Constipation can have an awful impact on quality of life among frail seniors. First of all, it increases urinary tract infections. Then, at its worse, it results in fecal impaction and incontinence. This increases caregiver burden and stress. Ultimately, the person ends up being unable to live at home. What a disaster. That’s why I think it’s so important to avoid constipation. The goal should be a solid, medium-sized, bowel movement with complete evacuation. In addition, at a regular time every day. That’s constipation relief!! Now, what’s the scoop?
Step 1: Are medicines causing the constipation?
The last post discussed causes of constipation. Drugs contribute to constipation up to 40% of the time. Narcotics slow down intestinal transport. Diuretics (also known as water pills) and calcium channel blockers are widely used and commonly constipating. It’s good to review all medicines and see if constipation is a side effect. Doctors frequently add another medicine to treat the constipation. However, it doesn’t hurt to ask if an alternative drug can be used.
Step 2 The importance of routine
When I was a little kid, my Mom taught me good habits. Every day, after breakfast and before school, it was straight to the bathroom. This is a lifelong message. Good bowel habits start with a regular schedule. Seniors tend to have more flexible time. But developing a bowel routine is important. The gastrocolic reflex makes the colon more active soon after a person starts eating. In addition, food is digested in the intestines all night. It’s good to go to the bathroom daily after breakfast even if there is no urge. This establishes “bowel memory”.
The routine also needs to be comfortable. This is especially true for frail, mobility impaired, seniors. A person who is unsteady will have difficulty focusing on evacuation. A toilet seat riser with handles makes a nice throne. The riser sits on top of the toilet seat and makes it easier to sit down and get up. The handles provide an arm rest and extra security. A toilet stool under the feet also helps. Muscles relax and evacuation is easier when the knees are high. If at all possible, avoid using bedpans. They should be used only as an unavoidable evil.
The overall message is that having a bowel movement shouldn’t be an ordeal. Make it a routine that is comfortable and relaxing. Praise after successful bowel training is important in frail patients, just as it is for children.
Step 3 Lifestyle habits
More fluids and fiber are needed when stools are small, compacted, or dry. The fiber is not digested and results in a larger poop. Fiber should be increased gradually until stools are softer and larger.
Prunes are a natural laxative and can be taken daily. Prunes work for mild to moderate constipation. Start with 3 prunes or half a cup of juice and increase if needed. Ten prunes provide 7 grams of fiber, a quarter of the daily recommended dietary fiber. Prunes are safe for most diabetic patients. They taste sweet but have a good glycemic index. This means that blood sugar does not go up dramatically after eating them. Prunes are also high in antioxidants. They can help people lose weight, improve cholesterol, and lower blood pressure.
People who are more active tend to have better bowel movements. This is probably due to good overall health. On the flipside, frailty and immobility are associated with constipation. This is partly due to difficulty getting to the bathroom. Immobility is a progressive downhill problem. The less a person walks, the more immobile a person becomes. For this reason, constipation frequently gets worse in the hospital. Prevent constipation by keeping a person mobile.
I am an advocate of gentle abdominal massage for constipation. It is a natural way of stimulating the colon. It helps when a person has Parkinson’s disease, stroke, or constipation of uncertain cause. Massage is also a “hands on” way of caring for a person. Routine massage can help retrain the colon.
Step 4 Over the counter remedies
The good news is that there are rows and rows of products you can buy for constipation. The bad news is that they vary in efficacy, tolerability, side effects, and price. They fall into the below categories (with some brand names in parentheses):
Bulk forming agents (FiberCon, Metamucil) have fiber and increase the size of stools. FiberCon is a medium sized tablet. Metamucil is a powder that needs to be mixed with fluid. They are useful when stools are small, compacted, or hard. I use these first when the primary problem is inadequate dietary fiber. Side effects tend to be minor, mostly gas or bloating.
Stimulants (SeneKot, Dulcolax) work by increasing motility in the intestines. They are useful when constipation is due to medicines or underlying medical conditions. Stimulants are widely used partly because they are small, easy to take, pills. They sometimes cause diarrhea, abdominal discomfort, or cramping.
Polyethylene glycol (Miralax) draws fluid into the intestines and stool. It is a powder that needs to be mixed with fluids. It is flavorless but has a thick consistency. Polyethylene glycol is an effective first line treatment for chronic constipation. It is generally well tolerated but some people don’t like drinking it. It causes occasional nausea, abdominal discomfort, or diarrhea.
Magnesium draws fluid into the intestines and stool. Magnesium laxatives are useful to get a quick response. Magnesium hydroxide is the classic Milk of Magnesia. People say it tastes like chalk. It should not be used frequently. Magnesium citrate must be taken with a large amount of fluid. In the past it was used to clear out the intestines. Magnesium based products should not be used regularly. They can draw large amounts of fluid into the intestines and cause illness.
Docusate (Colace) is a “stool softener”. It lubricates and moisturizes stool. There is not good evidence that it works well. Yet, many of my patients like to use it. It is easy to take and has few side effects. My impression is that it helps for mild constipation. Docusate is available combined with senna, a natural stimulant.
What about probiotics? The body is full of bacteria. Some are essential for health while others are harmful. Illness or antibiotic use can change the bacteria in the body. Probiotics are used to increase the beneficial bacteria in the body. They contain live bacteria and yeasts. Oral probiotic capsules are available as a treatment for constipation. Yogurt has also been promoted this way. However, it is not yet clear whether probiotics improve constipation. Probiotics are not generally harmful.
Step 5 Prescription drugs for constipation
Prescription drugs should only be used when other efforts have failed. A number of medications have recently become available for chronic constipation. Secretagogues are drugs which increase secretion into the intestines and improve motility. Lubiprostone (Amitiza) and linaclotide (Linzess) are in this class. Prucalopride (Motegrity) is a serotonergic agonist with a different mechanism of action. The most common side effects from these medicines are gastrointestinal. These medicines have not been studied in frail elderly patients. As a result, the side effect profile and the correct dosage are unclear. Discuss these medicines with a health professional.
Constipation is a problem that can be talked about all day. There is no “best way” that works for everyone. Some people tolerate regimens that others don’t.
Too often people hope for fast results. A person can say: " I haven't had a bowel movement in 3 days!!" It’s fine to take a glass of prune juice or some Milk of Magnesia when that happens. But lasting improvement is better than quick relief. Constipation does not need to be a fact of life. Go step by step as outlined above. Be patient and figure out what works. Success is on the way. Some people do need long term use of over-the-counter remedies. That’s the scoop.
There is one major problem that requires extra attention: fecal impaction. I’ll discuss this next time.
PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.
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