Caregiver Guide: Constipation Problems

Understanding the Problem

Constipation occurs when bowel movements are small, hard, and dry and happen three times a week or less. If more than three days pass without a bowel movement, the contents of the intestines (guts) may harden.  This can make it difficult or painful for the person to have a bowel movement.

Constipation can also occur when the person strains during bowel movements, or does not feel like the bowel movement has been completed.

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 should 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. Also, some people naturally have firmer stools than others. 

Constipation is the most common gastrointestinal complaint in the United States.  This results in about two million medical visits each year. However, most people treat themselves without seeking medical help.

Your goals are to:

  • Relieve the older person’s constipation
  • Prevent constipation by
    • Providing plenty of water and other liquids
    • Serving foods rich in fiber
    • Encouraging exercise
    • Call for professional help when needed

Click on each of the topics below to read more

When to Get Professional Help

Call the healthcare provider immediately or go to the emergency room if the following occurs

Severe abdominal pain

Pain in the abdomen (stomach area) could be caused by an ulcer, an irritable bowel, or other serious disorders, including obstruction (blockage) or cancer of the colon.

Pain or vomiting along with constipation

This could be a result of the bowel not moving because of an blockage.

Call the healthcare provider during office hours to discuss the following problems

Severe straining on the toilet with no results

This could be caused by a large amount of hard, dry stool that builds up in the bowel.  That can make 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. Pay attention to the pattern of the older person’s bowel movements - when they happen and what type they are. 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.  Another possibility is that a healthcare provider may remove stools using a finger in the rectum.

Blood around the outside of the stools or problems with hemorrhoids

Bleeding can happen if the older adult passes large, hard stools. These can cause cracks in the skin around the rectum, which are uncomfortable. Hemorrhoids are the enlargement of veins around the rectum.  They often happen to people with a long history of constipation and can be caused by straining on the toilet. They can become irritated and bleed. 

Any kind of rectal bleeding should be reported to a healthcare provider.

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 a healthcare provider.

Know the answers to the following questions before calling a healthcare provider

  • How often or what is the pattern of the bowel movements?
  • When was the last bowel movement? 
  • What did it look like (watery or dry)? What color was it?
  • Was there blood in the stool? 
  • Are medicines (such as laxatives, stool softeners, Metamucil™, Citrucel™) being taken to help move the bowels? Or are suppositories or enemas being used?
  • 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
  • What medicines were taken in the last two to three days?  Some medicines can affect normal bowel activity. The healthcare provider will recognize which pills might make the older adult constipated. Make sure to mention all medicines that are being taken, including supplements (such as vitamins) and over-the-counter medicines. It is especially important to report use of the following medicines:
    • Pain medicines
    • Over-the-counter cold/flu/allergy tablets
    • Diuretics or water pills
    • Anti-hypertensives (medicines for blood pressure)
  • What and how much did the older adult eat and drink in the last 24 hours?
  • Was there any nausea or vomiting? 
It is important to tell the healthcare provider what and how much food and fluid the older person took in during the last 24 hours.  This can help the provider judge if the constipation is an emergency requiring a visit to the hospital.

What You Can Do to Help

Early on, before the discomfort from constipation becomes severe, try the following

  • Serve fresh fruits and vegetables.
  • Serve dried fruits such as apricots, prunes, and figs, which can help trigger a bowel movement. It can also help to make a paste of foods that can help bowel movements.  Mix equal amounts of prune juice, chopped prunes, applesauce, and wheat bran and blend them together.  You should give the older person 1 tablespoon a day.  This can be increased by 1 tablespoon every other day up to a maximum of 4 tablespoons. This mixture keeps well in the refrigerator.
  • Make sure the older person is drinking enough fluids.

For immediate relief of constipation, try the following:

Rectal suppositories

If the older person needs immediate relief of their constipation, consider using rectal suppositories.  A suppository is a soft capsule that is placed into the rectum, which helps make the lower bowel move. Many times just inserting a suppository can cause a bowel movement. 

Glycerin suppositories are very safe. You can purchase Dulcolax™ suppositories over the counter. If needed, use a little lubricant on your finger (such as 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 two to five minutes or until there is a strong urge to go to the bathroom.

Enemas

If the suppository does not work, try an enema. Use Fleet™ or tap water enemas for immediate relief. A simple tap water enema is very effective. Place warm 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 five-minute period.

Only one or two enemas should be needed to relieve constipation. If the enemas do not work, call a healthcare provider. 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 can be weakened even more.

Oral laxatives

Consider using a mild laxative such as milk of magnesia along with a stool softener. The laxative helps the bowel to move the stool out of the body.  The stool softener draws water into the bowel, making the stool softer and easier to pass. Both can be bought without a prescription.

Remember that 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 the healthcare provider at the next visit. Some laxatives are better than others if required for a prolonged time. Avoid daily use of laxatives that contain the ingredients senna or phenolphthalein. 

Preventing constipation

Encourage the older person to go to the bathroom when the urge is felt

Some people delay having a bowel movement because they do not want to use toilets outside the home. Others ignore the urge to go because of emotional stress or because they are too busy. However, people who ignore the urge to have a bowel movement may eventually stop feeling the urge, which can lead to constipation. Going to the bathroom when they feel the urge can help prevent constipation from happening.

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 five 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.   Here are some foods with fiber to include in the older person’s 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, lightly cook or grate them.)
  • Bran. 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, as too much bran eaten too quickly may cause diarrhea, stomach cramps, and make it harder for the body to absorb certain vitamins. 

Water, water, water 

Liquids like water and juice add fluid to the colon and bulk to stools.  That makes 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. Liquids like coffee and soft drinks that contain caffeine should be avoided since they can have a drying out effect.

Older people sometimes cut back on fluids, especially if they are not eating regular or balanced meals. Therefore, encourage the older person to drink fluids.  However, talk to the healthcare provider about how much fluid the older person should drink.  In some cases, people with certain health conditions or taking medicines like diuretics (for blood pressure or reducing swelling) should drink less fluids.

Encourage exercising each and every day

Encourage the older adult to exercise each and every day.  Taking a walk or stretching is very helpful. Any movement is better than none, even if it is just walking around the house. If the older person 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

The person you are caring for should follow a schedule of regular toileting, diet, exercise, and medicines to prevent constipation. The older person should 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 their daily routine is altered. For example, traveling may increase the risk of constipation. This may be related to changes in lifestyle, schedule, diet, and drinking water. 

Review medications

You should review all the medicines that the older person is taking with a healthcare profession, to see if any of them could be causing some of the constipation.  Make sure to include all medicines - prescription and nonprescription, as well as herbal or other remedies.

Many medicines can cause constipation. These include pain medicines (especially narcotics), antacids that contain aluminum, anti-spasmodic drugs, antidepressant drugs, tranquilizers, iron supplements, anticonvulsants for epilepsy, drugs for Parkinson's disease, and calcium channel blockers for high blood pressure.

Carrying Out Your Plan

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?"

You may think that the older person hasn’t eaten enough to be constipated.  However, the body makes waste products and stool even when people eat very little. Little physical activity or certain medicines can make constipation more likely to happen.

"My father is 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 healthcare provider Many people will talk about embarrassing things to healthcare providers 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 presentation? 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?

You need to make plans for solving these problems.

Checking on Progress

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 4 (or more) glasses of water a day. Consider regular exercise after discussion with the older person’s healthcare provider. 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

Ask if the person’s 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 presentation?

What to do if your plan isn't working

Go over the suggestions in this presentation to be sure you are doing everything you can to deal with the problem. If constipation continues, call the healthcare provider for help. Explain what you have done and what the results have been.

Updated July 2015