Prepared by: Alison
Deux, 4th year
pharmacy student
TOILET TROUBLES
Constipation affects more than 4.5 million
Canadians!
 Constipation affects twice as many women as
men

WHAT IS CONSTIPATION?




Constipation is generally defined as infrequent
and/or unsatisfactory defecation fewer than 3
times per week.
Patients may define constipation as passing hard
stools or straining, incomplete or painful
defecation.
Constipation is a symptom,
NOT a disease.
Constipation has many causes
and may be a sign of undiagnosed
disease.
RISK FACTORS FOR CONSTIPATION

The following factors can increase a person’s
likelihood of becoming constipated; however,
these do not need to be present for constipation to
occur:
 Female
gender
 Over 65 years of age
 Low caloric intake (eating less food)
 Greater number of medications used
 Sedentary lifestyle (lack of exercise)
 Ignoring the urge to defecate
CAUSES OF CONSTIPATION







Diet
Lack of exercise
Age
Nerves, stress
Ignoring the urge
Drug induced – pain medications, iron, calcium, blood
pressure medications, etc
Disease States/Conditions – Multiple Sclerosis,
hypothyroidism, hemorrhoids, Parkinson’s, senility,
Irritable Bowel Syndrome, pregnancy, diabetic
neuropathy, etc.
SIGNS AND SYMPTOMS OF CONSTIPATION
 Infrequent
defecation
 Nausea
 Vomiting
 Anorexia
 Feeling
full quickly
 Stools that are small, hard, and/or difficult to
evacuate
 Rectal bleeding
 Weight loss (in chronic constipation)
WHEN SHOULD I CONTACT A HEALTH CARE PROVIDER?
•
•
•
•
•
•
Constipation for more than 2 weeks
(or has not had a bowel movement for
more than 7 days) despite use of
laxatives; particularly in elderly and in
those with chronic medical conditions
such as diabetes or parkinson’s
disease
If medication is suspected to be the
cause of constipation
Blood or mucus in stool or rectal
bleeding, fever
Symptoms suggestive of anemia such
as tiredness or lethargy
Family history of colon cancer
(particularly if patient is >50 years
old)
Persistent abdominal pain
•
•
•
•
•
•
•
•
•
Vomiting
Severe pain upon defecation
Diarrhea alternating with constipation
Recent abdominal surgery
Eating disorders
Moderate to extreme thirst
Unexplained weight loss of greater than
5%
Chronic illness associated with
constipation
Rectal or abdominal mass
PREVENTION OF CONSTIPATION
•
•
•
•
•
High fibre diet
Minimum fluid consumption of 1500mL daily
Regular, private toilet routine
Heed the urge to defecate
Use of a laxative if using constipating medication or
in presence of diseases associated with
constipation
I’M CONSTIPATED, NOW WHAT?
Two
approaches to consider:
Non-drug
Approach
Drug Approach
I’M CONSTIPATED, NOW WHAT?

Non-Drug Measures:






Increase calories in low calorie diets
Have a regular bowel regimen: patients should attempt to have a
bowel movement at the same time each day especially after
breakfast since colonic activity is highest at that time. Patients
should not repress the urge to defecate or spend prolonged periods
of time at the toilet. Placing a footstool in front of the toilet helps
elevate the thighs, thus placing the pelvis in the optimum position for
defecation.
Consume a high fibre diet: the target is 25-28g of fibre daily
Eat more fruits: apples, pears, and prunes contain the natural
laxative sorbitol
Exercise: inactivity is associated with constipation
Weight loss: want BMI to be between 18.5-24.9
I’M CONSTIPATED, NOW WHAT?

Drug Measures:

There are many different types of drugs that can be used for
constipation:
Bulk-forming Agents
 Emollients/Stool Softeners
 Osmotics
 Hyper-osmotics
 Stimulants

I’M CONSTIPATED, NOW WHAT?

Bulk-Forming Agents:
Examples: Metamucil, Benefiber, FiberSure
 Are considered the safest agents and are suitable for long-term
use
 Each dose of a bulk-forming laxative should be administered
with a full glass of water or juice
 Do not use if patient is dehydrated or fluid restricted
 Are the drug of choice for prevention; not for immediate relief

I’M CONSTIPATED, NOW WHAT?

Emollients/Stool Softeners
Example: Docusate
 Used for prevention; not for immediate relief
 Used very often but lack of data showing it actually works
 Company says that this product “makes it easier to go”

I’M CONSTIPATED, NOW WHAT?

Osmotics:
Examples: Milk of Magnesia
 Limitations for use of this group of laxatives include frequent
diarrhea, and multiple electrolyte abnormalities.
 Should be administered with sufficient water to prevent
dehydration.
 Not used very often

I’M CONSTIPATED, NOW WHAT?

Hyper-Osmotics:




Examples: Glycerin Suppositories, Lactulose Syrup, Lax-a-Day (PEG
3350)
PEG produces the loosest stool and overall greatest efficacy
compared to other members in this class. It may have benefit in
patients unresponsive to other treatments. Daily use of PEG is safe
and does not have significant side effects and may facilitate the
discontinuation of other laxatives. May take 2-4 days to see an
effect. This is the drug of choice in almost all situations!
Lactulose is very safe to use long term. May see increase in gas and
bloating compared to other options. Takes 1-2 days to work.
Glycerin suppositories have a quicker onset of action (usually 30-60
minutes). They are less effective if the stool is dry and hard.
I’M CONSTIPATED, NOW WHAT?

Stimulants:
Examples: Senokot, Dulcolax (bisacodyl)
 This group produces rhythmic muscle contractions in the
intestines and may be recommended if osmotic laxatives fail or
are not tolerated.
 Are usually given at bedtime and they usually provide overnight
relief (work within 8-12 hours).

SPECIAL CONSIDERATIONS IN THE ELDERLY










Treatment is often complicated by chronic conditions, multiple drug use,
and cognitive impairment.
Management should be tailored to each individuals needs and
expectations regardless of age or place of residence.
The patients functional abilities related to mobility, following
instructions, communicating needs, eating, drinking, and cognitive
status must be assessed.
Fluid intake should target 1500-2000mL daily unless fluid restrictions
are imposed as in those with heart failure.
Dietary fibre should be targeted at 25-30g daily.
Exercise to patients capacity.
Drug review is essential to rule out drug induced constipation.
Renal impairment must be monitored prior to using laxatives.
Don’t use laxatives for more than a week unless the doctor says it is ok.
Safest laxative to use is a bulk forming agent such as Metamucil.
SPECIAL CONSIDERATIONS IN NURSING HOME
RESIDENTS
Many nursing homes have “bowel programs”
for their residents. These include exercise,
increasing the amount of fibre in the meals,
and bowel retraining.
 Oral agents are commonly used:

 Senokot
is common for quicker relief
 Lax-a-Day or Metamucil very common for prevention
 Lactulose is very useful for people who are bedridden
SUMMARY
Constipation is very common in the elderly and
nursing home residents.
 There are many causes of constipation; it should
be considered a symptom, not a disease.
 There are many options for prevention and
treatment. The choice should be tailored to each
individual person.
 Talk to your health care provider if you have any
concerns or if constipation lasts for longer than
one week.

THANK-YOU