CONSTIPATION IN ELDER AND BEDRIDDEN PATIENTS
Natural bowel movement varies among individuals. For certain people it would be considered usual to have three bowel movements a day; for some, it is usual to have one bowel movement every two or three days. Someone could be said to have constipation if they occasionally and with difficulty move hard stools (straining). It’s the change in bowel function or pattern so it’s crucial to decide what’s natural for this individual. Constipation may be a symptom of a variety of various conditions, so it is vital to seek treatment from the doctor whether you tend to feel constipated frequently, or whether the symptoms are long-lasting or serious and are not improved by laxatives, or whether other symptoms occur including excessive weight loss or blood bleeding in some of the stools you move.
Constipation triggers any or more of these factors:
- Bowel obstruction, abdominal distension, small or hard stools, and feeling like everything didn’t come out
- Abdominal pain and bloating
- Feeling of nausea and vomiting
- Reduced appetite, Bad breath, and Bad taste in the mouth
- Lethargy, confusion
- restlessness and agitation
- Fecal incontinence overflow diarrheas
- Retention or Incontinence of urine
Constipation left untreated will lead to more extreme and painful conditions such as hemorrhoids, fissures, and fecal impaction. Fecal impaction is where the intestines are filled with a large mass of feces that the individual cannot move through.
Causes of constipation:
- Diet: Low appetite and poor food consumption, low fiber diet, low intake of liquids
- Endocrinological: diabetes, hypothyroidism, pseudohypoparathyroidism, hypopituitarism, hypocalcemia, glucagonoma, pregnancy, phaeochromocytoma
- Metabolic: porphyria, amyloidosis, hypokalemia, uremia, dehydration
- Neurological: a brain tumor, spinal cord involvement, sacral nerve infiltration, autonomic failure (Parkinson disease, multiple sclerosis, scleroderma, motor neuron disease, diabetic neuropathy)
- Psychiatric: depression, psychosis, anorexia nervosa, obsessive-compulsive disorders
- Operations: pelvic operations, anal operations, narrowing following anastomoses
- Organic obstructive diseases: tumors, adherences, strangulated hernias, volvulus, invagination, endometriosis
- Functional diseases: functional obstructive bowel diseases, congenital or acquired aganglionosis, Ogilvie syndrome, megacolon, irritable bowel disease
- Pelvic exit obstruction: rectal prolapse, rectocele, rectal intussusception, rectal stenosis, megarectum, hypertonus of the internal sphincter, paradoxical contraction of the puborectal muscle
- Pharmacological agents: antacids, antiepileptics, antiemetics, antihypertensives, antiparkinsonians, anticholinergics, antidepressants, antitussives, antidiarrheals (by causing dehydration), cancer chemotherapy agents, diuretics (by causing dehydration), iron (orally administered), opioid analgesics, neuroleptics
- Painful anorectal conditions(hemorrhoids, anal fissure, perianal abscess)
- Environmental: A lack of privacy, comfort, or toilet assistance
- Other factors: Advanced age, inactivity, decreased mobility, bed-ridden patients, depression, sedation
The factors which contribute to bedridden constipation include:
- Bedridden patients appear to eat fewer, leading to longer transit periods for stools, and constipation.
- Diminished mobility reduces the colon’s peristaltic, wavelike contractions. This in turn results in insufficient emptying of the bowel and a dryer stool.
- Many patients who are confined to bed are on medication, which can adversely affect normal bowel movements, especially drugs like Antiarrhythmics, blood pressure medications, anti-depressants, antacids, and anti-Parkinson drugs.
The usual sequence of investigations starts with plain abdominal X-ray
- Supine and erect plain abdominal X-ray
- Abdominal ultrasound (this is of limited use in obstruction of the intestine and/or in patients with distended bowel because the air can obscure and camouflage the underlying findings, restricting ultrasound transmission)
- CT scan
- Overview of conventional barium, upper gastrointestinal and small bowel series, enteroclysis (fluoroscopic X-ray of the small intestine)
- Follow-through water-soluble contrast (this investigation is safer than barium in perforation and peritoneal spread cases and likely has a therapeutic benefit for small intestine adhesive obstruction)
- Contrast (barium or water-soluble) enema
- CT scan with double contrast (intravenous and oral or rectal)
- Endoscopy (colonoscopy, esophagogastroduodenoscopy, ileoscopy)
Management of constipation
The existence of numerous different constipation pharmacological agents makes symptomatic treatment seductive. However, treatment should be directed to correcting the underlying anomaly where possible. We should strongly discourage the chronic use of laxatives, especially stimulant laxatives. Successful therapy should include a conversation of the wide range of normal stooling function and the patient’s own normal stooling concepts. Therapeutic interventions in themselves are often identifying misconceptions and providing patients with information about normal stooling patterns. Identifying the patient’s expectations for treatment could be helpful.
Bowel retraining is basically a form of behavior modification and is especially useful in patients who do not have a constipation cause that is readily identifiable. The patients are encouraged to have a regular daily routine, with time for bowel movement being cast aside. This time should preferably be within five to 10 minutes of a meal, thus taking advantage of the gastrocolic reflex. Such a routine encourages patients to respond to signals and the urge to defecate. Enemas or suppositories may occasionally be required in the chronically constipated patient to support the defecatory urge. Generally, these interventions work by distending the rectal ampulla which stimulates the defecatory urge and process.
