Geriatric Nursing 41 (2020) 992 999

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Geriatric Nursing
journal homepage: www.gnjournal.com

Feature Article

Non-pharmacological interventions to improve constipation amongst

older adults in long-term care settings: A systematic review of
randomised controlled trials
Iria Dobarrio-Sanz, MSc, BSc, RNa,
Jose
Manuel Herna
ndez-Padilla, PhD, MSc, PGCertEd, BSc, RNa,b,*,
María Mar Lo
pez-Rodríguez, PhD, MSc, BSc, RNa,
Cayetano Ferna
Granero-Molina, PhD, BA, BSc, RNa,c,

ndez-Sola, PhD, BA, BSc, RNa,c, Jose
María Dolores Ruiz-Ferna
ndez, PhD, MSc, BSc, ANPa
a
Department of Nursing, Physiotherapy and Medicine. Universidad de Almería. Almería, Spain
b
Adult, Child and Midwifery Department. School of Health and Education. Middlesex University. London, United Kingdom
c

noma de Chile. Temuco, Chile
Associate Researcher. Faculty of Health Sciences. Universidad Auto

A R T I C L E I N F O A B S T R A C T

Article history: Constipation is a highly prevalent condition amongst older adults in long-term care settings and laxatives are
Received 26 May 2020 not always the solution. We aimed to examine the characteristics and the effects of non-pharmacological
Received in revised form 21 July 2020 interventions to improve constipation amongst older adults in long-term care settings. Eligible studies were
Accepted 22 July 2020
identified using PubMed, CINAHL, Scopus, Web of Science, Cochrane and EMBASE (up to April 2019). We
Available online 5 August 2020
included 7 studies with a total of 657 patients. Five interventions improved the number of bowel movements
(i.e. laxative tea, fermented oat drink, patient education, probiotics and multi-component intervention). The
Keywords:
administration of probiotic capsules and fermented oat drinks also improved stool form. Auricular acupres-
Constipation
Aged
sure improved constipation symptoms and constipation-related quality of life. After appraising the trials’
Older adults methodological quality and risk of bias, we cannot recommend any non-pharmacological interventions to
Nursing homes improve constipation amongst older adults in long-term care settings until more robust studies have been
Systematic review conducted.
© 2020 Elsevier Inc. All rights reserved.

Introduction of defecations, (5) use of manual manoeuvres to facilitate defecation

Constipation is a common gastrointestinal disorder that nega-
tively affects people’s quality of life and burdens healthcare services
worldwide.1 3 It is estimated that constipation affects between 6 and
18% of community-dwelling older adults4,5 and more than 60% of
older adults in long-term care settings.6,7 In older adults, constipation
is associated with frailty8 and decreased quality of life.4,9 Therefore,
prevention and treatment of constipation should be a priority for
nurses who look after older adults in long-term care settings.
The Rome IV criteria define constipation as the presence of two or
more of the following symptoms: (1) straining to evacuate in more
than 25% of defecations, (2) lumpy or hard stools in more than 25% of
defecations, (3) sensation of incomplete evacuation in more than 25%
of defecations, (4) sensation of anorectal blockage in more than 25%
*Corresponding author at: Department of Nursing, Physiotherapy and Medicine, Uni-
versidad de Almería, Carretera Sacramento s/n. CP: 04007, Almería, Spain.
E-mail address: j.hernandez-padilla@ual.es (J.M. Hern
andez-Padilla).
in more than 25% of defecations, and (6) fewer than three spontane-
ous bowel movements per week.10,11 According to these criteria,
symptoms must have started at least 6 months before the diagnosis
and they must have been present for at least 3 months.10,11
In older adults, constipation has been linked to flatulence, abdom-
inal pain, bloating, reflux, dysphagia, sickness and vomiting.12,13 Fur-
thermore, constipation in older adults is associated with anorexia,14
urinary incontinence,15 faecal impaction,5 osteoporosis, arthritis16
and colorectal cancer.17 Other evidence suggests that constipation in
older adults could also be linked to anxiety, depression,9,18 loneliness,
social isolation,19 sleep disturbances and frailty.6
Laxatives are often used to alleviate constipation symptoms
amongst older adults in long-term care settings.5,16,20 However,
some evidence suggests that laxatives are not always effective21 and
their prolonged use could have a negative impact on older adults’
health.19,22 It is recommended that nurses design and implement
non-pharmacological interventions to improve constipation amongst

