Eldercare at Home: Constipation
Caregiving How Tos
Understanding the Problem
Constipation is passage of small amounts of hard, dry bowel movements, usually fewer than three times a week. As a rule, if more than three days pass without a bowel movement (also called stool), the intestinal contents may harden, and a person may have difficulty or even pain during elimination. Stool may harden and be painful to pass, however, even after shorter intervals between bowel movements. Straining during bowel movements or the feeling of incomplete evacuation may also be reported as constipation. Other symptoms of constipation include feeling bloated, uncomfortable, and sluggish.
Many people think they are constipated when, in fact, their bowel movements are regular. For example, some people believe they are constipated, or irregular, if they do not have a bowel movement every day. However, there is no right number of daily or weekly bowel movements. Normal may be three times a day or three times a week depending on the person. In addition, some people naturally have firmer stools than others.
Constipation is the most common gastrointestinal complaint in the United States, resulting in about 2 million annual visits to the doctor. However, most people treat themselves without seeking medical help, as is evident from the $725 million Americans spend on laxatives each year.
Your goals are to:
- Relieve the constipation
- Prevent constipation by:
- Providing plenty of water and liquids
- Serving foods rich in fiber
- Encouraging exercise
- Call for professional help when needed
Call the doctor or nurse immediately or go to the emergency room if any of the following symptoms occur
- Severe abdominal pain.
This could be caused by an ulcer, an irritable bowel, or other serious disorders, including cancer of the colon.
- Pain or vomiting along with constipation.
This could be a result of the bowel not moving because of an obstruction.
Call the doctor or nurse during office hours to discuss the following problems:
- Severe straining on the toilet with no results.
This could be caused by a large accumulation of hard, dry waste material in the bowel, making it difficult to have a bowel movement.
- The normal routine was one bowel movement a day and now it has been 3 or 4 days since the last bowel movement.
Constipation can be very uncomfortable. If it is not taken care of immediately, it can be difficult to treat. Explain to the doctor or nurse what the pattern of bowel movements has been (when they happen and the type of movements the person had). If there are smears of stool on the clothes or the older person feels full in the rectal area, the lower bowel may need to be cleared. A laxative, stool softener, or enema may be prescribed, or a nurse or doctor may remove stool manually with a finger in the rectum.
- Blood around the outside of the stools or problems with hemorrhoids.
Bleeding can result from the passage of large, hard stools that cause cracks in the skin around the rectum. These cracks are also uncomfortable. Hemorrhoids (enlargement of veins around the rectum) are often present in people with a long history of constipation and can be caused by straining on the toilet. They can become irritated and bleed. Rectal bleeding should be reported to the doctor.
- The person you are caring for has had a recent, significant decrease in the frequency of bowel movements
Some serious bowel problems, like colon cancer, can show up as a new problem with constipation or a new change in the appearance of bowel movements. This should be reported to the doctor.
Know the answers to the following questions before calling the doctor:
How often or what is the pattern of the bowel movements?
When was the last bowel movement? What did it look like (color, watery or dry)? Was there blood in the stool? These questions let the doctor know if food is being digested properly and if the stool has enough water in it as it passes through the digestive tract. Color is also important to report. Very dark stools could mean blood in the stool, unless iron or certain laxatives are being taken, which can make the stool darker.
Are medicines being taken to help move the bowels, such as laxatives, stool softeners, MetamucilTM, CitrucelTM, or polyethylene glycol? Or are suppositories or enemas being used?
Know the answers to the following questions before calling the doctor:
Is the constipation interfering with normal activities such as walking or eating?
Does the older person have any of these symptoms?
- bloating of the abdomen
- pain in the abdomen
- a feeling of pressure or fullness in the rectal area
- small, frequent "smears" of stool
- small amounts of loose stools or "leaking"
- rectal pain with a bowel movement
- constantly feeling the need to have a bowel movement but unable to pass stool
- small amounts of diarrhea
- bleeding from the rectum
Answers to these questions help the doctor or nurse understand what might be stopping normal bowel movements. If there is no bowel movement for days except for small amounts of diarrhea, the problem may be impaction or hard stool and the doctor may recommend a gentle enema or a visit to the clinic for a rectal exam.
