Study of defecation disorders in elderly patients Coloproctology Journal of

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w w w . j c o l . o r g . b r

Journal of

Coloproctology

Review Article

Study of defecation disorders in elderly patients

Isaac José Felippe Corrêa Neto

^a^,^b^,∗

, Mario Mosca Neto

^a^,^b

, Vanessa Santos Lanfranchi

^b

, Thales Ranieri Pedroso

^b

, Henrique Carvalho e Silva Figueiredo

^a

, Jéssica Mocerino

^a

, Marcia Pascutti

^b

, Laercio Robles

^b,c

aHospitalSantaMarcelina,FaculdadeSantaMarcelina,SãoPaulo,SP,Brazil

bFaculdadeSantaMarcelina,SãoPaulo,SP,Brazil

cDepartmentofGeneralSurgery,HospitalSantaMarcelina,SãoPaulo,SP,Brazil

a r t i c l e i n f o

Articlehistory:

Received16November2019 Accepted22January2020 Availableonline22February2020

Keywords:

Defecationdisorders Pelvicﬂoor

Seniors

Analincontinence Intestinalconstipation

a bs t r a c t

Introduction:Defecationdisorders,whetheranalincontinenceorchronicintestinalconsti- pation,arefrequentpelvicﬂooralterationsinthegeneralpopulationandaremorecommon inthosewithriskfactors,i.e.,intheelderly,womenwithanobstetricbackground,andthose withcomorbidities,historyofpelvicradiotherapy,diabetics,thebedridden,orthosewith historyoforiﬁcesurgery,amongothers.

Objective:Toanalyzetheincidenceofdefecationdisordersingeriatricpatientstreatedat theMedicalSpecialtiesOutpatientService(MSOS)ofHospitalSantaMarcelina.

Methods:Prospective, randomized study that interviewed the same patients in two moments:1)subjectiveanamnesisthroughspontaneoushistoryand2)objectiveanamnesis withspeciﬁcquestionnairestoassessanalincontinenceandchronicconstipation.

Results:BetweenMarch2016andJune2017,149patientswereanalyzed,ofwhom114(76.5%) werefemale,withasimilarmeanagebetweengenders;51.67%hadsymptomsofanal incontinenceand/orchronicconstipation.Only35.5%ofpatientswithcomplaintsoffecal leakageorﬂatusspontaneouslyreportedthem,while87.1%ofconstipatedpatientsdidso.

Inthepresentstudy,nosigniﬁcantcorrelationwasobservedbetweenthemodeofdelivery (p=0.106),pregnancy(p=0.099),andthenumberofdeliveries(p=0.126)withanalinconti- nence.Inturn,therewasnohigherincidenceofchronicintestinalconstipationinfemales (p=0.099)andmostpatientswiththiscomplainthadBristoltype1or2stools.

Conclusion: Theincidenceofdefecationdisordersinthegeriatricpopulationishighand, mostnotably,analincontinenceisnotspontaneouslyreportedbymostpatients.

licenses/by-nc-nd/4.0/).

∗ Correspondingauthor.

E-mail:[email protected](I.J.CorrêaNeto).

https://doi.org/10.1016/j.jcol.2020.01.006

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Estudodosdistúrbiosdadefecac¸ãoempacientesidosos

Palavras-chave:

Distúrbiosdaevacuac¸ão Assoalhopélvico Idosos

Incontinênciaanal Constipac¸ãointestinal

r e s u m o

Introdução: Osdistúrbiosdaevacuação,sejaaincontinênciaanalouaconstipaçãointesti- nalcrônica,representamalteraçõesdoassoalhopélvicobastantefrequentenapopulação emgeralemaiscomumentenaquelescomfatoresderisco,ouseja,emidosos,mulheres compassadoobstétrico, comorbidades,antecedentederadioterapiapélvica,diabéticos, acamados,históriadecirurgiasorificiais,dentreoutros.

