Remedies for Chronic Constipation:  Bringing Relief to Older Patients

While it is generally recognized that older people are more concerned than younger generations with their bowel health and even preoccupied by the myth of needing a daily bowel movement, the fact is that older individuals are more likely to routinely experience problems with constipation.  In fact, researchers have found that 33% of the elderly suffer from chronic constipation.¹ Women are two to three times more likely to experience constipation than men.  Chronic constipation is quite common across the American population and responsible for some 2.5 million office visits with physicians annually.² It is therefore essential for nurses – both those in primary care and those functioning in specialties such as continence nurses  – to deepen their understanding of chronic constipation.

While constipation is typically defined by infrequent bowel movements (fewer than three a week) and/or hard, even painful stool to evacuate, it is slow transit that often receives greatest attention as symptoms are addressed.  An even more common but less frequently addressed factor is the lack of coordination of pelvic floor muscles and general weakness of the muscles.  This explains why evacuation is such a problem for many. The sphincters (circular muscles around rectum) and the puborectalis muscles must relax to have a bowel movement, and they stay contracted to prevent one.  When functioning normally, this balance is controlled by the pressure from accumulating stool in the rectum, which is sensed by nerves in the body and the brain's decision of whether or not to respond to this sensation.  Anatomic problems, such as rectal prolapse, only exacerbate the problem of outlet obstruction and are the result themselves of pelvic floor muscle weakness.  In fact, repeated straining to have a bowel movement only worsens the degree of prolapsed organs. (Of course, you should insure by means of a colonoscopy there is not a blockage caused by colon or rectal cancer.  If prolapse in the form of a rectocele (anterior vaginal wall collapse) or enterocele  (vaginal ceiling collapse) is present, it must be addressed surgically or with a pessary.)  Nevertheless, unless the underlying problem of pelvic floor dysfunction is fully addressed, efforts aimed at reducing transit time will not remedy the problem of evacuation caused by lack of coordination of pelvic floor muscles and general muscle weakness.  In most cases, both slow transit and problems with evacuation must be addressed for enduring success.

Other causal factors need to be identified in a complete patient assessment.  Pain medication for chronic inflammation such as osteoarthritis is a frequent culprit, as a frequent side effect is slowed bowel action.  Even temporary pain medication following surgery can cause sudden changes in bowel regimen, triggering chronic constipation.  A history of sexual abuse can even contribute to chronic constipation later in life.  Knowing the patient’s full history is essential to determining just what steps to take in treatment and whether ultimately referral to a specialist such as a colon and rectal surgeon is needed. To aid in this investigation, readers may wish to become familiar with a new validated instrument developed at UCSF for assessing the severity of constipation.³

Physical therapy can be helpful for these patients in numerous ways.⁴ Constipation is addressed by getting patients moving and teaching abdominal contraction exercises to assist in peristalsis, (movement of feces through the bowel). A personalized abdominal strengthening program is also crucial since the abdominal wall must first contract for the ability to relax the muscles holding up the anal sphincter muscles to complete stool evacuation. There are numerous techniques for strengthening pelvic floor muscles, such as electrical stimulation to the muscles, pelvic floor weights for strengthening, and a personal exercise program to strengthen the pelvic floor. These techniques can be adapted to limitations of an elderly patient.

To address transit, conservative remedies work well in most cases and consist of: 1) increasing dietary fiber and even fiber supplements, especially insoluble fiber that adds bulk and weight to the stool; 2) increasing physical activity and exercise to improve peristalsis; and 3) increasing fluid intake and even adding a mild non-prescription laxative to help make the stool more spongy, such as MiraLAX®.

Taking time to fully assess causal factors and symptoms is key to being successful in remedying chronic constipation.  In the majority of cases, simple advice and intervention work.

¹Bharucha AE, Zinsmeister AR, Locke GR, Seide BM, McKeon K, Schleck CD, Melton LJ. Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN. Gastroenterology. 2005; 129(1):42-9.

²Varma MG. Bowel Health: Managing Chronic Constipation, presented at A Woman's Guide to Pelvic and Bladder Health Program, hosted jointly by the National Association For Continence and the UCSF Women’s Center of Excellence and Department of Urology, October 3, 2009, San Francisco.

³Varma MG, Wang JY, Berian JR, Patterson TR, McCrea GL, Hart SL. The constipation severity instrument: a validated measure.  Diseases of the Colon & Rectum.  2008; 58 (2): 162-72.

⁴ Wisinski C.  Neurological disorders get help from physical therapy.  Quality Care. 2003 (4).