Constipation among Korean older adults in long-term care facilities: A scoping review

Article information

J Korean Gerontol Nurs. 2024;26(1):4-18

Publication date (electronic) : 2024 February 28

doi : https://doi.org/10.17079/jkgn.2023.00213

Yuseon Jeong^1,2, Dukyoo Jung³, Eunju Choi^,4

¹Graduate Student, College of Nursing, Ewha Womans University, Seoul, Korea

²Nurse, Ewha Womans University Mokdong Hospital, Seoul, Korea

³Professor, College of Nursing, Ewha Womans University, Seoul, Korea

⁴Doctoral Student, College of Nursing, Ewha Womans University, Seoul, Korea

Corresponding author: Eunju Choi College of Nursing, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea TEL: +82-2-2650-5348 E-mail: celestial_@naver.com

Received 2023 October 15; Revised 2024 January 7; Accepted 2024 February 15.

Abstract

INTRODUCTION

Owing to the rapid aging of the population, the number of people aged 65 years and above is expected to reach 9.18 million in 2022 in Korea, or 17.5% of the total population, and is expected to reach 20.6% by 2025, rapidly becoming an ultra-elderly society [1]. Consequently, the number of geriatric conditions, such as dementia and chronic diseases, is increasing [2], and the number of cases in which older adults need to rely on others to perform activities of daily living is increasing, leading to an increase in the use of long-term care (LTC) facilities to support the older adults [3]. After the introduction of the LTC insurance system for older adults, the number of residents in LTC facilities in Korea increased from 66,715 in 2008 [4] to 216,784 in 2022 [5], and the number is expected to increase further due to the increase in social support for older adults’ care [6].

Institutionalized older adults often suffer from numerous chronic conditions such as dementia, and circulatory, musculoskeletal, and endocrine diseases, which can lead to a decline in physical and cognitive functions and reduced independence in daily living [7]. In addition to this decrease in activity, environmental changes and social isolation caused by institutional living can increase depression, leading to digestive dysfunction [8], and an increase in the prevalence of constipation in older adults living in institutions. Furthermore, the risk of constipation increases because the cost of meals in LTC settings can make it difficult to consistently provide fruits and dairy products, such as milk, which are high in vitamins and minerals, to meet the recommended intake of essential nutrients [9]. The prevalence of constipation in institutionalized older adults has been reported to be 37% in men and 51% in women [10] compared to 20% in community-dwelling older adults [11], suggesting that a large number of institutionalized older adults suffer from constipation.

Inappropriately managed constipation increases the risk of developing complications such as fecal impaction and bowel obstruction, leading to economic burdens such as reduced quality of life and increased healthcare costs [12]. Constipation can also negatively impact the daily well-being and health of institutionalized older adults. This highlights the importance of managing constipation to improve the health and quality of life of institutionalized older adults, thus a careful review of the current research on constipation in institutionalized older adults is crucial.

The prevalence of constipation in older adults is 18.9% globally [13], whereas that in institutionalized older adults is as high as 71.8% [14]. Due to their high morbidity and vulnerability, overseas LTC facilities spend copious amount of money and time on constipation-related nursing activities [15]. Research on constipation in institutionalized older adults has been ongoing since the 1980s, which includes descriptive [16], intervention [17,18], and validation studies [19] on the application of self-reported constipation measures developed for community-dwelling and institutionalized older adults. Some intervention studies use randomized controlled trials [20-22]. Studies using a variety of research methods, such as a systematic review of non-pharmacological interventions in 2020, are conducted according to the needs of constipation research in institutionalized older adults [23].