https://doi.org/10.1016/j.gerinurse.2020.07.012
0197-4572/$ see front matter © 2020 Elsevier Inc. All rights reserved.
 I. Dobarrio-Sanz et al. / Geriatric Nursing 41 (2020) 992 999
older adults in long-term care settings.18,23,24 Previously published
studies have evaluated the effects of non-pharmacological interven-
tions such as probiotics,25 trans-anal irrigation,26 abdominal mas-
sage27 or acupuncture.28,29 Nonetheless, the effectiveness of these
interventions amongst older adults in long-term care settings needs
to be studied in more depth.
Nurses are first line professionals in long-term care settings30;
hence the importance for them to implement non-pharmacological
interventions that improve constipation amongst older adults in
long-term care settings. To date, several systematic reviews have
evaluated the effectiveness of laxatives in the treatment of constipa-
tion amongst community-dwelling31 and older adults in long-term
care settings.32 Other literature reviews have also assessed the effects
of complementary therapies33 and probiotics34 in community-dwell-
ing older adults with constipation. However, to the best of our knowl-
edge, no systematic review of randomised controlled trials has been
conducted yet that would allow us to rigorously assess the effects of
non-pharmacological interventions to improve constipation amongst
older adults in long-term care settings. The aim of this study was to
examine the characteristics and the effects of non-pharmacological
interventions to improve constipation amongst older adults in long-
term care settings.
Methods
Design
We conducted a systematic review of randomised controlled trials
following the Cochrane Handbook35 and the PRISMA guidelines.36
Search methods
We searched the literature in six databases (PubMed, CINAHL,
Scopus, Web of Science, Cochrane and EMBASE) between January
and April 2019. For example, we used the following search strategy
in the database PubMed: “constipation” AND (elderly OR aged OR
older) AND ("nursing home" OR "home for the aged" OR "care
home") AND (treatment OR therapy OR program OR programme OR
intervention). All the other search strategies in the different data-
bases can be accessed in Appendix 1.
Eligibility criteria
The criteria for the studies to be included in this review were: (1)
for the participants to be older adults (aged 60 or above) living in
long-term care settings; (2) to follow a randomised controlled trial
design; (3) to have been published in English, Spanish, French, Italian
or Portuguese language; (4) to implement and evaluate a non-phar-
macological intervention to improve constipation; (5) to include a
description of the methods used to assess constipation symptoms.
Search outcomes
In the identification phase, the databases search yielded 850
results. After removing 320 duplicates, we had 530 records left (see
Fig. 1). Then, we removed 453 records after screening by title and
abstract. In the eligibility phase, two reviewers from the research
team independently assessed 77 full-text papers. Both reviewers
agreed to remove 70 records for different reasons (see Fig. 1). Lastly,
we included 7 articles reporting 7 randomised controlled trials.
Quality appraisal
We followed the recommendations of the Cochrane Handbook for
systematic reviews of interventions to assess the studies’ risk of
993
bias.35 Two reviewers independently assessed the studies, and all the
discrepancies in the evaluation of risk of bias were reconciled by con-
sensus.
Risk of bias
We applied the Cochrane Collaboration tool35 to assess the stud-
ies’ risk of bias, rating each criterion as high, unclear or low risk of
bias (see Fig. 2). One study presented an unclear risk of bias in rela-
tion to the random sequence generation and five studies did not pro-
vide sufficient information about allocation concealment before
assignment. Four studies did not provide enough information about
blinding and their risk of performance bias was rated as unclear.
Three studies presented a low risk of detection bias as they clearly
described the methods used to blindly assess the outcome measures
in both groups. One of the studies did not mention the reasons for
attrition and presented a high risk of attrition bias. Four of the studies
presented a low risk of reporting bias and one of the studies pre-
sented a high risk of reporting bias. Lastly, four studies presented a
high risk of conflict of interest.
Data abstraction and synthesis
Two researchers independently extracted the information from
the seven studies included in this review. Following the Cochrane
Handbook, we created a template with the following headings for the
reviewers to independently extract the information: first author’s
name, year of publication, study title, sample size, study location,
study design, intervention characteristics, outcome measures and
main findings. We piloted the data extraction method with two of
the articles included in this review. There were no differences in the
data extracted by both reviewers and they reported not to have had
any issues with the extraction. The reviewers used this template to
extract the data from all studies. Then, an experienced third reviewer
verified the extracted data on the basis of their accuracy and com-
pleteness. A summary of extracted data can be seen in Table 1. We
could not conduct a meta-analysis due to the heterogeneity of the
interventions, the assessment methods and the findings reported in
the studies. Therefore, we performed a narrative synthesis of the
findings based on the characteristics of the interventions, the studied
variables and the reported findings.
Results
Narrative summary
This systematic review included 7 studies with a total of 657 older
adults in long-term care settings. All the studies followed a rando-
mised controlled trial design. The studies varied broadly in type of
intervention (drinks with laxative properties, individualised care
interventions, acupressure and probiotics), characteristics of inter-
vention (duration and follow-up), sample size and reported findings.
In addition to assessing the effects of the interventions on constipa-
tion, some studies also assessed their effects on urinary and faecal
