Constipation in the Elderly - Essay Example

Evidence Based Practice. Constipation in the Elderly Introduction Constipation is a frequently citedproblem in the elderly population, with more than 2.5 million annual visits to physicians made because of this complaint (Cheskin L, Schuster M: 1994). This figure does not include the millions of self-treated people who use laxatives either routinely or during an acute occurrence. Studies have found that more than 30% of 60-year-old community-dwelling people are regular laxative users and that close to 30% of men and women over age 65 consider themselves to be constipated (Pettigrew, Watt, and Sheldon, 1997, 1-52, Rycroft-Malone, J., et al., 2002, 174-180). Although constipation in medical terms has been defined as a frequency of fewer than three bowel movements a week, a patient may define constipation as one or more of the following: straining at stool, painful bowel movements, perceived infrequent bowel movements, feelings of incomplete bowel movements, or loss of ability to recognize the urge to defecate (Annells, M. & Koch, T. 2002, 124-6). What is a normal pattern of bowel elimination for one person may constitute constipation for another (Harari D, et al, 2004, 571-582). The aim of this essay is to critically evaluate two original research articles that have utilized different methodologies. The first article chosen titled "Older people seeking solutions to constipation: the laxative mire" by Merilyn Annells and Tina Koch. The second article titled The second article is: Constipation and diet in a community sample of older Australians. (Original Research) by Nicholas J. Talley MD, Ph.D. Nicholas J. Talley is Ph. D in Gastroenterology and working in Health Sciences Research that shows he has the requisites to carry out this research. Author chosen 'constipation' issue of nursing practice, as many age-related changes and other causes contribute to reports of constipation in older adults and number of nurses is taking care of patients suffering this problem. By reading and understating the research literature related to managing constipation will definitely help readers to have managed the patients. To get the perfect research paper I have searched online by writing keywords that is 'constipation in elderly' that returned 898,000 results, to get the more specific result I put in keywords 'nursing practice constipation in elderly research' that has shown 123,000 results, then I started access all the searches till the most suited research found. The first article chosen online titled "Older people seeking solutions to constipation: the laxative mire" by Merilyn Annells and Tina Koch. Whereas, for second research paper, I have taken help from my nearby library. Research Article 1 The first article title is: Older people seeking solutions to constipation: the laxative mire (publication 11 October 2001) is production of two authors Merilyn Annells PhD, RN Research Consultant and Proprietor, MP Annells Research, Adelaide, Australia And Tina Koch PhD, RN, Director, Research Unit, Royal District Nursing Service of South Australia Inc., Glenside, Australia. Research Design The research was a qualitative and partly quantitative descriptive survey in which data were collected by in-depth, semi structured, individual interviews. The research process was overseen by a multidisciplinary health profession panel. Qualitative approaches to research make fewer suppositions concerning research phenomena. They need you to scrutinize people in action and detain their experiences and meanings. As a consequence, you are capable to conceptualize what is happening and give a new way of thinking about and describing it. The research did not find a randomized sample. As, randomized sample is statistically representative of a particular population. The subjects who are randomized may or may not be a random sample from some larger population. Usually, when human subjects are involved, they are volunteers. Convenience sampling is used as it is the easiest though potentially most dangerous. Often good results can be obtained, but perhaps just as often the data set may be seriously biased. Databases of older people seeking health care assistance with constipation would bind participation to those who had get to the point of requiring professional help. A broader spectrum sample was required. Furthermore, both pilot studies had substantial difficulty in acquiring limited sample sizes through database selection. People are tending to be loath to argue private body functions in detail. Through very minimal research of this nature, a non-representative sample, was still considered valuable, especially for a primarily qualitative study. A pilot study was designed to help determine the content of the final role functioning battery and to address practical issues, such as the battery length, the specific types of prevalent role limitations, and the rate of missing data for different types of items. Another reason for the pilot study was to conduct formal empirical tests of any gains in precision of a longer role functioning measure over a short-form measure in order to determine if any gains justified the additional respondent burden of administering a longer version. The