Objetivo:Analisaraincidênciadedistúrbiosdefecatóriosempacientesgeriátricosatendidos noAmbulatóriodeEspecialidadesMédicas(AME)doHospitalSantaMarcelina.

Metodologia: Estudoprospectivoealeatóriocomaentrevistadomesmopacienteemdois momentos:1)Anamnesesubjetivaatravésdahistóriaespontâneae2)Anamneseobjetiva comquestionáriosespecíficosparaavaliaçãodeincontinênciaanaleconstipaçãointestinal crônica.

Resultados: Foramanalisados149pacientesentreMarc¸ode2016eJunhode2017,sendo114 (76,5%)dosexofemininocommédiadeidadesemelhanteentreossexos;51,67%apresen- tavamsintomasdeincontinênciaanale/ouconstipac¸ãointestinalcrônica.Apenas35,5%

dospacientescomqueixasdeescapedefezesouflatosrelataramdeformaespontâneae 87,1%dospacientesconstipadosofizeram.Nopresenteestudonãoseverificoucorrelação significativaentreviadepartop=0,106,gestaçãop=0,099enúmerodepartosp=0,126 comincontinênciaanal.Poroutrolado,nãoseverificoumaiorincidênciadeconstipação intestinalcrônicanosexofemininop=0,099eamaioriadospacientescomessaqueixa apresentavamfezesressecadastipoBristol1ou2.

Conclusão:Incidênciadedistúrbiosdadefecac¸ãonapopulac¸ãogeriátricaéelevadae,notada- menteaIAnãoéreferidadeformaespontâneapelamaioriadospacientes.

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Defecationdisorders,whether anal incontinenceorintesti- nalconstipation,arefrequentpelvicﬂooralterationsinthe general population and are more common in those with risk factors, i.e., in the elderly, women with an obstetric background,andthosewithcomorbidities,historyofpelvic radiotherapy,diabetics,thebedridden,orthosewithhistory oforiﬁcesurgery,amongothers.^1,2

Analincontinence(AI)isdeﬁnedastheinvoluntaryand recurrentpassageoffecesorgasthroughtheanalcanal.^3–5It isamultifactorialdisorderwithasigniﬁcantimpactonquality oflife,duetoitsphysicalandpsychologicalconsequences,^6–8 anditisthesecond leadingcauseofinstitutionalizationin theelderlypopulationintheUnitedStates.^9,10 Itsestimated incidencerangesbetween2%and7%,⁵andcanreachupto 13.6%inindividualsover65years¹¹and16.9%inthoseover85 years.However,itshouldbenotedthatthesedataarewidely underestimated,¹²sinceabout50%to70%ofpatientswithAI haveneverreportedittotheirphysicians,^13,14whichmakes theresearchonthisconditionextremelyimportant.

Inturn,intestinalconstipationisoneofthemostcommon functional gastrointestinal disorders, with high prevalence inthepopulation, affecting16%ofadultsand33%ofthose over 60 years of age,¹⁵ notably females,^16,17 witha female tomale prevalenceof2:1.¹⁸ Furthermore,severe intestinal

constipation,i.e.,lessthantwobowelmovementspermonth, ispracticallyexclusivetowomen.¹⁹

To identify and classify chronic constipation,the Rome III criteria²⁰ can be used to deﬁne constipation through a combinationofobjective(frequencyofstools,manualmaneu- vers necessary for defecation) and subjective symptoms (drystools,feelingofincompleteevacuation, andfeelingof obstruction).

Inastudyconductedbytheauthors,²¹ahigherincidenceof constipationwasobservedinfemalepatients(p=0.002),without astatisticallysigniﬁcantcorrelationwithage(p=0.576).

Moreover, a substantial correlation was observed between reportedorsubjectiveconstipationwiththeRomeIIIcriteria, withakappavalueof0.665.

