Dear Dr. Jeff: Recently our facility had a patient who complained of abdominal pain and vomiting. She was sent to the emergency department where she received a Fleet enema and was returned with a diagnosis of “fecal impaction.” The family complained to surveyors who cited us for a Level G deficiency and imposed a $5,000 fine. The facility leadership has focused on the decision to transfer the resident to the hospital as the problem, but it seems to me that more needs to be fixed. Any suggestions? Dr. Jeff responds: You are absolutely correct that there are larger issues than the systems that allowed a problem — which certainly could have been treated in the facility with readily available treatments and staff — to evolve into a painful but preventable condition for a resident. There appear to have been major issues in assessment and probably care planning for this resident. The nursing home’s administration may focus primarily on the reportable status of an emergency department (ED) visit, the fine itself, the potential effect of the deficiency on the facility’s federal Star rating, or perhaps the facility’s reputation at the local hospital. But the “actual harm” included as a necessary component of a Level G deficiency was not the transfer to the ED but the suffering your resident experienced and the delay in identification and relief. The interdisciplinary team, and particularly medicine, nursing, dietary, and consulting pharmacist, should do a root cause analysis or its equivalent to examine the nursing home’s care processes and consider potential improvements to protect your residents from similar problems in the future. Constipation is not the sexiest issue on most lists. In the COVID-19 era, infection control has surged into an overarching concern, and other major concerns such as skilled nursing facility management of congestive heart failure, federal and state concentration on the potential overuse of psychotropic medications, the role of opioids in pain management, sliding-scale insulin regimens, accurate diagnosis of urinary tract infections, polypharmacy, communication with distressed families, fall prevention, and improving dementia care have all taken a back seat. But even in calmer times bowel management was at the bottom of the list. It is easy to make bad puns about bowel movements (feel free to fill in your favorite potty humor here), but bowels are a major quality of life issue for many residents. They are also a paradigm for quality geriatric care. Even though the event prompting a new admission might be first stroke, fracture, pneumonia, or urosepsis, everyone has a history of bowel activity since childhood. Chronic constipation is almost never listed as a diagnosis, yet multiple studies have documented a high prevalence of constipation complaints in community-dwelling older persons. So the evaluation for constipation should begin on admission during the history and physical. Transfer documents are rarely helpful for this evaluation, particularly as many medication reconciliations do not include “as-needed” medications or they faithfully reproduce the common hospitalist order sets with as-needed orders for both diarrhea and constipation without any record of whether they were ever needed or used. Also, few home medicine cabinets lack one or more laxative preparations used anywhere from daily to rarely. Whatever regimen a particular patient used at home, it is unlikely to have been included on their admission medication list because these were not prescription medications — and sometimes aren’t medicine at all. Most geriatricians are familiar with the prominent role that prunes and prune juice play in the lives of many older patients. Prunes are, of course, a high-fiber preparation, and fiber is the laxative of choice for most mildly constipated individuals regardless of age. Prunes also contain a significant amount of sorbitol, which is an osmotic laxative like lactulose. Sorbitol is actually sold in powdered and liquid forms to be used as a laxative, and it is used in some facilities as a less expensive alternative to its pricier cousin. Questions regarding prune usage should be part of the dietary history as well as included in an overall medical review of past medicine use, along with determination of prior laxative use or abuse. It is by no means unusual for patients to have routinely manually disimpacted themselves at home, a habit that is unlikely to be shared unless a discussion of bowel habits occurs. Many admission physical examinations barely mention the abdominal examination, and rectal exams are routinely avoided by both practitioners and nurses, even when the resident has been rolled on the side to check the sacrum for breakdown. Clearly the approach to a patient who has been taking several different preparations daily along with frequent home enemas would be different from that to a laxative-naive individual. Diagnoses that may require younger individuals to be placed in long-term care, such as multiple sclerosis and traumatic paraplegia or quadriplegia, are often associated with bowel constipation as well. Some restrictive diets provide inadequate quantities of fiber and may need modification wherever possible. Poor oral intake inhibits the gastrocolic reflex, through which stretching the stomach triggers lower-bowel motility. Physical mobility encourages bowel peristalsis, adding an additional concern when the resident is mobility impaired. Of course, decreased activity may be related to underlying medical conditions, but often it reflects insufficient attention to or compliance with ambulation schedules. Also, the use of bedpans, while occasionally necessary, presents anatomic and emotional barriers for many residents who wish to defecate. The most common cause of potentially preventable constipation is medications. Heading the list are opioids and related preparations such as tramadol. There is a common slogan in palliative care that says the hand that writes the narcotic prescription must write the laxative order (sometimes revised to be more threatening: the fingers that write the opioid prescription should be prepared to be to do the disimpaction). Pain relief regimens are, of course, absolutely necessary for many patients, particularly those with recent surgery, but every clinician should be aware that decreased bowel activity is an inevitable pharmacologic aspect of opioid therapy, not an occasional side effect. Many other commonly prescribed medications are constipating as well. Frequently these are newly added medications during a recent hospitalization intended for either temporarily or long-term use. Among the most common are iron and calcium. Iron supplementation is often necessary after acute significant blood loss to replenish the body’s iron stores. However, iron supplementation is not useful to treat anemia (unless it is iron-deficiency anemia). Nor is supplementation helpful for the frequently occurring blood loss into soft tissues after a trauma such as a hip fracture — the iron in that blood remains in the body, and it is mobilized to create replacement red blood cells. Even when iron is needed, it should not be prescribed beyond the maximum that the body can absorb, which is