pilot study was administered to a sample of patients and other people waiting to see physicians in a typical ambulatory clinic. Altogether Ninety older people were recruited. Twenty-nine participants were recruited by invitation after identification from the database of a district nursing organization (clients requiring bowel management for constipation in the previous 12 months). The other 61 participants were self-selected in response to community advertising (e.g. by posters in pharmacies and multiple media advertisements). Data collection For data collection audio-tape recording was used to record interview data for the credibility of research, it is also mentioned that tapes were later transcribed verbatim. Referral was also made if participants requested advice about, or treatment of constipation to suitable experts. The audio-tape recording of interviews enabled a more objective analysis to be conducted after the event. These multiple perspectives facilitated the verification of data (Merriam, 1998). The kind of interview used in this study was a semi-structured interview, which means that a brief and very general interview schedule (set of questions) was used to prompt participants in duration of 41 minutes and they were guided by a list of questions based initially on pre-tested questions developed for the pilot studies. This ensures that the interviewer gets the information they need devoid of overly influencing the participants' responses. This freedom in the course of the interview is significant in qualitative research as it allows information to appear that the researcher might not anticipate, potentially flaking a whole new insight onto a problem. All participants were interviewed in participants' homes. This was to endeavor to lessen the "interviewer effect" - specifically, when participants react to the interviewer in definite ways according to their role as respondent. By using an informal setting, the researchers expected to reduce the interviewer effect and attain more valid data. Data Analysis and Results To make sense of qualitative data, it must be analyzed rigorously and methodically just as numerical data is. There are numerous different ways of analyzing interview data depending on the researchers' punitive perspectives as well as what they hope to take from the data. In this study, the researchers conceptualized the interview data as narratives or life stories. Early on during data collection, a constant comparative data analysis method was originated. This primary analysis included every interview transcript being read numerous times, and then understands by qualitative coding. Comparative data analysis needs are assess in two ways: First, the needs as well as priorities for comparative data are dogged during the assessed and understand phase of the included planning process. Second, process owners establish the need for process improvement (Schmidt, F. L. 1996, 115-129). After all 90 interviews had been analyzed individually, an uncertain overview was written of the 'thrust' of the data congregated, themes listed and memos cautiously connected to the themes. Secondary analysis then originated, with the focus moved to the block of ninety answers for each question. Overall, participants' compound story is of a strong imperative to self-management of constipation and an avid search for solutions. Laxative use appears to be as common in older. Elderly regular using laxatives are a preventive measure as well as a treatment for actual constipation. The older people interviewed were often not sure about the cause of their constipation, although some had ideas about causative factors. All desire to know the reason and most aggressively seek to find what that reason might be. Some wonder if the medications prescribed by their doctors might be causing constipation. A check of prescribed medications being taken by the participants suggests that numerous of these might be either causing or causative to the constipation. This is similar with the results of the pilot studies for this project that recommended poly-pharmacy to be a plausible factor in several constipation onset. However, best nursing practice strategies for older people lean to be silent concerning the need for deliberation of other medications as a constipation cause, though there is emerging acknowledgment of this factor for nursing clients generally. Ethical and professional Issues For the credibility of research approval of the Committee is important in the interests of successful and ethical research. For this study approval from the ethics committee of the organization that awarded funding for the project was gained prior to participant recruitment. The research protocol was evaluated according to the Australian National Health and Research Council guidelines for ethical research involving human participation. Although this question is pertinent in ethical assessments of research despite of where the research is conducted, it is being posed with special force. Therefore, the question of what benefits research sponsors must make offered to participants at the conclusion of a clinical trial. Research Article 2 The second article is: Constipation and diet in a community sample of older