incontinence (n = 1), activity level, fluid and caloric intake (n = 2) and
anorectal dyssynergia (n = 1).
Interventions’ details
The duration of the studies’ interventions ranged from 10 days to
32 weeks. The frequency with which subjects received the interven-
tions was either once a day (n = 4), twice a day (n = 1) or four times a
day (n = 2). All the studies implemented their interventions at an
individual level. The interventions were carried out by nurses across
six studies. The remaining study did not specify who implemented
994 I. Dobarrio-Sanz et al. / Geriatric Nursing 41 (2020) 992 999
Fig. 1. PRISMA study flowchart.
the intervention. Whilst four studies did not report any follow-ups,
other studies carried out either a 10-day (n = 2) or 6-month (n = 1)
follow-up. All the studies were carried out in the long-term care set-
tings where the participants lived. The studies were conducted in the
USA, Taiwan, Hong Kong, Finland and South Korea.
Three studies used products of identical appearance for the exper-
imental and placebo groups (i.e. tea, oat drinks and capsules). Four
studies used individualised care interventions. One of these studies
implemented an intervention in which participants were given an
individualised manual (simple sentences with pictures) on individual
instruction regarding the strategies for reducing constipation target-
ing personal risk factors (i.e. taking 25 30 g of fibre per day, guaran-
teeing a fluid intake of 1500 2000 ml a day, increasing physical
activity, promoting regular bowel patterns, carrying out abdominal
massage). Another study implemented an intervention in which
nurses checked participants for incontinence and prompted them to
use the toilet, offered a choice of food and fluid snack items and
prompted them to exercise (i.e. repeat sit-to-stands and walking or
wheelchair propulsion for up to five minutes). This was done four
times a day. Another study also implemented an intervention in
which nurses checked participants for incontinence and prompted
them to use the toilet, encouraged drinking (water or assorted juices)
and prompted them to exercise. This intervention was also imple-
mented four times a day. The remaining study implemented an auric-
ular acupressure intervention using plasters with magnetic pellets.
Five studies implemented interventions focused on a single com-
ponent such as a laxative herbal tea,37 a fermented oat drink,38 auric-
ular acupressure,39 capsules with probiotic formulation40 and a
manual on individual instruction regarding the strategies for reduc-
ing constipation targeting personal risk factors.41 Two studies carried
out a multi-component intervention. One of these studies imple-
mented an intervention in which participants were checked for
incontinence and prompted to use the toilet, offered a choice of food
and fluid snack items and prompted to exercise.42 The other multi-
component intervention study did the same but did not offer snack
items.43 In 5 studies, the sample was divided into two groups (i.e.
control and experimental). In 2 studies, the results were compared
between 3 groups (i.e. two experimental groups and one control
group). The control groups received either “usual care” (n = 3) or a
placebo (n = 4).
 I. Dobarrio-Sanz et al. / Geriatric Nursing 41 (2020) 992 999
Fig. 2. Risk of bias summary.
Patient outcomes
Bowel movements
Six out of seven studies evaluated the number or frequency of
bowel movements as an outcome criterion using daily records com-
pleted by the staff of geriatric institutions. Interventions that showed
to be effective in increasing the number of bowel movements in con-
stipated older adults were: drinking a cup of tea with laxative herbs
once a day (mean difference = 4.14; SD = 9.54; SE mean = 1.50;
p = .017)37; a manual on individual instruction regarding the strate-
gies for reducing constipation targeting personal risk factors
(F = 5133; p = .029)41; double-coated capsules of probiotic prepara-
tions (p < .05)40; prompting toilet use, offering a choice of food and
fluid snack items and prompting exercise (X2 = 25.4954; p < .001).42
In addition, oat drinks with B.Longum ferments (mean differ-
ence=6.7; 95% CI=(1.0, 12.4); p = .021) and B.Lactis ferments (mean
difference=5.2; 95% CI=(0.3, 10.2); p = .038) have shown to be effec-
tive in increasing the number of stools amongst older adults in long-
term care settings.38 In contrast, the intervention based on nurses
prompting participants to use the toilet, encouraging them to drink
(water or assorted juices) and prompting them to exercise did not
lead to a significant improvement on the number of defecations
(group x time F = 2,94, p = .090).43
995
Stool characteristics
Three studies evaluated the shape, amount and consistency of
stools. All three studies used participants’ daily bowel records. Yeun
and Lee40 evaluated the symptoms of constipation following the
Rome III criteria44 and found that capsules with probiotic formulation
improved "hard or lumpy stools" when compared to the administra-
tion of a placebo (p < .05). Pitk€ala
€ et al.38 developed their own scoring
system according to the amount of stool and its consistency (1=func-
tioning normally with solid or normal consistency of stools; 2=func-
tioning a little with solid or normal consistency of stools; 3=not
functioning; 4=functioning with soft stools; 5=functioning with diar-
rhoea). They did not find between-groups differences in the percent-
age of days in which older adults had diarrhoea or loose stools
(p = .585). Normal stool was significantly more frequent in the groups
of subjects who ingested oat drinks with B.Longum (mean differ-
ence=7.1; 95% CI=(2.3, 11.9); p = .004) and B.Lactis (mean differ-
ence=6.7; 95% CI=(2.5, 10.9); p = .002) when compared to subjects
assigned to the control group. Furthermore, 37% of the subjects who
took B.Longum and 30% of the subjects who took B.Lactis had normal
stools on at least 30% of the days, compared to 13.7% of subjects in
the control group (OR=3.44; 95% CI=(1.22, 9.70); p = .020 and
OR=2.75; 95% CI=(1.07, 7.07); p = .036, respectively). Another study
used the Bristol Scale to assess stool form45 and did not find a manual
996 I. Dobarrio-Sanz et al. / Geriatric Nursing 41 (2020) 992 999