However, an analysis of nursing services provided in Korean LTC facilities found that relatively little time was spent on excretion care compared to other physical support services, such as personal hygiene, eating, exercise, and mobility [24]. This shows that the role of nurses in facilities is mainly focused on ritualistic aspects such as meals, housing, and basic life care [25], sparing little time and resources for constipation management. Additionally, research on constipation in older adults in LTC facilities in Korea [7,26] began in the 2000s. However, previous research on older adults in Korean LTC facilities, including community-dwelling or hospitalized older adults is lacking. Mainly descriptive surveys and quasi-experimental studies are conducted. Therefore, to identify the current status and research gaps in constipation-related studies on older adults in LTC facilities in Korea, it is necessary to systematically analyze the literature using a scoping review method.

A scoping review maps the literature on a particular topic or research area and is performed when researchers intend to identify gaps in knowledge by examining the extent of research conducted on a particular topic and to investigate key features or factors related to a particular concept [27]. In contrast to a systematic review, it determines the current state of a broad range of questions and identifies key concepts [28]. By identifying the trends and characteristics of existing research on constipation in institutionalized older adults in Korea using the scoping review method, this study intends to guide the research and development of constipation-related measurement tools and interventions for institutionalized older adults in Korea.

Thus, this study aims to identify the characteristics and research trends of constipation-related studies in institutionalized older adults in Korea using a scoping review method and provide baseline data on constipation interventions by analyzing key interventions.

METHODS

2. Data search, Collection, and Selection Process

This study was conducted according to the Joanna Briggs Institute (JBI) Manual for scoping reviews [29]. The research steps include: 1) deriving a research title and questions, 2) providing selection criteria, 3) search strategy, 4) data collection and selection, 5) data extraction and analysis, and 6) presentation of the results.

1) Research Question

According to the JBI scoping review manual, participants, concepts, and context were defined as follows: Participants were older adults aged 65 and above, living in Korean LTC facilities. The concept was constipation, and the context was a domestic LTC facility. The research question for this study was: What are the trends in research on constipation among institutionalized older adults in Korea? Specifically, this study aimed to determine the factors associated with constipation in institutionalized older adults, how constipation is measured, and what interventions are related to constipation.

2) Inclusion and Exclusion Criteria

The selection criteria for this study were as follows: (1) study participants were older adults aged 65 or older admitted to an LTC facility for older adults as facility benefit providers under Article 31 of the Long-Term Care Insurance Act; (2) the study was related to constipation; and (3) the study was conducted on Korean older adults. The exclusion criteria were as follows: (1) studies in which the full text was not available, and (2) dissertations published in academic journals.

3) Search Strategy

The literature review was not restricted by the year of publication to ensure a broad understanding of the topic and to search for literature published up to August 25, 2023. The search databases were selected based on the Core, Standard, and Ideal model developed by the US National Library of Medicine, and international databases were used to include domestic studies submitted abroad. The international databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and PsycINFO and the Korean databases Research Information Sharing Service (RISS), Korean Studies Information Service System (KISS), and ScienceON were used to search the literature, and a few articles were searched manually.

This was a scoping review of studies on constipation among older adults in LTC facilities in Korea. The search terms were set based on participants (P), concept (C), and context (C). When searching in domestic and international databases, we used a combination of the following terms: (a) participant-related terms: “aged,” “older adults,” “older persons,” “older people,” “nursing home patients,” “elderly people,” “geriatric,” “aging,” “older,” “elder,” “elderly,” and “senior”; (b) concept-related terms: “constipation,” “bowel obstruction,” “intestinal obstruction,” “ileus,” “intestinal movement,” “intestinal hypomotility,” “bowel hypomotility,” “bowel irregularity,” and “fecal impaction”; and (c) context-related terms: “residential facilities,” “long term care,” “nursing home,” “nursing facility,” “residential care,” and “institutionalized.” Also, MeSH terms, CINAHL headings, and text words were used as search terms, and the Boolean operator AND/OR and cut search function were applied to increase the sensitivity and specificity of the search (Supplementary Material 1).

