The Burden of Constipation in our Ageing Population

Transcription

1 The Burden of Constipation in our Ageing Population Working Towards Better Solutions Executive Summary A report developed by the International Longevity Centre-UK (ILC-UK) and Norgine in consultation with a European expert working group. Commissioned and funded by:

2 To review a full copy of the report and NORGINE and the sail logo are registered trademarks of the Norgine group of companies. All images are used for illustrative purposes only and all people depicted in them are models.

3 The Burden of Constipation in our Ageing Population - Working Towards Better Solutions This report provides a comprehensive review of the true extent of the impact of constipation in the ageing population across Europe, both in terms of quality of life and financial burden. This review focuses on the situation for older people living both in care homes and in the community. The publication results from a collaboration between the International Longevity Centre- UK (ILC-UK), Norgine and a multi-disciplinary, pan-european group of representatives involved in the care of older adults, nursing, gastroenterology, pharmacy and women s health. The aim is to highlight key issues and challenges surrounding the subject of constipation, an often hidden health condition that is set to increase as our population ages. The aims of the report are: to improve knowledge and understanding about constipation to highlight the impact of constipation on those affected in terms of pain, quality of life and emotional well-being to highlight the impact of untreated or under-treated constipation on healthcare resources to review and share existing guidance and guidelines, which support the diagnosis and management of constipation and to highlight where gaps exist to develop practical recommendations on how constipation can be better diagnosed and managed in people over the age of 65 to encourage information exchange across all relevant stakeholders supporting the health of this vulnerable section of the population. David Sinclair, Assistant Director, Policy & Communications, ILC-UK comments: Despite estimated figures of 80 per cent of care home residents suffering from constipation, this is a problem in older adults that is clearly not being taken seriously enough. We hope this report will provide a lever to improve earlier recognition of constipation and, importantly, to encourage all those involved in the care of older adults to take the positive and immediate steps outlined in this report that will lead to improved care. Key findings: Constipation can have a significant impact on physical and mental quality of life this impact is comparable to more recognised conditions such as diabetes, osteo-arthritis or osteoporosis 1 Constipation can exacerbate symptoms in patients with mental conditions, such as dementia 2 and if untreated, can have serious medical consequences, such as faecal impaction, which may require admission to hospital 3 Constipation already places a significant burden on healthcare systems 4-6 and this burden is set to rise as the population ages 7 There is a lack of evidence-based guidance on the management of constipation in older adults across Europe. This is having a direct impact on the ability to manage patients effectively. 1

4 By % of the EU population will be aged 65 years or older, so the economic cost of constipation will continue to grow as the population ages.7 Preventable and treatable Constipation is a common digestive condition,1,8 the prevalence of which increases with age.9-11 Sadly, the rates are higher among older people who live in care homes or institutions than amongst people living in the community.6,11 In many cases constipation can be prevented and/ or treated effectively and therefore should not be overlooked, trivialised or regarded as an inevitable consequence of ageing.12,13 Constipation affects around 16-17% of the adult population in Europe. It is more common in older adults, reported in up to one in five adults aged 65 and over % of people in care homes are constipated % of people in care homes suffer from faecal impaction14,15 In England in 2011, 61,162 hospital admissions due to a primary diagnosis of constipation21 40% of hospital admissions due to constipation were in patients aged over 65 years21 80% of hospital admissions due to constipation were emergency admissions and led to an average stay of 4.9 bed days21 2 Constipation can lead to significant ill health Chronic constipation can cause significant pain and suffering and if it is left untreated, it has the potential to lead to serious medical consequences.3,16 An audit of older people affected by chronic constipation across the UK revealed that 30% were suffering from faecal impaction, a condition which may need hospital intervention.5 Studies show that constipation can significantly reduce a patient s quality of life and may be associated with high levels of anxiety and depression,4,17,18 as well as embarrassment and loss of dignity.11,19 It can impact on the management of patients with cognitive or neurological illness, leading to irritability and increased anxiety in those with dementia.2,18 Counting the cost of constipation Constipation represents a significant burden on health resources in terms of nursing time, investigation, intervention, medication and ongoing management.4-6,20 Constipation associated with incontinence can lead to the breakdown of care at home and may be among the factors that can contribute to premature admission to care homes.13