Australians. (Original Research) by Nicholas J. Talley MD, Ph.D. Nicholas J. Talley is Ph. D in Gastroenterology and working in Health Sciences Research that shows he has the requisites to carry out this research Research Design This research is also qualitative method. This study is taken during 2002. The main Objective was to estimate the prevalence of constipation and laxative use in a sample of people 65 years and over and examine relationships between usual diet and constipation. Randomly selected sample was of 330. Basically, Random selection is mostly related to the external validity (or generalizability) of results. As it was large sample research participants better represent the larger group from which they're drawn. Random assignment is most related to design. In fact, when we randomly assign participants to treatments we have, by definition, an experimental design. Therefore, random assignment is most related to internal validity. After all, we randomly assign in order to help assure that our treatment groups are similar to each other (i.e., equivalent) prior to the treatment. Random sampling can be defined as "a selection process in which each element in the population has an equal, independent chance of being selected." (Polit, D. F., & Beck, C. T. 2004; 295). "Using a large sample helps to improve concerns about statistical noise in the simulated cluster properties" (Posavac, E.J., & Carey, R.G. 1997). Data collection The best thing about this paper is that the questionnaire was very descriptive that helps in having absolute answer from respondent. It ranges from diagnostics to questions on general health, laxative use, gender, age, education, and marital status. Most questions only required a yes or no response, but some questions required subjects to select a category of response (i.e. never, occasionally, sometimes, and often). Diagrams were included to assist respondents to identify the body region of any pain experienced that might be related to the gastrointestinal tract. Respondents were able to add comments if desired. Questionnaires were then mailed out. Information on food consumption, perceptions and attitudes to food was collected at interview. It is also very focused about respondents that specify study subjects had to be: Community dwelling; aged 65 years or over; able to do their own shopping. And Subjects were excluded if: they had advanced dementia and were unable to complete the questionnaire; they had bowel cancer as it would be difficult to determine a normal bowel pattern; they were receiving 'meals on wheels' as this would have restricted food choice. Mailed questionnaires are relatively cost effective because they require little time to administer on the part of the investigators and do not require the hiring of persons to administer the instrument. Information can be obtained relatively rapidly, that is, in a few weeks, but a poor response rate is often obtained because of the impersonality and likely lack of rapport with the investigator (Denzin, N. K., & Lincoln, Y. S. 2000:84). The interviews were a combination of qualitative and quantitative questions exploring subjects' definitions of constipation and their perceptions as to why they were or were not constipated. In addition, subjects were also asked the frequency of consumption of cereals, fruit, vegetables, supplements and fluids and to self-report the number of serves of vegetables and fruit they usually consume in a day. Questions on attitudes and beliefs were used to obtain information on perceived barriers to dietary change. Data were also collected on quality of life. Data Analysis and Results Descriptive statistics, frequencies and two sample t-tests with 95% level of significance were used in the analysis of the quantitative data. Descriptive statistics are characteristically illustrious from inferential statistics. With descriptive statistics you are basically describing what is or what the data shows. Through inferential statistics, you are trying to attain conclusions that expand beyond the instantaneous data alone. Descriptive Statistics are used to present quantitative descriptions in a controllable form (Roth, P. L., Be Vier, C. A., Switzer, F. S., HI, & Schippmann, J. S. 1996, 548-556). In a research study we might have lots of measures. Or we might measure a great number of people on any measure. Descriptive statistics assist us to basically large amounts of data in a reasonable way. Every descriptive statistic lessens lots of data into a simpler summary. (Polit, D. F. & Beck, C. T. 2003) Qualitative content analysis was conducted on the open-ended responses to interview questions. These were coded and then categorized into themes. Frequency was measured by counting participants' responses within each theme. Open-ended questions asking respondents to identify other possible problems not included in the sample of items from published questionnaires were included in the questionnaire (Streubert Speziale, H. J., & Carpenter, D. R. 2003). Of the 330 individuals to whom questionnaires were mailed, 30 were ineligible for various reasons (illness, death, changed addresses, or simply returned unopened). Seventy-nine completed questionnaires were returned by 32 females and 47 males aged