3Toilet Troubles Constipation affects more than 4.5 million Canadians! Constipation affects twice as many women as men
4What is constipation?Constipation is generally defined as infrequent and/or unsatisfactory defecation fewer than 3 times per week.Patients may define constipation as passing hard stools or straining, incomplete or painful defecation.Constipation is a symptom,NOT a disease.Constipation has many causesand may be a sign of undiagnoseddisease.
5Risk factors for constipation The following factors can increase a person’s likelihood of becoming constipated; however, these do not need to be present for constipation to occur:Female genderOver 65 years of ageLow caloric intake (eating less food)Greater number of medications usedSedentary lifestyle (lack of exercise)Ignoring the urge to defecate
6Causes of constipation DietLack of exerciseAgeNerves, stressIgnoring the urgeDrug induced – pain medications, iron, calcium, blood pressure medications, etcDisease States/Conditions – Multiple Sclerosis, hypothyroidism, hemorrhoids, Parkinson’s, senility, Irritable Bowel Syndrome, pregnancy, diabetic neuropathy, etc.
7Signs and symptoms of constipation Infrequent defecationNauseaVomitingAnorexiaFeeling full quicklyStools that are small, hard, and/or difficult to evacuateRectal bleedingWeight loss (in chronic constipation)
8When should I contact a health care provider? Constipation for more than 2 weeks (or has not had a bowel movement for more than 7 days) despite use of laxatives; particularly in elderly and in those with chronic medical conditions such as diabetes or parkinson’s diseaseIf medication is suspected to be the cause of constipationBlood or mucus in stool or rectal bleeding, feverSymptoms suggestive of anemia such as tiredness or lethargyFamily history of colon cancer (particularly if patient is >50 years old)Persistent abdominal painVomitingSevere pain upon defecationDiarrhea alternating with constipationRecent abdominal surgeryEating disordersModerate to extreme thirstUnexplained weight loss of greater than 5%Chronic illness associated with constipationRectal or abdominal mass
9Prevention of constipation High fibre dietMinimum fluid consumption of 1500mL dailyRegular, private toilet routineHeed the urge to defecateUse of a laxative if using constipating medication or in presence of diseases associated with constipation
10I’m constipated, now what? Two approaches to consider:Non-drug ApproachDrug Approach
11I’m constipated, now what? Non-Drug Measures:Increase calories in low calorie dietsHave a regular bowel regimen: patients should attempt to have a bowel movement at the same time each day especially after breakfast since colonic activity is highest at that time. Patients should not repress the urge to defecate or spend prolonged periods of time at the toilet. Placing a footstool in front of the toilet helps elevate the thighs, thus placing the pelvis in the optimum position for defecation.Consume a high fibre diet: the target is 25-28g of fibre dailyEat more fruits: apples, pears, and prunes contain the natural laxative sorbitolExercise: inactivity is associated with constipationWeight loss: want BMI to be between
12I’m constipated, now what? Drug Measures:There are many different types of drugs that can be used for constipation:Bulk-forming AgentsEmollients/Stool SoftenersOsmoticsHyper-osmoticsStimulants
13I’m constipated, now what? Bulk-Forming Agents:Examples: Metamucil, Benefiber, FiberSureAre considered the safest agents and are suitable for long-term useEach dose of a bulk-forming laxative should be administered with a full glass of water or juiceDo not use if patient is dehydrated or fluid restrictedAre the drug of choice for prevention; not for immediate relief
14I’m constipated, now what? Emollients/Stool SoftenersExample: DocusateUsed for prevention; not for immediate reliefUsed very often but lack of data showing it actually worksCompany says that this product “makes it easier to go”
15I’m constipated, now what? Osmotics:Examples: Milk of MagnesiaLimitations for use of this group of laxatives include frequent diarrhea, and multiple electrolyte abnormalities.Should be administered with sufficient water to prevent dehydration.Not used very often
16I’m constipated, now what? Hyper-Osmotics:Examples: Glycerin Suppositories, Lactulose Syrup, Lax-a-Day (PEG 3350)PEG produces the loosest stool and overall greatest efficacy compared to other members in this class. It may have benefit in patients unresponsive to other treatments. Daily use of PEG is safe and does not have significant side effects and may facilitate the discontinuation of other laxatives. May take 2-4 days to see an effect. This is the drug of choice in almost all situations!Lactulose is very safe to use long term. May see increase in gas and bloating compared to other options. Takes 1-2 days to work.Glycerin suppositories have a quicker onset of action (usually minutes). They are less effective if the stool is dry and hard.
17I’m constipated, now what? Stimulants:Examples: Senokot, Dulcolax (bisacodyl)This group produces rhythmic muscle contractions in the intestines and may be recommended if osmotic laxatives fail or are not tolerated.Are usually given at bedtime and they usually provide overnight relief (work within 8-12 hours).
18Special Considerations in the elderly Treatment is often complicated by chronic conditions, multiple drug use, and cognitive impairment.Management should be tailored to each individuals needs and expectations regardless of age or place of residence.The patients functional abilities related to mobility, following instructions, communicating needs, eating, drinking, and cognitive status must be assessed.Fluid intake should target mL daily unless fluid restrictions are imposed as in those with heart failure.Dietary fibre should be targeted at 25-30g daily.Exercise to patients capacity.Drug review is essential to rule out drug induced constipation.Renal impairment must be monitored prior to using laxatives.Don’t use laxatives for more than a week unless the doctor says it is ok.Safest laxative to use is a bulk forming agent such as Metamucil.
19Special Considerations in nursing home residents Many nursing homes have “bowel programs” for their residents. These include exercise, increasing the amount of fibre in the meals, and bowel retraining.Oral agents are commonly used:Senokot is common for quicker reliefLax-a-Day or Metamucil very common for preventionLactulose is very useful for people who are bedridden
21SummaryConstipation is very common in the elderly and nursing home residents.There are many causes of constipation; it should be considered a symptom, not a disease.There are many options for prevention and treatment. The choice should be tailored to each individual person.Talk to your health care provider if you have any concerns or if constipation lasts for longer than one week.