Research Makes Gastrointestinal Health A Senior Care Priority (Part 2 of 2)

Gastrointestinal Problems

The NCI identifies the most common gastrointestinal problems examined by gastrointestinal specialists or gastroenterologists as constipation, impaction, bowel obstruction, diarrhea, radiation enteritis, gastrointestinal perforation, anthrax, gastroenteritis/colitis, laxative overdose, angiodysplasia of the colon and gastrointestinal bleeding.


Constipation is the slow, uncomfortable and possibly painful movement of dry, hard stool through the large intestine. This condition worsens as more fluid is absorbed and the waste becomes drier and harder.

If waste matter is not removed from the intestine at least once a day to three per day and at least three per week, physicians may diagnose a senior patient with constipation.

A physician assesses for constipation by reviewing the history of a patient’s bowel habits, including distention, gas passage, cramping and rectal fullness, a change in diet and drug use and by conducting occult blood tests and regular physical exams.

A lack of physical activity, a form of disability or social barriers such as the lack of bathroom accessibility, can cause constipation. So, too, can depression and anxiety brought on by cancer treatment or pain, insufficient water or fluid intake and the ingredients of certain pain relievers, though these last two factors can be managed.

To manage constipation, doctors may suggest that patients increase their intake of fiber through fruits, vegetables, whole-grain cereals, breads and bran and water or other fluids.

In fact, research was conducted involving senior patients, including cancer patients, to compare the medical care effectiveness, cost and management of a natural laxative mix of raisins, currants, prunes, figs, dates and prune versus the use of stool softeners, lactulose and other laxatives. The results found the natural laxative mix to be more medically and cost efficient.


By contrast, while constipation is uncomfortable and painful, fecal impaction is dangerous. Impaction is the collection of dry, hard waste matter in the rectum or colon.

Most senior patients with impaction may exhibit circulatory, cardiovascular or respiratory problems more than gastrointestinal issues but the main symptoms are back pain and bladder, urethra and urinary problems, especially frequent urination.

Physicians assess for impaction by asking the patient questions about constipation, using instruments to listen for bowel sounds, examining the abdomen to determine the level of gastrointestinal activity and conducting a rectal exam for the presence of stool in the rectum or colon and an abdominal X-ray for such features as gas passage.

Stool movement around impaction may produce diarrhea and coughing. It may also lead to stool leakage, which comes with nausea, vomiting, abdominal pain and dehydration.

Such a patient may be found in a confused or disoriented state and suffering from fever and high or low blood pressure. If not detected and addressed immediately, impaction may result in death.

The main causes of impaction are opioid medication, a lack of physical exercise or activity, changes in diet, psychiatric illness or abuse of laxatives. In fact, laxative abuse aimed at decreasing constipation is considered the major cause of impaction. Overuse of laxatives makes the colon insensitive to natural reflexes caused by distention.

Doctors treat impaction by watering and softening the stool for removal. They use enemas that incorporate oil retention, tap water or hypertonic phosphates to moisten the bowel and remove the stool. Often, docusate, mineral or olive oil and glycerin suppositories are used.

Occasionally, after an enema is used, a patient may be disimpacted digitally to address the remaining waste matter.

Bowel Obstruction

Large or small bowel obstruction is a partial or complete blockage of the bowel by a method other than constipation and impaction. Eighty percent of bowel obstructions take place in the small intestine while the other 20 percent happens in the colon. A physician may make a determination of obstruction if there is no gas.

An obstruction is classified by three ways: the type of obstruction, the mechanism of obstruction (whether mechanical or nonmechanical) and the part of the bowel in question. Often, it is termed “twisted bowel.”

Total or partial obstruction is typically caused by structural disorders like bowel lesions connected to cancer, post-surgical abdominal problems or hernias. Additionally, a patient with a colostomy, a type of surgery that re-directs a part of the colon to avoid a damaged part of the gastrointestinal tract, are at risk of developing constipation.

There are four types of obstruction: simple in which one site is blocked; closed-loop with blockage in two places; strangulated involving decreasing blood flow, and; incarcerated when the strangulated state is not resolved.

To determine bowel obstruction, physicians may examine a patient for abdominal pain, vomiting and gas or stool passage and may conduct a white blood cell count, electrolyte panel, urinalysis, sepsis, flat or upright abdominal films, enemas and gastrointestinal series.

To treat and manage obstruction, doctors may perform volume resuscitation, elecrolyte imbalances, transfusion support, distended bowel decompression efforts via intestinal tubes, a change in diet and the use of stents.


As diagnosed, diarrhea is an unhealthy increase in stool liquid and frequency of passage of more than three instances of waste matter from the intestine in a 24-hour period. It can span more than four days but less than two weeks. While considered less prevalent than constipation, diarrhea is considered chronic if it lasts more than two months.

Increasingly, the process of cancer care, especially radiation therapy and the stress and anxiety caused, antibiotic therapy, bone marrow transplants or gastrointestinal surgery, are among the main causes of diarrhea and the results can be physically and emotionally damaging.

Diarrhea can change a senior patient’s diet, prompt dehydration, cause electrolyte imbalance, stop function, induce fatigue, affect skin health, restrict physical activity and can be dangerous.

To manage diarrhea, physicians may treat such conditions as impaction; change the laxative therapy in use and the diet of the patient in question for low-fiber, mineral-rich foods that don’t upset the digestive tract; introduce opioid and aspirin use, and; increase liquid intake of water, broths, weak teas, caffeine-free soft drinks, clear juices and gelatin.

Radiation Enteritis

Radiation enteritis is a disorder of the large and small bowels that occurs during and after a session of radiation therapy to the abdomen, pelvis or rectum. The large and small bowels are vulnerable to radiation meant to treat cancer. While radiation dosages can effectively control cancerous tumors, normal tissues can be damaged in the process.

To assess radiation enteritis, physicians may seek out acute signs of injury to the digestive tract after the first session of radiation therapy and up to eight weeks later though some symptoms may present after many months or years. The signs include nausea, vomiting, abdominal cramping and pain, weight loss, and watery diarrhea.