5 Why does this situation prevail? A policy review was conducted to assess the provision of guidance, guidelines and care pathways for the management of constipation across Europe. This review highlighted a lack of official guidance, particularly evidencebased guidance supporting the diagnosis and management of constipation in adults and specifically those over the age of 65 years. Expert standards of care for incontinence are more widely available and in some cases make reference to constipation. 22,23 Quality care indicators for the health and welfare of those living in long term care, care homes or other institutions do not include constipation as a quality indicator to be measured or monitored. This is despite the high prevalence of constipation in institutions and the associated distress it causes. On a more positive note, there are some excellent examples from around the world of good reference resources developed by expert groups. These include: World Gastroenterology Organisation (WGO) guidelines on constipation 24 World Health Organisation (WHO) report 25 American Gastroenterological Association (AGA) technical review on constipation 6 IMPACT Bowel Care for the Older Person guide to the management of constipation and faecal impaction in older people, developed in Australia. 26 Diagnostic tools are also available to support effective diagnosis of constipation and include the Rome III diagnostic tool and the Bristol Stool Form Scale. A broad range of treatments are available to manage constipation, but there is often a greater focus on diet and lifestyle changes as the first course of action. There is, however, limited evidence to support the efficacy of this approach alone. Even where guidance exists, a robust structural framework is needed to integrate recommendations into day-to-day care. Without this, sub-optimal management of constipation will continue. Addressing unmet need highlighting the priorities This new publication unveils the current unmet need for improved recognition, appropriate prevention, diagnosis, management and monitoring of constipation in older age groups. Six key priorities were identified based on the conclusions of the research and the authors suggest recommendations for achieving each goal. Policy review: overall findings Focus on incontinence not constipation Fragmented approach with lack of specific indicators Non government organisations call for improved quality care standards 3

6 Priorities Priority #1 Functional constipation should not be underestimated or trivialised and should not simply be considered as an inevitable consequence of ageing or frailty Priority #2 Chronic constipation should be classified and recognised as a condition in its own right, not just a set of symptoms associated with other disorders Priority #3 Recognition and awareness of the typical symptoms and causes of constipation, as well as understanding how to effectively prevent and treat it, should be a training priority across the whole multi-disciplinary team and social care professionals working with older people Priority #4 Constipation needs to be better diagnosed so it can be promptly treated and managed more effectively in-line with agreed best practice and recognised standards Priority #5 The taboo nature of constipation needs to be addressed amongst the general public such that older people start to feel more comfortable and less embarrassed about self-reporting suspected constipation, knowing that they will be taken seriously and always treated with respect Priority #6 Highlight the true cost of failing to effectively manage constipation in older people, in terms of economic and societal burden to health services, as well as the cost in terms of individual suffering and reduction in quality of life Recommendations Raise awareness of the key messages and issues raised within the report amongst all healthcare professionals and other healthcare providers, as well as at a policy level Support the development of policy and guidelines to support appropriate prevention, diagnosis and management of constipation as a separate condition to continence Develop an internationally-agreed, clear and simple definition of constipation Highlight constipation within established continence guidance as a separate but related issue Develop clear and simple guidance for older people in care homes to prevent, report and promptly manage constipation in older adults Increase information about constipation as an issue across training materials and resources to improve attitudes of the whole multidisciplinary care team towards this condition. Specific focus on nursing staff who have more frequent patient contact Develop on- and off-line resources, for example e-learning modules, risk assessment tools, template training packs and care home resources, to offer easy access to practical resources Support measures to encourage the review of medicines to avoid unnecessary poly-pharmacy Include evidence-based preventative measures into globally accepted best practice care pathways and ensure endorsement by key multi-disciplinary professional bodies and dissemination throughout membership Increase proactive case-finding of constipation in care homes through monitoring and screening programmes Encourage prompt treatment to avoid complications, including faecal impaction and worsening of symptoms of neurological disease, such as dementia Develop clear guidelines and care pathways for constipation Implement strategies for guidance to ensure this is accepted in daily practice Evaluate existing diagnostic tools and promote best practice in using them Encourage greater open discussion about constipation as a common health issue through campaigning and information provision Develop information resources for patients/carers Support better self-reporting through sensitive questioning techniques Gather economic data to target health service providers and commissioners/payers to highlight the cost of complicated constipation, in terms of hospitalisations etc Develop communication tools to highlight the impact on quality of life Encourage routine prevention and treatment of constipation in a hospital and care setting Challenge inaction amongst healthcare providers how can they afford NOT to deal with this preventable condition? 4

