Long-Term Care Survey Alert

These care strategies can turn around even persistent cases.

Talk about a tough nursing problem: Residents with bowel incontinence and chronic diarrhea.

While these individuals require almost constant hygiene care to prevent skin breakdown, a careful assessment may hold the answers to getting the person back on the road to normalcy.
Start by reviewing the resident's medications, suggests Charles Crecelius, MD, PhD, CMD, a multi-facility  medical director in St. Louis, MO.  "Look for forgotten laxatives, including fiber remedies, current antibiotics (especially macrolides like erythromycin), a history of antibiotic use - and certain other medications, such as Reglan or some proton pump inhibitors," he suggests. (Proton pump inhibitors are the family of drugs used to treat stomach ulcers and gastric reflux.)

Don't overlook over-the-counter herbal remedies, which a resident may be purchasing on her own or receiving from her family. "Glucosamine chondroitan sulfate can cause diarrhea, for example," says Crecelius.

Tip: A search of Epocrates, an electronic drug information system, shows 801 prescription medications with diarrhea listed as a possible side effect. So review the entire medication list carefully and consider talking to the prescribing clinician about doing trials off certain medications, if appropriate, says Crecelius.

Check for blood in the stool, which may occur with inflammatory disease and cancers (villous adenomas often present this way), says Crecelius. Consider asking the prescribing clinician to order a routine culture, especially if one has never been done. "Look for Clostridium difficile, which is common in acute diarrhea but can be seen in chronic diarrhea, as well, especially in association with ischemic bowel disease," he says.

Dietary factors can cause or aggravate diarrhea - for example, lactose intolerance or celiac disease. The latter condition, which requires a blood test to detect, can be treated with a gluten-free diet.

Did you know? The medical literature suggests the geriatric population has a lot of undiagnosed celiac disease, which can present with diarrhea or constipation with bloating, says Kathleen Thimsen, RN, ET, MSN, principal of RARE Consulting Group in Bella Vista, AR. "Untreated celiac disease can also cause neurological and cardiac symptoms and arthritic type pain."

So-called functional diarrhea (where no cause can be found) can normally be managed by a diet of modified residue, avoiding foods that appear to trigger diarrhea - and sparing use of anti-motility medications, says Crecelius. "Probiotic agents are very useful in cases associated with overgrowth syndromes such as C. difficile colitis," he advises.

Beware: While yogurt with live cultures can help restore normal bowel flora, it can provoke diarrhea in lactose-intolerant individuals. "Probiotic agents would be the preferred choice in such cases," says Crecelius.