% for bran-treatment subjects over the course of treatment from a mean of 7.06 (SD = 5.73) per week at baseline to 1.39 (SD = 1.08) at maximum bran dose (last 3 weeks of study). Medication intake remained unchanged for usual-care-control subjects (mean intake = 13.22/week, SD = 5.50 and mean intake = 13.28/week, SD = 5.68 at baseline and last 3 weeks of study, respectively). Individual subject data for the bran-treatment group showed that, by the last 3 weeks of the study, three subjects were using two to three enemas or suppositories per week and no laxatives (at 5 to 6 tablespoons bran mixture/day), two subjects were using one suppository or fewer/week and no laxatives (at 5 tablespoons bran mixture/day), and one subject was taking no bowel medications at all (at 4 tablespoons bran mixture/day).
DISCUSSION The results of this controlled study support the bran mixture’s effectiveness in reducing bowel medication use in institutionalized older men with a pattern of chronic constipation and medication use. Treatment involved gradually increasing daily doses of the bran mixture with adequate fluid intake. Oral laxatives were discontinued in all patients at a dose of 3 tablespoons of bran mixture/day. Subjects in the bran-treatment condition saw an 80% reduction in total bowel medication use (laxative, suppository, or enema) compared with no change in control patients. The number of bowel movements/week did not change over the course of the study,
Geriatric Nursing 2000 • Volume 21 • Number 2
FIGURE 1
FIGURE 2
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15
Number of Bowell Medications/Week
Subject 1-c Subject 2-c Subject 3-c Subject 4-c Subject 5-c Subject 6-c
10
5
0
20
15
10
Subject 1-c Subject 2-c Subject 3-c Subject 4-c Subject 5-c Subject 6-c
5
0 Baseline
Mid-treatment assessment interval
Maximum dose
indicating no adverse effect on bowel function. The fact that significant results were obtained with such a small sample is notable. Statistically, this result required a large effect size, a finding consistent with the observation that oral laxative use completely ceased for all bran-treatment subjects, total bowel medication use was reduced by nearly six laxatives/week (5.72) relative to controls, and reductions were observed for all subjects in the treatment group. Another important note is that bran-treatment and usual-care-control groups differed at baseline in number of bowel medications used with control subjects initially using more medications. This initial difference would be expected to decrease the likelihood of finding a treatment effect because brantreatment subjects already were using fewer medications and thus had less chance of showing a large decrease. Thus, the observed large effect size is particularly encouraging. Results at midtreatment showed a bowel medication reduction trend that was not statistically significant. This finding is consistent with nurses’ observations that clinical results often were not seen until subjects were maintained on their maximum dosage. In fact, during earlier dosage periods, considerable encouragement was needed for nurses to persist with treatment. However, once the effect was achieved, nurses reported improved bowel regularity and decreased impaction along with softer stools among their patients receiving the bran mixture, which reduced patient discomfort even when rectal stimulation or enemas/suppositories were needed. All subjects remained on the bran mixture after the study closed, and additional patients subsequently were selected to receive this regimen. A recent report with community-dwelling older adults with chronic constipation suggested that, although fiber supplementation did not correct pelvic floor dyssynergia, the most frequent underlying abnormality, it did produce such clinical benefits as improved
Geriatric Nursing 2000 • Volume 21 • Number 2
Baseline
Mid-treatment assessment interval
Maximum dose
transit time.15 In the current study, the bran mixture also appeared to improve the predictability of bowel movements so that patients could be toileted more accurately. Despite the observed favorable effects of the bran mixture on medication use and bowel function, continued overuse of bowel medications may have persisted. Chart reviews suggested cases in which bowel medications were used even when a movement had occurred or before the threshold criteria of 3 consecutive days of no bowel movement had lapsed. Continuing staff training to modify current practice patterns, concurrent with implementation of bran protocols as reported by Benton and colleagues,14 may improve outcomes further. This treatment was tested for male nursing home patients who already were dependent on bowel medications, and the bran treatment produced both statistically and clinically significant reductions in bowel medication use. This intervention also may merit testing in similar populations who are not yet medication-dependent to examine whether bran dosing can prevent chronic constipation, gastric-colonic dysfunction, and medication dependence. In addition, further studies are needed to systematically assess patient and staff satisfaction with bran versus usual care protocols, the cost-benefits of bran versus other bowel medication protocols, and optimal bran mixture and dosing. REFERENCES 1. Alessi CA, Henderson CT. Constipation and fecal impaction in the long-term care patient. Clin Geriatr Med 1988;4:571-88. 2. Burkitt DP, Meisner P. How to manage constipation with high-fiber diet. Geriatrics 1979;34(2):33-5. 3. Harari D, Gurwitz JH, Minaker KL. Constipation in the elderly. J Am Geriatr Soc 1993;41:1130-40. 4. Harari D, Gurwitz JH, Avorn J, Choodnovskiy I, Minaker KL. Constipation: assessment and management in an institutionalized elderly population. J Am Geriatr Soc 1994;42:947-52. 5. Kamm MA. Constipation. Br J Hosp Med 1989;41:244-50. 6. Tramonte SM, Brand MB, Mulrow CD, Amato MG, O’Keefe ME, Ramirez G. The treatment of chronic constipation in adults: a systematic review. J Gen Intern Med 1997;12:15-24. 7. Hope AK, Down EC. Dietary fiber and fluid in the control of constipation in a nursing home population. Med J Austral 1986;144:306-7.