The incidence of radiation enteritis may involve the following factors: dosage of therapy; tumor size and extent; the volume of the bowel treated; other symptoms and illnesses experienced by the patient; the malfunction of the digestive tract in terms of the absorption of fat, lactose, bile salts and vitamin B12; the level of pain felt by the patient; the nature of accompanying discharge, and; the presence of blood in the tract.

To manage enteritis, doctors will consider the level of diarrhea, dehydration, lack of absorption of nutrients and pain and discomfort experienced; attempt to address these with medicine such as brand-name Kaopectate and Immodium liquid formulas, opioids, steroid foams and replacement enzymes; changes in diet, including the use of lactase, fish, poultry and meat, fruit, white bread and toast, pasta, potatoes, vegetables and dairy products; bowel surgery, and; physical rest.

Gastrointestinal Perforation

Gastrointestinal perforations are holes in the wall of the stomach, small intestine, large bowel or gall bladder and a matter of medical emergency. Perforations are generally caused by illnesses such as appendicitis, diverticulitis, ulcer disease, gallstones or gallbladder infection and inflammatory bowel disease, including Crohn’s disease and ulcerative colitis. They lead to leakage of intestinal substances into the abdomen, leading to a form of inflammation called peritonitis.


Anthrax, an infectious disease caused by the bacteria called bacillus anthracis, involves the skin, the gastrointestinal tract or the lungs. This illness, which affects hoofed animals such as sheep and goats, inflicts humans who come into contact with them.
Typically, farm workers, veterinarians and tannery and wool workers tend to be patients. They may contract cutaneous anthrax through a cut or scrape on the skin, inhalation anthrax through the lungs with anthrax spores and gastrointestinal anthrax through anthrax-tainted meat.


Gastroenteritis/colitis, an inflammation of the stomach or intestine due to infection by the virus cytomegalovirus (CMV), is caused by a herpes-type virus related to one that leads to the onset of chickenpox.

Throughout their lives, most people confront the virus by saliva, urine, respiratory droplets, sexual contact and blood transfusions. It creates mild or no symptoms in healthy individuals.

However, some individuals with weak immune systems can develop CMV infections, including patients receiving chemotherapy for cancer, treatment for AIDS and immune-suppressing drugs after an bone marrow or organ transplant.

Those with strong immune systems may acquire CMV infections from a physical injury, kidney failure or infection.

Laxative Overdose

Laxative overdose can take place when an individual accidentally or intentionally ingests more than the normal or recommended amount of drugs. Some overdoses in children are by accident but adults primarily abuse laxatives to lose weight.

The toxic ingredients in the most abused laxatives are bisacodyl (Dulcolax), carboxymethylcellulose, castor oil, docusate, glycerin, lactulose, magnesium citrate, magnesium hydroxide, magnesium oxide, magnesium sulfate, malt soup extract, methylcellulose, milk of magnesia, mineral oil, potassium bitartrate and sodium bicarbonate, psyllium, psyllium hydrophilic mucilloid, senna and sodium phosphate.

Angiodysplasia of the Colon

Angiodysplasia of the colon, which involves enlarged and fragile blood vessels in the colon that result in bleeding in the gastrointestinal tract, primarily affects senior patients. It relates to the aging and degeneration of the blood vessels.

Research is still determining the cause of this illness. The greatest cause are normal spasms of the colon that enlarge blood vessels in the gastrointestinal tract.

With severe swelling, a small route develops between a very small artery and vein, which is called an arteriovenous fistula. It is in that portion of the colon wall that a senior patient may experience bleeding.

Angiodysplasia of the colon is not connected to the diseases of the blood vessels, cancer and diverticulosis, another condition of intestinal bleeding in senior patients.

Gastrointestinal Bleeding

Gastrointestinal bleeding refers to bleeding that starts in the upper part of the small intestine to include the small and large bowels in the digestive tract, which starts from the mouth and ends with the anus.

The extent of bleeding ranges from miniscule that can only be detected by laboratory testing to massive and it may indicate serious illness. Long-term microscopic bleeding can mean anemia. Severe massive bleeding can result in hypovolemia, shock and death.

The bleeding can take place at any age from the time of birth onward. The level and location of bleeding dictates what type of tests will be conducted to find the cause. Once bleeding is detected, a number of treatments are available to stem it.

Causes of gastrointestinal bleeding include anal fissure, aorto-enteric fistula, arterio-venous growth, diverticulum, cancer of the small intestine, colon cancer, cow’s milk allergy, Crohn’s disease, duodenal ulcer, dysentery, esophagitis, gastric ulcer, hemorrhoids, intestinal polyps, intestinal obstruction, intestinal vasculitis, nosebleed, portal hypertensive gastropathy, radiation injury to the bowel, stomach cancer and ulcerative colitis.

Foodborne Illnesses

With age, the immune system gradually ceases to function, leading to a decrease in the level of disease-fighting cells and an increased risk of infections. Exacerbating this is the frequency of surgeries by senior patients, which further compromises the body’s ability to ward off infections.

This makes it easier for foodborne illnesses to take hold, James L. Smith, a microbiologist with the U.S. Department of Agriculture concluded in his research.

Smith arrived at this finding after reviewing data from foodborne illnesses at nursing homes, conducting regular physical exams, studying the immune and digestive systems of seniors and looking at the importance of long-term exercise in strengthening the immune system.

Additionally, with aging, inflammation of the lining of the stomach and a drop in stomach acid takes place. The stomach is instrumental in restricting the amount of bacteria in the small intestine so that a decrease in stomach acids raises the danger of infection if it is digested with food or liquid.

Worsening this condition is the deceleration of the digestive process, enabling the spread of bacteria, fungi and viruses in the gut and the development of poison.

Malnutrition is connected to foodborne illness in that it leads to more infections and takes place with seniors in part because of a decrease in the pleasure of eating, the use of various medicines, digestive illnesses, nondigestive diseases, physical disabilities or depression, all of which may lead to a loss of appetite. Sound nutrition is key to keeping a healthy immune system.

Symptoms of foodborne illness include diarrhea, abdominal cramping, fever, blood or pus in the stools, headache, vomiting and severe exhaustion. This depends on the type of bacteria involved and the sum of toxins digested.

