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Hindawi Publishing CorporationGastroenterology Research and PracticeVolume 2012, Article ID 290231,7pagesdoi:10.1155/2012/290231

Research ArticleDrugs and Constipation in Elderly in Nursing Homes:What Is the Relation?

Gunvor S. Fosnes,1, 2 Stian Lydersen,2 and PerG. Farup2, 3

1 Department of Medicine, Innlandet Hospital Trust, 2819 Gjvik, Norway2 Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Faculty of Medicine,

Norwegian University of Science and Technology, 7491 Trondheim, Norway3 Department of Research, Innlandet Hospital Trust, 2381 Brumunddal, Norway

Correspondence should be addressed to Per G. Farup,per.farup@ntnu.no

Received 29 November 2011; Accepted 22 December 2011

Academic Editor: P. Enck

Copyright 2012 Gunvor S. Fosnes et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Introduction. Constipation is a common adverse drug reaction. Objective. Study associations between drugs and constipationin nursing home residents. Design. Cross-sectional study. Material and Methods. Nursing home residents above 60 years of agewere included. Demographics, diet, physical activity, activity of daily living, nutritional status, use of drugs, and diseases wererecorded. Constipation was defined as functional constipation or constipation-predominant IBS according to the Rome III criteriaand/or regular use of laxatives. Drugs were classified according to the Anatomical-Therapeutic-Chemical Classification System

(ATC), and anticholinergic effect was noted.Results. In all, 79 men and 188 women with a mean age of 85.4 (SD 7.1) years wereincluded. The prevalence of constipation was 71.5%. Use of drugs in general, including polypharmacy, was not associated withconstipation. Reduced activity of daily living (OR = 0.71, 95% CI : 0.600.84,P < 0.001),other antidepressants (N06AX) (OR3.08, 95% CI : 1.098.68, P = 0.03), and benzodiazepine derivatives (N05BA) (OR = 2.80, 95% CI : 1.127.04, P = 0.03) weresignificantly associated with constipation; drugs with markedly anticholinergic effect (OR =3.7, 95% CI: 0.7817.53,P =0.10),natural opium alkaloid(N02AA) (OR =5.01, 95% CI: 0.9525.94,P= 0.06), andpropionic acid derivatives(M01AE) (OR=7.00,95% CI: 0.7565.08,P = 0.09) showed a trend. Conclusion.In elderly with constipation, focus should be on specific groups ofdrugs and nonpharmacological factors, not on drugs in general.

1. Introduction

Chronic functional constipation affects 1740% of the eld-erly and reduces quality of life [14]. In nursing homes, theprevalence of constipation is in the order of 4474% [47].

Gastrointestinal symptoms including constipation arecommon adverse drug reactions [8]. Drugs have beenreported as one of the most important causes of constipation,in addition to insufficient intake of fluid and dietary fibre,reduced activity of daily living, lack of exercise, and diseasessuch as neurological and metabolic disorders [57,9].

In general, the use of drugs is high in elderly in nursinghomes [1013]. Frail elderly with chronic diseases, alteredpharmacokinetics and pharmacodynamics, and use of sev-eral drugs with anticholinergic effects and in part unknown

interactions appear to be at high risk of side effects of drugs[8,1012,1416].

This cross-sectional study aimed at finding the impact ofdrugs on constipation in elderly in nursing homes.

2. Material and Methods

2.1. Study Design and Methods. In 2008-2009, this cross-sectional study was performed in nursing homes in thecounties of Oppland and Hedmark, Norway. Registeredand auxiliary nurses with good knowledge of the residentscollected data from the medical records and got informationfrom the residents and their next of kin. A blood sample wascollected.

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2.2. Study Population. Residents above 60 years of age livingin nursing homes for more than 8 weeks and without organicgastrointestinal diseases that could cause constipation wereincluded in the study.

2.3. Variables. The following variables were recorded: age,

gender, weight, height, smoking habits, use of alcohol,somatic and psychiatric diseases, physical activity (walkingsteps/day, mobility), activity of daily living (Katz Activityof Daily Living (ADL) index (score 0 (very dependent)6(independent)), nutritional status (Mini Nutritional Assess-ment (MNA score 030:

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Table1: Characteristics of the participants and comparisons between participants with and without constipation. The results are given asmean (standard deviation (SD)), median (range), and number (proportion (%)).

Characteristics1 All participantsn = 267

Participants withconstipation

n = 191

Participants

withoutconstipation

n = 76

StatisticsPvalue

Age (years) 85.4 (SD 7.1) 85.3 (SD 6.9) 85.6(SD 7.5) 0.69

Gender (female) 188 (70.4%) 139 (72.8%) 49 (64.5%) 0.19

Ability to give informed consent 98 (36.7%) 66 (34.6%) 32 (42.1%) 0.26

Functional constipation (RomeIII) (n = 266)

95 (35.7%) 95 (50.0%)2 0 n.a.

Body mass index (kg/m2)(n = 251)

25.5 (SD 4.9) 24.5 (SD 5.3) 24.7 (SD 4.9) 0.72

Smoking (n = 263) 19/49/195 13/30/144 6/19/51

Current/before/never (7.2/18.6/74.1%) (7.0/16.0/77.0%) (7.9/25.0/67.1%) 0.22

Use of alcohol>once a month(n = 263) 39 (14.6%) 28 (14.9%) 11 (14.7%) 1.00

Walking steps/day (n = 184) 200 (05000) 139 (05000) 400 (05000) 0.02

Mobility 120/80/67 100/48/43 20/32/24

Bedridden/walk indoors/walkoutdoors

(44.9/30.0/25.1%) (52.4/25.1/22.5%) (26.3/42.1/31.6%)

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Table2: Use of drugs by the participants and comparisons between participants with and without constipation. The results are given asproportion (%) if not otherwise indicated.