4) Study Selection

Data were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines [30]. A total of 473 articles were retrieved from domestic and international databases, including 27 from RISS, six from KISS, 22 from ScienceON, 169 from CINAHL, 203 from PubMed, 45 from PsychINFO, and one from a handwritten source. After excluding 105 duplicates, 368 articles were independently reviewed by two researchers according to the inclusion and exclusion criteria. After excluding 348 articles that did not meet the inclusion criteria regarding participants, concepts, and contexts by reviewing titles and abstracts, 20 articles were initially selected. After reviewing the 20 articles by applying the same criteria and process as the initial inclusion and exclusion criteria, 12 articles were excluded, and a total of eight articles were selected. No additional articles were added as a result of footnote search (Figure 1). All article selection processes were conducted independently by two researchers and were peer-reviewed to ensure that the final selection of articles was consistent.

Figure 1.

Flow chart of the selection process.

RESULTS

1. General Characteristics of the Literature

The general characteristics of the eight articles selected for this study are listed (Table 1). Among the eight selected articles, the publication years were between 2006 and 2022, with three articles (37.5%) [A1,A3,A4] during 2006~2010, four articles (50.0%) [A2,A5,A6,A8] during 2011~2015, and one article (12.5%) [A7] in 2022, with the largest number of articles published in 2011~2015. The analyzed articles included one (12.5%) [A7] from journals listed in both Science Citation Index and SCOPUS, one (12.5%) [A6] from SCOPUS, one (12.5%) [A1] from journals listed in both the Korean Citation Index (KCI) and SCOPUS, one (12.5%) [A5] from KCI, three (37.5%) [A2,A4,A8] from Korean Citation Index candidated, and one (12.5%) [A3] from other thesis. The research methods included two descriptive survey studies (25.0%) [A1,A2], five quasi-experimental studies (62.5%) [A3-A7], and one experimental study (12.5%) [A8], with quasi-experimental studies being the most common. Descriptive studies [A1,A2] were conducted in 2008 and 2011, respectively. Quasi-experimental studies [A3-A7] were conducted continuously from 2006 to 2022, but a randomized controlled trial [A8] was only attempted in 2009. Based on the authors’ information, the field of study was mainly nursing with seven articles (87.5%) [A1-A5,A7,A8] and one article (12.5%) [A6] in the field of physical therapy.

Table 1.

Characteristics of Included Literature (N=8)

2. Overview

For the content analysis, we divided the articles included in this study into article number, author name and year of publication, study objectives, study subjects, measures used to assess constipation, main results, constipation-related factors (general characteristics, health-related factors, diet-related factors), and intervention characteristics (type, method, target, session, intervention time per session, intervention frequency, intervention duration, intervention provider), and results are shown in Table 2~4 (Appendix 1) [11,31-37].

Table 2.

Summary of Included Literature (N=8)

Table 4.

Interventions of Constipation in Intervention Studies (N=6)

3. Study Characteristics

1) Key Findings

In the two descriptive studies included in this review that examined the prevalence and factors influencing constipation in institutionalized older adults, several older adults took laxatives to relieve constipation and had irregular bowel habits. Lee and Sung [11] [A1] highlighted that older adults with medical conditions were more likely to be constipated than those without medical conditions, and constipation was more prevalent before admission to a facility. Park et al. [32] [A2] reported that the risk of constipation varies according to age, admission period, LTC classification, and daily fluid intake. While sex was a common factor associated with constipation, sleep satisfaction, and depressive symptoms [A1], the state of mobility, LTC classification, digestants, and diet type [A2] were also identified as factors that may affect constipation in institutionalized older adults.