Table 1
Summary of studies included in the review.

Author, year, location 1. Design 1. Intervention setting Intervention Outcome measures

2. Sample size 2. Length of the intervention
3. Testing intervals 3. Control condition

Bub et al., (2006), USA.
Huang et al., (2015), Taiwan.
Li et al., (2014), Hong Kong.
€l €
Pitka a et al., (2007), Finland.
Schnelle et al., (2010), USA.
Simmons and Schnelle (2004), 1. RCT
USA. 2.130
3. Pre/Post
1. RCT 1. Nursing home (n = 1) Participants drank one cup of herbal tea contain- Number of bowel movements.
2. 92 2. 28 days ing 20 mg of sennosides in the afternoon. Number of laxatives taken.
3. Pre/Post 3. Placebo tea Cost of laxative treatment.
1. RCT 1. Nursing home (n = 4) Participants were given an individualised manual Frequency of defecation.
2. 43 2. 8 weeks (simple sentences with pictures) on individual Constipation symptoms.
3. Pre/Post 3. Care as usual instruction regarding the strategies for reduc- Stools form.
ing constipation targeting personal risk factors. Type and dosage of laxatives.
1. RCT 1. Nursing home (n = 13) Participants in the experimental group received Constipation symptoms.
2. 99 2. 10 days auricular acupressure using auricular plasters Constipation-related quality of life.
3. Pre/Post/10 days 3. Auricular plasters with magnetic pellets. Participants in placebo-
controlled group received auricular acupres-
sure using auricular plasters with Semen
Vaccariae.
1. RCT 1. Nursing home (n = 2) Participants allocated to experimental group 1 Normal bowel movements.
2. 209 2. 21 days drank a 200 ml oat drink with fermented Bifi- Diarrhoea or loose stools.
3. Pre/Post/6 months 3. Placebo drink dobacteria longum (B. Longum) once a day. Normal bowel function.
Participants allocated to experimental group 2
drank a 200 ml oat drink with fermented Bifi-
dobacterium lactis (B. Lactis) once a day.
1. RCT 1. Nursing home (n = 6) Nurses checked participants for incontinence and Number of defecations.
2. 125 2. 3 months prompted them to use the toilet, offered a Incontinence.
3. Pre/Post/10 days 3. Care as usual choice of food and fluid snack items and Fluid and caloric intake (between meals).
prompted them to exercise (i.e. repeat sit-to- Level of activity.
stands and walking or wheelchair propulsion
for up to five minutes). The intervention was
implemented four times a day.
1. Nursing home (n = 2) Nurses checked participants for incontinence and Number of bowel movements.
2. 32 weeks prompted them to use the toilet, encouraged Functional status.
3. Care as usual drinking (water or assorted juices) and Nutritional status.
prompted them to exercise. The intervention
was implemented four times a day.

