Strategies to treat constipation without medications

Constipation impacts over 30% of the general population with an even higher percentage identified in nursing homes. Many long-term care residents receive at least one medication to treat constipation with most receiving two to three medications. With lifestyle change noted to be the frontline treatment, are dietitians doing enough for the seniors in our care? 

Who is affected? 

Constipation becomes more common after age 60. Women are more frequently affected, often the result of complications resulting from childbirth. There are unknown numbers of silent sufferers, as many people treat themselves with over-the-counter medications and never seek medical treatment. This may be due to the belief that constipation is not a big deal or because of embarrassment. 

Constipation costs 

Every year in the United States approximately $82 million are spent on over-the-counter laxatives. Seventy-four percent of long-term care residents use laxatives daily. Testing for constipation costs almost $7 billion annually. 

A recent study analyzed the cost of nursing time spent treating constipation. The results showed costs of over $2,500 per person to deal with this problem, including assessment, medication and enema administration. Extrapolating this cost to the number of people in U.S. nursing homes would amount to over $3 billion. This is a problem worth looking into. 

What is constipation? 

Constipation is often defined as fewer defecations per week. Other symptoms include a sensation of incomplete evacuations, abdominal bloating, straining, elongated or failed attempts to defecate, hard stools, and the necessity for digital disimpaction. 

Primary constipation, or functional constipation includes constipation-predominant irritable bowel syndrome, slow transit constipation related to myopathy or neuropathy, and functional defecation disorders. 

Secondary constipation may be the result of metabolic disorders like hypercalcemia, medications (e.g., calcium channel blockers, opiates), primary colonic disorders (e.g., cancer, proctitis), and neurologic and psychosocial issues. 

When assessing for constipation, clinicians should rule out red flag gastrointestinal symptoms such as, unintentional weight loss, stools with blood, positive family history of inflammatory bowel disease or colonic cancer, iron deficiency anemia, or positive fecal occult blood test. These changes in bowel movements may signify a serious underlying medical condition. 

Lifestyle changes are the first line of defense 

All seniors in long-term care can benefit from making the following lifestyle changes. Early implementation may prevent constipation or have a greater impact on symptom management.  

Increasing fluid intake 

Adding additional fluid to a diet is most effective when the resident is already dehydrated. Chronic dehydration can be very common in seniors due to long-term inadequate beverage intake.  

Whether because of inadequate access, need for assistance, fear of not getting to the bathroom on time, or struggling with swallowing difficulties, seniors often suffer from low level dehydration. This is particularly evident for those on thickened liquids.   

Increasing fiber 

Low intake of fiber leads to a greater probability of constipation. Increasing the intake of sorbitol, psyllium, and insoluble fiber from foods like fruits, oats, and bran can improve intestinal transit time. Unfortunately, fiber can have undesirable side effects, such as flatus or bloating. These side effects can be minimized by gradually adding fiber-rich foods to the diet.  

The recommended fiber intake for the treatment of constipation is 25 to 30 grams. This can be very challenging to achieve, especially for seniors with poor appetites and soft diets. Simple strategies include:

• Swap cake or ice cream for a fruit-based dessert  
• Ensure wheat bread is whole wheat or whole grain   
• Stock and serve pear and prune juice with meals and snacks 
• Choose menu and snack foods with the fiber content in mind  

Probiotics 

Studies continue to also show probiotics to be effective in the relief of constipation symptoms.  Probiotic supplementation has been reported to both increase bowel transit time and soften stool in the elderly. There are fewer side effects compared to fiber and less interactions with medications. Foods with naturally occurring probiotics can be served, in addition to probiotic supplements.  

Exercise 

Exercise, such as walking, has been shown to improve symptoms of constipation. This is especially challenging because many seniors have limited mobility. Consult with physical therapy for some simple exercises that can be incorporated into daily activities or routine nursing care. 

Timing 

Bowel training programs need to take advantage of the natural rhythms of the body. Although bowel movements often occur after mealtimes, the urge to go should not be ignored.  

Biofeedback has been used successfully in retraining programs. This strategy aims to restore normal pattern of defecation and correct dyssynergia between abdominal, rectal, and anal sphincter muscles and to increase rectal perception. 

It is unrealistic to expect that we would eliminate the use of medication for the treatment of constipation entirely. Both the origin and the treatment of the disease is complex. However, by paying more attention to the problem and implementing the recommended diet changes, there are many opportunities to improve the care of seniors.

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References: 

“Current Overview on Clinical Management of Chronic Constipation.” Jakeb Wlodarczyk, et al. Clin. Med. 2021,10,1738.

“Chronic Constipation In The Elderly: A Primer For The Gastroenterologist.” De Giorgio, et al. BMC Gastroenterology. 2015, 15:130.  

“Chronic Constipation in the Elderly Patient: Updates in Evaluation and Management.” Mari A, et al. Korean J Fam Med. 2020, 41:139-145 

“Prevalence and Effectiveness of Laxative Use Among Elderly Residents in a Regional Hospital Affiliated Nursing Home in Hsinchu County.” Nurs Midwifery Stud. 2014, 3(1). 

“Constipation and Laxative Use Among People Living in Nursing Homes in 2007 and 2013.” Gustafsson, et al. BMC Geriatrics. 2019, 19:38.