Original Study| Volume 22, ISSUE 12, P2559-2564, December 2021

Laxative Agents in Nursing Homes: An Example of Prescribing Cascade



      Laxatives are among the most prescribed medications to nursing home (NH) patients, and we evaluated the hypothesis that laxative agents could be prescribed as a result of a prescribing cascade. The aims of the study are (1) to investigate the use of laxative drugs in a large sample of Italian NHs and (2) to assess the relationship between medications that can induce constipation and laxative use.


      Retrospective cross-sectional multicenter study.

      Setting and Participants

      Individuals living in long-term care NHs.


      Study conducted in a sample of Italian long-term care NHs distributed throughout the country. Information on drug prescriptions, diseases and sociodemographic characteristics collected 4 times during 2018 and 2019.


      Among the 2602 patients recruited from 27 NHs (mean age ± standard deviation: 88.4 ± 8.5; women: 1994, 76.6%), 1248 were receiving laxatives (48%). Parkinson disease, cerebrovascular disease, and hemiplegia were associated with laxative prescription, and diabetes was associated with a decrease. Benzodiazepines, anti-Parkinson dopaminergic agents, and antidepressants (tricyclic antidepressants and mirtazapine) were associated with laxative treatment in univariate and adjusted models. Tricyclic antidepressants users were 3 times more likely to be taking laxatives than nonusers (odds ratio 2.98, 95% confidence interval 1.31-6.77, P = .0093). A larger number of drugs that can induce constipation was associated with laxative use (P = .0003). In all, 2002 individuals had at least 2 different prescription times: from the first to the last visit laxative use rose from 46.1% to 49.9%. Time of stay was also associated with laxative use (P = .016).

