Constipation


Constipation is defined as a condition that consists of fewer than three bowel movements in a week or having bowel movements with stools characterized as dry or hard in consistency, or small in size that lead to painful and difficult passage of stool.5 Normal frequency of bowel movements may vary from three times a day to three times a week, and the patterns vary in each individual.5 In persons with regular bowel movements, constipation can cause symptoms such as bloating and abdominal pain. These symptoms are not easily conveyed or expressed in patients with IDD. 


In individuals with IDD, constipation should be considered as a possible primary cause of many other conditions. Common co-existing symptoms of constipation include fever, anorexia, vomiting, pneumonia, seizures, decreased level of consciousness, and behavioral outbursts. Constipation may also lead to medication intoxication due to increased absorption time as a result of slower bowel transit time and even death among patients with IDD. Community-based clinicians must be aware of the presenting symptoms of bowel obstruction so that this potentially life-threatening condition can be recognized and treated in a timely manner. Common presenting symptoms of constipation among persons with IDD include decreased bowel sounds, vomiting, abdominal bloating and rigidity, fever, seizures, or behavioral outbursts. Many medical conditions present as behavioral conditions in patients with IDD, as this may be the only way that they can communicate discomfort.



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Causes. Several common causes exist for increased frequency of constipation among patients with IDD, including decreased gastrointestinal motility, immobility, lack of sensation, diet, certain medications, and the presence of pica. Medications that are commonly prescribed to individuals with IDD that can lead to constipation include anti-epileptic drugs (AEDs), antipsychotics, and iron supplements. According to DSM-5 criteria, pica is considered as eating non-nutritive substances for longer than one month, consuming non-nutritive substances that are not appropriate for an individual’s developmental level, or consumption that is not related to a cultural or social norm practice.6 Pica is often seen in the presence of other mental health disorders that are associated with impaired intellectual or developmental functioning and can lead to bowel obstruction among individuals with IDD. 


Potential Complications. The potential complications of a bowel obstruction are many. There is risk of many different complications due to electrolyte imbalances, which can alter sodium and potassium levels and can lead to metabolic alkalosis or acidosis. Dehydration and jaundice are also possible complications of a bowel obstruction. The most life-threatening complications are an intestinal perforation, tissue necrosis, and infection. If constipation leads to vomiting, this can result in aspiration, which can also lead to pneumonia or death.


Diagnostics. Initial diagnostic testing that can be ordered to detect the presence of an early bowel obstruction may include laboratory testing such as a chemistry panel and a complete blood count (CBC). A flat and upright radiograph of the abdomen is a relatively inexpensive diagnostic test that can be very helpful in the case of a simple small bowel obstruction. These radiographs may also be used to identify fecal impaction or fecal stasis and allow for bowel-cleansing regimens before symptoms worsen. However, plain radiographs are of little assistance when it comes to determining the differential regarding strangulation versus simple obstruction.7 Other diagnostic testing that can be helpful in determining the presence of a bowel obstruction include computed tomography (CT) scanning, magnetic resonance imaging (MRI), and ultrasonography. However, obtaining these diagnostics may likely not be well tolerated in some patients with IDD. It is important to consider how well a person with IDD might tolerate or cooperate with certain procedures compared with the value of the information that will be revealed by the test. Sometimes it may be too stressful for the patient to undergo a particular test, and it may cause more harm by leading to an unpleasant experience that could sensitize him or her against having future needed medical procedures.


Treatment. Evidenced-based treatment of constipation includes medications and manual modalities. Medications including laxatives, stool softeners, and suppositories are often needed on a daily basis among patients with IDD. Manual modalities include enemas and disimpaction. If a bowel obstruction is present, treatment may include placement of a nasogastric tube to alleviate abdominal swelling and vomiting. If symptoms do not improve, an immediate referral to general surgery for consideration of surgical intervention is warranted. 


Prevention. Diet modifications play an important role in the prevention of constipation. Diet-related modalities pertaining to prevention include increased fiber intake and promotion of adequate fluid intake. It is important to ensure adequate fluid intake when increasing fiber intake to avoid the increased incidence of fecal impaction. Due to the presence of increased risk factors for constipation among individuals with IDD, various agents may be given daily as part of the preventive plan of care. Common agents given for prevention are bulking agents, osmotic agents, and softening agents.


