Systemic changes in the function of digestion and absorption of nutrients result from changes in older patients’ cardiovascular and neurological systems rather than their GI system. For example, arteriosclerosis causes decreased mesenteric blood flow, thus decreasing absorption from the small intestine (Meiner, 2011). In addition, peristalsis decreases, and esophageal emptying slows. Older adults often experience changes in the GI system that impair digestion and elimination (JBI, 2008) (Table 46-1).

Older adults also lose muscle tone in the perineal floor and anal sphincter (Holman et al., 2008). Although the integrity of the sphincter remains intact, they often have difficulty controlling bowel evacuation and are at risk for incontinence. In addition, nerve impulses to the anal region slow, causing some individuals to become less aware of the need to defecate. Older adults, especially residents in long-term care facilities, sometimes develop irregular bowel movements and an increased risk for constipation (Kyle, 2007a).

Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber, the nondigestible residue in the diet, provides the bulk of fecal material. Bulk-forming foods such as whole grains, fresh fruits, and vegetables help flush the fats and waste products from the body with more efficiency (Holman et al., 2008). The bowel walls stretch, creating peristalsis and initiating the defecation reflex. With stimulation of peristalsis, bulk foods pass quickly through the intestines, keeping the stool soft. Ingestion of a high-fiber diet improves the likelihood of a normal elimination pattern if other factors are normal. Diets high in vegetables and fruits have been linked to decreased risk of colorectal cancer (ACS, 2011b).

Gas-producing foods such as onions, cauliflower, and beans also stimulate peristalsis. The gas formed distends intestinal walls and increases colon motility. Some spicy foods increase peristalsis but also cause indigestion and watery stools.

Food intolerance is not an allergy but rather a particular food that causes the body distress within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cow’s milk and have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk sugar lactase and therefore are lactose intolerant. Another condition called celiac disease is a syndrome in which the patient has a hypersensitivity to protein in certain cereal grains and gluten.

An inadequate fluid intake or disturbances resulting in fluid loss (such as vomiting) affect the character of feces. Fluid liquefies intestinal contents, easing its passage through the colon. Reduced fluid intake slows passage of food through the intestine and results in hardening of stool contents. Unless there is a medical contraindication, an adult needs to drink at least 1100 to 1400 mL of fluid daily. An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk of constipation because of greater resorption of fluid in the colon, resulting in hard, dry stools (Kyle, 2007a).

Prolonged emotional stress impairs the function of almost all body systems (see Chapter 37). During emotional stress the digestive process is accelerated, and peristalsis is increased. Side effects of increased peristalsis are diarrhea and gaseous distention. A number of diseases of the GI tract are associated with stress, including ulcerative colitis, irritable bowel syndrome, certain gastric and duodenal ulcers, and Crohn’s disease. If a person becomes depressed, the autonomic nervous system slows impulses; peristalsis decreases, resulting in constipation.

General anesthetic agents used during surgery cause temporary cessation of peristalsis (see Chapter 50). Inhaled anesthetic agents block parasympathetic impulses to the intestinal musculature. The action of the anesthetic slows or stops peristaltic waves. The patient who receives a local or regional anesthetic is less at risk for elimination alterations because this type of anesthesia generally affects bowel activity minimally or not at all.

Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed.

Some medications have certain expected actions on the bowel (e.g., there are medications to promote defecation or control diarrhea). In addition, medications prescribed for acute and chronic conditions often have secondary effects on the patient’s bowel elimination patterns (Table 46-2).

Constipation is a symptom, not a disease (Box 46-1). Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feces (McWilliams, 2010). When intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls, and most of the fecal water content is absorbed. Little water is left to soften and lubricate the stool. Passage of a dry, hard stool causes rectal pain (Fig. 46-4).

Constipation is a significant health hazard. Straining during defecation causes problems for the patient with recent abdominal, gynecological, or rectal surgery. The effort to pass a stool often causes sutures to separate, reopening the wound. In addition, patients with histories of cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), and increased intracranial pressure need to prevent constipation and avoid using the Valsalva maneuver.

An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to defecate (Chien and Bradway, 2010). You suspect impaction when a continuous oozing of diarrhea stool occurs. The liquid portion of feces located higher in the colon seeps around the impacted mass. Loss of appetite (anorexia), nausea and/or vomiting, abdominal distention and cramping, and rectal pain often accompany the condition. If an impaction is suspected, gently perform a digital examination of the rectum and palpate for the impacted mass (Steggall, 2008).

Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration (Gray, 2007).

Excess loss of colonic fluid results in serious fluid and electrolyte or acid-base imbalances. Infants and older adults are particularly susceptible to associated complications (see Chapter 41). Because repeated passage of diarrhea stools also exposes the skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care and containment of fecal drainage is necessary to prevent skin breakdown (see Chapter 48).

Many conditions cause diarrhea. Antibiotic use via any route of administration alters the normal flora in the GI tract (Vonberg et al., 2008). Patients receiving enteral nutrition are also at risk for diarrhea. Consult a dietitian when diarrhea occurs (Tabloski, 2009). See Chapter 44 for interventions to decrease diarrhea caused by enteral feedings. Food allergies and intolerances increase peristalsis and cause diarrhea. Surgeries or diagnostic testing of the lower GI tract also cause diarrhea. The aim of treatment is to remove precipitating conditions and slow peristalsis.

Another common causative agent of diarrhea is Clostridium difficile (C. difficile), in which symptoms range from mild diarrhea to severe colitis. C. difficile infection is acquired in one of two ways: by factors that cause an overgrowth of C. difficile, and by contact with the C. difficile organism. A new strain of C. difficile has been identified that is more virulent with more toxic effects (Grossman, 2010). Antibiotics (cephalosporins, ampicillin, amoxicillin, and clindamycin (Calfee, 2008), chemotherapy, and invasive bowel procedures such as surgery or colonoscopy disrupt normal bowel flora and may cause an overgrowth of C. difficile. Some patients acquire the organism from a health care worker’s hands or direct contact with the environmental surfaces contaminated with it. Only hand hygiene with soap and water is effective to physically remove C. difficile spores from the hands. In addition, evidence supports the use of diluted bleach (1 : 10) as an environmental disinfectant to decrease the incidence of C. difficile (Calfee, 2008; Vonberg, 2008). The most common diagnostic test for the bacteria is the enzyme-linked immunosorbent assay (ELISA) test, which detects C. difficile A and B in the stool.

Communicable foodborne pathogens also cause diarrhea. Hand hygiene following the use of the bathroom, before and after preparing foods, and when cleaning and storing fresh produce and meats greatly reduces the risk of foodborne illnesses. When diarrhea is the result of a foodborne virus, the goal usually is to rid the GI system of the pathogen rather than slow peristalsis.

Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image (see Chapter 33). In many situations the patient is mentally alert but physically unable to avoid defecation. The embarrassment of soiling clothes often leads to social isolation. Physical conditions that impair anal sphincter function or control cause incontinence. It occurs in a variety of settings. Conditions that create frequent, loose, large-volume, watery stools also predispose to incontinence. Using an anal bag or a bowel management system helps to prevent perineal skin breakdown (Fig. 46-5).

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