Abstract
Introduction
Older adults are particularly vulnerable to adverse drug effects from opioids, including constipation, delirium, immobility, and delayed discharge. Despite NICE guidance recommending prophylactic stimulant laxatives with opioid prescriptions, older surgical inpatients frequently receive inadequate bowel care. Prescribing must also consider comorbidities such as renal impairment and cognitive decline. This quality improvement project aimed to optimise opioid and laxative prescribing safety in an elderly surgical population.
Methods
A two-cycle audit was performed on a long-stay general surgery ward over two 7-day periods. Data collected included patient age, cognition, renal function (eGFR), opioid use, and laxative co-prescription. After cycle one, a ward-based intervention was introduced:
- A visual prescribing guideline
- Junior doctor teaching sessions
- Bowel chart reviews integrated into daily ward rounds
Cycle two re-audited the same parameters to assess impact.
Results
25 patients in each cycle received opioid prescriptions. Following intervention:
- Laxative co-prescribing rose from 56% to 84%
- Rescue enema use dropped from 24% to 6.25%
- Use of phosphate enemas in patients ≥65 fell from 66% to 0%
- Opioid prescribing in those with eGFR <45 mL/min/1.73m² halved (24% to 12.5%)
- However, laxative prophylaxis remained poor for patients with cognitive impairment in both cycles
Conclusion
This project demonstrates that simple, low-cost measures can substantially improve prescribing safety for older surgical inpatients. Reducing avoidable constipation, especially in those with frailty or renal impairment, supports improved recovery and discharge planning. Cognitive impairment remains a critical gap requiring targeted intervention. Embedding such approaches into geriatric surgical pathways may enhance multidisciplinary safety and care quality.