Abstract
Background
Chronic diarrhoea is a functional gastrointestinal disorder affecting up to 10% of older adults and has negative impacts on quality of life. Constipation is an issue for many older adults living in care, but overtreatment with laxatives may result in the development of diarrhoea. Provision of adequate dietary fibre may reduce the need for laxative use, however, data regarding provision and consumption are lacking. Data concerning the prevalence and impacts of chronic diarrhoea on older adults living in care is also lacking. The low Fermentable Oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is a well-established dietary intervention for reducing symptoms of chronic diarrhoea, its effectiveness has primarily been studied in individuals under the age of 65 years, but to date there has been no studies in older adults. Older adults are at risk of micronutrient deficiencies and malnutrition therefore any dietary interventions need to be undertaken with care. Currently, specific guidelines for manging chronic diarrhoea in older adults, especially those living in residential care are lacking.
Objectives
This research aimed to determine the prevalence of chronic diarrhoea among older adults living in residential care and explore contributing factors (such as medications) and impacts on quality of life. It is also aimed to explore the role of dietary fibre as a management strategy to prevent constipation along with provision and consumption adequacy of dietary fibre for older adults in care. Finally, this research set out to determine if the low FODMAP diet is an effective treatment for the management of chronic diarrhoea in older adults and whether the low FODMAP diet could be conducted safely without compromising nutritional status.
Methods
A retrospective observational study of resident clinical, medication, bowel chart and healthcare data from 36 residential care facilities throughout New Zealand was conducted. In addition, an in depth observational study was conducted of residents from seven residential care facilities. Residents completed validated gastrointestinal and quality of life questionnaires.
A meta-analysis was conducted to evaluate the adequacy of the provision and consumption of dietary fibre by older adults living in care, the meta-analysis was registered with PROSPERO and followed the PRIMSA guidelines. A qualitative study to understand the views and knowledge regarding dietary fibre with a small cohort of Christchurch residential care residents was undertaken. The opinions regarding dietary fibre provision and consumption of New Zealand registered dietitians providing residential care services were also sought through an anonymous online survey.
A prospective open label study of older adults with chronic diarrhoea was conducted to test the safety and effectiveness of the low FODMAP diet. Participants were recruited from Christchurch Hospital Gastroenterology department following a colonoscopy where no organic cause of chronic diarrhoea was found. Once screened for eligibility, patients were invited to undertake the low FODMAP diet, under the instructions of the PhD candidate, for 6 weeks followed by instructions for the reintroduction process. Participants completed gastrointestinal and quality of life questionnaires and a four-day food diary prior to and after the low FODMAP elimination diet. At the follow up appointment, participants completed a qualitative questionnaire on their experience while following the low FODMAP diet.
Based on the literature review and research conducted by the PhD candidate, a functional diarrhoea pathway was written for Allied Healthways. The pathway was written using a standardised template for Allied Healthways and underwent comprehensive peer review.
Results
This research revealed that at least 25% of residents living across the 36 residential care facilities experience chronic diarrhoea (618/2411), many of whom are taking laxatives (65%, 404/618), presumably to treat constipation. Having chronic diarrhoea negatively impacted on quality of life and was associated with an increased risk for pressure injuries.
Increasing dietary fibre may be an effective tool to prevent constipation, however, the meta-analysis findings indicated that both the provision and consumption of dietary fibre is below recommended intakes to manage constipation. Further, for residents requiring higher levels of care or consuming a puree diet, dietary fibre intake was even lower, regardless of health state. Christchurch residential care residents (n=20) were aware of the benefits of fibre for bowel regularity and were willing to eat more dietary fibre but felt that the menus provided limited opportunities. New Zealand registered dietitians, who work with older adults living in residential care (n=14), support the use of dietary fibre to manage constipation and believe that residential care menus have the potential to provide sufficient fibre, but residents were eating less than served. Referral rates to dietitians to assess bowel function of residents in care are low, dietitians feel confident in providing dietary and lifestyle management for constipation but less so for diarrhoea.
The low FODMAP diet was a feasible intervention for community living older adults who experience chronic diarrhoea as determined by a pilot study of 20 older adults recruited from Christchurch hospital. Older adults were able to follow the diet but preferred verbal instruction rather than written. The low FODMAP diet improved symptoms of diarrhoea without reducing nutritional adequacy and quality of life improved while following the diet.
The Allied Healthways pathway for functional diarrhoea was developed, peer reviewed and has been published on Allied Healthways website for Canterbury allied health clinicians.
Conclusion
Chronic diarrhoea is a problem for older adults living in care and laxative use seems a significant contributor. Having chronic diarrhoea can impact on quality of life. Dietary strategies to manage diarrhoea could include increasing dietary fibre, to reduce constipation and subsequent laxative use, or undertaking a low FODMAP diet. Dietary changes need to be planned carefully to ensure that they are appropriate for an older adult and evidence-based accessible resources are important for dietitians to increase confidence.