What medicines were taken in the last 2 to 3 days? It is especially important to report use of these medicines:
- Pain medicines?
- Over-the- Counter cold/flu/allergy tablets?
- Diuretics or water pills
- Anti-hypertensives (medications for blood pressure)
Some medicines can affect normal bowel activity, and the doctor or nurse will recognize which pills may be contributing to constipation. However, remember to mention all medicines that are being taken including supplements and over the counter medicines.
What and how much was eaten or drunk in the last 24 hours?
Information about how much food or fluid was taken in can help the doctor judge if the constipation is an emergency requiring a visit to the hospital.
Was there nausea or vomiting?
Here is an example of what you might say when calling for help:
"My name is Sally Smith and I am calling for my aunt, Marie Bloom. I am concerned because she has not had a bowel movement for four days. She said she feels like she should go, but nothing happens. She is also having some bloating and mild pain in her abdomen."
Early on, before the discomfort from constipation becomes severe, try the following:
- Serve stewed fresh fruits and vegetables.
- Serve dried fruits such as apricots, prunes and figs which can help trigger a bowel movement.
Another helpful remedy is a mixture of equal amounts of prune juice, chopped prunes, applesauce and miller's bran blended to form a paste. Give one tablespoon a day and increase by one tablespoon every other day up to a maximum of four tablespoons. This mixture keeps well in the refrigerator.
- Assure adequate fluid intake.
For immediate relief of constipation:
- Rectal suppositories.
Suppositories help make the lower bowel move. Many times just putting a suppository into the rectum can cause a bowel movement. Glycerin suppositories are very safe. You can also purchase Dulcolax suppositories over the counter. If needed, use a little lubricant on your finger (like K-Y jelly or mineral oil) to help insert the suppository. Be sure to unwrap the suppository before inserting it into the rectum. Encourage the older person to hold in the suppository for 2 to 5 minutes or until there is a strong urge to move his or her bowels, or defecate.
If the suppository does not work, try an enema. Use tap water enemas or Fleets(TM); for immediate relief. A simple tap water enema is very effective. Place warm (not hot) water in a plastic enema bag. Lubricate the end of the bag with oil or Vaseline and insert into the rectum. Make sure the person is lying on the left side near a bathroom. Allow the fluid to run in over a 5 minute period. Only 1 or 2 enemas should be needed to relieve constipation. If the enemas do not work, call your doctor or nurse. Do not use soap suds enemas. These can be very irritating and can cause an infection in the bowel. In general, enemas should be used only for occasional relief. If enemas are used too often, the bowel's normal ability to move will be further weakened.
- Oral laxatives.
Use a mild laxative such as milk of magnesia together with a stool softener to get the best results. The laxative helps the bowel to move the stool out of the body, and the stool softener draws water into the bowel making the stool softer and easier to pass. Both can be bought without a prescription. Remember: some laxatives can be habit forming and actually cause problems to the bowel if used all the time. Laxatives should be used only for temporary constipation and discussed with your doctor at the next visit. Some laxatives are better than others if required for a prolonged time, and this should be discussed with your doctor. Avoid daily use of laxatives that contain senna or phenophalen.
- Encourage going to the bathroom when the urge is felt
People who ignore the urge to have a bowel movement may eventually stop feeling the urge, which can lead to constipation. Some people delay having a bowel movement because they do not want to use toilets outside the home. Others ignore the urge because of emotional stress or because they are too busy.