The symptoms can present themselves a half-hour after eating or may not arrive for days or weeks. They may start in a day or two but can stay as long as a week to 10 days. In healthy individuals, foodborne illnesses don’t last long and are not dangerous but they can be both lengthy and lethal in seniors.

In the case of foodborne illness, senior patients or their families must act immediately, Smith says in his research. Seniors must store and mark a portion of the suspect food, recording the food type, the date, the time consumed and the moment the symptoms began.

They must obtain treatment, call their local jurisdictional health department if they digested the food at a large event, from a restaurant or food facility and contact the Food and Drug Administration’s (FDA) consumer food information line if they have questions, he says.

Senior patients must also avoid food poisoning in the future by removing uncooked foods from their diets. Their physicians advise them to steer clear of raw fin fish and shellfish, including oysters, clams, mussels and scallops; unpasteurized or untreated milk or cheese or fruit or vegetable juices; soft cheese such as feta, Brie, Camembert, blue-veined and Mexican-style cheese; raw or uncooked egg or egg products such as salad dressings, cookie or cake batter, sauces and egg nog; raw meat or poultry, and; or raw alfalfa sprouts.

Most fruit or vegetable juices in the nation — amounting to 98 percent — have been treated to eliminate bacteria. The FDA requires companies to place warnings on their products.

Natural Foods, Herbal Remedies for Gastrointestinal Health

Aside from the aforementioned treatments and modes of management for gastrointestinal illnesses as constipation, impaction, bowel obstruction, diarrhea, radiation enteritis, gastrointestinal perforation, anthrax, gastroenteritis/colitis, laxative overdose, angiodysplasia of the colon and gastrointestinal bleeding, a variety of natural foods and herbal remedies exist to treat these conditions.

To respond to these diseases, physicians also recommend the use of chamomile tea, green tea, high-fiber flaxseeds, oats, omega-3s, flax oil, ginger, milk thistle, psyllium, saw palmetto, high-fiber hot peppers, onions, sweet red bell peppers, rice, barley, cabbage, beets, carrots, Brussels sprouts, cauliflower and water.

Chamomile tea has and still remains a remedy for relaxation, to cure insomnia and to soothe an aching stomach. Being researched for its antioxidant, antispasmodic and antiseptic properties, it has been used to treat skin irritation, intestinal cramps and wracked nerves. In tea form, chamomile is drunk three to four times daily to eliminate gastrointestinal upset.

Flaxseeds contain protein, dietary fiber and omega-3 fats and can be found in breads and cereals. Flaxseed oil is a rich source of lignans, a plant compound with hormone-like effects on the body, and omega-3 alpha-linolenic acid, a fatty acid that makes up 55 percent of its oil and is anti-inflammatory and boosts the immune system.

Omega-3s and lignans cut back on the risk of certain types of cancer such as breast, colon, prostate and uterus. Physicians recommend grinding the flaxseeds into a coffee grinder before placing them on bread, pancakes or muffin batters. The flax oil also are used as a supplement and can be placed in salads.

Ginger has long been used as a digestive aid as it enables the secretion of digestive juices in the stomach. Research also finds that ginger is effective in treating nausea, especially from motion or sea sickness and from surgery.

The most natural means of using ginger is to make infusions from grated or sliced ginger root though dosage isn’t calculated. For powdered root, the dosage of ginger is 150 milligrams to 1 gram in capsule several times a day.

It can also be obtained as candied or crystallized ginger at gourmet or Asian markets. A one-inch square is equal to one 500-mg capsule.

However, ginger is not recommended for individuals enduring chemotherapy if their blood cell count is low as it functions as a blood thinner and could place a senior patient at risk for internal bleeding.

Green tea is also useful as an herb to hydrate patients and contains antioxidants that defend against bacteria, which is important as dehydration can lead to constipation. Aside from teas, senior patients are also urged to drink plenty of fluids, particularly water.

Milk thistle, because of its active ingredient silymarin, can guard liver cells against poisons, including medications, viruses and radiation. In fact, it fights inflammation and disease caused by alcoholism, toxins and poisonous mushrooms and can help a liver reconstruct with no side effects.

Diabetics are asked to speak with their physicians about watching their blood sugar while taking milk thistle. A normal dosage amounts to 140 milligrams in a capsule two to three times per day.

Psyllium contains soluble fiber through the dried husks of its seeds. It lowers blood cholesterol and functions as a laxative on an over-the-counter basis. It is also present in some cereals. The FDA approved health claims on cereals containing psyllium.

The agency mandates that each product contain at least 1.7 grams of fiber per serving. Senior patients must drink plenty of water and other drinks when eating psyllium-rich cereals or it can lead to gastrointestinal blockage.

Saw palmetto serves as an inflammatory agent but it also offers relief to men suffering from benign prostatic hyperplasia, or BPH, or the slow but gradual growth of the prostate gland. Daily dosing amounts to 160 milligrams twice. The herb also works well with others such as nettle root and pumpkin seed extract without serious side effects.

Some processed medicines used by senior patients can be used with herbs. Some blood thinners and anti-clotting agents can work with Asian ginseng, dong quai, ginkgo, ginger, feverfew and garlic. However, heart drugs like digoxin produce negative interactions when mixed with Asian ginseng or St. John’s wort.

As a result, senior patients must follow instructions when dosing herbals. Researchers ask seniors over the age of 70 to take about 80 percent of the recommended adult dosage of any herbal preparation. Seniors who are frail or cannot take some drugs should begin with half the recommended dosage of medicines.

Some foods have been billed as colon cleaners when eaten raw. These include hot peppers, onions and sweet peppers. Oats join flaxseeds as being highest in soluble and insoluble fiber. Other foods that also known to cleanse the digestive tract include barley, beets, Brussels, cabbage, carrots, cauliflower and watermelon.