Advising on posture to use the toilet can also be beneficial:
- Sit forward with forearms placed on thighs
- Raise your feet up on a tiny footstool
- Relax and give plenty of time to open the bowel.
In bedridden patients, can get out of bed to go to the toilet, maintaining the right posture mentioned above on the toilet can help with colon evacuation.
Diet plays an important role in bowel movements, particularly for elderly people. Strong epidemiological evidence has shown that more crude dietary fiber is associated with reduced constipation prevalence and other gastrointestinal disorders, including diverticular disease and colorectal cancer. Fiber significantly increases the bulk and weight of stools and speeds the transit time of the intestines. These observations may account for several mechanisms
- Fiber can act as a bulk-forming agent
- Fiber can bind fecal bile salts, which have a noticeable cathartic effect.
- Fiber is metabolized to non-absorbable, volatile fatty acids by colonic bacteria that may act as an osmotic cathartic.
Drink plenty of fluids to maintain the stools wet-at least 6-8 glasses of water-based drinks a day (approx. 1.5 to 2 liters). It can help to bring in soft jellies, ice cream, and soups. Avoid constipating food like white rice and refined grains, unripe banana, tea, cheese, chocolate, etc. Regularly eat or drink foods like beans, whole grains especially bran, vegetables, fresh and dried fruit, nuts, high fiber foods, etc.
Anyone’s bedridden diet should have 25 to 35 grams (both soluble and insoluble) of dietary fiber. In fruits, beans, vegetables, salads, and porridge, soluble fiber is found; there is insoluble fiber in wholemeal bread, brown bread, and bran. Staying hydrated also is essential, as dehydration is a major cause of constipation.
Physical exercise can boost gastric emptying and reduce the relative risk of colon cancer in most populations. However, extreme, intense exercise prevents gastric emptying, disrupts with gastrointestinal absorption, and induces several symptoms, most notably gastrointestinal bleeding. For frail elderly and immobile people, seated exercises, walking short distances, or standing up from a chair may help.
There are many attempted and proven home remedies that can help to alleviate constipation symptoms follow,
- Fruit bran tea acts as an important constipation cure. Mix 2 tablespoon bran and 2 ounces sliced figs or raisins in a saucepan. Apply four cups of water to it and cover with a lid over the vessel. Strain the essence in the morning, and drink it hot or cold.
- Some of the other home remedies that can aid with constipation are flax seeds, parsley, and lemon juice.
- Prune, fig, and raisin tea are a perfect way to start your day. Mix in saucepan equal amounts of figs and prunes, and two tablespoons of raisins. Now add two pints of water to the saucepan and allow cooking for 30 minutes.
- To induce a bowel movement, a natural laxative, castor oil derived from the castor bean can be taken orally. This ancient oil not only lubricates the intestines but it also allows the intestines to contract. Take castor oil as instructed, at an empty stomach, one to two teaspoons. Enable up to 8 hours until there is a bowel movement.
- Senna is a herb that makes use of the cassia plant’s leaf, flower, and fruit. It has been used as a natural laxative for thousands of years.
- Oral aloe vera for soothing of the digestive tract. Drink aloe vera juice pure or apply it to smoothies or other drinks to aid in constipation
- Magnesium is naturally present in coconut water, which helps to transfer fecal matter out of the body from the muscles in the intestinal wall.
- Using one or two teaspoons of ghee to warm milk at night to facilitate gently and spontaneously a bowel movement the next morning.
- Fennel is a laxative that is mild and natural. In the evening, roasted fennel may be added to warm water and drank.
Ayurveda for constipation
In mild constipation, the herbs like Hareetaki (Terminalia chebula), Draksha (Vitis vinifera), Patola (Trichosanthes dioica), Katukarohini (Picorrhiza kurroa), etc are used. In severe constipation Jaypala (Croton tiglium), Danti (Baliospermum montanum), Thrivrit (Operculina turpethum), etc are to be used.
Large varieties of medicine available in ayurvedic text for constipation. The medicine like Tripahala churnam, Avipathi churnam, Trivrit lehyam, Icchabhedi rasam, Gandharvahastha eranda taila, Abhayarista, etc is used according to patient’s condition and severity of constipation.
Magnesium is an advantageous salt used to treat constipation. It acts as a natural osmotic laxative once it enters the colon, drawing water into the colon which in turn adds moisture to the stool. Magnesium sulfate is most often present in seawater. The body isn’t readily absorbing magnesium sulfate, which ensures it makes it to the colon to help cure constipation.
If the above treatments don’t work, laxatives are given to relieve the symptoms of constipation. There are a number of laxatives for treating constipation. Some of the more popular forms used by health care professionals include stimulant laxatives, saline laxatives, hyperosmolar laxatives, and bulk-forming laxatives. Most laxatives form a habit and are not recommended for extended use. Healthcare services will help you choose the right one.
Extreme chronic constipation patients were treated with a number of surgical procedures like hemicolectomies and semicolectomies etc. Patient satisfaction is recorded high with the outcome of this treatment.
Special issues occur for the bedridden or chair-bound patient. The use of potent laxatives may result in fecal soiling, as the patient may not be able to recognize or respond quickly to the urge to defecate. Bulking agents may also encourage soft stools and regularity. Especially important are the behavioral programs (i.e., stool training or timing). It may also be effective to position the patient over the toilet and to use the tap-water enemas.