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8. Behm RA. A special recipe to banish constipation. Geriatr Nurs 1985;6:216-7. 9. Smith DA, Newman DK. The bran solution. Contemp Long Term Care 1989;12:66. 10. Karam SE, Nies DM. Student/staff collaboration: a pilot bowel management program. J Gerontol Nurs 1994;20:32-40. 11. Brown MK, Everett I. Gentler bowel fitness with fiber. Geriatr Nurs 1990;11: 26-27. 12. Finlay M. The use of dietary fiber in a long-stay geriatric ward. Nutr Elderly 1989;8:19-30. 13. Mantle J. Research and serendipitous secondary findings. Can Nurse 1992;88:15-9. 14. Benton JM, O’Hara PA, Chen H, Harper DW, Johnston SF. Changing bowel hygiene practice successfully: a program to reduce laxative use in a chronic care hospital. Geriatr Nurs 1997;18:12-7. 15. Cheskin LJ, Kamal N, Crowell MD, Schuster MM, Whitehead WW. Mechanisms of constipation in older persons and effects of fiber compared with placebo. J Am Geriatr Soc 1995;43:666-9.
CE
LOIS V. HOWARD, RN, MS, NP, is a nurse practitioner at Finger Lakes Rheumatology, PC. DIANE WEST, RN, MSN, is comanager of the geriatrics and extended care line at the VA Healthcare Network in
Canandaigua, N.Y. DEBORAH J. OSSIP-KLEIN, PhD, is a research associate professor in the Department of Community and Preventive Medicine and Cancer Center at the University of Rochester School of Medicine and VA Healthcare Network in Canandaigua. Portions of this study were presented on the Annual Research Day at the Veterans Affairs Medical Center in Buffalo, N.Y., May 1995. This research was supported in part by funding from the Department of Veterans Affairs Health Services Research and Development Service Developmental Program (DEV 92-005). Acknowledgment: The authors thank the dedicated nursing staff of Unit 9B at the Canandaigua VA Medical Center for their assistance in carrying out study procedures, and Michael McDermott, PhD, at the University of Rochester for statistical analyses. Copyright © 2000 by Mosby, Inc. 0197-4572/2000/$8.00 + 0
Test I.D. No.: G107132 Contact hours: 1.0 Processing fee: $9 Passing score: 70% (seven correct answers)
1. What is the incidence of constipation for nursing home residents? A. 10% to 12% B. 25% to 30% C. 50% to 73% D. 80% to 93%
5. What was the maximum daily bran dose used in this study? A. 2 to 3 tablespoons B. 4 to 5 tablespoons C. 5 to 6 tablespoons D. 6 to 8 tablespoons
2. From the literature reviewed, what was the general concept regarding bran studies? A. Studies were of a small population group. B. Varying doses of bran decreased the need for laxatives. C. More studies are needed. D. All of the above
6. When were oral laxatives stopped in this bran study? A. At day 1 B. When the bran dose reached 3 tablespoons per day C. When the bran dose reached 5 tablespoons per day D. When the bran dose reached 8 tablespoons per day
3. This study defined constipation as being: A. 0-2 stools/week B. Fecal impaction C. Straining at stool D. 2-4 stools/week 4. This study provided pharmacologic intervention: A. Only for the controlled study patients B On request C. At 3 days without bowel movement regardless of study condition D. At 1 to 2 days without bowel movement for the bran group
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7. What was the duration of this study? A Approximately 6 months B. 9 months C. 3 months D. 4 months
9. Significant results with the bran group were seen: A Immediately B. At the beginning of the bran treatment C. Midtreatment D. At the maximum bran dose treatment level 10. Besides instituting a bran protocol, what other suggestion was made for future studies? A. Use female subjects B. Focus on a singular underlying disease C. Increase staff training to modify current practices D. Focus on decreasing all medication use