In six intervention studies on constipation, abdominal massage was used by Song [31] [A3] and Hong and Gu [37] [A8], and aromatic foot massage by Kang et al. [36] [A7]; all showed a significant increase in defecation frequency after massage. Moreover, Song [31] [A3] and Kang et al. [36] [A7] showed a decrease in the Constipation Assessment Scale (CAS) score, and Hong and Gu [37] [A8] showed an effect on defecation-related characteristics, confirming that massage is effective as a constipation relief program in institutionalized older adults. Kim et al. [34] [A5] highlighted that defecation frequency and the Bristol Stool Scale (BSS) score increased significantly after acupressure, whereas Wang et al. [35] [A6], showed that both the CAS and Bowel Function Assessment Form (BFAF) were significantly different after silver spike point (SSP) electrostimulation and acupuncture. Shim [33] [A4] studied sea tangle pellets and showed that there were no significant differences in the BSS; however, significant differences existed in defecation frequency and defecation-related characteristics (Table 2).

2) Constipation Measurement Methods

Eight articles (100.0%) [A1-A8] used defecation frequency to measure constipation, followed by four articles (50.0%) [A1,A2,A4,A8] that examined defecation-related characteristics and three articles (37.5%) [A1, A2, A8] that examined the actual condition of constipation. Except for the studies by Park et al. [32] [A2] and Kang et al. [36] [A7], the frequency of defecation per week was used [A1,A3-A6,A8], and the frequency of defecation was confirmed by the facility’s medical records or defecation diary. Furthermore, the included studies identified defecation-related characteristics [A1,A2,A4,A8] such as defecation habits, time required to defecate, associated symptoms, difficulty in defecating, abdominal discomfort and pain, constipation symptoms, and constipation condition [A1,A2,A8] such as constipation, constipation before admission, use of non-pharmacological therapies, use of constipation medications, and use of laxatives. The following methods were used to measure constipation: four used CAS (50.0%) [A1,A3,A6,A7], four used BSS (50.0%) [A4,A5,A6,A8], one used Eton scale (12.5%) [A2], and one used BFAF (12.5%) [A6] (Table 2).

3) Factors Associated With Constipation

In total, ten factors associated with constipation were identified in the two descriptive articles included in this review, of which five were related to general characteristics, three to health, and two to diet. In terms of frequency, the most common characteristics were sex (two articles) [A1,A2], age [A2], admission period [A2], LTC classification [A2], and history of digestion [A2]. Health-related factors included mobility status [A2], sleep satisfaction [A1], and depressive symptoms [A1], while diet-related factors, including the type of diet [A2] and daily fluid intake [A2], were identified as factors that may influence constipation in institutionalized older adults (Table 3).

Table 3.

Associated Factors of Constipation in Descriptive Studies (N=2)

4) Intervention Program Characteristics

The total number of participants in the selected articles ranged from 15 to 46, with four articles (66.7%) [A3,A5,A6,A7] having 21 to 40 participants. The number of participants in experimental and control groups ranged from 10~24, with a relatively even distribution of 10~24 in the experimental group and 10~22 in the control group. The interventions included two massage interventions, one acupressure intervention, one fiber intervention, one intervention with SSP and acupuncture in each group, and one combined intervention study with abdominal massage and lower-extremity range of motion (ROM) exercises. The duration of each intervention session varied from 10 to 30 minutes, with three (42.9%) [A3,A5,A8] lasting within 10 minutes and three (42.9%) [A3,A6,A7] lasting more than 10 minutes. The number of intervention sessions was mainly between 11 and 20 for four articles (57.1%) [A3,A5,A6,A8], and the frequency of intervention was seven times a week in three articles (42.9%) [A3,A5,A8]. The duration of the intervention ranged from 2~4 weeks, for three articles (50%) [A3,A5,A8] lasting 2 weeks or less and three articles (50%) [A4,A6,A7] lasting more than two weeks. The intervention provider was most often the researcher [A3,A5] or a combination of the researcher and research assistant [A3,A8] (Table 4).

DISCUSSION

This study attempted to identify the research trends, characteristics of research, and suggest research directions by analyzing Korean literature on constipation in institutionalized older adults. A total of 473 articles were retrieved from six Korean and international databases and manually searched; finally, eight articles were analyzed.