Drugs All participants

n = 267

Participants withconstipation

n = 191

Participantswithout

constipationn = 76

StatisticsPvalue

Use of drugs 98.5 98.4 98.7 1.00Number of drugs (median with range) 6 (020) 6 (020) 6 (019) 0.90

Drugs with markedly anticholinergic effect 6.4 7.9 2.6 0.17

Laxatives regularly only 61.0 85.3 01

Laxatives on demand only 5.2 0 18.4

Laxatives regularly and on demand 68.9 96.3 01

Contact laxatives (A06AB) 28.5 39.8 01

Osmotically acting laxatives (A06AD) 52.1 72.8 01

Enemas (A06AG) 4.9 6.8 01

Proton pump inhibitors (A02BC) 14.2 15.7 10.5 0.15

Insulin and analogues (A10A) 3.7 2.6 6.6 0.15

Potassium (A12BA) 7.9 7.9 7.9 1.00Platelet aggregation inhibitors (B01AC) 39.7 41.4 35.5 0.41

Bivalent oral iron (B03AA) 13.9 14.7 11.8 0.70

Vitamin B12 (B03BA) 12.4 9.4 19.7 0.04

Organic nitrates (C01DA) 8.2 6.8 11.8 0.22

Sulphonamides, plain (diuretics) (C03CA) 36.0 37.2 32.9 0.57

Beta blocking agents, selective (C07AB) 17.2 15.2 22.4 0.21

Dihydropyridine derivatives (C08CA) 6.7 7.9 3.9 0.29

Angiotensin II antagonists2 (C09CA DA) 4.9 3.7 7.9 0.20

HMD-CoA reductase inhibitors (C10AA) 12.7 11.5 15.8 0.42

Thyroid hormones (H03AA) 9.7 6.8 17.1 0.02

Antibacterialssystemic use (J01) 15.0 14.1 17.1 0.57

Propionic acid derivatives (M01AE) 4.9 6.3 1.3 0.12Bisphosphonates (M05BA) 6.4 6.8 5.3 0.79

Natural opium alkaloids (N02AA) 6.7 8.4 2.6 0.11

Phenylpiperidine derivatives (N02AB) 4.9 6.3 1.3 0.11

Other antiepileptics (N03AX) 4.1 4.7 2.6 0.73

Benzodiazepine derivatives (N05BA) 19.5 22.5 11.8 0.06

Benzodiazepine related drugs (N05CF) 29.2 30.9 25.0 0.37

SSRI3 (N06AB) 31.5 30.4 34.2 0.56

Other antidepressants (N06AX) 15.7 18.8 7.9 0.03

Anticholinesterases (N06DA) 6.7 4.7 11.8 0.06

Phenothiazine derivatives (R06AD) 5.2 5.2 5.3 1.001

Use of laxatives regularly is included in the definition of constipation.2Both plain and in combination with diuretics.3Selective serotonin reuptake inhibitors.

6, 12]. The definition of constipation, which included regularuse of laxatives, might contribute to the high prevalence ofconstipation [5, 6, 11, 12]. Subjects on regular use of laxativesprobably have constipation when treatment is stopped, but itcould not be ruled out that some patients continue treatmentafter ended indication. Despite these limitations, the externalvalidity is judged as satisfactory since all other variables (age,sex, mobility, etc.) were within the range described in otherstudies [5,6,11,12].

More information than normally in clinical studies wasbased on information from the nurses, next of kin and themedical journals, and less from the residents themselves,since the majority of the participants had cognitive impair-ment. This might have reduced the validity of the data, butuse of deputies was inevitable.

Groups of drugs were analyzed at ATC-level 4, whichare drugs with similar chemical structure and uniform sideeffects. Analyses on ATC-level 5 would have resulted in too

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Table 3: Variables associated with constipation. The analyses were performed with either number of drugs (Analysis 1), anticholinergiceffect (Analysis 2), or groups of drugs (Analysis 3) as independent variables in backward logistic regression analyses.

Independent variables

Constipation

Analysis 1 Analysis 2 Analysis 3

OR (95% CI) Pvalue OR (95% CI) Pvalue OR (95% CI) Pvalue

Number of drugs1

1.04 (0.941.15) 0.43Drugs with markedlyanticholinergic effect1

(n = 17)

3.69 (0.7817.53) 0.10

Benzodiazepine derivatives(N05BA) (n = 53)

2.80 (1.127.04) 0.03

Other antidepressants(N06AX) (n = 42)

3.07 (1.098.68) 0.03

Vitamin B12 (B03BA)(n = 33)

0.39 (0.160.93) 0.03

Levothyroxine sodium(H03AA) (n = 26)

0.27 (0.100.72) 0.01

Propionic acid derivatives

(M01AE) (n=

13)

7.00 (0.7565.08) 0.09

Natural opium alkaloids(N02AA) (n = 17)

5.00 (0.9525.94) 0.06

Age1 1.00 (0.951.05) 0.94 0.99 (0.951.04) 0.70 1.01 (0.961.06) 0.78

Gender (female)1 1.66 (0.863.21) 0.13 1.53 (0.812.91) 0.19 1.80 (0.893.61) 0.10

Activity of daily living 0.73 (0.630.85)

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