Thus, withtheprogressiveaging ofthe population, this subject has become more relevant due to the associated conditions. In this regard, data from the Brazilian Insti- tuteforGeographyandStatisticsindicatethat,in2050,the lifeexpectancy ofBraziliansatbirthwillbe81.3years,the same asthatofthe Japanesepopulation,and inthat same year, the elderly populationover 65 willreach 18%, equal- ing that of those under 14 years.²² In the United States, the life expectancy of a 65-year-old woman is another 20 years, and the population over 85 years is expected to increasefromﬁveto20millionbetweentheyears2000and 2050.²³

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Objective

Toanalyzetheincidenceofdefecationdisordersingeriatric patientstreatedattheMedicalSpecialtiesOutpatientClinic (MSOC)ofHospitalSantaMarcelinaandtocorrelatethepelvic ﬂoordisorderswithsymptomsofdepressioninthisagegroup.

Methods

Thiswasprospective,randomizedstudycarriedoutbyinter- viewingpatientsattheGeriatricsandGerontologyMSOCof HospitalSantaMarcelinabetweenMarch2016andJune2017.

To collect data, the same patient was interviewed in two moments.Intheﬁrstinstance,asubjectivecasehistorywas obtained through spontaneous history-taking; in a second analysis, conducted immediately after the ﬁrst,a directed questionnairewasapplied,objectivelyanddirectlyaddressing whetherthepatientreferredsymptomsofAIand/orconstipa- tion,withsubsequentquestioningofpossibleriskfactorsfor bothAIandconstipation.

Allpatientsovertheageof60yearsthatwereattendedtoat theoutpatientclinicduringthereferredperiodwereincluded;

thosewithintestinaldiversionorwhodidnotconsenttopar- ticipateintheresearchwereexcluded.

Theanalyzeddatawereasfollows:sex,age,comorbidities, medicationsinuse,bodymassindex(BMI),previouspelvicor oriﬁcesurgery,historyofdepression,historyofsmokingand alcoholuse,defecationdisorders(usingtheRomeIIIcriteria), AIsymptoms(usingtheClevelandClinicAIindex),andstool consistency. In cases of female participants, the following obstetricdatawerecollected:numberofpregnancies,numberofdeliveries,numberofabortions/miscarriages,routesof delivery,useofforceps,historyofepisiotomy,andhighestfetal weight.

Allpatientssignedaninformedconsent,andthestudywas approvedbytheResearchEthicsCommitteeofHospitalSanta Marcelinawithsubstantiatedopinionnumber3,308,394.

Statisticalanalysis

Thiswasadescriptivestudyusingmeansandstandarddevi- ationsforquantitativevariables;theirqualitativedistribution wasassessedusingthechi-squaredtestorFisher’sexacttest whennecessary.

Alltestsperformedtookintoaccountabidirectional␣of 0.05and a95% conﬁdenceinterval (95%CI),and were per- formedusingIBMSPSSv.23andExcel2010® (MicrosoftOfﬁce).

Results

Atotalof149elderlypatientsfromtheGeriatricsandGeron- tologyMSOCofHospitalSantaMarcelinawererandomlyand prospectivelyanalyzedbetweenMarch2016andJune2017,114 (76.5%)ofwhomwerefemale;themeanagewas77.49years inwomen(60–103years)and78.31yearsinmen(60–94years).

Ofthetotal,96.65%ofpatientshadatleastonecomorbidity, andthemeanBMIinmenwas26.81kg/m²(14.5–39.08kg/m²) inmenand27.33(11.7–48.68kg/m²)inwomen.

Complaintsofdefecationdisorders(symptomsofAIand/or intestinalconstipation)wererecordedin77patients(51.67%):

12men(34.28%)and65women(57.01%).