      Conclusions and Implications

      Laxatives are among the most prescribed medications in Italian NHs. Medications that can induce constipation, such as antidepressants, anti-Parkinson dopaminergic agents, and benzodiazepines, are often used together with laxatives, and combinations of these drugs further increase the use of laxatives. Optimizing the prescription of psychotropic drugs could help reduce the “prescribing cascade” with laxatives. The length of stay in NHs is often proportional to laxative use and chronic treatment is very common.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Avorn J.
        • Gurwitz J.H.
        Drug use in the nursing home.
        Ann Intern Med. 1995; 123: 195-204
        • Dwyer L.L.
        • Han B.
        • Woodwell D.A.
        • et al.
        Polypharmacy in nursing home residents in the United States: Results of the 2004 National Nursing Home Survey.
        Am J Geriatr Pharmacother. 2010; 8: 63-72
        • Teramura-Grönblad M.
        • Raivio M.
        • Savikko N.
        • et al.
        Potentially severe drug-drug interactions among older people and associations in assisted living facilities in Finland: A cross-sectional study.
        Scand J Prim Health Care. 2016; 34: 250-257
        • Herr M.
        • Grondin H.
        • Sanchez S.
        • et al.
        Polypharmacy and potentially inappropriate medications: A cross-sectional analysis among 451 nursing homes in France.
        Eur J Clin Pharmacol. 2017; 73: 601-608
        • Halvorsen K.H.
        • Selbaek G.
        • Ruths S.
        Trends in potentially inappropriate medication prescribing to nursing home patients: Comparison of three cross-sectional studies.
        Pharmacoepidemiol Drug Saf. 2017; 26: 192-200
        • Pasina L.
        • Novella A.
        • Cortesi L.
        • et al.
        Drug prescriptions in nursing home residents: An Italian multicenter observational study.
        Eur J Clin Pharmacol. 2020; 76: 1011-1019
        • Gustafsson M.
        • Lämås K.
        • Isaksson U.
        • et al.
        Constipation and laxative use among people living in nursing homes in 2007 and 2013.
        BMC Geriatr. 2019; 19: 38
        • Fosnes G.S.
        • Lydersen S.
        • Farup P.G.
        Drugs and constipation in elderly in nursing homes: What is the relation?.
        Gastroenterol Res Pract. 2012; 2012: 290231
        • Blekken L.E.
        • Nakrem S.
        • Vinsnes A.G.
        • et al.
        Constipation and laxative use among nursing home patients: prevalence and associations derived from the residents assessment instrument for long-term care facilities (interRAI LTCF).
        Gastroenterol Res Pract. 2016; 2016: 1215746
        • Rey E.
        • Barcelo M.
        • Jiménez Cebrián M.J.
        • et al.
        A nation-wide study of prevalence and risk factors for fecal impaction in nursing homes.
        PLoS One. 2014; 9: e105281
        • Chen I.C.
        • Huang H.J.
        • Yang S.F.
        • et al.
        Prevalence and effectiveness of laxative use among elderly residents in a regional hospital affiliated nursing home in Hsinchu County.
        Nurs Midwifery Stud. 2014; 3: e13962
        • Hosia-Randell H.
        • Suominen M.
        • Muurinen S.
        • Pitkälä K.H.
        Use of laxatives among older nursing home residents in Helsinki, Finland.
        Drugs Aging. 2007; 24: 147-154
        • Snowdon J.
        • Day S.
        • Baker W.
        Audits of medication use in Sydney nursing homes.
        Age Ageing. 2006; 35: 403-408
        • Taxis K.
        • Kochen S.
        • Wouters H.
        • et al.
        Cross-national comparison of medication use in Australian and Dutch nursing homes.
        Age Ageing. 2018; 47 (Erratum for: Age Ageing 2017;46:320–323): 319
        • Dzierżanowski T.
        • Ciałkowska-Rysz A.
        The occurrence and risk factors of constipation in inpatient palliative care unit patients vs nursing home residents.
        Prz Gastroenterol. 2018; 13: 299-304
        • Pont L.G.
        • Fisher M.
        • Williams K.
        Appropriate use of laxatives in the older person.
        Drugs Aging. 2019; 36: 999-1005
        • Roque M.V.
        • Bouras E.P.
        Epidemiology and management of chronic constipation in elderly patients.
        Clin Intervent Aging. 2015; 10: 919-930
        • Werth B.L.
        • Williams K.A.
        • Pont L.G.
        Laxative use and self-reported constipation in a community-dwelling elderly population: A community-based survey from Australia.
        Gastroenterol Nurs. 2017; 40: 134-141
        • Jamshed N.
        • Lee Z.E.
        • Olden K.W.
        Diagnostic approach to chronic constipation in adults.
        Am Fam Phys. 2011; 84: 299-306
        • AlMutairi H.
        • O'Dwyer M.
        • Burke E.
        • et al.
        Laxative use among older adults with intellectual disability: A cross-sectional observational study.
        Int J Clin Pharm. 2020; 42: 89-99
        • Bharucha A.E.
        • Wald A.
        Chronic constipation.
        Mayo Clin Proc. 2019; 94: 2340-2357
        • Every-Palmer S.
        • Newton-Howes G.
        • Clarke M.J.
        Pharmacological treatment for antipsychotic-related constipation.
        Cochrane Database Syst Rev. 2017; 1: CD011128
        • Ueki T.
        • Nakashima M.
        Relationship between constipation and medication.
        J UOEH. 2019; 41: 145-151
        • Gage H.
        • Goodman C.
        • Davies S.L.
        • et al.
        Laxative use in care homes.
        J Adv Nurs. 2010; 66: 1266-1272
        • Rochon P.A.
        • Gurwitz J.H.
        The prescribing cascade revisited.
        Lancet. 2017; 389: 1778-1780
        • By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel
        American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
        J Am Geriatr Soc. 2015; 63: 2227-2246
      1. AIFA-Agenzia Italiana del Farmaco.
        • Elliott W.J.
        • Ram C.V.
        Calcium channel blockers.
        J Clin Hypertens (Greenwich). 2011; 13: 687-689
        • Russell R.P.
        Side effects of calcium channel blockers.
        Hypertension. 1988; 11: II42-II44
        • Sturtzel B.
        • Elmadfa I.
        Intervention with dietary fiber to treat constipation and reduce laxative use in residents of nursing homes.
        Ann Nutr Metab. 2008; 52: 54-56
        • Yang J.
        • Wang H.P.
        • Zhou L.
        • Xu C.F.
        Effect of dietary fiber on constipation: A meta- analysis.
        World J Gastroenterol. 2012; 18: 7378-7383
        • McRorie J.W.
        • Chey W.D.
        Fermented fiber supplements are no better than placebo for a laxative effect.
        Dig Dis Sci. 2016; 61: 3140-3146
        • Emmanuel A.
        • Mattace-Raso F.
        • Neri M.C.
        • et al.
        Constipation in older people: A consensus statement.
        Int J Clin Pract. 2017; 71
      2. SIMG Società Italiana di Medicina Generale e delle cure primarie.
        • Palsson O.S.
        • Whitehead W.E.
        • van Tilburg M.A.
        • et al.
        Rome IV Diagnostic Questionnaires and Tables for Investigators and Clinicians.
        Gastroenterology. 2016;