Constipation

DEALING WITH CONSTIPATION
Constipation is one of the most troublesome disorders affecting the elderly. Senior citizens tend to be paranoid with regular/irregular bowel movements and at least 50% of them consume laxatives unnecessarily. It is said that their anxiety in relation to irregular bowel motions also causes headaches, exhaustion and loss of appetite.

Types of Constipation
There exist two types of constipation,

  • An elderly person may pass stools daily, but it will be hard and sticky.
  • Stools may not be hard but bowel movements will be irregular.

Causes of constipation

  • Lack of adequate fibrous matter in the food consumed.
  • Intestinal cancer, hernia, piles and/or fissure in the anus, thyroid gland malfunctioning, excess calcium in the body, lack of potassium (hypokalemia) and mental depression.
  • The elderly tend to avoid drinking adequate quantities of water, due to the fear of urinating frequently (especially true of old women).
  • Drugs like iron tonics, painkillers, antacids, diuretics, anti-depressants, antihypertensive agents and sleeping tablets.
  • Lack of adequate exercise.
  • The elderly avoid visiting the toilet frequently because of unhygienic lavatory conditions.
  • Restricted mobility due to arthritis (in the hips and knees) or stroke.

Consequences

  • Chronic constipation leads toa complication that affects the overall health of individuals. Anxiety is uncalled for even if someone does not pass stools for a day or two. However, chronic constipation should be attended to immediately to avoid further complications.
  • Elderly people suffering from constipation may strain too much while defecating, which can result in chest pain. They may also experience a syncopal attack due to the transient reduction of blood supply to the brain.
  • Chronic constipation leads to prolonged intra-abdominal pressure due to straining, leading to hernia and varicose veins in the legs.
  • Hard and sticky stools may cause fissures in the anus and bleeding.
  • The distended rectum obstructs the urinary passage and causes retention of urine, particularly in those with an enlarged prostate.
  • Stagnation of stools in the large intestine may cause an obstruction, while the stagnating and impure water may leak out of the anus, causing spurious diarrhoea.
  • Taking laxatives for prolonged periods of time can be habit-forming and result in a dilated colon.
  • Irregular bowel movement can cause anxiety and stress.
  • Patients may become so obsessed about their so-called constipation, that they may take purgatives in large doses, resulting in diarrhea. Excess fluid and potassium losses can cause severe ill health, apathy and weakness.

MANAGEMENT Treatment of primary causes

  • If a specific cause is identified, it should be corrected, for example, treating hypothyroidism, management of depression, correction of dehydration etc.
  • If medication is responsible for these issues, it must be stopped or the dosage may be reduced.

High fluid intake

  • A high fluid intake must be maintained.
  • An older person should consume at least 2-2.5 litres of fluids per day.

Regular exercise

  • Physical activity is encouraged. Daily exercises like walking is very essential in order to avoid constipation. Those who are bed ridden must do their exercises in the bed itself.
  • Abdominal massage has been proven to prevent constipation.
  • Pelvic floor exercises along with abdominal exercises are good methods of preventing constipation.

Intake of dietary fibre

  • The fibre content in the diet plays an important role in the prevention of constipation.
  • Many older persons select a diet that lacksadequate fibre content.
  • This, along with an inadequate fluid intake, can lead to persistent constipation and thus, the use of harmful laxatives and mineral oils.
  • Dietary fibres absorb and hold water, thus being valuable bulky agents as they increase the transit time in the gut.
  • The elderly should include 40 grams of dietary fibre per day in their diet.
  • Dietary fibre not only prevents constipation but also reduces the risk of cancer of the colon, reduces blood sugar and cholesterol levels as well as the incidence of gall stones.
  • High fluid intake is essential along with fibrous food. Fibre may interfere with the absorption and digestion of fat, protein and calcium. The benefits of including fibrous food in the diet are likely to outweigh any drawbacks.
  • Food items like millets, wheat, raagi, and rice bran are rich sources of fiber. To get relief from constipation, the patient should mix 2-4 spoonful’sof any fibre supplement either in milk or water and drink it.
  • There exists plenty of roughage in greens, plantain stem, cabbage, cauliflower, drumstick, bitter-gourd, dates, mangoes, figs, guava and wood apple.
  • It is believed that bananas are good for constipated patients but the quantity of roughage in bananas is insignificant. The starch present in bananas loosens and softens the stools.
  • There is plenty of fibrous matter in pepper, coriander, dried chillies, omurn, fenugreek and sundaikai (dry). Milk, sugar, fat, eggs, meat and fishes are devoid of soluble fibre.