Regardingthespontaneousreportoffecalleakageand/or ﬂatus,itwasfoundthat64.5%ofthepatientsdidnotreportit, exceptwhenquestioneddirectly;ofthepatientswithsymp- tomsofAI,85.4%werefemale,occurringin36%oftheelderly womenand20%oftheelderlymen;thisdifferenceininci- dencewasnotstatisticallysigniﬁcant(p=0.803).Inthisgroup ofpatients,theminority(8.3%)hadsoftstools(Bristol5,6,or 7).

Moreover,ofthewomenwithsymptomsofAI,97.5%had vaginaldelivery, whileinthose without this morbidity the percentagewas 90.7% (p=0.106). Nostatisticallysigniﬁcant correlationwasobservedbetweenpregnancy(p=0.099)and numberofdeliveries(p=0.126)withsymptomsofAI.

Whenassessingthecomorbiditiesingeriatricpatients,it wasobservedthat75individuals(50.33%)haddiseaseswith potentialriskfactorsforAIand,ofthese,33%reportedsymp- toms ofAI. Moreover,28.26% had associated symptomsof constipation.

Inturn,93.75%ofpatientswhomettheRomeIIIconsti- pationcriteriareportedthesymptomspontaneously,witha meanageof78.87years.Ofthesepatients,78.12%werewomen (p=0.099)and56.25%haddrystool(Bristol1or2).

Itwasalsoobservedthat42patientsreportedsomedegree ofdepression(28.18%),withanincidenceof17.14%inmenand 31.57%inwomen.Ofthese42patients,40.47%hadsymptoms ofAIandnine(21.42%)hadintestinalconstipationassessed using the objective Rome III criteria. When stratifying the referredsymptomofdepressiontosex,44.44%ofwomenwith depressionhadAIand16.67%ofthemhadintestinalconstipation.Inturn,16.67%ofmenwithdepressionhadAIand33.33%

ofthemhadintestinalconstipation.

Discussion

Theprogressiveincreaseinlifeexpectancyworldwideandin Brazil,combinedwithotherrisingfactors,suchasobesityand diabetesmellitus,willleadtoagreaterincidenceofpelvicﬂoor disordersinthenot-so-distantfuture,especiallyinpatients withotherriskfactorsforthismorbidity(Table1).

With advancingage, decompensated clinical conditions, suchasdiabetesmellitus,stroke,cognitivealterations, and impairedmobility,apparentlyhaveamoreprominentinflu- ence on continence mechanisms, whether anal orurinary, thandirectdamagetothepelvicfloor,^24,25 accordingtodata presentedhere;thepresentstudydidnotobserveevidenceof asignificantcorrelationbetweenparityandrouteofdelivery withsymptomsoffecalleakageandflatus.

Studies report the incidence of AI ranging from 7% to 12%^26,27and,similarlytootherstudiesintheliterature,^1,28,29 the present study observed an incidenceof elderly people withsymptomsofhigh AI(30.87%).Alsocorroboratingpre- vious data, most patients do not report this symptom to their physicians spontaneously; in addition to other phys- ical and emotionalproblems, this issuemay leadthem to isolation from social life.^3,13 Regarding the presence of AI symptomsintheelderly,theliteratureindicatesanincidence

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Table1–Incidenceandepidemiologicaldataofdefecationdisordersintheelderly(analincontinenceandconstipation).

Analincontinence Intestinalconstipation

Incidence 30.87% 20.8%

Spontaneouslyreportedsymptom 35.5% 87.1%

Meanage 79.43years(60–103years) 78.87years(65–96years)

MeanBMI 27.08kg/m²(11.7–48.68kg/m²) 27.18(15.47–48.68)

Index 82.6%mildanalincontinence 90.32%>2RomeIIIcriteria

Consistencyofstool 8.69%Bristol6or7 54.83%Bristol1or2

ofapproximately15%inthecommunity,18%–33%inhospi- tals,38%innursinghomes,andbetween50%to70%inelderly institutions.^30–32

