id you ever notice that many of our elderly residents enjoy talking about their bathroom habits? What surprises me most is how quickly an innocent conversation can wind up in the toilet. For example, the other day I was interviewing a new resident, Mrs. McDaniel. I asked her if she had any favorite foods and she replied, “I like everything, but no cheese, dear, because cheese causes constipation.” I felt it was my duty as a nutrition professional to explain to her that there was no reason to believe that cheese causes constipation—but she wouldn’t hear any of it.Her roommate, Mrs. Paris, chimed in that she hadn’t gone to the bathroom that day, and maybe it was because she had eaten a grilled cheese sandwich for lunch. Suddenly, the two roommates were passionately discussing the problems they had keeping regular and made a pact that they would never again eat another grilled cheese sandwich. Myths about constipation abound, so let’s set the record straight.
What is Constipation?
Constipation is a symptom; it is not a disease unto itself. There are many definitions of constipation. One common definition is that constipation is a decrease in the frequency of bowel movements, accompanied by prolonged or difficult passage of stools. There is no accepted rule or correct number of bowel movements per week. Many people think they are constipated when, in fact, they are following their own individual patterns. It is not mandatory to have a bowel movement every single day. For some people, regularity may be a bowel movement only three times per week. For others, it may be daily bowel movements.
Sometimes, older people get very concerned when they don’t have bowel movements every single day. Reassurance should be given, but it is also important to remember that after three or four days without a bowel movement, intestinal contents may harden and may be harder to pass. For this reason, it is imperative to accurately complete activities of daily living sheets and take it seriously when a resident complains of constipation.
Constipation Prevalence
The number of people who suffer from constipation is difficult to estimate, because it depends on how you define constipation. What we do know is that constipation is considered relatively common in countries, such as the United States, where diets are low in dietary fiber and sedentary lifestyles prevail. According to the 1996 National Health Interview Survey, about three million people in the United States have frequent constipation. Those reporting constipation most often are women and adults age 65 and over. Pregnant women also complain of constipation, and it is a common problem following childbirth or surgery. Constipation is one of the most common gastrointestinal complaints in the United States, resulting in about two million doctor visits annually. However, most people treat themselves without seeking medical help, as is evident from the millions of dollars Americans spend on laxatives each year1.
Causes of Constipation
Constipation can be caused by many different problems and situations. A diet low in fiber is often the easiest cause to identify and, luckily, is easy to correct. The new Dietary Reference Intake (DRI) for fiber for adults over age 50 is 30 grams per day for men and 21 grams for women2. According to the Harvard School of Public Health, the average American consumes only 14 to 15 grams of fiber each day3. This is well short of the recommendation and may also lead to many other health concerns, such as colon cancer, heart disease, diverticulitis, and type 2 diabetes.
Inadequate fluids are another common cause of constipation. Liquids add fluid to the colon and bulk to the stools, making bowel movements softer and easier to pass. Table 1 lists many other causes of constipation. Table 2 lists some of the medications that may cause constipation.
Diagnosis
Extensive testing is usually not required to diagnose constipation. A medical history and a physical exam are usually all that is required. However, more extensive testing may be necessary if symptoms are severe or there is a sudden change in bowel movements or blood is present in the stool. Most physicians will begin with routine blood tests and a digital rectal exam. The stool is tested for occult blood. If further testing is required, a barium enema x-ray and a sigmoidoscopy or colonoscopy may be performed.
A barium enema x-ray allows viewing of the rectum, colon, and lower part of the small intestine. The night before the exam, bowel cleansing is necessary, since even a small amount of stool can obscure proper results. During the exam, the bowel is filled with barium so it is visible on the x-ray. A sigmoidoscopy allows viewing of the rectum and lower colon, while a colonoscopy views the rectum and entire colon. Both of these procedures use a flexible, lighted tube inserted through the anus and rectum into the colon.
Treatment
The first line of treatment is usually a dietary change. Adding additional fiber to the diet is often the key to keeping regular. This means additional whole grain breads, fresh fruits and vegetables, bran cereals, oatmeal, and lentils and beans. Processed foods should be slowly replaced with high-fiber foods, because there may be a temporary increase in bloating, fullness, and gas as the body adjusts to the additional fiber. This feeling will go away if the high-fiber diet is continued, but it is advisable to increase fiber slowly. Drinking plenty of fluids with the new high-fiber diet is equally important.
Commercial bulking agents are sources of natural or synthetic fiber. These products are generally considered safe but are not a substitute for a proper diet. Often called fiber supplements, these products are taken with water. They absorb the water in the intestine and make stool bulkier and softer. Products in this category include Metamucil® and Citrucel®.
There are many other types of laxatives. Laxatives are only for short-term use, as extended use can cause dependency. The physician should determine which type is to be used and for how long. Stimulants cause rhythmic muscle contractions in the intestines. These products include Correctol®, Dulcolax®, and Senokot®. Stool softeners, such as Colace® and Surfak®, provide moisture to the stool. Mineral oil is a common example of a lubricant, which greases the stool enabling it to move through the intestine. The final category of laxatives is saline laxatives. These act like a sponge to draw water into the colon for easier passage of stools. Examples of this type are Phillips’® Milk of Magnesia and Haley’s M-O®.
Regular exercise is also a part of the treatment plan. Many of our long-term care residents may not be able to vigorously exercise, but regular activity should be encouraged as tolerated. Creating a regular bathroom routine has also proven useful for many people. For example, setting aside 15 minutes every day after breakfast for undisturbed visits to the bathroom may encourage regularity. The urge to defecate should not be ignored.
The Bottom Line
At times, residents complain that they have to wait a long time to receive assistance to get to the bathroom. Sometimes residents even say they purposely don’t drink liquids in order to limit their trips to the bathroom. Residents have confided that they were told to “go in the bed,” “hold it in,” and “wait because it is shift change.” The next time someone asks you for help, remember it is important, both physically and psychologically, not to ignore the urge. Bathroom habits are something we usually don’t talk about, and all of our residents would prefer not to require our help in toileting. But since they do need our assistance, realize that privacy and dignity are just as important to curing constipation as are the facts about fiber. |
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