Yeun and Lee (2015), South 1. RCT 1. Nursing home (n = 1) Participants received one capsule (350 mg) con- Frequency of defecations.
Corea. 2. 40 2. 2 weeks taining six bacterial strains doubly coated with Changes in Rome III criteria.
3. Pre/Post 3. Placebo capsule proteins and polysaccharides. Changes in faecal bacteria.

on individual instruction regarding the strategies for reducing consti-
pation targeting personal risk factors to significantly improve stool
form (F = 0,301; p > .05).41
Use of laxatives
Four studies described ‘use of laxatives’ as an outcome measure.
However, one of them does not provide clear data on the statistical
significance of the between-groups differences, hence why these
data have not been interpreted as evidence of the intervention’s effi-
cacy.37 Another study attempted to analyse laxative use from a sub-
sample of the total sample, but on such a small scale that it was
considered insufficient to draw conclusions by its own authors.39
One study found no significant association between having oat drinks
with ferments and a decreased use of laxatives.38 Lastly, another
study showed that a decrease in the number of laxatives used was
associated with time (F = 4776; p = .014) and not with a manual on
individual instruction regarding the strategies for reducing constipa-
tion targeting personal risk factors (F = 0,168; p > .05).41
Other constipation-related symptoms
Three studies explored other symptoms related to constipation
using various assessment tools. One study explored changes in bowel
sounds. Using a stethoscope, a trained nurse explored each partici-
pant's abdomen 5 15 min before each meal. A manual on individual
instruction regarding the strategies for reducing constipation target-
ing personal risk factors was associated with a significant increase in
bowel sounds (F = 5176; p = .01).41 Yeun and Lee40 evaluated other
symptoms of constipation following Rome III criteria.44 This study
found that capsules with probiotic formulation improved manual
manoeuvres to facilitate defecation compared to a placebo (p < .05).
However, these capsules did not lead to a significant improvement in
the sensation of anorectal obstruction or blockage and the effort to
evacuate (p > .05). Two studies39,41 used the Patient Assessment of
Constipation Symptoms Questionnaire (PAC-SYM), which assesses
constipation symptoms in 3 areas: abdominal symptoms, rectal
symptoms and faeces.46 The intervention based on a manual on indi-
vidual instruction regarding the strategies for reducing constipation
targeting personal risk factors was not shown to be effective in
improving constipation symptoms (F = 2392; p > .05).41 In contrast,
auricular acupressure was associated with an improvement in consti-
pation symptoms immediately after the intervention (b= 0.31; 95%
CI=( 0.45, 0.10); p  .001) and at 10 days (b= 0.21; 95% CI=( 0.38,
0.05); p = .013).39 Li et al.39 also used the Patient Constipation Qual-
ity of Life Assessment Questionnaire (PAC-QOL) to assess quality of
life associated with constipation in terms of physical discomfort, psy-
chosocial discomfort, fears and concerns.47 Auricular acupressure
was shown to significantly improve quality of life amongst older
adults with constipation immediately after the intervention
(b= 0.28; 95% CI=( 0.40, 0.17); p  .001) and at 10 days of follow-
up (b = 0.19; 95% CI=( 0.32, 0.06); p = .005). Auricular acupressure
significantly reduced physical discomfort (b= 0.16; 95% CI=( 0.24,
0.08); p  .001), fears and concerns (b= 0.16, 95% CI=( 0.24,
0.08); p  .001) and increased satisfaction (b= 0.73; 95% CI=( 1.12,
0.35); p  .001). At follow-up, these positive changes were main-
tained in the 'fears and concerns' (b= 0.14; 95% CI=( 0.23, 0.05);
p = .003) and 'satisfaction' dimensions (b= 0.77; 95% CI=( 1.18,
0.34); p  .001) but there was no improvement in the 'psychosocial
distress' dimension (b=0.7; IC 95%=( 1.23, 2.63); p = .475).
 I. Dobarrio-Sanz et al. / Geriatric Nursing 41 (2020) 992 999
Discussion
In this review, we systematically examined the effects and charac-
teristics of non-pharmacological interventions to improve constipa-
tion amongst older adults in long-term care settings. We reviewed 7
studies reported in 7 articles. Interventions were found to vary in
duration, frequency and content, which made the comparison
between studies challenging. We suggest unifying criteria for consti-
pation assessment and adapting interventions to the assessment of
these criteria in order to confirm their effectiveness. Future studies
should consider the possibility of combining some of the interven-
tions included in this review with the aim of improving constipation
symptoms as well as the emotional, nutritional and functional status
of older adults in long-term care settings.