Research on constipation in adults in LTC facilities in Korea began in 2006 with Song [31], who demonstrated the effect of applying abdominal massage and lower-extremity ROM exercise to relieve constipation in institutionalized older women and was most active from 2011 to 2015, with a decreasing trend after 2016. This may be because constipation in older adults is considered a common symptom of daily life or a physiological consequence of aging [26] or because it has received less research and clinical attention than other geriatric conditions [38]. However, 170,000 people aged 70 and above are reported receiving medical treatment for constipation [39], and the prevalence of constipation is higher in institutionalized older adults, who have more comorbidities and hospitalizations, take an average of 6.1 medications per day, and are more functionally dependent and frail than community-dwelling older adults [40]. Therefore, there is an urgent need for research on constipation in institutionalized older adults.

In terms of study design, two selected articles were descriptive studies, five were quasi-experimental studies, and one was a randomized controlled trial, which indicates that mainly, quasi-experimental studies were conducted to alleviate constipation in institutionalized older adults. Specifically, descriptive studies were not conducted only in 2008 and 2011 and have not been conducted since, and quasi-experimental studies have been continuously conducted since 2006; however, research on the factors affecting constipation in institutionalized older adults in Korea is lacking. In comparison, randomized controlled experimental studies have been actively conducted overseas [20-22], and a systematic review of non-pharmacological interventions for constipation in institutionalized older adults [23] has been conducted based on the accumulation of these intervention studies. This may be due to the difficulty of artificial control due to environmental constraints in Korean LTC facilities [41], which may have limited the number of randomized controlled trials. However, randomized controlled trials of constipation interventions in institutionalized older adults are required to provide strong scientific evidence of their effectiveness.

Among the measures of constipation used in the selected articles, the most commonly used was defecation frequency, and the most commonly used tools were CAS and BSS. Constipation is a symptomatic condition that varies from person to person and is not easy to define objectively, hence it is mainly diagnosed by considering the frequency of defecations, the symptoms reported during defecation, and the shape of the stool [42]. However, older adults find it difficult to recognize that they are constipated because the condition is not immediately accompanied by life-threatening or severe symptoms to make daily activities difficult [43]. Hong and Gu [37] showed that although a tool for measuring stool consistency exists, there is no tool for measuring symptoms or the time required to defecate; therefore, a scale developed by the researcher was used. Additionally, the CAS is a self-report tool that records subjective symptoms and signs of constipation [44], which is difficult to apply to institutionalized older adults, many of whom have cognitive impairment. Frank et al. [19] showed that institutionalized older adults had difficulty interpreting questionnaire items and recalling relevant information because of physical, cognitive, and emotional factors. Therefore, identifying indicators to monitor constipation in the future and developing more valid measurement tools is crucial.

The two descriptive studies included in this review [A1,A2] found that constipation in institutionalized older adults was influenced by sex, age, mobility status, time of admission, LTC classification, sleep satisfaction, depressive symptoms, type of diet, daily fluid intake, and history of digestants. Women are more susceptible to constipation due to female hormones and childbirth, which inhibit peristalsis of the large intestine [11], and the prevalence of constipation is higher among older adults due to their limited mobility [32,37]. In particular, the risk of constipation may increase as the length of stay in the facility increases owing to the environmental conditions of the nursing home, making it difficult to exercise regularly [32]. Moreover, changes in the environment of a facility may affect sleep satisfaction and increase depression, which may increase the incidence of constipation due to decreased peristalsis and dietary intake [11]. Additionally, older adults in facilities have been reported to have insufficient fluid intake compared to the recommended fluid intake for older adults [32], and most have weakened digestive function due to long-term laxative use, which also contributes to constipation [7]. Overseas, the incidence of constipation is higher in women than in men. Factors similar to those in Korea, such as decreased daily activities, dietary habits, low fluid intake, medications [45], admission period [46], cognitive and physical disabilities, and speech disorders [14], have been reported to affect constipation. Therefore, in future studies, establishing an intervention plan for constipation that considers the general characteristics of older adults in LTC facilities is necessary.