between 65 and 82 years. When respondents were compared with census data for the area from which the sample was drawn (52% males and 48% females) the respondent group contained a higher proportion of males (59%). The research didn't mentioned that either they kept subject blind about what they are intending to find. As subjects in the study should kept blind to which experimental, or involvement of known value is being given to any one subject. This reduces the effects of proposition that might bias subjects to experience better or worse as per the beliefs of the researchers, and according to the subjects' own hope of improvement with a given treatment (Abramson JH, Abramson ZH. 1999: 53). Evaluations of symptomatic change, for better or worse, are as well made by diagnosticians who are visor to the finicky therapy being given, for related reasons (Bowling A, 1997: 78). The overall all discussion section of the paper is very explanatory. The analysis given a means of recognizing those who were constipated but did not understand it, those who were functionally constipated but did not self-report), those who considered themselves constipated even though they did not meet the criteria of functional constipation and those who considered themselves to be constipated and also met the criteria for functional constipation. For those who are functionally constipated but do not self-report, there may be long term implications for bowel function or underlying physiological problems, whereas those who self-report but do not have functional constipation have been found in other studies to self-medicate with over the counter laxatives. Five subjects in this study who had reported symptoms of functional constipation did not self-report being constipated. It is possible that subjects who report constipation, in the absence of symptoms of functional constipation are using as yet unidentified indicators to characterize constipation and until these are identified appropriate strategies for management cannot be determined. Therefore, it is important to explore how this group of subjects defines or categorizes their constipation. The basis of an experiment is that all but one aspect is held constant, and that single factor is diverse to see what consequence it has on the observable fact under investigation. (Aiken, L. S., & West, S. G. 1991: 34) To be considered experimentation, a study should meet two criteria. First, it should have as a minimum two groups, a control group and an experimental group; secondly, the subjects should be randomly allocated to one of those groups. The experimental design is a authoritative one in that if one group of subjects if treated one means and another group in a different way, and there are no other issues manipulates the group differentially, then a reason effect relationship can be recognized, and the data can be used to simplify findings beyond the subjects in the study (Roth, P. L. 2003, 279-281). Ethical and professional Issues For the credibility of research approval of the Committee is important in the interests of successful and ethical research. For this study approval the project was approved by the Deakin University Ethics Committee (project number EC99-197). Deakin University is one of Australia's leading universities. Conclusion Investigating troublesome behaviors can help nurses to plan and implement evidence-based practice that makes a positive difference to the practice of managing adults with constipation. The term 'evidence-based practice' has been used mainly in the medical field. Medical experts have assumed that procedures used in medicine, such as the lengthy 'scrub-up' before operations, were derived from scientific research. However, recently it has found that there was little research to support many procedures and they are now calling for evidence-based medicine. A commitment to evidence-based practice means that the speech-language pathologist will seek out all the available evidence for a particular treatment, before implementing it. (Altman E., & Hernon P. 1997:30) By analyzing both the research, I realize there is lot more work in the constipation issue has to be done. The basic limitation of these studies is that they haunt discuss about Psychological Interactions. Both of these studies were qualitatative but the second paper was partly quantitative. Though by analyzing these papers will definitely help to gain their knowledge and will definitely improve their practice. The Total Word Count is 3085 Reference: Cheskin L, Schuster M: Constipation. In Hazzard WM et al, editors: Principles of geriatric medicine and gerontology, New York, 1994, McGraw-Hill. Pettigrew M, Watt I, Sheldon T: Systematic review of the effectiveness of laxatives in the elderly, Health Technol Assess 1 (13):1-52, 1997. Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A., et al., (2002). Ingredients for change: Revisiting a conceptual framework. Quality and Safety Health Care, 11(2), 174-180. Annells, M. & Koch, T. (2002). Faecal impaction: Older people's experiences and nursing practice. British Journal of Community Nursing, 7(3), 118, 120-2, 124-6. Harari D, Gurwitz JH, Minaker KL. Constipation in the elderly. 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