8. Effectiveness was measured by: A Decrease in bowel movements B. Increase in bowel movements C. Decrease in laxatives or bowel movement medications D. Increase in softer stools
Geriatric Nursing 2000 • Volume 21 • Number 2
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Geriatric Nursing 2000 • Volume 21 • Number 2
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Correction Part of the legend for Figure 1 in the article “Chronic Constipation Management for Institutionalized Older Adults” (March/April 2000) was incorrect. The correctly labeled figure is shown here. GN regrets the error.
Mean Bowel Medication Use for Treatment Group
Geriatric Nursing 2000 • Volume 21 • Number 3
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Chronic Constipation Management for Institutionalized Older Adults Lois V. Howard, RN, MS, NP, Diane West, RN, MSN, and Deborah J. Ossip-Klein, PhD
Abstract: Bran’s effectiveness in reducing the need for bowel medication for intermediate care patients was examined at a VA medical center in New York. Twelve older men with chronic constipation and bowel medication use were matched and randomized to receive either bran treatment or usual care (controls). After baseline assessment, six patients were given gradually increasing daily doses of a bran mixture. Results over a 4-month period showed that these patients completely discontinued oral laxative use and had an 80% reduction in total bowel medication use without adversely affecting bowel frequency. The six men who received usual care (controls) experienced no changes. (Geriatr Nurs 2000;21:78-82)
78
Geriatric Nursing 2000 • Volume 21 • Number 2
C
onstipation—defined as two or fewer stools per week, straining at stool, or hard feces often with fecal impaction—is a chronic, recurrent concern that affects approximately 50% to 73% of nursing home residents.1-5 The most common interventions are laxatives, enemas, and other invasive procedures, such as manual removal of fecal impaction. These interventions are not without risk and may produce such undesired side effects as cramping, bloating, dehydration, anal irritation, fecal incontinence,1,3 and defecation syncope. They are unpleasant for both caregivers and patients and incur pharmacologic and nursing time costs. A small body of research, primarily case studies, recommends dietary fiber to manage constipation in institutionalized older patients.6 For example, Hope and Down7 followed 30 nursing home patients for 12 months in a pre/post design using fiber biscuits with 1500 mL fluid. Results showed that bowel medications could be discontinued when bran intake reached 25 g daily. Behm8 reported a recipe for an inexpensive, easily formulated bran mixture that significantly reduced oral laxative use in a nonrandomized test group using 2 tablespoons/day of this mixture. Several additional studies reported success with this or similar bran mixtures. For example, Smith and Newman9 reported a pre/post trial of 11 patients whose intake of the bran mixture gradually was increased to 6 tablespoons/day over 6 weeks; laxative/enema use was decreased by 80%, and regular bowel function improved. In addition, habit training for fecal incontinence was facilitated because bowel movement timing was more easily predictable. Karam and Nies 10 found decreased laxative use in nine of 10 patients given 1 to 3 ounces of this mixture per day for 4 weeks. In a randomized, controlled trial, Brown and Everett11 followed 41 patients for 12 weeks using a lower dose of 2 to 4 tablespoons of a similar bran mixture, which decreased laxative use in the treatment group. The two other randomized, controlled trials in the literature, however, found no significant reductions in bowel medication use.12,13 Benton and colleagues14 developed a bowel care program for 30 continuing care patients on a pilot unit. The program consisted of