Aspiration


Aspiration is defined as the movement of saliva, liquid, food, vomit, or other endogenous or exogenous matter into the airway.8 Aspiration among patients with IDD may present with very subtle signs and symptoms. It can be a potentially life-threatening condition. The subtle signs and symptoms often seen with aspiration include coughing after swallowing solid food or liquids, recurrent pneumonia, and reactive airway disease. A cough during eating or drinking can be the only presenting sign of aspiration. Other symptoms that may be present with aspiration include fever, burping, hoarseness, decreased appetite, shortness of breath, recurrent wheezing, halitosis, excessive sweating, or colored sputum. Assessment findings may reveal rales or rhonchi of lung fields, decreased oxygen saturation, tachycardia, and altered mental status due to an underlying illness such as acute pneumonitis. Aspiration can cause acute pneumonitis and increase the incidence of aspiration pneumonia. Community-based clinicians need to be aware of the signs and symptoms that are indicative of aspiration so that early intervention and treatment can be initiated to prevent further complications. 


Causes. Aspiration in a patient with IDD is often aggravated by constipation, gastroesophageal reflux (GERD), dysphagia, gastrointestinal dysmotility, mechanical alterations in swallowing, and sedatives. Sedation can interfere with swallowing and may be related to medication effects or sedation related to postictal states after seizures. Pneumonia may develop as a result of the aspiration of oral cavity or nasopharynx microorganisms such as Streptococcus pneumoniae, Staphylococcus aureus, other gram-negative bacilli, or respiratory viruses such as Haemophilus influenza and respiratory syncytial virus.9 Aspiration pneumonia is considered a form of community-acquired pneumonia (CAP) and is the only form that is caused by multiple aerobic and anaerobic oral bacteria. By definition, aspiration pneumonia is the development of an infection in the lower airways as a result of bacteria that are a common component of the normal flora in a susceptible individual who is prone to experiencing aspiration.9 Aspiration pneumonia is considered to be one of the main risk factors that contributes to acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).10

Potential Complications. The development of acute pneumonitis or aspiration pneumonia is more likely when there are insufficient normal defenses to protect the lower airways, such as the lack of glottis closure, ineffective cough reflex, or the absence of other clearing mechanisms.9 Additional contributing factors include the introduction of a toxic substance into the lower airways such as gastric acid, the activation of the inflammatory process due to the presence of a bacterial infection, or an obstruction.9 The early reactive response to aspiration is considered an acute pneumonitis, defined as inflammatory in nature with the presence of fever and leukocytosis.10 Antibiotics are not always needed for the treatment of pneumonitis. However, it is often challenging to determine between aspiration pneumonitis and pneumonia, and strong consideration should be given for aggressive treatment in patients with IDD due to the difficulties they have in communicating worsening symptoms, which may lead to a rapid worsening of their condition.


Diagnostics. Various diagnostic testing can be ordered to evaluate patients for the presence of aspiration and possible complications associated with aspiration. Lab values that may need to be obtained include a CBC, arterial blood gases, and blood cultures. Sputum cultures may also be considered, but a patient’s ability to cooperate with this procedure may be very limited. A chest radiograph can prove to be a very beneficial baseline study when diagnosing pneumonia. Bronchoscopy and chest CT may also be useful, particularly in severe cases or in those resistant to standard treatment. Additional diagnostics that may be used to help determine the cause of the aspiration episode include swallowing function studies such as a modified barium swallow. Despite the increased incidence of aspiration pneumonia, it is still considered a diagnosis of exclusion due to the presence of ill-defined infiltrates on radiographs of the chest, in addition to hypoxia.10

Treatment. If aspiration pneumonia is present, initiating treatment early with antibiotics before culture results are obtained is strongly recommended.11 Once culture results are obtained, empiric therapy can be guided by the findings and tailored to the specific pathogen. This is especially so in patients who experience aspiration that is secondary to a small bowel obstruction or in patients who have gastric content colonization.12 However, it is important to discontinue antibiotic use if quantitative cultures do not reveal significant growth of bacteria.10 Severe cases of aspiration pneumonia may require hospitalization and ventilation to support breathing.