The number or frequency of bowel movements improved in five
out of seven studies included in this review.37,38,40-42 However, these
results should be interpreted cautiously because improved defecation
frequency may not lead to significant changes in stool characteristics
or general symptoms of constipation.41 Regarding frequency of bowel
movements, the findings from Bub et al.37 coincide with those from
other authors, who suggest that herbal medicine and sennosides are
effective non-pharmacological therapies to improve stool fre-
quency.22,33 Fermented oat drinks combined the laxative potential of
probiotics and fibre also improved stool frequency and normalisa-
tion.38 These results concur with studies that suggest supplementa-
tion with fibre and probiotics can increase the frequency of bowel
movements and improve other symptoms of constipation amongst
older adults in long-term care settings.32,34,40 The two multicompo-
nent intervention trials (i.e. toilet prompting, encouragement of
drinking and promotion of physical activity vs. toilet prompting,
encouragement of drinking and snacking and promotion of physical
activity) showed contradictory results regarding the improvement in
the number of defecations.42,43 While Schnelle et al. found a signifi-
cant improvement in stool frequency,42 Simmons & Schnelle did not
find their intervention to lead to significant changes in this outcome
variable.43 The difference between both interventions was that one
encouraged healthy snacking42 and the other one did not.43 There-
fore, it may be that increasing food intake and stimulating appetite
amongst older adults in long-term care settings could play a deter-
mining role in the prevention and treatment of constipation.7
Another study found that an individual instruction manual targeting
individual risk factors for constipation not only led to an improve-
ment in the number of defecations but also to a reduction in laxative
use associated with time.41 These results could be due to the fact that
nursing interventions based on promoting self-efficacy and self-care
can lead to patients actively participating in the management of their
own constipation.48 However, the studies by Schnelle et al.42 and
Huang et al.41 present an unclear risk of reporting bias (i.e. it is
unclear whether all statistically non-significant results were reported
by the authors) and it is difficult to ascertain the exact effectiveness
of their interventions.
Quality of life related to constipation amongst older adults in long-
term care settings was only assessed in one study.39 According to Li
et al.,39 auricular acupressure not only improves general symptoms of
constipation, but also physical discomfort, fears, concerns and satisfac-
tion associated with constipation amongst older adults in long-term
care settings. These findings concur with a study that suggests acu-
puncture could be an effective technique to treat constipation.33 This
concurrence could be due to the fact that auricular acupressure uses
the same body points as acupuncture.49 Furthermore, the findings
from Li et al.39 suggest that constipation has a direct impact on older
adults’ health at a biopsychosocial level19; hence why nurses should
consider constipation treatment and prevention a priority when caring
for older adults in long-term care settings.
997
Four out of the seven studies included in this review assessed the
participants’ use of laxatives as an outcome measure.37-39,41 How-
ever, none of the non-pharmacological interventions implemented in
these studies led to significant changes in the number of laxatives
used by older adults in long-term care settings.37-39,41 These findings
could be explained by the fact that, although the use of laxatives has
been shown not to guarantee normal stool frequencies or consisten-
cies,13,21 research suggests that the systematic use of laxatives in
geriatric institutions is often ingrained or in their care culture.13,23,50
In order to move away from a systematic use of laxatives, nurse clini-
cians and researchers should design, implement, and rigorously eval-
uate the effects of non-pharmacological interventions in constipated
older adults in long-term care settings.
The effects of non-pharmacological interventions to improve con-
stipation amongst older adults in long-term care settings were evalu-
ated differently in each study. Firstly, three studies used the number of
bowel movements as the only outcome variable,37,42,43 despite this
being only one of the criteria for the diagnosis of constipation. Then,
one study also evaluated stool consistency,38 another study evaluated
the results following the criteria of Rome III40 and two studies assessed
constipation symptoms included in the PAC-SYM.39,41 The evaluation