increased fiber in meals, increased fluid intake, timely toileting, and regular activity or exercise combined with staff training and clear expectations that performance standards would be met. During the 3 years of program implementation, the use of as-needed laxatives decreased from 91.2% to 40% and regularly prescribed laxatives decreased from 23.5% to 15.8%. These results appeared to compare favorably with data for a retrospective comparison unit, although statistical analyses of results were not provided. Overall, the data support the potential role of bran/fiber in the treatment of constipation in institutionalized long-term care (LTC). In general, more fa-
Geriatric Nursing 2000 • Volume 21 • Number 2
TABLE 1. Bran Treatment Protocol Bran Mixture* 3 cups unsweetened applesauce 2 cups unprocessed coarse wheat bran 1-1/2 cups unsweetened prune juice
Bran Dosing (Bran-Treatment Subjects Only) Give 1 tablespoon of bran mixture/day for 1 week. Increase weekly by 1 tablespoon/day until ≥ 3 tablespoons/day are tolerated (dosing is increased gradually to avoid abdominal discomfort). When a dosage of 3 tablespoons/day is achieved, discontinue all routine stool softeners and oral laxatives. Administer laxatives and enemas only if the patient has no bowel movement for 3 consecutive days. Continue to increase bran dose as needed, up to 6 tablespoons/day, in 1 tablespoon increments. Monitor the patient to ensure minimum fluid intake of 1500 mL/day.
Timing of Bran Dosing Up to 3 tablespoons/day: administer before breakfast. 4-plus tablespoons/day: administer split dose (before breakfast and before supper). *Smith DA, Newman DK. The bran solution. Contemp Long Term Care 1989;12:66.
vorable results appear to be obtained at higher doses of bran/fiber. However, most data came from uncontrolled studies. The current study was a controlled trial of bran’s effectiveness in reducing bowel medication use in institutionalized LTC patients.
METHODS Subjects. Twelve men on an intermediate care unit at the Canandaigua VA Medical Center who had chronic constipation (two or fewer stools per week) and average daily fluid intake of at least 1500 mL (necessary to increase bran intake) served as the subjects. Patient pairs were matched by age, bowel function, number of prescribed bowel medications (laxatives, enemas, and suppositories), and at least three of five areas of functional ability (basic hygiene, nutrition, and feeding; elimination; mobility; behavior; and orientation). The subjects gave their informed consent. One member of each pair was randomized to receive the bran mixture, and the other received usual care for a total of six patients per condition. Procedures. After a 3-week baseline assessment, subjects were added sequentially to the study during a 1-month period. The intervention was conducted for 5 months after baseline assessment; each subject was fol-
79
lowed for a minimum of 16 weeks. Each usual-care-control subject was followed during the identical interval as his paired bran-treatment subject. Bran-treatment subjects received the mixture using the protocol provided in Table 1. Usual-care subjects continued to receive their typical diet. Measures. Subjects were assessed at baseline (3week period before initiating bran mixture) and daily thereafter for number of bowel movements and bowel medications (laxatives, enemas, suppositories). No changes were predicted in bowel frequency because subjects who did not have a bowel movement for 3 days were given pharmacologic interventions regardless of study condition. Reduction was predicted in bowel medication use for subject in the bran-treatment group relative to usual-care controls. The number of tablespoons/day of bran mixture and fluid intake also were monitored for subjects in the bran group to ensure a minimum of 1500 mL fluid each day.