Altshuler, Larry, M.D., and Connors, Martha Schindler, “Seniors and Health,” Gastrointestinal Health Program,

American Accreditation Healthcare Commission,

American College of Gastroenterology,

American Gastroenterology Association,

Gastrointestinal Bleeding,

“Gastrointestinal Complications: Supportive Care – Health Professional Information,” National Cancer Institute,

“Gastrointestinal Health in Seniors,”

International Foundation for Functional Gastrointestinal Disorders (IFFGD),

“Keys To Gastrointestinal Health,”

Liver Foundation,

National Digestive Diseases Information Clearinghouse,

Research Makes Gastrointestinal Health A Senior Care Priority (Part 1 of 2)

Research on newer long-term illness issues, personal habits and socioeconomic trends are prompting senior care facilities to make gastrointestinal health one of its top medical concerns, healthcare providers, federal biological science investigators and medical policymakers say.

Documented key trends factoring into the decisions of senior long-term care and short-term care facilities to prioritize gastrointestinal health include the aging of the Baby Boomers, past and present drug abuse, alcoholism and cigarette smoking, the onset of cancer and other deadly diseases, environmental pollution, the use of bottled water, poor eating, sleeping and exercise habits and a struggling economy.

All impact the health of the digestive tract, research reveals, as aging in general without intervention from a proper diet, obtaining enough sleep and practicing physical exercise places gastrointestinal health in decline.

Namely, abuse of certain categories of drugs such as heroin cause constipation. Alcoholism undermines the function of the liver. Smoking, environmental pollution and sometimes contaminated bottled water can lead to heartburn, gastroesophageal reflux disease (GERD), peptic ulcers, liver disease, Crohn’s disease, colon polyps, pancreatitis and gallstones.

Radiation and other therapies to treat cancer causes gastrointestinal problems. An economic crisis is likely to negatively affect an individual’s eating, sleeping and exercise routines and, thus, affect gastrointestinal health, which is dependent on them.

Research by federal agencies such as the National Cancer Institute (NCI), the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK), the Food and Drug Administration (FDA) and professional trade associations such as the Liver Foundation, the American Accreditation Healthcare Commission, the American College of Gastroenterology, the American Gastroenterology Association, and the International Foundation for Functional Gastrointestinal Disorders connects the importance of the soundness of the gastrointestinal tract to overall physical and mental health.

With the outpouring of research on the total health of seniors and gastrointestinal illness over the years, senior care facilities have begun to collaborate more with nutritionists/dietitians, gastrointestinal specialists/gastroenterologists, surgeons, critical care nurses, activities directors, exercise specialists, physical therapists, occupational therapists, message therapists, medical assistants and radiologists to treat and rehabilitate their patients.

The digestive tract includes the mouth, teeth, esophagus, stomach, small and large intestines, rectum, anus, liver, pancreas and gallbladder. Care providers, researchers and policymakers say keeping the tract healthy is vital to good health, which means that each of these components must work properly.

Food is digested before it enters the small intestines where much of the process takes place between the enzymes in saliva and the stomach. More enzymes are made in the small intestines and pancreas. The remainder goes into the large intestine or the colon. Water is purged from what has not been digested.

However, with enzymes decreasing with age, digestion slows down as does, also, the body’s ability to take in nutrients. When this occurs, seniors start to lose benign bacteria, which leads to overuse of the liver and kidneys and courts a wide range of illnesses.

Symptoms of a deteriorating digestive tract include bloating, indigestion and constipation. As conditions worsen, so do the symptoms. Still, a malfunctioning tract can recover with proper nutrition. Enzymes to aid digestion can be bought in supplements to counteract bloating, indigestion and constipation.

Senior Care Concerns

In hospitals and senior care facilities, leadership-level dietitians advise directors of the nutrition department on management and development of clinical services and supervisors of the gastrointestinal surgery and critical care department on delivery, practice and design. These dietitians are expected to have extensive clinical nutritional experience and knowledge of gastrointestinal surgery and critical care.

In the case of seniors, they are aware that this cohort of patients face a unique set of health problems. Dietitians understand that the bodies of seniors differ from that of others and they are more vulnerable to a variety of illnesses and their attitudes towards health care are different as well.

Aging causes patients to change in body weight and composition as both men and women weigh more as they transition from young adult to middle age to senior adulthood. By their 70s, they start to lose weight. As they age, the bodies of seniors regulate blood pressure, body temperature and fluids less efficiently.

Illnesses in seniors can interrupt cell production. For instance, Alzheimer’s disease can lead to the early death of brain cells and Parkinson’s disease can eliminate an excessive number of nerve cells. By comparison, cancer delays cell death and enables cancer cells to proliferate.

The sum of these changes affect how a senior lives, the amount and the type of physical exercise he or she conducts as well as his or her health care needs.

Aside from the fact that seniors present a specific set of health concerns, no single aging adult has the same problems. No two seniors age at the same rate. Additionally, even within one senior, not all body systems changes are entirely synchronized.

Seniors process medicines, whether herbal or pharmaceutical, differently than young and middle-aged adults.

Seniors weigh less and have more body fat than they have muscle. As the percentage of body fat increases, the bodies of seniors metabolize drugs and other substances in fatty tissue, which means that these elements stay in their bodies longer and may be more stronger than similar medications in the bodies of young and middle-aged adults.

These medications collect in the bodies of seniors because their kidneys don’t function as effectively as they did when they were younger adults. As a result, for example, nonsteroidal anti-inflammatory drugs, also known as NSAIDs, are more at risk of causing gastrointestinal bleeding and kidney trouble in seniors than in young or middle-aged adults.
Gastrointestinal Health

Especially after a gastrointestinal surgical procedure or therapy, dietitians provide senior patients with advice about improving their health. While a variety of reasons exist for poor gastrointestinal health, food is the main one.

As a result, dietitians recommend that seniors prevent a range of digestive diseases, including gastrointestinal ones, by eating properly. This means eating a balanced diet of protein, carbohydrates and fats, fresh foods and fiber-rich fruits and vegetables.

A balanced diet clears the intestines, improves bowel movements and decreases constipation. Whole wheat carbohydrates are more fiber-rich than white-flour-based ones.

Seniors are encouraged to consume five portions of fruit and vegetables per day as part of the recommended daily intake with research revealing that this habit guards against life-threatening illnesses such as cancer and maintains a healthy digestive tract.

