MDS Alert

Providing more fiber can correct constipation or diarrhea.

When you do bowel assessments for the MDS or care planning, take note of residents with persistent constipation, diarrhea, or other intestinal problems. Then make sure the interdisciplinary team is doing everything possible to help the resident overcome these bothersome problems.

"Providers should not assume that a person with bowel problems has to live with them," says Pat Holland, RN, BSN, CGRN, a consultant in gastroenterology and endoscopy nursing in Golden, Colo. So "assess what the problem is and evaluate or look at some options."

The MDS 3.0 defines constipation as having "two or fewer bowel movements during the 7-day lookback period" or where for most of a resident's bowel movements, the stools are hard and difficult for them to pass, regardless of the frequency of bowel movements. Your best bets for correcting this common problem? Increase fluid intake and establish routine toilet times. If that doesn't do the trick, look for treatable conditions known to cause constipation. The list includes hypothyroidism and poor glucose control, according to a National Institutes of Health fact sheet.

Medications can also be the culprit, including iron, anticholinergics, calcium, aluminum, Parkinson's drugs, and anti-convulsants, says Holland. Other constipating meds include calcium channel blockers, pain medications (especially opioids), and antispasmodics, according to the NIH fact sheet: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/.

If the resident is taking one or more such meds, work with the consultant pharmacist and prescribing clinician to determine if the resident really needs the medication or can switch to a non-constipating alternative.

Tip: Avoid putting people on laxatives, advises Holland. "People can get hooked on them" where they need them to have normal bowel movements, she says.

Patients with diarrhea could have Clostridium difficile infection or Helicobacter pylori, says Holland, noting that clinicians sometimes don't consider the latter. A long list of medications can also cause diarrhea, including potassium and antibiotics, as well as toxicity caused by digitalis. To see an "A to Z" list of meds known to cause diarrhea, go to www.wrongdiagnosis.com/symptoms/diarrhea/side-effects.htm.

Tip: Make some dietary changes to see if that eases an ongoing problem with loose stools and/or flatulence.

Lactose intolerance can cause diarrhea, abdominal pain, and bloating.

"Fructose intolerance causes a lot of gas," says Holland. And "many foods contain high fructose corn syrup," which you can detect if you read food labels.

Resources: For tips on diagnosing and managing lactose intolerance, go to http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/.

This website provides information on fructose intolerance, including what foods and beverages to avoid: www.mayoclinic.com/health/fructose-intolerance/AN01574.

A person with a history of bowel problems could have Celiac disease, says Holland. "The definitive criteria for diagnosis include a combination of blood tests confirmed by small bowel biopsy and a response to going on a gluten free diet," says Elaine Monarch, founder and executive editor of the Celiac Disease Foundation (for details, go to www.celiac.org/).

Medication tip: Does the resident have a diagnosis of irritable bowel syndrome? "You can try antidiarrheal and anti-constipation drugs, depending on the patient's symptoms," says Holland. For IBS patients who have constipation, there's a new chloride channel activator lubiprostone approved last year, she adds. "It increases intestinal fluid secretion, which in turn increases intestinal motility" (for more information, go to www.amitiza.com/).

Consider putting residents on an acidophilus probiotic when they start antibiotics, especially IV antibiotics, such as vancomycin, advises Steve Warren, MD, DPA,in Bountiful, Utah. That's what the facility where he serves as medical director does. Patients who come to the facility with Clostridium difficile or who develop it while in the facility receive probiotic capsules that contain about five different kinds of probiotic bacteria, Warren adds.

"Since we've been using the probiotics, the residents have had fewer bowel problems and C. diff. infections. And people with C. diff. heal more quickly."

This strategy can help correct both constipation and diarrhea,  Holland says. "Soluble fiber forms a gel-like substance that softensstools," she says. Foods containing soluble fiber include oats, beans, most fruits, and psyllium products. Insoluble fiber absorbs water, which can bulk up the stool and accelerate colonic transit, Holland instructs. Insoluble fiber includes whole grain cereals and breads, wheat bran, and most vegetables, she says. Ideally, people should consume 20 to 35 grams of fiber a day, including a mixture of the two types, Holland advises. Nursing home residents, however, "probably won't be able to increase their fiber to the ideal amount." But you can potentially increase their intake. "Even 20 grams a day would be beneficial to a lot of people."

High-fiber cereals can provide anywhere from nine to 14 grams of fiber a day "in as a little as one-third of a cup sometimes," Holland points out. Prunes are very high in fiber. "Fiber supplements can also help increase fiber in the diet," she says. These usually provide 3 to 5 grams per dose and can be taken more than once a day. "People should probably take the supplements more than once a day," she says.

Key: When increasing dietary fiber, people may get gas and bloating initially, Holland cautions. And some people don't tolerate fiber well. So you should "increase fiber intake gradually to allow the body to adjust."

And if the person develops problems,  you can back off. The person should also drink six to eight glasses of fluid a day, which doesn't have to be water, says Holland.

2 tips: "If the resident has stool incontinence, try to improve the consistency of the stool by using fiber, advises Holland. Also implement regular toileting times. Residents with ileostomies can eat constipating foods to produce a less liquid stool, advises Mary A rnold Long, MSN , RN, CRRN, CWOCN-AP, A CNS - BC, principal of WOConsultation LLC in Cincinnati, Ohio. Examples include "starches (pastas, rice, bread, pretzels) and applesauce due to the pectin."