- Fiber and more fiber
The most common cause of constipation is a diet low in fiber, found in vegetables, fruits, and whole grains, and high in fats found in cheese, eggs, and meats. People who eat plenty of high-fiber foods are less likely to become constipated. On average, Americans eat about 5 to 20 grams of fiber daily, short of the 20 to 35 grams recommended by the American Dietetic Association. A low-fiber diet plays a key role in constipation among older adults. They often lack interest in eating and may choose fast foods low in fiber. In addition, loss of teeth may force older people to eat soft foods that are processed and low in fiber. Include the following foods with fiber in the diet:
- Whole grain cereals and breads
- Dried fruits that have been soaked and cooked, prunes, and raisins
- Popcorn, nuts, and seeds
- Beans, legumes, raw fruits and vegetables (If raw fruits and vegetables are hard to chew, cook or grate them.)
Sprinkle it on cereal. Try 2 teaspoons per day and increase it up to 2 tablespoons per day. A high fiber cereal can help relieve constipation. Be careful, too much bran too quickly may cause diarrhea, excess gas (flatus), stomach cramps, and reduce absorption into the body of certain vitamins.
- Drink plenty of water
Liquids like water and juice add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. People who have problems with constipation should drink enough of these liquids every day, about eight 8-ounce glasses. Other liquids, like coffee and soft drinks that contain caffeine seem to have a dehydrating effect. Older people sometimes cut back on fluids, especially if they are not eating regular or balanced meals. If the older person is taking a diuretic medicine for blood pressure, or to reduce swelling, or if the older person has been told to decrease his or her fluid intake for a health reason, ask the doctor or nurse doctor how much fluid he or she should drink in a day.
- Encourage exercising each and every day
Taking a walk or stretching is very helpful. Any movement is better than none, even if the older person just walks around the house. If he or she cannot move around much, a physical therapist may be able to recommend exercises that can be done from a bed or a chair.
- Keep to a schedule
Follow a schedule of regular toileting, diet, exercise, and medicines to prevent constipation. Pay attention to regularly eating fiber foods, drinking liquids, and taking preventive medicines, such as stool softeners, to prevent constipation. People often experience constipation when traveling, which may relate to changes in lifestyle, schedule, diet, and drinking water.
- Review medications
You should review all the medications that the older person is are taking, prescription and non-prescription, as well as herbal or other remedies, with the doctor to see if any could be contributing to constipation. Many medications can cause constipation. These include pain medications (especially narcotics), antacids that contain aluminum, antispasmodic drugs, antidepressant drugs, tranquilizers, iron supplements, anticonvulsants for epilepsy, antiparkinsonism drugs, and antihypertensive calcium channel blockers.
Problems You Might Have Carrying Out Your Plan
"She hasn't eaten much this month. How could anything be in there to plug her up or make her constipated?"
The body makes waste products and stool even when people eat very little. Certain medicines or little exercise make constipation more likely to happen.
"He's too embarrassed about his constipation to tell me about it. So, how can I help him?"
Put him in charge of his own care. He should understand what causes constipation and what to do about it. You could also have him speak to a nurse. Many people will talk about "embarrassing" things to health professionals that they won't discuss with their families.
Think of Other Problems You Might Have Carrying Out Your Plan
What other problems could get in the way of doing the things suggested in this section? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?
- Plan how to prevent constipation, especially if pain medicines are prescribed or if the older person is less active. Encourage a diet with fruits, vegetables and a little bran. Encourage drinking about 4 (or more) glasses of water a day. Consider regular exercise after discussion with your physician. Strong pain medicines containing codeine or morphine usually cause constipation. Patients on these medicines should use a daily stool softener and may need stimulant laxatives.
- Ask if bowel habits are changing. Is constipation happening less often? When does it happen? Do you both know what to do to relieve it? Are you seeing improvement when using the suggestions in this section?
What to Do If Your Plan Isn't Working
Review the section on "When To Get Professional Help" in this section. Go over the suggestions in this resource to be sure you are doing everything you can to deal with the problem. If constipation continues, call your doctor or nurse for help. Explain what you have done and what the results have been.