Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 496

The initial management of faecal incontinence is to identify and treat any underlying or contributing causes. Deprescribing and discontinuing culprit drugs is often an effective first step.

Normalizing the stool consistency, aiming for a type 4 or 5 on the Bristol stool form scale, can be highly effective in the treatment of faecal incontinence caused by either loose stool or constipation. Supplementation of dietary fibre with bran, increasing the intake of soft fruit and fruit juices, or using agents such as psyllium husk (Fybogel™, Metamucil™, and others) can treat both constipation and loose stool but should be introduced slowly and increased. Rapid increases in dietary fibre are associated with flatulence and abdominal discomfort. Involving a dietitian can be helpful in those with inadequate nutritional intake, and consideration should be given to the availability and affordability of changes to diet. For those with hard type 1 or 2 stool, stool softeners such as polyethylene glycol 3350 (PEG, Movicol™, Resoralax™, and others) are effective and the dose is highly adjustable. A common error made by patients is to wait until they are very constipated, then take a large dose of stool softener (leading to diarrhoea), and then stop the softener altogether or even take antidiarrhoeal agents. Individuals should be counselled to take a small dose regularly, increasing weekly until they have regular, soft, and controllable bowel movements that are easy to pass. If they overshoot and get loose stool, they should be advised to reduce the dose rather than stop. Docusate is ineffective and should not be prescribed.⁵⁵

Stimulant laxatives, including sennosides, bisacodyl, and others, are of value in those who are constipated with soft stool but lack the propulsive force required to evacuate fully, a situation often seen in neurological disease. Rectal preparations, either enemata or suppositories, are useful in constipation not amenable to oral treatment, and 5HT⁴ antagonists such as prucalopride can also be tried,⁵⁶ although the results can be somewhat too effective.

For those with loose stool, agents to induce constipation, including loperamide and codeine, can be helpful. As with stool softeners, starting at a low dose and increasing until the desired consistency is achieved is recommended. Loperamide is available as a liquid preparation, allowing precise dose adjustment. Occasionally, a ‘block and replace’ approach is necessary, deliberately inducing constipation and then using either oral or rectal stimulant laxatives to produce a predictable bowel movement. If bile salt malabsorption is suspected, a trial of cholestyramine can be both diagnostic and therapeutic.

In people living with dementia, clearly signed facilities with regular reminders and assistance to toilet are recommended. Utilizing the gastrocolic reflex can be helpful. The gastrocolic reflex induces the urge to defecate some 30–60 minutes after eating, and as such encouraging toileting after breakfast can be a way help achieve successful toileting. Unfortunately, in institutional settings with common mealtimes, this can be a way TO help challenging to arrange given staffing levels.