7 References 1. Belsey J, Greenfield S, Candy D et al. Systematic review: impact of constipation on quality of life in adults and children, Aliment Pharmacol Ther, 2010, vol. 31, pp Alzheimer Scotland, Information Sheet IS41, retrieved 21 August 2013, org/pages/info/constipation-faecal-impaction. htm. 3. Gallagher P and O Mahoney D. Constipation in old age, Best Practice & Research Clinical Gastroenterology, 2009, vol. 23, pp Norton C, Constipation in older patients, Brit J Nurs, 2006, vol. 15, no. 4, pp Addison R, Davies C, Haslam D et al. A national audit of chronic constipation in the community, Nursing Times, 2003, vol. 99, no. 11, pp American Gastroenterological Association, Technical Review on Constipation, Gastroenterology, 2013, vol. 114, pp EUROSTAT European Commission, Population structure and ageing, 2012, retrieved 21 August 2013, eu/statistics_explained/index.php/population_ structure_and_ageing#future_trends_in_ population_ageing. 8. Clinical Knowledge Summaries, Constipation, retrieved 21 August 2013, uk/constipation. 9. Peppas G, Alexiou V, Mourtzoukou E, et al. Epidemiology of constipation in Europe and Oceania: a systematic review, BMC Gastroenterology, 2008, vol. 8, no. 5, pp Talley N, Definitions, epidemiology, and impact of chronic constipation Rev Gastroenterol Disord, 2004, 4 Suppl 2:S3-S Potter J and Wagg A, Management of bowel problems in older people: an update, Clin Med, 2005, vol. 5, no. 3, pp Castledine G, Grainger M, Wood N et al. Researching the management of constipation in long-term care: Part 1, Brit J Nurs, 2007, vol. 16, no. 18, pp Wilson L, Understanding bowel problems in older people: part 1, Nursing Older People, 2005, vol. 18, no. 8, pp Barcelo M, Garcia-Sanchez R, Diaz-Rubio M, et al. Prevalence of fecal impaction among residents in nursing homes in Spain and associated factors, Gastroenterology, 2012, vol. 142, no. 5, pp Spinzi G, Bowel care in the elderly, Dig Dis, 2007, vol. 25, pp Tariq S, Constipation in long-term care, J Am Med Dir Assoc, 2007, vol. 8, pp Woodward S, Assessment and management of constipation in older people, Nursing Older People, 2012, vol. 24, no. 5, pp Eberhardie C. Constipation: Identifying the problem, Nursing Older People, 2003, vol. 15, no. 9, pp Potter J, Bowel care in older people, Clin Med, 2003, vol. 3, no. 1, pp Cusack S, Day M, Wills T et al. Older people and laxative use: comparison between community and long-term care settings, Brit J Nurs, 2012, vol. 21, no. 17, pp Dr Foster Health, Hospital Episode Statistics (HES), NICE, Faecal incontinence: The management of faecal incontinence in adults, 2007, retrieved 21 August 2013, ActiZ, Organisation of care entrepeneurs; LOC, National Organisation of clients councils; NVVA, Professional Association for Nursing Home Doctors and Social Geriatricians; Sting, National Professional Care Association; IGZ, Health Inspectorate; VWS, Ministry of Health, Welfare and Sports; ZN, Dutch Care Insurers, Quality Framework Responsible Care, 2007, retrieved 21 August 2013, Kwaliteitskader%20Verantwoorde%20Zorg%20 (english).pdf. 24. World Gastroenterology Organisation, Practice Guidelines: Constipation, 2007, retrieved 21 August 2013, org/assets/downloads/en/pdf/guidelines/05_ constipation.pdf. 25. World Health Organisation, Keep fit for life: meeting the nutritional needs of older people, 2002, retrieved 21 August 2013, who.int/nutrition/publications/en/nut_older_ persons_1.pdf. 26. IMPACT, A guide to the management of constipation and faecal impaction in the older person, 2010, retrieved 21 August 2013, com/54c7252d-c526-4f81-921a-0ebadaa005d6.

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