The Treatment of Chronic Constipation in Adults: A Systematic Review

OBJECTIVE: To evaluate whether laxatives and fiber therapies improve symptoms and bowel movement frequency in adults with chronic constipation. DATA SOURCES: English language studies were identified from computerized MEDLINE (1966 –1995), Biological Abstracts (1990 –1995), and Micromedex searches; bibliographies; textbooks; laxative manufacturers; and experts. STUDY SELECTION: Randomized trials of laxative or fiber therapies lasting more than 1 week that evaluated clinical outcomes in adults with chronic constipation. MEASUREMENTS AND MAIN RESULTS: Two independent reviewers appraised each trial's characteristics including methodologic quality. There were 36 trials involving 1,815 persons from a variety of settings including clinics, hospitals and nursing homes. Twenty-three trials were 1 month or less in duration. Several laxative and fiber preparations were evaluated. Twenty trials had a placebo, usual care, or discontinuation of laxative control group, and 16 directly compared different agents. Laxatives and fiber increased bowel movement frequency by an overall weighted average of 1.4 (95% confidence interval [CI] 1.1–1.8) bowel movements per week. Fiber and bulk laxatives decreased abdominal pain and improved stool consistency compared with placebo. Most nonbulk laxative data concerning abdominal pain and stool consistency were inconclusive, though cisapride, lactulose, and lactitol improved consistency. Data concerning superiority of various treatments were inconclusive. No severe side effects for any of the therapies were reported. CONCLUSIONS: Both fiber and laxatives modestly improved bowel movement frequency in adults with chronic constipation. There was inadequate evidence to establish whether fiber was superior to laxatives or one laxative class was superior to another

Predictors of Recovery in Activities of Daily Living Among Disabled Older Persons Living in the Community

OBJECTIVE: To identify the factors that predict recovery in activities of daily living (ADLs) among disabled older persons living in the community. DESIGN: Prospective cohort study with 2-year follow-up. SETTING: General community. PARTICIPANTS: 213 men and women 72 years or older, who reported dependence in one or more ADLs. MEASUREMENTS AND MAIN RESULTS: All participants underwent a comprehensive home assessment and were followed for recovery of ADL function, defined as requiring no personal assistance in any of the ADLs within 2 years. Fifty-nine participants (28%) recovered independent ADL function. Compared with those older than 85 years, participants aged 85 years or younger were more than 8 times as likely to recover their ADL function (relative risk [RR] 8.4; 95% confidence interval [CI] 2.7, 26). Several factors besides age were associated with ADL recovery in bivariate analysis, including disability in only one ADL, self-efficacy score greater than 75, Folstein Mini-Mental State Examination (MMSE) score of 28 or better, high mobility, score in the best third of timed physical performance, fewer than five medications, and good nutritional status. In multivariable analysis, four factors were independently associated with ADL recovery—age 85 years or younger (adjusted RR 4.1; 95% CI 1.3, 13), MMSE score of 28 or better (RR 1.7; 95% CI 1.2, 2.3), high mobility (RR 1.7; 95% CI 1.0, 2.9), and good nutritional status (RR 1.6; 95% CI 1.0, 2.5). CONCLUSIONS: Once disabled, few persons older than 85 years recover independent ADL function. Intact cognitive function, high mobility, and good nutritional status each improve the likelihood of ADL recovery and may serve as markers of resiliency in this population

Randomized Trial of Case-Finding for Depression in Elderly Primary Care Patients

OBJECTIVE: To determine the effect of case-finding for depression on frequency of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of follow-up in elderly primary care patients. DESIGN: Randomized controlled trial. SETTING: Thirteen primary care medical clinics at the Kaiser Permanente Medical Center, an HMO in Oakland, Calif, were randomly assigned to intervention conditions (7 clinics) or control conditions (6 clinics). PARTICIPANTS: A total of 2,346 patients aged 65 years or older who were attending appointments at these clinics and completed the 15-item Geriatric Depression Scale (GDS). GDS scores of 6 or more were considered suggestive of depression. INTERVENTIONS: Primary care physicians in the intervention clinics were notified of their patients' GDS scores. We suggested that participants with severe depressive symptoms (GDS score ≥ 11) be referred to the Psychiatry Department and participants with mild to moderate depressive symptoms (GDS score of 6 –10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group sessions on coping with depression led by a psychiatric nurse. Primary care physicians in the control clinics were not notified of their patients' GDS scores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Physician diagnosis of depression, prescriptions for antidepressant medications, prevalence of depression as measured by the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS ≥ 6) at baseline, including 162 in the intervention group and 169 in the control group. During the 2-year follow-up period, 56 (35%) of the intervention participants and 58 (34%) of the control participants received a physician diagnosis of depression (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.6 to 1.6; P = .96). Prescriptions for antidepressants were received by 59 (36%) of the intervention participants and 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P = .3). Two-year follow-up GDS scores were available for 206 participants (69% of survivors): at that time, 41 (42%) of the 97 intervention participants and 54 (50%) of the 109 control participants had GDS scores suggestive of depression (OR, 0.7; 95% CI, 0.4 to 1.3; P = .3). Comparing participants in the intervention and control groups, there were no significant differences in mean GDS change scores (−2.4 ± SD 3.7 vs −2.1 SD ± 3.6; P = .5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8 ± SD 3.1 vs 1.6 ± SD 2.8; P = .5) or mean number of hospitalizations (1.1 ± SD 1.6 vs 1.0 ± SD 1.4; P =.8) during the 2-year period. In participants with initial GDS scores >11, there was a mean change in GDS score of −5.6 ± SD 3.9 for intervention participants (n =13) and −3.4 ± SD 4.5 for control participants (n = 21). Adjusting for differences in baseline characteristics between groups did not affect results. CONCLUSIONS: We were unable to demonstrate any benefit from case-finding for depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more intensive patient education and follow-up will improve outcomes of primary care patients with depression