Constipation In Palliative Care Patients Research Articles

Effect of Auricular Acupressure in Management of Constipation in Palliative Care Patients.

Objectives: This experimental randomized-controlled study was performed to define the efficacy of auricular acupressure (AA) in the management of constipation developing in palliative care patients. Methods: According to the pre-prepared randomization list, 44 patients were included in the experimental group and 46 patients were included in the control group. Routine clinical treatment and care implementation were maintained in the patients in both groups. AA was performed for 4 weeks in patients in the experimental group. During the study, to determine the complaints of the patients regarding constipation, the information in the daily patient chart was examined at least 5 times by interviewing with the patient/patient's relative in the clinic and/or via phone call, and the results were recorded in the patient chart and data collection forms. The independent variable of the study is AA application, and the dependent variables are constipation and quality of life. Results: It was determined that there was no statistically significant difference between the daily defecation frequency of the 2 groups during the first 11 days. However, after the 12th day, the daily stool frequency of the experimental group was higher compared to the control group and this difference obtained between the 2 groups was statistically significantly different. AA was effective in decreasing laxative use. Conclusion: This intervention increased stool frequency, reduced physical and psychosocial symptoms, anxieties, and improved stool satisfaction and it was an effective approach to improving the quality of life. It is recommended that the daily use of AA should be evaluated. The healthcare providers including nurses, patients, and patient relatives should be trained regarding AA.

Proposed Criteria for Constipation in Palliative Care Patients. A Multicenter Cohort Study.

Although constipation is one of the most frequently reported symptoms in palliative care, there is no widely accepted definition of constipation and none suitable for patients unable to self-report or express symptoms. This study aimed to verify the objective and subjective symptoms of constipation to develop a diagnostic algorithm for constipation, which is also feasible in unconscious patients. In a pooled analysis of two observational studies, 369 out of 547 adult end-stage cancer patients met the inclusion criteria. The patient-reported difficulty of defecation correlated with observable measures, such as days since last bowel movement, and frequency of bowel movements. Difficulty became at least moderate when there were no bowel movements for ≥2 days, or the frequency of bowel movements was ≤3 per week. The diagnostic algorithm, comprising these three symptoms offers a simple, rapid, and comprehensive tool for palliative care, independent of the patient’s state of consciousness. A clinical trial is necessary to confirm its validity and usefulness.

Itopride increases the effectiveness of the management of opioid-induced constipation in palliative care patients: an observational non-interventional study

IntroductionIt is strongly recommended that laxatives be routinely prescribed for the prevention of opioid-induced constipation (OIC). The evidence supporting the effectiveness of prokinetics for this indication is sparse. This study aims to verify if itopride, added to preventive OIC therapy, increases the effectiveness of the prevention of opioid-induced constipation in adult palliative care patients.Material and methodsIn a questionnaire-based observational study, all patients received regular laxatives plus one of the following: oxycodone/naloxone (OXN); itopride (ITP); or oxycodone/naloxone + itopride (OXN + ITP). The primary measure was the decrease in the necessity of laxative use in a 0–4 scale assessed after 7 days of treatment.ResultsNinety-two patients met the inclusion criteria in the four groups: OXN (n = 12), ITP (11), OXN + ITP (9), and the control group (laxatives only if needed) (60). The necessity of laxatives decreased in groups where itopride was used, with a statistically significant difference versus control, oxycodone/naloxone (p = 0.009), or in combination. The OXN did not decrease laxative use (p = 0.22).ConclusionsAll interventions appeared similarly effective in the prevention of OIC. However, adding itopride, but not oxycodone/naloxone, resulted in a decrease in the necessity of laxative use in OIC patients, and it seems to be valuable in this often refractory condition. Randomised, controlled trials would be valuable to obtain good quality evidence without systematic bias.

Effects of abdominal massage on constipation in palliative care patients – a pilot study