RESULTS Statistical analysis. Data analyses were conducted using SAS software. Wilcoxon signed-ranks tests were performed for the six matched pairs of subjects for number of bowel movements and number of bowel medications (laxatives + enemas). Bran-treatment and usualcare-control subjects were compared for changes in these variables from baseline to the middle 3 weeks of the intervention period and from baseline to the last 3 weeks of the intervention period, at which time subjects were at their maximum bran dose. Subject characteristics. Subjects were older, institutionalized men who chronically used laxatives or enemas. The men ranged in age from 61 to 80, with a mean age of 72.6 for bran subjects and 73.8 for control subjects. Both groups averaged five diagnoses, including dementia for five of six men in each group. Other diagnoses included the typical range for chronic geriatric populations— Parkinson’s disease, cerebrovascular accident, degenerative joint disease, hypertension, coronary artery disease, etc. Subjects took about nine medications per day, including two or three bowel prescription medications, and had 2.39 to 2.72 bowel movements per week. Although the number of prescribed bowel medications did not differ between groups, subjects in the control group actually used more of these medications per week; this difference was of borderline significance (13.22 ± 5.50 versus 7.06 ± 5.73, P = .052 for control versus bran subjects, respectively). Four of six subjects in the bran-treatment group and three of six subjects in the control group were on a high fiber diet when the study began. Bran dose. The bran dose ranged from 4.0 to 5.33 tablespoons/day of the bran mixture during the 3 midtreatment weeks (mean = 4.28) and from 4 to 6 tablespoons/ day during the last 3 weeks of treatment (mean = 5.17). Bowel movements. No treatment-control differ-
80
ences in number of bowel movements were found between baseline and midtreatment or baseline and maximum dose periods (W = .5, P = 1.00 and W = -1, P = .875, respectively). Mean bowel movements per week at baseline and end of treatment were 2.39 (SD = .53) and 2.28 (SD = .39), respectively, for bran-treatment subjects and 2.72 (SD = 1.18) and 2.67 (SD = .79), respectively, for usual-care-control subjects. Bowel medication use. At midtreatment, a mean reduction of 3.39 bowel medications/week was found for treatment versus control subjects. Five of six treatment subjects showed decreases in medication use relative to controls ranging from 1.33 to 7.33 medications/week; only one subject showed no change relative to controls. Although in the predicted direction, this difference was not statistically significant (W = -7.5, P = .063). At maximum bran dose, the reduction in medication use from baseline was significantly greater among treatment subjects than among controls, with a mean subject/control difference in reduction of 5.72 medications/week (W = -10.5, P = .03). The reduction in medication use was greater in all treatment subjects than in controls, with subject/control differences in reductions ranging from 1 to 14 fewer medications/week. Changes in medication use over time for the bran-treatment and control groups are presented in Figures 1 and 2. Overall, bowel medication use decreased by about 80% for bran-treatment subjects over the course of treatment from a mean of 7.06 (SD = 5.73) per week at baseline to 1.39 (SD = 1.08) at maximum bran dose (last 3 weeks of study). Medication intake remained unchanged for usual-care-control subjects (mean intake = 13.22/week, SD = 5.50 and mean intake = 13.28/week, SD = 5.68 at baseline and last 3 weeks of study, respectively). Individual subject data for the bran-treatment group showed that, by the last 3 weeks of the study, three subjects were using two to three enemas or suppositories per week and no laxatives (at 5 to 6 tablespoons bran mixture/day), two subjects were using one suppository or fewer/week and no laxatives (at 5 tablespoons bran mixture/day), and one subject was taking no bowel medications at all (at 4 tablespoons bran mixture/day).
DISCUSSION The results of this controlled study support the bran mixture’s effectiveness in reducing bowel medication use in institutionalized older men with a pattern of chronic constipation and medication use. Treatment involved gradually increasing daily doses of the bran mixture with adequate fluid intake. Oral laxatives were discontinued in all patients at a dose of 3 tablespoons of bran mixture/day. Subjects in the bran-treatment condition saw an 80% reduction in total bowel medication use (laxative, suppository, or enema) compared with no change in control patients. The number of bowel movements/week did not change over the course of the study,
Geriatric Nursing 2000 • Volume 21 • Number 2
FIGURE 1
FIGURE 2
20
15
Number of Bowell Medications/Week
Subject 1-c Subject 2-c Subject 3-c Subject 4-c Subject 5-c Subject 6-c
10
5
0
20
15
10
Subject 1-c Subject 2-c Subject 3-c Subject 4-c Subject 5-c Subject 6-c
5
0 Baseline
Mid-treatment assessment interval
Maximum dose