They are advised to drink fresh and uncontaminated water, specifically two liters, which does not include coffee, tea or carbonated drinks, to stay hydrated and flush out poisons. Two liters equals six glasses daily. Habitual coffee drinkers are asked to remember to drink a glass of water after each cup as coffee has a dehydrating effect on the body.

In an age of national fracking and offshore oil and gas drilling, private home walls tainted by lead paint, radon gas seeping underground, carbon monoxide in homes and garages and electromagnetic waves emanating from nearby electrical poles and generators and other forms of environmental pollution, activities such as drinking safe, purified water becomes more critical to gastrointestinal health.

Tainted water contains bacteria, which may damage the intestines and destroy the digestive system, leading to vomiting and diarrhea.

Additionally, dietitians ask senior patients to steer clear of spicy foods. Extra spices cause high acidity and alkaline content in the intestines, kidney problems requiring dialysis and severe burning.

High acidity can be halted by consuming such foods sparingly, keeping the blood stream at a pH of 7.4 and using liver salts. For similar reasons, seniors are asked to avoid sour foods.

They are cautioned to eat light meals every two hours or to generally eat little but often and to space meals apart daily. Eating a large meal within hours of sleep for the night should be avoided.

Such practices, dietitians say, improve gastrointestinal health by decreasing the burden on the liver and the small intestine from which the blood supply declines and absorption of the nutrients from large amounts of food is made more difficult.

Seniors are also recommended to shy away from foods containing high fat, including deep-fried foods, and to adopt a low-fat diet instead. Avoiding high fat in the diet, dietitians say, prevents the development of gall stones.

Patients are told to cease smoking and drinking excess alcohol, as both or either lead to the formation of small sores in the stomach known as ulcers, compromising gastrointestinal health.

While seniors are prescribed a cocktail of painkillers and anti-inflammatory medication, they are instructed to avoid excess as these, too, lead to stomach ulcers.

Seniors are also advised to stop eating foods that cause allergies and this habit will lead to sounder gastrointestinal health. Symptoms include vomiting, itchy spots on the skin and reddishness around the mouth.

They are asked to take part in a moderate amount of daily exercise, especially those related to the abdomen, yoga or relaxation through message therapy as these are the means of ensuring sound gastrointestinal health and avoiding mental stress. Mental stress leads to gastrointestinal illness, particularly acidity in the stomach and ulcers.

Swimming is ideal as a form of exercise because it not only keeps a patient fit but also tones all the major muscle groups of the body.

Dietitians say sufficient hours of sleep and sleeping at the same time every night also leads to optimal gastrointestinal health as insufficient sleep leads to depression, which triggers unsoundness eating habits that compromise gastrointestinal health.

Gastrointestinal Exams, Programs

Physicians also recommend that seniors, especially those with gastrointestinal problems, participate in specific radiological health programs that include esophageal and anorectal manometry, pelvic muscle retraining, also known as biofeedback, and defecography.

The NCI and the American College of Gastroenterology report that colon and rectum cancers are the fourth most commonly diagnosed cancers and are second among cancer deaths nationally. Screening for colorectal cancer is regularly permitted by most insurers for patients aged 50 years or older and patients with family histories of cancer.

Some common gastrointestinal exams include colonoscopy, liver biopsy, paracentesis, esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancretography (ERCP), endoscopic ultrasound, and percutaneous endoscopic gastrostromy (PEG). Pulmonary tests include bronchoscopy, thoracentesis, bracheotherapy and tracheostomy. Other programs include photodynamic therapy.

Symptoms that warrant a esophageal motility study (EMS) include heart burn, difficulty swallowing, unexplained chest pain, pre-operative evaluation, anti-reflux surgery and diagnostic tool to identify scleroderma, achalasia and nutcracker esophagus.
Conditions that qualify for 24-hour pH monitoring include heart burn, difficulty swallowing, unexplained chest pain, chronic cough and hoarseness.

Problems that satisfy the need for anorectal motility with electromyography (ARM w/EMG) include evaluation of fecal incontinence, chronic constipation, evaluation of rectal pain, retraining on incontinence, pre-operative evaluation, rectal surgery and anal surgery.

To undergo radiological defecography, senior patients must present with the symptoms of prolapsed rectum, intussusception and enterocele. To receive pelvic muscle retraining, patients must exhibit symptoms of fecal incontinence, chronic constipation, difficult evacuation and anal pain.

Physicians also steer senior patients, who experience bleeding, pain, swallowing difficulties and a change in bowel movements, in the direction of endoscopy services that include non-invasive gastrointestinal and pulmonary procedures that last an hour to three hours on an outpatient basis.

Endoscopy involves examining inside the human body with an endoscope, a flexible tube holding a small camera. The type of endoscope used is named for the organs of the body they are meant to examine such as an arthroscope for the joints, a bronchoscope for the lungs, cystoscope for the bladder and a laparoscope for the abdomen.

A gastrointestinal endoscope is inserted through the mouth or anus or rectum and an ultrasound probe can be added to the endoscope, thus called an endoscopic ultrasound.

Small instruments can be used to take samples of possibly diseased tissues. Probes that pertain to the gastrointestinal tract include colonoscopy for colon polyps or colon cancer, EGD or esophagogastroduodenoscopy, enteroscopy and sigmoidoscopy. A patient may be asked to clear out his or her large intestine by enemas and laxatives to prepare for these tests.

For senior patients suffering from diarrhea, physicians may may also order fecal smears, a lab test to inspect a stool sample for bacteria, fungi, viruses or other type of microorganisms that start illnesses in the gastrointestinal tract.

There are multiple ways to collect the sample. One is to capture it in plastic wrap in a washroom and keep it in a clean container in the doctor’s office. Once the physician receives the results of the lab test, he or she can prescribe the most appropriate antibiotic treatment.

Doctors can also direct senior patients to take a rectal culture, a lab test to determine the type of microorganisms that cause gastrointestinal illnesses. With this type of test, a cotton swab is placed in the rectum, turned around and retrieved. A smear is used to grow bacteria or other organisms to observe the culture for growth.

The culture may be carried out in a hospital or nursing home to test a senior patient for vancomycin-resistant enterococcus or VRE in their intestine, a highly communicable disease.

