Digestive health in the elderly: faecal incontinence in adults.

Abstract

Adult faecal incontinence is defined as recurrent uncontrolled passage of faecal material or intestinal gas for at least 1 month. Among other conditions, faecal incontinence is frequently observed in the elderly and reflects alterations of digestive health in the aged population. Ageing is becoming a major health issue in the member states of the European Union, as it is in all western countries. The increasing number of elderly patients raises specific management issues for healthcare providers. In addition, diseases or pathological conditions tend to have a greater impact on quality of life in the elderly and the interaction of several diseases may impair overall outcome. The development of adapted management strategies specific for digestive disorders in the elderly population is thus an important issue for healthcare services in Europe. Two issues are particularly important in digestive health in the elderly: Nutritional disorders are an important cause of comorbidity in the aged population. Malnutrition, although often not obviously apparent, is frequent in aged patients and impairs chances of recovery from other diseases. Hospital stay or living in senior citizen centres increases the risk of malnutrition. Impairment of digestive functions is very common in the elderly, either ill or healthy, and is responsible for significant social isolation. Incontinence and disorders of defecation also occur in younger adults of all ages, but the scientific interest in these disorders is very limited, which means that a large group of patients do not have access to adequate care. The purpose of this short review is to underline the problem of faecal incontinence in adults, which represents a major healthcare issue, and to propose some actions to be undertaken for better management of these problems. Faecal incontinence may be partial or major.1 Partial incontinence is defined as loss of control of flatus (wind) and minor soiling of underwear, often only in the presence of loose stool consistency. Major incontinence is defined as frequent and regular deficiency in the ability to control stool of normal consistency. A complete list of aetiological factors is provided in Table 1. It is important to note that faecal incontinence may commonly occur in the presence of normal anal sphincters and pelvic floor function. That is to say, severe diarrhoea may overwhelm the normal continence mechanisms. Partial incontinence is a common problem in the elderly and in patients with neurological disease. Problems in these patients are usually due to faecal impaction, but there may be additional abnormalities of neuromuscular control, which have not yet been established. Patients with an internal anal sphincter deficiency, particularly if this is coupled with prolapsing haemorrhoids, frequently experience loss of control of flatus and soiling of their underwear. Major incontinence represents a clinical problem, as it is often responsible for severe disability. Clearly, any traumatic damage causing disruption of the pelvic floor and, in particular, the puborectalis muscle is likely to result in faecal incontinence. Such damage is most commonly the result of a pelvic fracture. Several studies have shown that in women, vaginal delivery but not pregnancy itself may be associated with neurological damage to the pelvic floor.2, 3 Pelvic trauma induced by childbirth is responsible for major functional problems in circumstances that induce persistent denervation: multiple deliveries, the use of forceps for assisting delivery, third-degree perineal tears and high birth weights.3 Faecal and urinary incontinence are associated with the end stage of a variety of pelvic floor disorders. Patients who have a habitual and prolonged pattern of straining at defecation are prone to develop perineal descent, a clinical abnormality that is closely allied to faecal incontinence. Patients with complete rectal prolapse are frequently incontinent, partly because of the anatomical anomaly and partly because of the subsequent pelvic denervation. Functional incontinence is diagnosed in patients who have no evidence of neurological or structural aetiologies. It appears to be more common in children than in adults.4 Functional faecal incontinence may be linked to stool retention, diarrhoea or irritable bowel syndrome, as 23% of irritable bowel syndrome patients report occasional faecal soiling.5 Published epidemiological studies have not distinguished between functional faecal incontinence and faecal incontinence due to structural or neurological causes. A few studies have evaluated the prevalence of faecal incontinence in various population groups. In a representative sample of 1010 French citizens aged 45 years and older, 6% reported faecal incontinence more than once per month,6 and in a German study, 5% of respondents reported occasional incontinence, but only 1.5% reported severe incontinence.7 Faecal incontinence is more common at the either end of the life span. It occurs in about 1.5% of children aged 7 years and declines with age. Subsequently, the incidence of faecal incontinence from all causes increases towards the end of the life span, especially in association with dementia.8 The incidence of gross faecal incontinence increases up to 1.5% of respondents aged 60 years and over (Figure 1). The incidence of faecal incontinence from all causes in a British nursing home population is estimated to be 30–39%.9 In children, functional faecal incontinence occurs four times more frequently in boys than girls.10Among adults with faecal incontinence, women outnumber men in most studies (Table 2).6, 7 Incidence of faecal incontinence according to age groups in the general adult population. A considerable number of patients with a functional disorder of the anorectum can be helped by comparatively simple, noninvasive methods. Where the problem arises from internal sphincter deficiency, perhaps in combination with minor denervation of the striated musculature, management with constipating agents may adequately restore function. On the other hand, when the disorder is the consequence of constipation and faecal impaction, vigorous attention to disimpaction and establishing a regular, normal bowel habit will rapidly improve continence. There has been a considerable interest in biofeedback techniques, which have been claimed to be efficacious and may reduce the need for surgical intervention.11–13 More recently, electrical nerve stimulation has been tested in patients with moderate faecal incontinence and proved effective in decreasing the number of incontinence episodes and their severity.14 Those patients who have a severe functional problem in the