indicating no adverse effect on bowel function. The fact that significant results were obtained with such a small sample is notable. Statistically, this result required a large effect size, a finding consistent with the observation that oral laxative use completely ceased for all bran-treatment subjects, total bowel medication use was reduced by nearly six laxatives/week (5.72) relative to controls, and reductions were observed for all subjects in the treatment group. Another important note is that bran-treatment and usual-care-control groups differed at baseline in number of bowel medications used with control subjects initially using more medications. This initial difference would be expected to decrease the likelihood of finding a treatment effect because brantreatment subjects already were using fewer medications and thus had less chance of showing a large decrease. Thus, the observed large effect size is particularly encouraging. Results at midtreatment showed a bowel medication reduction trend that was not statistically significant. This finding is consistent with nurses’ observations that clinical results often were not seen until subjects were maintained on their maximum dosage. In fact, during earlier dosage periods, considerable encouragement was needed for nurses to persist with treatment. However, once the effect was achieved, nurses reported improved bowel regularity and decreased impaction along with softer stools among their patients receiving the bran mixture, which reduced patient discomfort even when rectal stimulation or enemas/suppositories were needed. All subjects remained on the bran mixture after the study closed, and additional patients subsequently were selected to receive this regimen. A recent report with community-dwelling older adults with chronic constipation suggested that, although fiber supplementation did not correct pelvic floor dyssynergia, the most frequent underlying abnormality, it did produce such clinical benefits as improved
Geriatric Nursing 2000 • Volume 21 • Number 2
Baseline
Mid-treatment assessment interval
Maximum dose
transit time.15 In the current study, the bran mixture also appeared to improve the predictability of bowel movements so that patients could be toileted more accurately. Despite the observed favorable effects of the bran mixture on medication use and bowel function, continued overuse of bowel medications may have persisted. Chart reviews suggested cases in which bowel medications were used even when a movement had occurred or before the threshold criteria of 3 consecutive days of no bowel movement had lapsed. Continuing staff training to modify current practice patterns, concurrent with implementation of bran protocols as reported by Benton and colleagues,14 may improve outcomes further. This treatment was tested for male nursing home patients who already were dependent on bowel medications, and the bran treatment produced both statistically and clinically significant reductions in bowel medication use. This intervention also may merit testing in similar populations who are not yet medication-dependent to examine whether bran dosing can prevent chronic constipation, gastric-colonic dysfunction, and medication dependence. In addition, further studies are needed to systematically assess patient and staff satisfaction with bran versus usual care protocols, the cost-benefits of bran versus other bowel medication protocols, and optimal bran mixture and dosing. REFERENCES 1. Alessi CA, Henderson CT. Constipation and fecal impaction in the long-term care patient. Clin Geriatr Med 1988;4:571-88. 2. Burkitt DP, Meisner P. How to manage constipation with high-fiber diet. Geriatrics 1979;34(2):33-5. 3. Harari D, Gurwitz JH, Minaker KL. Constipation in the elderly. J Am Geriatr Soc 1993;41:1130-40. 4. Harari D, Gurwitz JH, Avorn J, Choodnovskiy I, Minaker KL. Constipation: assessment and management in an institutionalized elderly population. J Am Geriatr Soc 1994;42:947-52. 5. Kamm MA. Constipation. Br J Hosp Med 1989;41:244-50. 6. Tramonte SM, Brand MB, Mulrow CD, Amato MG, O’Keefe ME, Ramirez G. The treatment of chronic constipation in adults: a systematic review. J Gen Intern Med 1997;12:15-24. 7. Hope AK, Down EC. Dietary fiber and fluid in the control of constipation in a nursing home population. Med J Austral 1986;144:306-7.
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8. Behm RA. A special recipe to banish constipation. Geriatr Nurs 1985;6:216-7. 9. Smith DA, Newman DK. The bran solution. Contemp Long Term Care 1989;12:66. 10. Karam SE, Nies DM. Student/staff collaboration: a pilot bowel management program. J Gerontol Nurs 1994;20:32-40. 11. Brown MK, Everett I. Gentler bowel fitness with fiber. Geriatr Nurs 1990;11: 26-27. 12. Finlay M. The use of dietary fiber in a long-stay geriatric ward. Nutr Elderly 1989;8:19-30. 13. Mantle J. Research and serendipitous secondary findings. Can Nurse 1992;88:15-9. 14. Benton JM, O’Hara PA, Chen H, Harper DW, Johnston SF. Changing bowel hygiene practice successfully: a program to reduce laxative use in a chronic care hospital. Geriatr Nurs 1997;18:12-7. 15. Cheskin LJ, Kamal N, Crowell MD, Schuster MM, Whitehead WW. Mechanisms of constipation in older persons and effects of fiber compared with placebo. J Am Geriatr Soc 1995;43:666-9.