Abstract Introduction: The problem of constipation in Poland concerns 13.4% of the healthy population. In the case of patients treated with opioids, this number increases to 70-90%, which constitutes a serious problem that lowers the patients’ quality of life. The aim of the study was to assess the effects of abdominal massage, which successfully reduces constipation in various diseases, on palliative care patients. Material and methods: The research included 18 patients of a palliative care facility (mean age 78.3 ± 10 years), 11 of whom completed the study. The study participants were randomly divided into two groups, i.e. a pilot group (abdominal massage and kinesiotherapy) and a control group (kinesiotherapy). The therapy lasted 8 weeks and blind evaluation was carried out once per week. The study involved evaluating constipation intensity (The Bowel Function Index), the frequency of defecation (medical documentation) and abdomen circumference (anthropometric tape). The collected data were analysed statistically with the use of Statistica software. Results: The observed differences between the studied groups undergoing different therapies in subsequent weeks were not statistically significant. However, in the group in which abdominal massage was implemented, a decrease in the intensity of constipation, an increase in the frequency of defecation and a reduction in abdomen circumference were noted compared to the control group. The patients also indicated additional positive effects of this form of therapy, i.e. an improvement in breathing, easier urination, release of excessive gas and abdominal pain reduction. Conclusions: The collected data led to the conclusion that abdominal massage may result in a decrease in disorders accompanying opioid-induced constipation. Therefore, it is worth considering the implementation of this form of therapy in the case of patients in an advanced stage of cancer. There is also a need for further research in this field which will include a larger number of patients.

Behavioral risk factors of constipation in palliative care patients.

BackgroundConstipation is frequently encountered in palliative care patients and remains a significant therapeutic problem. The etiology of constipation is multifactorial. Nutritional and behavioral factors are considered common causes of constipation; however, their impact has not yet been assessed precisely.ObjectiveThe aim of this study was to assess the correlation between the frequency of bowel movements (FoBM) and risk factors of constipation in palliative care patients.Design and subjectsA cohort retrospective study was performed in three palliative care centers, including outpatient, home, and inpatient care cancer patients using questionnaires on bowel dysfunction symptoms, behavioral risk factors, and opioid use. The inclusion criterion was adult patients examined on the day of admission. The exclusion criterion was Karnofsky performance status score ≤20.MeasurementsSpearman’s rank correlation coefficient was used to measure the statistical dependence between two variables and frequency analysis was performed using the chi-squared test and Fisher’s exact test.ResultsTwo hundred thirty-seven valid questionnaires were collected. We found the correlation between FoBM and insufficient food and fluid intake (p < 0.0001), as well as for inadequate conditions of privacy (p = 0.0008), dependency on a caregiver (p = 0.0059), and the patient’s overall performance status (p = 0.013). We did not manage to prove bed rest as the independent risk factor of constipation.ConclusionsThe main risk factors of constipation in palliative care patients appeared to be insufficient fluid and food intake, inadequate conditions of privacy, dependency on a caregiver, as well as poor general performance status.

Pharmacological treatment of constipation in palliative care

The prevalence of constipation in palliative care patients varies. There is uncertainty about the choice from varying recommendations for pharmacological management of constipation and a varying clinical practice in palliative care settings. The purpose of the review was to evaluate the current recommendations of therapy guidelines and to determine the effectiveness and safety of laxative administration for the management of constipation in palliative care patients. Despite the clinical importance, there are limited data on the efficacy and safety of laxatives in palliative care patients. The social acceptability varies from country to country, but overall, oral laxatives should, where possible, be used in preference. Systemic opioid antagonists, such as naloxone and methylnaltrexone have been studied in few clinical trials. There is a paucity of well designed, prospective, randomized controlled trials with large enough numbers of patients suffering from constipation and treated with pharmacological methods. There are limited data available on the conventional pharmacological treatment of constipation in palliative care patients due to insufficient randomized controlled trials. However, subcutaneously administered methylnaltrexone was found to be effective in aiding of laxation and well tolerated with limited or transient side effects in palliative care patients.

Laxatives or Methylnaltrexone for the Management of Constipation in Palliative Care Patients

Laxatives or Methylnaltrexone for the Management of Constipation in Palliative Care Patients

Uptake of methylnaltrexone in Australian patients with opioid-induced constipation: a review of the number of prescriptions presented in the first 12 months of subsidisation

BackgroundDisturbed bowel habits are very common in palliative care patients, most commonly thought to be due to opioid use. The peripheral opioid-antagonist methylnaltrexone has been subsidised in Australia to ensure...