Gastrointestinal Gas

Gastrointestinal gas is defined as flatus or gas eliminated by burping or passing through the rectum. Research finds that individuals produce a normal quota of about one to three pints a day and experience flatulence 14 times a day though some believe they release too much.

The gas is made mostly of odorless substances, carbon dioxide, nitrogen, hydrogen and oftentimes methane. Foods containing carbohydrates cause gas while foods with fats and protein cause little.

The unpleasant scent stems from bacteria in the large intestine that emit gases containing sulfur. The gas comes from swallowed air and the breakdown of undigested foods by benign bacteria in the large intestine.

Air swallowed by a person is also known as aerophagia. Any person can swallow air when eating and drinking. Still, eating and drinking quickly, chewing gum, drinking with a straw, smoking and wearing loose dentures can cause some individuals to breathe in more.

Symptoms of gas include belching, flatulence and abdominal bloating and pain. Crucial factors are likely how much gas the body eliminates and an individual’s sensitivity to gas in the large intestine.

However, large amounts of flatus may signal an abnormality in which the intestine absorbs nutrients, especially if diarrhea or weight loss is present.

While eliminating gas is a healthy, daily digestive process, physicians recommend the omission of certain foods, including high-fat ones, from a patient’s diet to cut down on bloating and discomfort. Scaling back enables the stomach to empty more quickly, letting gas move onto the small intestine.

Gas-emitting foods include broccoli, baked beans, beer, brussels sprouts, cabbage, carbonated drinks, cauliflower, chewing gums, citrus fruits, corn, eggs, greens, milk products, oats, onions, potatoes, red wine and wheat. Doctors also recommend the start of a lactose-free diet to cut down on human gas emissions.

Enzymes such as lactase supplements aid digestion of carbohydrates and empower individuals to eat foods that produce gas. For example, the enzyme product Beano cuts down on gas production connected with baked beans.

Decreasing the amount of air swallowed or aerophagia is also presented as a solution. Aerophagia is associated with excess salivation and many physicians recommend avoiding such habits as too much gum chewing or smoking. They also seek to treat such digestive conditions as peptic ulcer, which may lead to hypersalivation or nausea.

A Conflict of Interest In Independent Pharmacy Consulting

Independent pharmacies that both dispense medications and provide consulting services to long-term care facilities at the same time, present a conflict of interest and may land themselves and the facilities in trouble, the U.S. Centers for Medicare and Medicaid (CMS) and other federal agencies say.

It is important for third-party pharmacies to provide consulting services without dispensing drugs so as to bring greater accountability, transparency and competence to medication choice, administration and overall business activities to satisfy state and federal inspection and review requirements, the agencies add.

Research from the U.S. Department of Health and Human Services, with the Agency on Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), finds that the Baby Boomer generation continues to age while the number of seniors over 85 will increase by 90 percent over the space of 20 years — with a total elderly population of 34 million.

Third-party independent pharmacies are increasingly serving the prescription needs of long-term and short-term care patients in those facilities, especially seniors.

With such an aging segment of the nation in need of medical care, pharmacies have grown instrumental in meeting their treatment needs and decreasing the costs to the facilities caring for them.

However, the CMS, federal regulators and policymakers say their daily business undertakings have raised issues of integrity. Some pharmacies who both distribute drugs and advise medical facilities have been reported to look out for their own best interests, especially in terms of profit-making, rather than root out the flaws or errors in a client’s medication policies and practices.

This compromises the quality of drugs, the appropriateness of their administration and medical outcomes for their patients, pointing to point a need for independent pharmacies to provide consultation without distributing drugs, they conclude.

Federal laws, Regulations

The Affordable Care Act of 2012 mandates that a long-term care facility carry out the recommendations of a third-party consultant pharmacist, including advice concerning drug formularies.

While the law recognizes the importance of recommendations made by a third-party consultant pharmacist to a long-term care facility, the nursing staff employed there are not imposed upon to execute these directives without inspections from a state agency.

Still, a long-term care consultant pharmacist’s enforcement of a drug formulary influences the facility’s negotiation of a drug manufacturer’s rebates.

Additionally, a number of states make exceptions to the responsibilities of long-term care consultant pharmacists.

For example, in Colorado, consultant pharmacists are expected to fulfill the tasks of legal compounding, evaluate the implementation of policies of the state’s Pharmacy Advisory Committee and publish quarterly reports to the committee on the status of pharmacy activity.

Under Idaho law, consultant pharmacists must supervise services when their employer-nursing facilities use more than one manufacturer of drugs. Such pharmacists in Mississippi must attend board-approved workshops to be trained in their duties.

In Oklahoma, they must assist with drug destruction and converse with the staff of their employer-facilities about policies and procedures related to destroying medications.

Overall, most states throughout the country are expected to authorize third-party consultant pharmacists to provide these aforementioned services to the employing long-term care facilities.

Still, nursing homes and skilled nursing facilities have stand-alone agreements that spell out duties for pharmacy dispensing services and consultant pharmacy services. For instance, New Jersey is the only one calling for a separation of such services so that the consultant pharmacist cannot work for the dispensing pharmacy.

In October 2011, CMS released a draft regulation that called for more independence on the part of third-party pharmacists employed by consultant pharmacies to avoid the conflict of interests it found when it investigated such practices tied to long-term care facilities, serving mostly seniors.

Titled “Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to the Conditions of Participation for Long Term Care Facilities,” the draft rule focused on the agency’s concern with pharmaceutical manufacturers paying third-party long-term care pharmacies to have their staff consultant pharmacists urge doctors to prescribe their drugs to facility patients.

Consequently, CMS questioned the ability of third-party consultant pharmacists to review drug regimens impartially and to avoid compromising the quality of such evaluations and, thus, endangering the health and safety of patients. The agency also raised issues about long-term care pharmacists maintaining ties with pharmaceutical manufacturers.

Through its investigations of industry, CMS revealed that third-party, long-term care pharmacies outsource consultant pharmacists to nursing homes for compensation below the expenses of such pharmacies and below market value.