CE
LOIS V. HOWARD, RN, MS, NP, is a nurse practitioner at Finger Lakes Rheumatology, PC. DIANE WEST, RN, MSN, is comanager of the geriatrics and extended care line at the VA Healthcare Network in
Canandaigua, N.Y. DEBORAH J. OSSIP-KLEIN, PhD, is a research associate professor in the Department of Community and Preventive Medicine and Cancer Center at the University of Rochester School of Medicine and VA Healthcare Network in Canandaigua. Portions of this study were presented on the Annual Research Day at the Veterans Affairs Medical Center in Buffalo, N.Y., May 1995. This research was supported in part by funding from the Department of Veterans Affairs Health Services Research and Development Service Developmental Program (DEV 92-005). Acknowledgment: The authors thank the dedicated nursing staff of Unit 9B at the Canandaigua VA Medical Center for their assistance in carrying out study procedures, and Michael McDermott, PhD, at the University of Rochester for statistical analyses. Copyright © 2000 by Mosby, Inc. 0197-4572/2000/$8.00 + 0
Test I.D. No.: G107132 Contact hours: 1.0 Processing fee: $9 Passing score: 70% (seven correct answers)
1. What is the incidence of constipation for nursing home residents? A. 10% to 12% B. 25% to 30% C. 50% to 73% D. 80% to 93%
5. What was the maximum daily bran dose used in this study? A. 2 to 3 tablespoons B. 4 to 5 tablespoons C. 5 to 6 tablespoons D. 6 to 8 tablespoons
2. From the literature reviewed, what was the general concept regarding bran studies? A. Studies were of a small population group. B. Varying doses of bran decreased the need for laxatives. C. More studies are needed. D. All of the above
6. When were oral laxatives stopped in this bran study? A. At day 1 B. When the bran dose reached 3 tablespoons per day C. When the bran dose reached 5 tablespoons per day D. When the bran dose reached 8 tablespoons per day
3. This study defined constipation as being: A. 0-2 stools/week B. Fecal impaction C. Straining at stool D. 2-4 stools/week 4. This study provided pharmacologic intervention: A. Only for the controlled study patients B On request C. At 3 days without bowel movement regardless of study condition D. At 1 to 2 days without bowel movement for the bran group
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7. What was the duration of this study? A Approximately 6 months B. 9 months C. 3 months D. 4 months
9. Significant results with the bran group were seen: A Immediately B. At the beginning of the bran treatment C. Midtreatment D. At the maximum bran dose treatment level 10. Besides instituting a bran protocol, what other suggestion was made for future studies? A. Use female subjects B. Focus on a singular underlying disease C. Increase staff training to modify current practices D. Focus on decreasing all medication use
8. Effectiveness was measured by: A Decrease in bowel movements B. Increase in bowel movements C. Decrease in laxatives or bowel movement medications D. Increase in softer stools
Geriatric Nursing 2000 • Volume 21 • Number 2
CE ANSWER/ENROLLMENT FORM To receive continuing education credit for any test in this issue, simply do the following: 1. Read the article. 2. Take the test for the article and record your answers on the form below. (You may make copies of the answer form.) You should complete one answer form for EACH test. 3. Mail the completed answer/enrollment form along with a check or money order. Payment must be included for your examination to be processed. 4. The deadline for submitting your answer/enrollment form is 2 years from the date of this issue. 5. Your results will be sent within 4 weeks after your answer form is received. Enrollees who have a passing score will receive a certificate. Instructions: Mark your answers clearly by placing an “x” in the box next to the correct answer. This is a standard form; use only the number of spaces required for the test you are taking. Test I.D. No. 1. ❑ A ❑B ❑C ❑D
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Geriatric Nursing 2000 • Volume 21 • Number 2
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Correction Part of the legend for Figure 1 in the article “Chronic Constipation Management for Institutionalized Older Adults” (March/April 2000) was incorrect. The correctly labeled figure is shown here. GN regrets the error.
Mean Bowel Medication Use for Treatment Group
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