Laxatives or methylnaltrexone for the management of constipation in palliative care patients

Background: Constipation is common in palliative care; it can generate considerable suffering due to the unpleasant physical symptoms. In the first Cochrane Review on effectiveness of laxatives for the management of constipation in palliative care patients, published in 2006, no conclusions could be drawn because of the limited number of evaluations. This article describes the first update of this review. / Objectives: To determine the effectiveness of laxatives or methylnaltrexone for the management of constipation in palliative care patients. / Search methods: We searched databases including MEDLINE and CENTRAL (The Cochrane Library) in 2005 and in the update to August 2010. / Selection criteria: Randomised controlled trials (RCTs) evaluating laxatives for constipation in palliative care patients. In the update we also included RCTs on subcutaneous methylnaltrexone; an opioid-receptor antagonist that is now licensed for the treatment of opioid-induced constipation in palliative care when response to usual laxative therapy is insufficient. / Data collection and analysis: Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. / Main results: We included seven studies involving 616 participants; all under-reported methodological features. In four studies the laxatives lactulose, senna, co-danthramer, misrakasneham, and magnesium hydroxide with liquid paraffin were evaluated. In three methylnaltrexone. In studies comparing the different laxatives evidence was inconclusive. Evidence on subcutaneous methylnaltrexone was clearer; in combined analysis (287 participants) methylnaltrexone, in comparison with a placebo, significantly induced laxation at 4 hours (odds ratio 6.95; 95% confidence interval 3.83 to 12.61). In combined analyses there was no difference in the proportion experiencing side effects, although participants on methylnaltrexone suffered more flatulence and dizziness. No evidence of opioid withdrawal was found. In one study severe adverse events, commonly abdominal pain, were reported that were possibly related to methylnaltrexone. A serious adverse event considered to be related to the methylnaltrexone also occurred; this involved a participant having severe diarrhoea, subsequent dehydration and cardiovascular collapse. / Authors' conclusions: The 2010 update found evidence on laxatives for management of constipation remains limited due to insufficient RCTs. However, the conclusions of this update have changed since the original review publication in that it now includes evidence on methylnaltrexone. Here it found that subcutaneous methylnaltrexone is effective in inducing laxation in palliative care patients with opioid-induced constipation and where conventional laxatives have failed. However, the safety of this product is not fully evaluated. Large, rigorous, independent trials are needed.

Managing opioid-induced constipation in advanced illness: focus on methylnaltrexone bromide.

Constipation is a common symptom in palliative care patients which can generate considerable suffering. There is uncertainty about the choice of treatment options from varying recommendations for management of constipation and a varying clinical practice in palliative care settings. The purpose of the review was to evaluate the current recommendations of therapy guidelines for the management of opioid-induced constipation in palliative care patients with a focus on methylnaltrexone bromide. Recent findings in the literature and related information on the opioid-induced gastrointestinal disorders in patients with advanced illness, as well as information on the opioid-antagonist methylnaltrexone, are discussed. Knowledge of the role of definitions, the causes of constipation and the pathophysiology of opioid-induced constipation must be given high priority in the treatment of patients receiving opioids. Diagnosis and therapy of constipation, therefore, should relate to findings in clinical investigation. Opioid-induced constipation and its adequate treatment is an important issue for patients with advanced illness and also poses therapeutic challenge for clinicians in daily routine. Methylnaltrexone bromide may represent an important therapeutic option for palliative care patients who are suffering from opioid-induced constipation with failure of conventional prophylactic oral laxative treatment.

Methylnaltrexone: a subcutaneous treatment for opioid-induced constipation in palliative care patients

Opioid-induced constipation is common in palliative care and causes considerable distress to patients taking opioids. Opioid-induced constipation can be difficult to manage with conventional laxatives, often requiring invasive rectal interventions. A unique bowel intervention linked specifically to opioid-induced constipation in the form of a subcutaneous injection is now available for the management of opioid-induced constipation. This article will examine all aspects of opioid-induced constipation with particular reference to this new management option, methylnaltrexone bromide (Relistor).

15 The Management of Constipation in Palliative Care: The St Catherine’s Hospice Approach

There is a lack of professional awareness and clear, practical guidance on the assessment, diagnosis and management of constipation in palliative care patients. St Catherine’s Hospice adopts an approach to the maintenance of bowel function based on successful, established clinical practice, underpinned by robust …