of an intervention to improve constipation should not be limited to
analysing its effect on bowel frequency and stool consistency. For
example, Huang et al.41 found that a manual on individual instruction
regarding the strategies for reducing constipation targeting personal
risk factors increased the number of bowel movements but did not
improve other symptoms of constipation. Failure to assess the effects
of different interventions on all symptoms supporting the diagnosis of
constipation is a methodological limitation that reduces the relevance
of the trials included in this review. Likewise, although it is recom-
mended to take into account the subjective descriptions of individuals
to support the diagnosis of constipation,19 only the trial by Li et al.39
evaluated the impact of their intervention on emotional aspects
related to constipation. Future studies will have to consider this and
assess the impact of their interventions on the emotional aspects of
constipation amongst older adults in long-term care settings.
The studies included in this review have some methodological
issues that could have affected their validity. Firstly, it is important
to emphasize that all the studies included in this review investi-
gated the effects of non-pharmacological interventions amongst
older adults in long-term care settings without focusing on a partic-
ular group of patients and including very heterogeneous samples.
Older adults in long-term care settings tend to present complex
pharmacological treatments in which opioids, derivatives of benzo-
diazepines, anticholinergic drugs, dopaminergic agents, antacids,
diuretics and tricyclic antidepressants are often present.23,51,52 Like-
wise, older adults in long-term care settings tend to present numer-
ous comorbidities.51,52 Both polypharmacy and comorbidities have
been associated with constipation and increased use of laxa-
tives.51,52 However, these two confounding variables were only
taken into account in two studies.40,41 Furthermore, in six out of the
seven trials included in this review, almost 80% of the participants
were women. This is relevant because it has been seen that women
are more at risk of using laxatives in geriatric institutions23 and
have a higher prevalence of constipation in general.53 Not having
considered the participants' gender, baseline conditions and phar-
macological treatments as confounding variables increases the risk
of bias, poses a threat to the studies’ external validity and limits the
generalisability of their results. Secondly, although it is known that
bedbound patients and people with cognitive impairment are at
higher risk of constipation,7 none of the studies included in this
review have taken into account these variables when selecting the
sample or analysing their data. This is particularly important
because four studies reported to have included large percentages of
998 I. Dobarrio-Sanz et al. / Geriatric Nursing 41 (2020) 992 999
bedbound or dementia patients in their trials.37,38,41,43 Not having
accounted for these two confounding variables affects the studies’
overall methodological quality and reduces their internal validity.
Although assessing self-reported constipation symptoms in older
adults with dementia can be challenging,37 studies exploring consti-
pation amongst patients with cognitive impairment should not limit
their outcome measures to the participants’ number of bowel move-
ments. We recommend future studies to include at least the follow-
ing Rome IV diagnostic criteria as outcome measures when
assessing constipation amongst older adults with dementia: stool
shape and consistency, number of spontaneous bowel movements
and number of manual manoeuvres used to facilitate defeca-
tion.10,11 Lastly, four studies included ‘use of laxatives’ as an out-
come measure.37-39,41 This means that their participants continued
to use laxatives throughout the trials, which jeopardises both the
internal and external validity of these studies. As participants con-
tinued to use laxatives during their trials, authors cannot ascertain
whether their results are caused by their non-pharmacological
interventions, the use of laxatives or a combination of both. We rec-
ommend that future studies make sure that laxatives have been dis-
continued from the participants’ treatment before commencing
their trials so that the effects of non-pharmacological interventions
to improve constipation amongst older adults in long-term care set-
ting can be assessed more rigorously.
Limitations
This systematic review has some limitations. Firstly, the literature
search yielded only seven studies that met the review’s inclusion cri-
teria, hence the decision to include all of them, regardless of their
methodological rigour. Consequently, the number of studies included