Selection of antibiotic therapy should be based on the most likely causative pathogen, current evidence-based guidelines, patient risk factors for antibiotic resistance, and existing comorbidities. The presence of certain comorbidities may play a role in the specific causative pathogens, in addition to the increased incidence of treatment failure.13,14 Therefore, taking these factors into consideration prior to initiating antibiotic therapy will increase the likelihood of successful treatment and positive outcomes. 


Streptococcus pneumoniae is the most common bacterial pathogen that causes CAP. Therefore, this should be taken into consideration when initiating antibiotic therapy before culture results have been obtained. Factors that increase the incidence of antibiotic-resistant Streptococcus pneumoniae include age older than 65, treatment with fluoroquinolone, macrolide, or beta-lactam antibiotics during the previous three to six months, alcoholism, immunosuppressive conditions, and exposure to other infected individuals.13,14 The presence of comorbidities such as cystic fibrosis, chronic obstructive pulmonary disease, recent influenza infection, recurrent aspiration, diabetes mellitus, and presence of various diseases related to the lungs, liver, or kidneys should be taken into consideration. Other factors that should be considered include recent hospitalizations, residing in a long-term care living arrangement, and allergies. 


If a patient with IDD has no risk factors for antibiotic-resistant Streptococcus pneumoniae, none of the previously mentioned comorbidities, no contraindications (ie, allergies), and has been previously healthy, the initial, first-line antibiotic of choice for aspiration pneumonia may include a macrolide antibiotic (ie, azithromycin or clarithromycin) or a tetracycline antibiotic (ie, doxycycline).13,14 If an antibiotic has been administered within the previous three months, consideration of combination antibiotic therapy may include azithromycin or clarithromycin in addition to a beta-lactam antibiotic (amoxicillin or amoxicillin-clavulanate) or a fluoroquinolone (ie, levofloxacin or moxifloxacin).13,14 If previously mentioned comorbidities are present, treatment with a single antibiotic may include levofloxacin or moxifloxacin or combination therapy of a beta-lactam antibiotic (amoxicillin, amoxicillin-clavulanate, cefuroxime, or ceftriaxone intramuscularly) plus a macrolide antibiotic (ie, azithromycin or clarithromycin).13,14

The evidence recommends antibiotic therapy for a minimum of five days or until the patient is afebrile for at least three days; however, extended duration of treatment should be considered if the identified pathogen is shown to be resistant to the initial antibiotic or if extrapulmonary infections are present.13,14 Community-based clinicians should always keep in mind that unnecessary extended use of antibiotics may increase the incidence of further complications, such as antibiotic-associated pseudomembranous colitis, which is most commonly caused by Clostridium difficile.15

The CURB-65 calculator can be used to assist community-based clinicians with determining inpatient versus outpatient treatment for pneumonia.16 The CURB-65 stands for Confusion, Urea (blood urea nitrogen [BUN] > 19 mg/dL), Respiratory rate ≥ 30 per minute, Blood pressure < 90 mm Hg systolic or ≤ 60 mm Hg diastolic, and age 65 or older.16 The presence of each finding counts as one scored point. Based on the CURB-65 calculator, patients with a score of 0 to 1 have a low risk and can likely be treated on an outpatient basis. A score of 2 should warrant consideration of hospital admission. Patients with a score of 3 or higher should be considered for treatment in an intensive care unit, especially with a score of 4 or 5.16 Community-based clinicians may find a simplified version called CRB-65 to be more practical to use to assist with decision-making, because it does not require a BUN value.16 However, hospital admission should be considered with either version if the score equals two or more points.


Prevention. The prevention plan for aspiration is determined by the frequency and severity of symptoms. Prevention may consist of simple modalities such as use of a reclined position or a thickened liquid diet. A feeding evaluation may yield valuable recommendations when developing a prevention plan. Recurrent aspiration that does not respond to a conservative prevention plan may require placement of a percutaneous endoscopic gastrostomy (PEG) tube or a jejunostomy tube (J-tube).



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