typically one standard dose per day rather than the routinely recommended three times daily regimens. Calcium supplementation is frequently provided to patients after fractures or other orthopedic procedures. A new fracture often identifies untreated osteoporosis or osteopenia, which in turn leads to the introduction of supplemental calcium. However, the role of additional calcium to promote bone healing for otherwise healthy bone is controversial; some studies suggest it might delay fracture healing, particularly when given with other preparations designed to interfere with bone remodeling. Among calcium preparations, calcium carbonate is the most constipating. Considerable attention has been paid to the potential adverse effects of anticholinergic medications on cognition and memory. However, even those that are claimed not to cross the blood-brain barrier will decrease bowel motility, so they deserve careful attention when used for residents with multiple other risk factors for constipation. The list of medications with anticholinergic side effects is exceptionally long and includes many medications commonly used in long-term care such as most antipsychotics, some selective serotonin reuptake inhibitors, antihistamines such as diphenhydramine, and amantadine and furosemide. Constipation may be part of a cycle in which one medication is added, then a second to treat the side effects of the first, then a third to treat the side effects of the second, and so on. There are multiple indexes of anticholinergic burden downloadable from the internet. Consulting pharmacists can help with the process of simplifying and deprescribing in complex drug regimens. The language to describe bowel activity can create confusion for practitioners. Constipation technically refers to decreased frequency of bowel movements, but there is no “normal” here. Some older patients expect to move their bowels daily and will experience distress if a day goes by without stool production. This is often tied to popular health concepts of “regularity” and the need to rid the body of harmful substances. These notions have moved into New Age enthusiasms for various decontamination regimens such as coffee enemas. By contrast, some patients who have two bowel movements on the same day will describe it as diarrhea, which is a term referring to stool consistency rather than frequency. (Some clinicians have prescribed inappropriate antidiarrheals for patients without determining whether the patient actually has diarrhea.) Most residents will become symptomatic if they do not move their bowels for three days or more, with symptoms including abdominal distention or lower abdominal cramping, sensation of a need to void, and decreased appetite. Cognitively intact residents can usually describe these symptoms, but many residents cannot. All too often, rectal distention places pressure on the bladder outlet and induces urinary retention. Acute urinary retention is extremely uncomfortable. Simply relieving the urinary retention, typically with a catheter, should be accompanied by a digital rectal exam to exclude rectal etiologies, rather than reflex attribution to urinary infections as the etiology. Symptomatic constipation (sometimes referred to as obstipation) defines those residents whose infrequent or absent bowel movement have progressed to a more serious stage and should be promptly addressed. This is probably what your resident had, particularly as a Fleet enema would be unlikely to relieve a fecal impaction. Fecal impaction refers specifically to circumstances where stool buildup completely or partially obstructs the bowel. Radiographic evidence of stool and gas do not, of themselves, determine impaction, particularly when present throughout the colon. Although impaction is usually caused by hard stool, even soft stool can produce impaction. Residents with impaction may, paradoxically, have multiple episodes of scanty diarrheal stools as peristalsis attempts to push more liquid bowel contents around the incomplete obstruction. Impaction with hard stool can produce stercoral ulcers, rectal bleeding, or even intestinal perforation. Bowel issues require the same thorough evaluation that should characterize quality post-acute and long-term care. Comprehensive assessment should lead to diagnoses and an interdisciplinary care plan to address the identified issues. The results of this care plan should be monitored periodically with changes as necessary. Because the medication regimens and activity levels of post-acute residents frequently change over days to weeks, bowel regimens may need more frequent reevaluation. An assessment for constipation should go beyond history and physical examination and diagnosis. In addition to those with a history of constipation or actual issues at the time of admission, there are many residents who are “at risk” for constipation. Typically, that risk relates to other parts of the care regimen. Routine bowel mobility requires adequate fluid intake and usually enough fiber. Fluid restriction ordered to address cardiac, renal, or electrolyte diagnoses will place a resident at risk and should be addressed. Stool softeners, such as docusate sodium, are not laxatives. As already noted, it is possible to be constipated or even impacted with soft stool. Although excessively hard stool can play a role in constipation for some residents, particularly those with inadequate fluid intake or rectal issues such as hemorrhoids or fissures, they need not be part of routine orders for all admissions, and they are unlikely to address many of the causes of constipation (particularly when constipation is established) because they have no effect on stool already present in the lower bowel and rectum. Some facilities have attempted to overcome existing care issues for bowels with standardized order sets used facility-wide. Although these are better than not addressing the issue at all, they are a poor substitute for person-centered care. Bulk laxatives are considered the first-line treatment of choice by many gastroenterologists, but they are often problematic for many frail residents because of the volume required for their use. Overuse of phospho-soda enemas may be extremely irritating to the rectum. These are problems that should involve the entire interdisciplinary team and effective communication. Nursing assistants at the bedside are often the best sources of information, and their active input into patient care is obviously superior to simply checking a box on the presence of a bowel movement during their shift. Also, as the team members most involved with dressing and toileting for residents, they can be valuable observers of abdominal girth, straining at stool, or changes in appetite that signal various bowel-related concerns. Although many long-term care facilities boast about their advanced comprehensive care of various cardiopulmonary or neurologic conditions, few websites or brochures brag that the residents in their facilities have regular bowel movements. But this is a major component of quality of life for most residents, and it could be an ideal area for a quality improvement project to address. Do not wait for the deficiency citation to be a wakeup call.