IS 41 August 2011 Information sheet Constipation & faecal impaction Introduction ........................................... 1 What is constipation? ............................. 1 Left untreated, constipation can lead to more Causes of constipation ........................... 2 serious and painful conditions such as Constipation and dementia..................... 2 haemorrhoids, fissures and faecal impaction. Preventing constipation ......................... 3 Faecal impaction is where the bowel is What if you suspect someone is overloaded with a large mass of faeces which constipated?........................................... 3 the person is unable to pass. Treatment for constipation..................... 4 Faecal impaction .................................... 4 This information sheet explains what Treatment for faecal impaction .............. 5 constipation is, what can cause it and how it Long-term management of constipation.5 can be prevented. It examines how partners Where to get help................................... 5 and families can identify when someone with Dietary fibre ........................................... 6 dementia may be suffering from constipation and explains how faecal impaction can occur, Introduction particularly following a stay in hospital. This information sheet is aimed at people with What is constipation? dementia and their partners and families. Normal bowel function varies from person to Non-specialist care professionals may also find person. For some people, having three bowel it useful. movements a day would be considered normal; for others, a bowel movement every Most of us will experience constipation at two to three days is normal. some point in our lives but usually treat it ourselves at home using an over-the-counter Someone can be said to be constipated if they medicine. We tend not to be comfortable are passing hard stools infrequently and with discussing our bowel habits publicly and many difficulty (straining). It is the change in bowel people carry on treating their constipation with function or pattern that is important, therefore laxatives over long periods without speaking it is important to establish what is normal for to their GP. that person. Rare or infrequent episodes of constipation are Constipation causes some or all of the usually nothing to worry about but following: constipation can be a symptom of a number of Stools (faeces) become hard and different conditions, so it is important to seek difficult or painful to pass advice from your doctor if you start to get Bloating in the abdomen constipated regularly, or if the symptoms are Feelings of nausea long-lasting or severe and not helped by Sometimes pain low down in the laxatives, or if other symptoms develop like abdomen unexplained weight loss or blood in any stools Bad breath you pass. Bad taste in the mouth Page 1 Constipation & faecal impaction Reduced appetite likely to be less active, may reduce their fluid Lethargy intake (perhaps because of worries about Restlessness bladder control and/or incontinence) and may Confusion have a reduced appetite or difficulty eating General inability to function normally. sufficient dietary fibre to keep “regular”. Faecal incontinence Retention of urine People with neurological conditions such as Incontinence of urine Multiple Sclerosis, Parkinson’s Disease and Problems with catheter drainage. Stroke are also more prone to constipation. This may be due to the effect of these People with constipation may also feel that conditions on the relevant muscles and nerves there is “more to come” even after they have as well as the reduction in physical activity, produced faeces. swallowing problems, medication and possible psychological impact, when going to the toilet Causes of constipation can seem like too much of a struggle. The most common causes of constipation are: Lack of fibre (roughage) in the Functional constipation or primary diet. Dietary fibre gives bulk to help constipation speed the passage of waste products In spite of having a good diet, drinking a lot of through the bowel. fluid, being active, without any disease or Lack of fluids. Fluids help to soften taking any medication that can cause the stools and make them easier to constipation, some people still become pass. Dry, hard stools are more constipated. Their bowels are said to be difficult to pass. underactive. This is sometimes called Lack of exercise or reduced functional constipation or primary mobility. Activity helps stimulate the constipation. Most cases occur in women and muscle contractions needed to keep the the condition tends to start at a young age waste moving through your system. and persists into later life. Constipation can also be one of the side Constipation and dementia effects of some types of medicines or The ageing process, lifestyle and treatment for combinations of medicines. Pain killers are other medical conditions may pre-dispose particularly prone to cause constipation. some people with dementia to develop constipation. But the effect of dementia itself Some say it is the number of medicines that may also lead a person to become are the problem, rather than any particular constipated. medication. One study 1suggests that people taking 5 or more medicines are more at risk of In order to control our bowel, we have to be constipation – not uncommon among older aware of the need empty our bowel, or 'call to people who may be taking medication for stool'. This awareness happens when the several conditions. faeces move into the rectum, causing it to expand and send messages to the brain via As people get older they may start to develop the sensory pathways that the bowel needs problems with their bowels as the relevant emptied. At this stage, the finely tuned nerve muscles age and deteriorate. They are also endings are able to differentiate between whether the stool is solid, liquid or wind so we can react accordingly. 1 Potter JM, Norton C, Cottenden A (2002) Bowel Care in Older People: Research and Practice. London: Royal College of Physicians. Page 2 Constipation & faecal impaction In the early and mid stages of dementia, this distances, or standing up from a chair may not be a problem but as the illness may help progresses, there is increased damage to the pay attention to bowel signals, and brain and, as the person’s confusion increases, don’t ignore them - if you feel the urge, he or she may start to ignore (or be less go as soon as possible aware of) the sensation of stool in the rectum, know your own bowel habits – each of leading to constipation. us will have times when our bowels are at their most active, particularly a People with severe cognitive problems may certain time after meals. When we eat become less concerned or less aware about we stimulate activity throughout our their bowel habits. If they depend on other digestive system, helping to move stool people for their care or if they cannot easily through the gut ready to be pushed find or access the toilet, this can also affect out. This is especially so after their bowel habits. breakfast. By attempting to open your bowels after a meal the gastrocolic Constipation in people with dementia can lead reflex can help you to empty your to a worsening of their confusion, as well as bowel more easily. Timing your bowel symptoms of irritability or aggression. This is care or toileting after a meal may make thought to be due to the pain and discomfort it more effective. of the constipation; but if constipation is not sit on the toilet properly. Sitting up diagnosed it can be assumed that these straight makes it easier to push stools symptoms are just part of the person’s out without straining. You may need to ongoing dementia. This can lead not only to use a footstool in front of the toilet to the person not receiving treatment for help with this. See the diagram at constipation but also to him or her being the end of this information sheet of prescribed an antipsychotic medication for the the ideal position to sit on the aggression or irritability. Some anti-psychotic toilet. medicines can cause constipation, so the problem is made worse. People with dementia are likely to need support to keep up a healthy bowel regime as Preventing constipation their condition progresses. Establishing a There are various things we can do to help regular toilet routine may be needed if the keep our bowels healthy: person is ignoring the urge to go to the toilet. eat more high-fibre foods such as wholegrain bread, wholegrain breakfast What if you suspect someone is cereals, fruit and vegetables. Note: if constipated? increasing fibre intake, you should also make sure your fluid intake is adequate At home to avoid constipation. Partners and family members should be alert drink lots of fluids to keep the stools for any changes which could signal that the moist - at least 6-8 water based drinks person is constipated so it can be treated as a day (approx 1.5 to 2 litres). early as possible. Knowing the person’s habits Introducing soft jellies, ice cream and and routine can help greatly. soups may help. increase your physical activity as this It may be useful to keep a diary of the helps to increase bowel activity. For person’s bowel movements and dietary and frail elderly and immobile people, fluid intake as well as any changes you seated exercises, walking short observe as this could help the doctor make a diagnosis. Page 3 Constipation & faecal impaction constipation being missed and untreated. Simple measures like increasing the person’s Without treatment, constipation which lasts fluids and dietary fibre might help to begin over days or even weeks can lead to a much with, but if that does not work, then a laxative serious condition called faecal impaction. may work. Speak to the person’s GP or the pharmacist in case there is any reason why a Faecal impaction laxative should not be given.