All the interventions included in this review were non-pharmacological. Although pharmacological, non-pharmacological, and surgical methods can be used to manage constipation, trend of using complementary therapies over pharmacological and surgical treatments owing to their cost and complications is increasing [47]. Among these non-pharmacological interventions, massage interventions, such as abdominal massage and aromatic foot massage, and meridian therapy, such as acupressure and acupuncture therapy, are mainly performed. This is because they are simple yet specialized nursing interventions that can be performed by nurses alone to improve constipation in older adults in LTC facilities [23]. In particular, massage interventions were preferred as an intervention for constipation because they have relatively few side effects, do not require special tools or a lot of time, and are highly acceptable and sustainable because they can be performed by individuals as well as professionals if the practitioner receives certain training [38]. In contrast, various non-pharmacological interventions, such as abdominal massage [22], acupressure [48], dietary fiber [49] or Lactobacillus intake [21,50], exercise [51], and lifestyle interventions [20] have been reported to be effective for constipation in previous studies. In Korea, these non-pharmacological interventions should be actively explored to treat constipation in institutionalized older adults and validate their effectiveness so that effective constipation-related interventions can be applied to institutionalized older adults.

The duration, sessions, frequency, and duration of interventions in the six intervention studies included in this scoping review showed that the duration of interventions ranged from 2 to 4 weeks, with daily interventions being the most common, and the number of sessions ranged from 11 to 20. The length of the interventions varied from 10 to 30 minutes per session, and the number, frequency, and duration of interventions varied. This diversity of interventions is similar to that found in a systematic review of non-pharmacological interventions for institutionalized older adults [23]. Dobarrio-Sanz et al. [23] attributed the variation in interventions to differences in the definitions and criteria for constipation across studies. These differences in evaluation criteria can reduce comparability and consistency across studies; therefore, applying consistent criteria for assessing constipation and allowing for comparisons and integrated interpretation across studies would provide a clearer picture of effectiveness in practice.

Through a scoping review, this study described the general characteristics of studies related to constipation among older adults in LTC facilities in Korea, factors related to constipation, and characteristics of constipation measurement methods and intervention programs used. Notably, this study suggests trends in research related to constipation among older adults in LTC facilities and directions for future research and practice.

The limitations of this study are as follows. First, although the literature was searched using a combination of search terms, some relevant studies may not have been identified. Second, the study was limited to the literature on older adults in LTC facilities in Korea, which limits the generalizability of the findings to the constipated population as a whole, or to international older adults in nursing homes. Third, the scoping review method does not include quality of evidence assessment to ensure a comprehensive review that includes a wide range of literature, which may lead to potential bias in the literature.

CONCLUSION

This study identified research trends on constipation among older adults in LTC facilities in Korea and provided an overview of the existing literature to suggest directions for future research. Eight articles were selected, and the review showed that research on constipation began in 2006, with the most active period from 2011 to 2015. Most existing studies are quasi-experimental, and there is a lack of descriptive surveys and randomized controlled experimental studies. The factors associated with constipation in institutionalized older adults in the selected studies included sex, age, mobility status, time of admission, LTC classification, sleep satisfaction, depressive symptoms, type of diet, daily fluid intake, and digestant use. Constipation is mainly measured by the frequency of defecation, and massage is the most common nursing intervention used to relieve constipation.

Based on the results of this study, the following recommendations are made: First, it is necessary to diversify the research on frequently reported constipation problems to improve the health-related quality of life of older adults in LTC facilities. Second, a constipation measurement method that reflects the characteristics of older adults in LTC facilities is required and a valid measurement tool must be developed. Third, intervention studies for the prevention and management of constipation should be developed and tested, considering the characteristics of older adults in LTC facilities.

Supplementary materials

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