presence of fully formed stool are most likely to benefit from surgery. Surgical management is determined by the nature of the disorder that is responsible for incontinence. Post-anal repair is effective in young patients with moderate nerve dysfunction.15 Anal sphincter repair is indicated when sphincter damage is present.16 In patients with severe structural damage and major faecal incontinence, neosphincter construction may merit consideration.17, 18 Continence is achieved in 50–70% of operated patients. The current health-resource situation can be depicted as the pyramidal distribution of two parameters: the available resources for medical care and the level of knowledge of the concerned population (Figure 2). The two pyramids are directed in opposite directions. In other words, the requirement for information is set against the current information availability; the medical specialists with the appropriate knowledge are often not accessed by or accessible to most of the patients. This situation has led to a failure of existing healthcare structures to provide adequate therapy to a large percentage of patients with incontinence, leading to an overuse of palliative treatments, such as protective products (A.M. Leroi, pers. comm.). Current situation in the management of patients with incontinence. The most informed and specialized doctors are accessed by a minority of patients in hospitals acting as referral centres. A few studies have evaluated the costs generated by faecal incontinence in adults. Indirect costs are difficult to characterize; impairment of quality of life, delay in hospital discharge and nursing care at home may not be appropriately measured. The clinical and economic outcome of surgical treatments for faecal incontinence has been reviewed in a meta-analysis of controlled trials.19 The clinical results of the various surgical procedures are good in the literature, with up to 75% of patients improved by either graciloplasty or artificial sphincter.20, 21 However, randomized trials do not allow firm conclusions to be drawn because of variations in aetiology, difficulty in standardizing procedures, overall patient numbers, and the need for long-term follow-up. In one study from America in women with incontinence secondary to obstetric injuries, the average cost per patient was US$17 166, regardless of the treatment proposed.22 The total cost including evaluation and follow-up was US$65 412 per patient, of which physiological assessment accounted for 64%. Comparing post-anal repair and total pelvic floor repair, Buttafuoco and Keighley found that the latter procedure was more effective and generated less costs induced by recurrence of faecal incontinence.23 Although some studies have shown that surgical treatments may be very effective in patients with severe faecal incontinence, the costs generated by this condition are mainly due to medical treatment, especially with respect to elderly patients admitted to nursing homes. In another American study of patients in nursing homes, the yearly cost of incontinence, including nursing time, laundry and incontinence supplies, was estimated at $9771 per patient. In the USA, in any 24-h period, $6.8 million is the cost of the 1.4 million staff hours spent changing adult pads. Another $3.8 million is spent in the same 24-h period by nursing homes on adult disposable briefs.24 Graciloplasty appeared in an American study to be 2.5 times more expensive than a conventional treatment but was, on the other hand, half the cost of a colostomy when costs are calculated on a lifelong basis.25 In Europe, SCA Hygiene estimates the total number of sufferers at 10 million, of whom 7 million suffer from light incontinence. It is estimated that 6% of the population suffer some degree of urinary incontinence and about 1% suffer faecal incontinence. Based upon current market information and available population data for 1996, there are 57 625 000 adults over 65 years of age in the 15 countries of the European Union. Based on 5% of this population total, the theoretical requirement could be about 6.3 billion units of incontinence supply, generating a global market of €20 billion per year.26 Conventional treatment of faecal incontinence relies mainly on protectants, pads and nursing time, without attempting to improve the patient's condition. In various patient groups, however, the cost of faecal incontinence could be lowered with improved, more ambitious management of the condition. Prevention is of course the easiest way to decrease the burden of faecal incontinence, but it will be effective only in selected groups of patients. Faecal incontinence frequently acts as a worsening factor for the global condition of the patient. Several studies have shown that improving the global health status of the patient favourably influences the outcome of incontinence in elderly patients. In a study involving nursing home residents, the regular practice of low-intensity functionally orientated exercises improved all functional outcomes, including the control of sphincters.36 Management of incontinent patients, whatever the cause, requires a multidisciplinary approach, taking into account the frequent association of faecal with urinary incontinence, and allowing for access to an accurate diagnostic examination and to all therapeutic modalities (A.M. Leroi, pers. comm.). Moreover, appropriate management is based upon close co-operation between medical and nursing staff. As shown in Figure 2, the vast majority of incontinent patients still do not get the appropriate management they deserve, because efficient treatments are limited to tertiary referral centres. A recent German study has shown that a standardized diagnostic and therapeutic approach to an incontinent patient may result in a significant reduction of costs.37In this study, a computerized expert system helped the medical and nursing teams to adapt the treatment strategy employed for each patient. Faecal incontinence is widely distributed in the European adult population and is responsible for tens of billions of Euro in healthcare costs. The analysis of the existing healthcare resources shows that many patients do not receive appropriate support, which could generate significant savings and enable reallocation of resources towards treatment that better takes into account the patient's quality of life. Public health authorities should promote research and development of regional networks to bring the healthcare resources to the patient. It should be noted that many of the studies published on the topic are produced by American teams, suggesting that the perceived importance of the issue is somehow lower in European countries, despite its relative frequency and disabling social consequences.