Kanget al.³³ demonstrated a signiﬁcantincrease inthe incidence of AI in people over 50 years (p=0.001), with- outanimportantdifferencebetweenmenandwomen(6.2%

vs. 6.8%; p=0.717) and without a predilection forpatients withdiabetes(p=0.069).Therewasalsoastatisticallysignif- icantcorrelation,ingeneral,betweenAI,moreliquidstools (p<0.001),irritablebowel(p=0.04),andsomatizationofsymptoms(p=0.001).However,whencomparingpeopleolderand youngerthan50years,thefactorsinvolvedwithahigherinci- denceoffecalleakageandﬂatuswereconsistencyofthestools (p=0.002),functionaldiarrhea(p=0.001),functionalconstipa- tion(p=0.025),andsomatizationofsymptoms(p=0.016).

InBrazil,Lopes³⁴demonstrated,inhisMasterDegree’sthe- sis,anAIprevalenceof10.9%intheelderlyattendedtoata generalgeriatricoutpatientclinicoftheHospitaldasClínicas oftheFacultyofMedicineoftheUniversityofSãoPaulo,while inthepresentstudythisincidencewas30.87%.

Regardingthecoexistenceofcomorbiditieswithpossible risk factors for defecation disorders, it was observed that 50.33% of the elderly had diseases that are potential risk factorsforAI.Similarly, Tronconetal.³⁵ analyzeddigestive symptomsinpatientswithdiabetesandcomparedthemwith individualswithoutdiabetes;thoseauthorsdemonstrateda 16.9%rateofconstipationinthispopulationanda4.5%rate ofAI,butthedifferenceinprevalencebetweengroupswasnot statisticallysigniﬁcant.

Furthermore,itisalsonoteworthythat40.42%ofpatients withdepression reported flatus leakageor stainingof gar- ments;44.44%ofwomenwithdepressionhadAI.Similarly, Wuetal.²⁵ observedanimportantassociationbetweenthis modifiableriskfactorandAI,withanincreaseofuptofive- fold;Matthewsetal.alsodemonstratedthisassociation,with ariskfactorof2.28.²⁴

Inturn,consistentwiththeliteraturedata,15,16,21,36intesti- nalconstipationwaspresentin20.8%oftheelderlystudied.

Moreover, this symptom is more spontaneously reported bypatients:anequivalencewasobservedbetweenreported constipationandconstipationveriﬁedthroughtheRomeIII criteria,asdemonstratedinpreviousstudies.^21,37 Regarding theassociationofconstipationwithdepression,inthepresent studythiscorrelationwasobservedin16.67%and33.33%of womenand men,respectively.Inthissense, Gomesetal.³⁶ foundarelativeriskof1.96forantidepressantconsumption and constipationinfemales, withgreater inﬂuence ofone morbidityonanotherinwomenthaninmen(p<0.05).

Finally,thisstudypresentsdatathatallowtheauthorsto inferthatageisinitselfanimportantriskfactorforpelvic

ﬂoordefecationdisorders,sincetherewasnostatisticalsig- niﬁcancenoraclearlinkbetweenpregnancy,deliveryroute, andnumberofdeliverieswithsymptomsofAIintheelderly.

Furthermore,inthisagegroup,unlikeothers,sexdidnothave astatisticalinﬂuenceonahigherpercentageofconstipation infemales.

Asalimitingfactorofthestudy,itisnoteworthythefact thatthestudywasconductedinaspecializedoutpatientclinic ratherthaninthegeneralpopulation;however,themethod- ology ofthe studyandthe interviewmethod,whichaimed toassesshowthesymptomswerenaturallyreported,makes itavalidwarningtohealthprofessionalswhoworkwiththe geriatricpopulation.

Conclusion

Theincidenceofdefecationdisorders inthegeriatricpopu- lationishigh,particularlyAI;moreover,AIisnotacondition thatpatientsnaturallyreporttotheirphysicians.Therefore,it isimperativetobeawareoftheriskfactorsinvolvedinthese disordersinordertoprovidebettercaretothesepatients.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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