As a result of its findings, the agency stated that it pondered calling for long-term care facilities to hire independent pharmacists. By definition, an “independent” entity would be described as, for example, a licensed pharmacist not employed, under contract or connected otherwise to a long-term care facility’s pharmacy, pharmaceutical company or distributor.

The agency explained that it meant to rid a consultant pharmacist of any financial ties to any long-term care pharmacies or facilities that would prevent him or her from providing impartial drug regimen reviews and evaluations.

In April 2012, CMS unveiled a final rule that would not enforce such a regulation but instead invited comments on the topic. Still, the agency indicated that it would continue to examine the matter of enacting a rule to render long-term care consultant pharmacists independent.

The Role of Consultant Pharmacies in Long-Term Care

Over 20 years ago, industry experts say consultant pharmacies were formed to guarantee that long-term care patients receive the correct medications in the proper dosage at the right time.

Responding to projections of a growing aging population at the time, pharmaceutical companies developed dozens of drugs for each of the most chronic illnesses such as Alzheimer’s disease, diabetes, osteoporosis, rheumatoid arthritis and respiratory lung disorders, they say.

Overtime, such pharmacies evolved to empower 10,000 pharmacists nationwide to provide a broad range of administrative, distributive and clinical services to nearly two million mostly assisted living and skilled nursing facility patients. The most progressive pharmacies would be staffed with other medical professionals such as nurses, physicians, dietitians and laboratory staff.

Seniors, who make up the majority of long-term and short-term care patients, are the main focus of third-party consultant pharmacy practice because they are the most likely to endure drug-related hurdles such as adverse drug reactions, toxic interactions, improper use and fatal, repeated drug administration. As a result, elderly patients account for billions of dollars in drug costs.

According to the American Society of Consultant Pharmacists (ASCP), third-party consultant pharmacists tied to long-term settings provide pharmacological services; educate facility staff and administrators about medicine; serve as clinical practitioners; advocate quality care for patients and families, and; join a patient’s medical team.

Third-party, long-term care consultant pharmacists review drug regimens (DRR); evaluate drug use; develop new formularies and drug distribution systems; assess the health of facility patients; create plans of care; promote infection control; support diet and nutrition services; craft clinical policy and procedure; order and interpret laboratory tests; participate in state surveys, and; engage in clinical research.

They also handle durable medical equipment (DME); perform surgical appliance fittings; counsel patients on pain management; initiate intravenous therapy for patients; create and improve quality assurance programs; manage enteral feeding products; ensure outpatient packaging compliance; provide home diagnostic services; maintain medical/surgical supplies, and; generate computer forms and reports.

Additionally, the federal agency CMS regulates third-party consultant pharmacists to visit licensed nursing facilities every 30 days to provide drug regimen reviews for all patients served.

Long-term and short-term categories of care served by third-party consultant pharmacies include acute care hospitals; adult day care; alcohol/drug rehabilitation centers; ambulatory care; assisted living; community-based care facilities; congregate care; continuing care retirement communities (CCRC); correctional facilities; group homes; health maintenance organizations (HMOs)/preferred provider organizations (PPOs); home health agencies; hospice or post-surgical/palliative care centers; industrial plants; mental institutions; nursing homes; senior independent living, and; skilled nursing facilities.

The most common categories of care that consultant pharmacies serve nationally are assisted living facilities with between 30,000 to 40,000 such centers caring for more than one million persons, and, skilled nursing facilities.

Throughout the country, the remaining most common categories include board and care with 32,000 licensed homes for 500,000 persons; adult day care with 10,000 projected to be built and maintained by the end of the decade, and; home health care at 14,000 such agencies serving six million patients.

Additionally, the pharmacies nationwide serve hospice care with 2,500 centers serving 340,000 persons a year; CCRCs to grow from 1,000 at present to 10,000 over the next few decades; senior independent living with more than 2,500 communities, and; senior citizen centers as 12,000 of them serve between five and eight million patients annually.

Insurance Company Audits

Independent pharmacies, especially those that dispense drugs and may or may not necessarily provide consulting services, must anticipate pharmacy compliance audits and more pharmacies have been subjected to them in recent years.

Before an audit occurs, an audit and compliance vendor/contractor will mail an independent pharmacy a notice, describing plans to visit this facility to carry it out. These vendors or contractors tend to represent third-party prescription insurance companies.

Two weeks before this appointment, an assigned representative will phone a pharmacy to confirm his or her visit. An independent pharmacy may be faxed a copy of all of the prescriptions that must be inspected. The pharmacy may not receive a entire code number but sufficient information to retrieve a prescription drug file.

On the day of the audit, the pharmacy may need hired help to assist with the retrieval, replacement, document management and delivery of the necessary paperwork during the whole process.

Hired help comes in the form of a pharmacy assistant or the pharmacy’s pre-existing ancillary team. A pharmacy needs an assistant or team because an auditor’s direct questions will become more complex if data is not made available.

Consequently, an independent pharmacy must ensure that the pharmacy assistant or team comprehends the company’s entire prescription billing and recordkeeping process as it will satisfy an auditor’s quest for answers.

First, a pharmacy must be sure to make its signature logs, whether electronic or manual, policies and procedures manuals and compound formula worksheets easily accessible. Auditors will request to see its policies to judge how the pharmacy handles compounding even if it performs very little. They may also demand to view its policies on delivering drugs to facilities or patient’s homes.

Some audits can truly escalate. They may examine claims submitted two years ago and may peruse at at least 100 or more prescriptions in an afternoon. Any gaps or inconsistencies may require an adjustment unless an audited pharmacy can produce documentation as evidence of the claim. A mere undocumented refill in a pharmacy’s computer may result in thousands of dollars in adjustments.

When the audit is complete, a pharmacy will receive reports about an auditor’s revelations and adjustments. Adjustments of several thousands of dollars may appear in the audit, which translates into money that the pharmacy may have already paid that an insurer may hold back from future payments until that sum is paid in its entirety.

In fact, it may not escape an audited pharmacy that the auditors focus most of their attention on drugs with the highest potential for financial withholding. An audit may review all of the most expensive prescriptions, insulin pens and vials, brand-name inhalers and any other drug that was reimbursed for more than $500.