Laxatives

  • Laxatives may be used as the last resort when the measures mentioned above fail.
  • There are different types of laxatives, as follows:
  • Lubricants and stool softeners (Liquid paraffin).
  • Bulking agents (Methyl cellulose and fibre supplements).
  • Osmotic agents (Sodium, potassium, magnesium salts and lactulose).
  • Chemicals (Senna, phenolphthalein and castor oil).
  • Prokinetics (Cisapride).
  • As a stool softener, liquid paraffin can be used. However, prolonged usage is not advisable as it may reduce the absorption of fat soluble vitamins and cause pulmonary aspiration. The surface acting agents like ‘Dulcolax’ allow penetration of water into the fecal matter as well as increase the transit through the intestine. This laxative should be used only when the fecal matter is hard.
  • ‘Isapagol’ and other natural fibre supplements absorb water and increase the bulkiness of the motion. They must be taken with plenty of fluids and should not be taken by those who have difficulty in swallowing or have obstructive lesions of the small/large intestine.
  • Osmotic agents are useful for immediate evacuation of bowels, but long term management lubricants are said to be gentler. ‘Lactulose’ is fairly expensive and is taken as a sweet syrup.
  • Chemical laxatives like ‘senna’tend to stimulate the contractions of the colon through direct contact. Castor oil acts the quickest, though not suitable for regular use.

Enema

  • It refers to a procedure wherein a solution is injected into the rectum and the colon. The solution breaks up the fecal mass, stretches the rectal wall and initiates the defecation reflex.
  • An enema is used only if the above measures fail.
  • There are many types of enemas, the simplest being the cleaning enemas. They promote the complete evacuation of feces from the colon. The commonly used enema solutions are tap water, normal saline/hypertonic saline and soap water solution. However, water enemas often result in the irritation of the mucosa and are advised only for long standing constipation. The most commonly used enema is the glycerin enema. The advantage is that only small quantities are administered and it also softens the stools. This is ideal for the Geriatric age group.
  • Other enema solutions that are used include oil retention enemas, carminative enemas and medicated enemas. However, these are rarely used.
  • Prolonged use of enemas can cause rectal ulceration, bleeding and electrolyte imbalance. In old people who suffer from dehydration, the enemas should be administered carefully, since fluid loss may worsen the already existing dehydration. Hence, in the case of the above mentioned patients, it is better that a qualified personnel administers the enema.

Suppositories

  • Suppositories (enema pellets) are another alternative method to relieve constipation. This is well suited for bedridd en patients and those with restricted mobility.
  • Since one cannot predict the time of bowel evacuation with laxatives, suppositories are ideal where one can get the desired response within ½ hours of insertion of the suppositories.
  • The hazardous effect of suppositories is the same as that of an enema.

Do's and Don'ts

  • Ensure adequate exercise.
  • Drink plenty of fluids.
  • Eat regularly and don't skip meals.
  • Start the day with a healthy breakfast.
  • Never hold back a bowel movement. As soon as you feel the urge, visit the loo. If possible, go around the same time each day, even if you do not feel the urge to visit the loo.
  • Chew your food thoroughly and eat slowly.
  • Never take a laxative unless prescribed by the doctor.
  • Eat plenty of fresh vegetables and fruits.