in this review is low and the variability in methodological quality
amongst them is high. Secondly, studies with different designs but
reporting relevant findings may have been excluded from this
review. Future reviews could take this into account and include
quasi-experimental studies. Thirdly, the heterogeneity of the inter-
ventions, the assessment methods and the findings reported in the
studies included in this review prevented us from conducting a
meta-analysis, which could have improved the validity of our find-
ings. Lastly, although the inclusion of all the found trials was aimed
at analysing the existing evidence on non-pharmacological interven-
tions to improve constipation amongst older adults in long-term care
settings, the high risk of bias of some trials could limit the validity of
this review’s findings.
Conclusion
Due to the risk of bias and methodological issues present in some
studies, we cannot recommend any non-pharmacological interven-
tions to improve constipation amongst older adults in long-term care
settings until more robust studies have been conducted. Future stud-
ies should take into account that older adults living in long-term care
settings have heterogeneous and complex characteristics that can act
as confounding variables in the data analysis. High-quality, well-
designed studies with rigorously planned interventions are needed
to be able to assess their efficacy objectively on all the dimensions of
constipation. Due to the high prevalence of constipation amongst
older adults in long-term care settings, we need effective non-phar-
macological interventions that can be integrated into daily care as an
effective alternative to the use of laxatives. It is recommended that
nurses rigorously design, implement and evaluate the effects of new
non-pharmacological interventions to improve constipation amongst
older adults in long-term care settings.
Declaration of Competing Interest
The authors declare not to have any conflict of interest.
Acknowledgements
We would like to thank the Health Sciences CTS-451 Research
Group and the Health Research Centre (CEINSA) from the Universidad
de Almería for their support.
Author contributions
Iria Dobarrio-Sanz contributed to the conception of the study, the
acquisition of data and their analysis. Iria has also been involved in
drafting the manuscript and has given her final approval of its sub-
mitted version. Iria agrees to be accountable for all aspects of the
work in ensuring that questions related to the accuracy or integrity
of any part of the work have been appropriately investigated.
Jos
e Manuel Herna
ndez-Padilla contributed to the conception,
design and data interpretation in the study. Jose
Manuel has also
been involved in drafting the manuscript and has given his final
approval of its submitted version. Jose
Manuel agrees to be account-
able for all aspects of the work in ensuring that questions related to
the accuracy or integrity of any part of the work have been appropri-
ately investigated.
María del Mar Lo
pez-Rodríguez contributed to the design of the
study and its data collection. María del Mar has also been involved in
drafting the manuscript and has given her final approval of its sub-
mitted version. María del Mar agrees to be accountable for all aspects
of the work in ensuring that questions related to the accuracy or
integrity of any part of the work have been appropriately investi-
gated.
Jos
e Granero-Molina contributed to the analysis and interpretation
of the data. Jose
has also been involved in revising the manuscript
and has given his final approval of its submitted version. Jose
agrees
to be accountable for all aspects of the work in ensuring that ques-
tions related to the accuracy or integrity of any part of the work have
been appropriately investigated.
Cayetano Ferna
ndez-Sola contributed to the analysis and interpre-
tation of the data. Cayetano has also been involved in revising the
manuscript and has given his final approval of its submitted version.

agrees to be accountable for all aspects of the work in ensuring
Jose
that questions related to the accuracy or integrity of any part of the
work have been appropriately investigated.
María Dolores Ruiz-Ferna
ndez contributed to the design of the
study and its data analysis. María Dolores has also been involved in
drafting the manuscript and has given her final approval of its sub-
mitted version. María Dolores agrees to be accountable for all aspects
of the work in ensuring that questions related to the accuracy or
integrity of any part of the work have been appropriately investi-
gated.
Supplementary materials
Supplementary material associated with this article can be found
in the online version at doi:10.1016/j.gerinurse.2020.07.012.
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