While this aspect of the audit is clearly imposing, a pharmacy still has legal recourse to appeal its findings. By state or federal law, an audited pharmacy has 30 days to send documentation that challenges these adjusted claims.

An audited pharmacy is urged to examine all adjustments meticulously. If a prescription lacks refill authorization, the pharmacy should consult a prescribing physician and explain the circumstances of the audit. In turn, the physician must account for the missing refill documentation on letterhead and most are willing to cooperate to assist a pharmacy in this endeavor.

Adjustments of drug supplies that last a matter of days can be appealed for partial pay. Even partial pays on costly drugs can be worthwhile. Categories of drugs that warrant calculations include insulin, drops, topicals, inhaled therapy and liquids.
Challenges To Independence

Many in the industry agree with federal agencies on the importance of third-party independent pharmacists forming their own consulting practices without dispensing medicines whether they’ve just completed their studies or have worked in their professions for a long time.

However, industry experts also acknowledge the difficulties faced by pharmacists to create their own entities with the roles they play in patient care, payment and reimbursement trends and the manner in which they deliver care.

Under the new payment and modes of delivery that include accountable care organizations (ACOs) and bundled Medicare/Medicaid payments, third-party consultant pharmacists are finding it harder to deliver cost-effective, quality patient services that would help avoid hospital admissions as required by the federal ACA law and the CMS’ Hospital Readmission Reduction Program.

Third-party independent pharmacies face the challenges of decreased reimbursements, shrinking margins and large national drug chains planning mergers and acquisitions, thus raising the potential for them to act with a conflict of interest such as making profits off distributing drugs.

However, these same pharmacies are providing new types of services such as medication therapy management and synchronization and are searching for new opportunities to grow and achieve different means of generating incomes.

Developing Independent Practices

Industry experts say that a third-party, independent consultant pharmacy is not restricted to a choice few practitioners and a specific academic degree is not required.

They say that any licensed pharmacist can open up an independent practice as long as they have a solid background in pharmacotherapy, an interest in the field of geriatrics and are grounded in an understanding in the drug and therapy needs of this age cohort.

In other words, knowing how to make recommendations to long-term care facility staff and administrators and understanding what drugs and dosages should be used for seniors is a good start for a long-term care pharmacist who wishes to grow an independent consultant practice.

Such an independent consultant pharmacist will become a Certified Geriatric Pharmacist under the National Commission for Certifying Agencies (NCCA), the accrediting body created to evaluate and regulate pharmacists, ensuring that they have the requisite knowledge in geriatric pharmacotherapy and ability to provide drug care to elderly patients.

To start their practice, experts say, independent pharmacists would have to decide how much it would cost to provide services in order to structure pricing to charge the employing long-term care facilities.

They must also consider travel time, vehicle wear, technology equipment, repair and upkeep and printing costs into their budgets. All of these costs depend on the location of the facility and the number of patients they plan to serve.

Starting out, some of an independent pharmacist’s problems include the starting expense to the employing long-term care facility. Prior to such an arrangement, experts say, long-term care facilities have not borne the costs of a pharmacist’s time because long-term care consultant facilities have always used pharmacist staff as a means of reducing costs.

To convince a prospective employer to accept his or her services, an independent consultant pharmacist must be able to prove that his or her pharmaceutical care skills command a higher price, they say.

Such demonstration tactics include pharmaeconomic reviews for the facility’s patients. Medicare pays for the care of a facility’s patients on a daily basis and any funds saved from obtaining drugs would boost the facility’s income.

This, in turns, reduces the risk of hospital readmissions and ensures that drugs are carefully monitored so that the facility can avert punitive financial fees during surveying.

Industry experts say that, before embarking on building an independent pharmacy practice, a consultant pharmacist ought to explore the opportunity. He or she must conduct market research, ask relevant questions and attempt to answer them on their own.

Specifically, a consultant pharmacist must discover how many facilities exist in their location. He or she must learn whether new nearby entities like his or hers are opening and if his or her market is expanding, experts say.

The independent pharmacist must determine if these prospective long-term care facilities are pleased with the quality of services they are receiving from these rivals and exactly where the gaps in performance are.

The consultant pharmacist must find out what he or she have to offer that is different from that of his or her competitors. He or she must know how he or she would make use of his or her present talents and relationships for this new pharmacy practice.

The pharmacist must also decide what type of investment would be needed to start his or her business, the advantages and disadvantages, the staff needed and the strategy he or she devised to land his or her first assignment.


To get started, Mark Prifogle, CEO of Grandview Pharmacy in Brownsburg, Ind., assembled multiple resources to enable consultant pharmacists to begin.

Aside from the above-mentioned recommendations for planning a launch of an independent pharmacy practice, other tools are available at the following sites:

–McKesson Corporation at and by e-mailing [email protected];

–The U.S. Centers for Disease Control and Prevention at;

–The National Consultant Pharmacists Association at;

–Managed HealthCare Associates at;

–The National Association of Boards of Pharmacy at, and;

– website, specifically for starting, buying and selling pharmacies.


Alves, Jared BS, BA; Yee, Colin MPH; Coppage, Mary BA; Lukens, Ellen MPH; Advani, Protima MA; “Long-Term Care Pharmacy: the Evolving Marketplace and Emerging Policy Issues,” Avalere Health LLC, October 2015, pp. 1-33.

Leuck, Peter, “Pharmacy Compliance Audits: What Pharmacists Can Expect,” (Last accessed: Jan. 4, 2017)

McKesson Corporation, “Becoming a Long-Term Care Pharmacy: Opportunities and Important Considerations,”, 2015, pp. 1-16.

Simonson, William PHARM.D., is Associate Professor of Pharmacy Practice, Oregon State University, and Associate Professor of Pharmacy Practice, Oregon Health Sciences University, both in Portland, “Practitioner Update: Pharmacy Practice in the Long-term Care Environment,” Journal of Managed Care Pharmacy, Vol. 3. No.2 Mar/Apr 1997, pp. 189-94.

The Lewin Group, “CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services: Long-Term Care Pharmacy Primer,” (Prepared for the U.S. Centers for Medicare and Medicaid Services), Dec. 30, 2004, pp. 1-38.