Screening for Constipation in Palliative Care Patients

The objective of this study was to establish screening criteria for constipation in palliative care and, subsequently, to determine data for diagnostic suspicion of constipation in a palliative care population. Also we investigate the incidence of fecal impaction in the same sample of palliative care patients. A descriptive, multicenter cross-sectional study was done. All patients in active care by a group of hospital and home palliative care teams were studied. A questionnaire on signs (frequency and consistency of stools) and symptoms (pain, discomfort, or a sensation of incomplete evacuation when having a bowel movement) of constipation in last weeks, and a verbal numerical scale (VNS) (0-10) on discomfort or difficulty with constipation was completed by the patients. The patients were asked about impaction in the last 3 months. One hundred twenty patients from 21 palliative care teams were included; the majority of patients received opiates (66%) and also laxatives (60%). Bowel movement rate less than three stools per week was found in 13% of patients, stools harder than normal were experienced in 24% patients, and 33% exhibited pain, discomfort, or sensation of incomplete evacuation. Of the patients studied 13% had some signs of habitual constipation but they did not complain of symptoms, others (17%) had some discomfort in spite of not having signs of constipation. As screening criteria for constipation in palliative care we elected to include indistinct presence of constipation symptoms or constipation signs in recent weeks. A diagnosis of suspicion of constipation was established in almost 1 of 2 patients (48%) of our palliative care population. VNS with cutoff point of 3 or more of 10, showed a sensitivity of 0.70 and a specificity of 0.74 and positive predictive value (PPV) of 73% positive and negative predictive value (NPV) of 70%. In addition to these findings a considerable number of our palliative care patients (20%) reported episodes of fecal impaction in the last 3 months. The screening for constipation in palliative care should be performed exploring subjective symptoms and other objective signs. A diagnosis of suspected constipation was found in almost half of the palliative care patients studied. A VNS of constipation did not produce good predictive values for the detection of constipation in our sample.

The management of constipation in palliative care: clinical practice recommendations

Constipation is one of the most common problems in patients receiving palliative care and can cause extreme suffering and discomfort. The aims of this study are to raise awareness of constipation in palliative care, provide clear, practical guidance on management and encourage further research in the area. A pan-European working group of physicians and nurses with significant experience in the management of constipation in palliative care met to evaluate the published evidence and produce these clinical practice recommendations. Four potentially relevant publications were identified, highlighting a lack of clear, practical guidance on the assessment, diagnosis and management of constipation in palliative care patients. Given the limited data available, our recommendations are based on expert clinical opinion, relevant research findings from other settings and best practice from the countries represented. Palliative care patients are at a high risk of constipation, and while general principles of prevention should be followed, pharmacological treatment is often necessary. The combination of a softener and stimulant laxative is generally recommended, and the choice of laxatives should be made on an individual basis. The current evidence base is poor and further research is required on many aspects of the assessment, diagnosis and management of constipation in palliative care.

Management of constipation in palliative care patients

Constipation is a common symptom in palliative care patients that can generate considerable suffering due to both unpleasant physical symptoms and psychological preoccupations that may arise. There is uncertainty about the choice from varying recommendations for management of constipation and a varying clinical practice in palliative care settings. The purpose of the review is to evaluate the current recommendations of therapy guidelines and to determine the effectiveness of laxative administration for the management of constipation in palliative care patients. Recent findings in the literature include an updated version of the Rome criteria and related information on the functional gastrointestinal disorders, as well as information on opioid antagonists. Knowledge of the role of definitions, causes of constipation and the pathophysiology of opioid-induced constipation must be given a high priority in the treatment of patients receiving opioids. Diagnosis and therapy of constipation, therefore, should relate to findings in clinical investigation. The treatment of constipation in palliative care is based on inadequate experimental evidence, such that there are insufficient randomized controlled trial data. Recommendations for laxative use can be related to efficacy. Particularly in patients with advanced-stage tumor disease this must be undertaken with careful consideration of their physical activity and dietary needs.

Management of constipation in palliative care patients undergoing opioid therapy: Is polyethylene glycol an option?

This study assessed the efficacy of laxative use for treatment of constipation in patients receiving opioid therapy, with special attention to polyethylene glycol 3350/electrolyte solution (PEG-ES). Computerized data from 206 patients were analyzed using descriptive statistics. Subgroups were analyzed using confirmatory statistics. Constipation occurred in 42.7 percent of patients. Laxatives were administered to 74.3 percent of these patients using a standardized step scheme, with good results in 78.4 percent. As a therapy for constipation, the combined administration of PEG-ES, sodium picosulphate, and liquid paraffin proved most effective, although statistical analysis yielded no significance. Early use of PEG-ES using a step scheme holds promise for treatment of opioid-related constipation in palliative care patients, although further investigation is warranted.

Constipation in Palliative Care Patients

SUMMARYConstipation is a common result of advanced disease and drug therapy. It occurs in as many as 50% of advanced cancer patients and 85% of patients taking high dose opioids. Potential causes are described. Prevention and early reversal are important. Nondrug and pharmacological methods of preventing and treating constipation are described. Evaluation instruments that have been used for this symptom are described. Some open research questions are listed. A management algorithm, evidence tables, and drug therapy tables which include drug costs are presented.