Nutrition Connection: Bothered by Bowels

(reprinted from Dietary Manager, October 2010)

Changes in all bodily functions occur with aging. Many medications affect bowel health resulting in either constipation or diarrhea. 'Normal’ bowel habits vary from three movements per day to three per week. It is important to know what is typical for the patient or resident. As part of resident-centered long-term care, the CDM will be interacting more with residents as part of the MDS and CAA process. MDS 3.0 includes a section on bowel and bladder habits. Bowel habits are tracked by nursing and monitored for changes. Changes in bowel habits are important for nursing to incorporate into the overall care of the patient or resident. Any information the CDM can share with nursing will be helpful in developing the care plan and in meeting care needs.

Constipation
Constipation has different meanings to different people based on life experiences and health beliefs. The medical community usually defines constipation as a decrease in stool frequency. Many elders may also consider constipation as difficult passage of feces, hardness of stool, straining, a sensation of blockage, or a feeling of incomplete emptying of the colon.

Constipation is the most common gastrointestinal complaint in the elderly, with up to 60 percent of elderly outpatients reporting laxative use. The overall prevalence of self-reported constipation is 24 to 37 percent, with women reporting more constipation than men. In the institutionalized elderly, up to 50 percent self-report constipation, and up to 74 percent use laxatives daily. About 50 percent of elderly persons describe their constipation as infrequent defecation, 20 percent as excessive straining or incomplete emptying of the colon, and 30 percent as both. Constipation can lead to abdominal discomfort, loss of appetite, and nausea.

Contributors to Constipation

Age and disease-related changes in bowel anatomy can predispose the elderly to constipation. Various medical and surgical conditions and certain medications can cause or worsen constipation as noted in Tables 1 and 2.

Complications of Constipation
The major complication of constipation in the elderly is fecal impaction, which can result in intestinal obstruction, ulcers in colon, or overflow incontinence (leakage of stool around obstructing feces). Fecal impaction is not the same as constipation because the individual is unable to move the large stool in the rectum. Medical intervention is required to remove the fecal mass. Adding dietary fiber or fiber supplements are not helpful to resolve a fecal impaction and may make matters worse.

Fecal impactions are most likely in patients or residents with limited mobility, impaired cognitive function, or who have disorders of the nervous system. Excessive straining may have adverse effects on the brain, heart, and circulatory system, resulting in fainting, decreased blood flow to the heart, and transient ischemic attacks (TIAs or mini strokes). Also, excessive straining can result in hemorrhoids, pain, and bleeding. Individuals with fecal impactions have reduced appetites and may complain of stomach pain or cramping, back pain, and general complaints of not feeling well. Once impaction is resolved, the patient/ resident may have considerable weight loss, poor appetite, and fears about eating certain foods.

Table 1: Conditions That Cause or Worsen Constipation

Prevention and treatment of Constipation:
Dietary approaches

Constipation is often easier to prevent than treat with dietary and behavioral changes. Dietary intake is the cornerstone of treatment, but may not be effective for all patients/ residents. Increasing dietary fiber intake to 20-30 gm/day with sufficient fluid intake will add bulk to the stool and promote normal bowel movements. Menus can be enhanced with dietary fiber by serving more whole grain foods, bran, fresh fruits, legumes and vegetables. Some high fiber foods, like the skin of fruits or dried fruits, may not be suitable for seniors with chewing or swallowing difficulties. However, high fiber fruits like dried plums and apricots can be stewed and pureed. Legumes should be well cooked and pureed if necessary. Hearty soups chock- full of vegetables and legumes can be pureed to a smooth texture for individuals who cannot manipulate different food textures in the mouth at the same time. Increasing fiber in the diet may cause bloating and excessive gas initially, however these symptoms usually resolve with continued use.

Treatment of Constipation: Behavioral Changes—
Immobility is associated with constipation and fecal impactions. Individuals who are mobile may benefit from increased physical activity. Exercise strongly stimulates defecation and helps strengthen the abdominal muscles that aid defecation. Patients with constipation should attempt to move their bowels in the early morning, especially after breakfast, when colonic motor activity is highest.

Treatment of Constipation: Fiber Supplements—
When dietary approaches alone do not provide enough fiber, fiber supplements may be beneficial. Some fiber supplements are high in sugar and are not suitable for all patients/residents. Adding dietary fiber to the diet or from fiber supplements can be harmful to individuals with bowel obstructions, enlarged colon, or enlarged rectum. These patients/residents require a fiber-restricted diet with a regular schedule of laxatives or enemas to minimize risk of constipation and fecal impaction.

Table 2: Medications That Cause Constipation

• Pain medications
• Pain medications
• Antacids
• Antidepressants
• Antihistamines
• Antipsychotics
• Antispasmodics
• Anticonvulsants
• Antihypertensives
• Antiparkinson drugs
• Calcium
• Diuretics
• Iron

Diarrhea

Diarrhea is an increase in the frequency of bowel movements (usually more than 3 per day) or greater looseness of stool. It is a change from normal bowel habits. Acute diarrhea lasts a few days up to a week. Chronic diarrhea lasts for several weeks. Patients or residents with diarrhea have lower than normal blood pressure, weakness, dry mouth (which can impair speech and swallowing), poor appetite, and weight loss. Diarrhea can be due to many conditions noted in Table 3.

During normal digestion, food is kept in a liquid state by secretion of water by the stomach, upper small intestine, pancreas, and gallbladder. As food is digested throughout the small intestine and colon, water is reabsorbed and undigested food becomes a semi-solid stool. Increased fluid in stool can occur if the stomach or small intestine secretes too much water or the undigested food passes too quickly through the colon for water to be reabsorbed. Some viruses, bacteria, and parasites can cause increased secretion of fluid by releasing toxins which triggers inflammation in the small intestines. Inflammation of the gut from the bacteria can increase the speed at which food travels in the intestines, reducing the time for water reabsorption.

Complications of Diarrhea

Dehydration is the most common complication of acute or chronic diarrhea. It occurs when there is excessive loss of fluids and electrolytes. If vomiting is also present the risk for dehydration and electrolyte imbalances is greater. For individuals with cardiac problems, electrolyte imbalances can be life threatening.

Diarrhea treatment: Dietary approaches

The treatment for diarrhea is based on its cause and may require medications. Individuals with diarrhea often have poor appetites and weight loss. rapid weight loss is usually related to dehydration. The first goal is to replenish water loss. Intravenous fluids may be ordered if dehydration is present and the person is unable to eat or drink sufficient amounts of fluid.

If the individual is able to eat, serve bland, low-fat foods. The BrAT diet (bananas, rice, applesauce, and toast) is a combination of foods that have been used to treat diarrhea for decades. Potatoes and lactose-free products are usually well tolerated. Caffeine and lactose-containing dairy products should be avoided temporarily, as these foods can make diarrhea worse. Families may ask the CDM about providing sports drinks. Check with the physician before offering sports beverages. These products contain sugar, sodium, and potassium and may be contraindicated due to another medical condition. Once diarrhea subsides, avoid alcoholic beverages and spicy foods for at least two days.

Diarrhea treatment: Probiotics

Millions of friendly bacteria live in our intestines and play important roles in digestion. A bout of diarrhea can be linked to imbalance of useful bacteria in the gut. Probiotics are either bacteria or yeast. They are added to yogurts, cereals, and in supplement form. These beneficial microbes may be helpful to treat some cases of diarrhea, but research studies have not demonstrated how probiotics work. CDMs should consult with the rD and physician before recommending probiotics.

Colon Cleansing

Colon cleansing is a popular 'home remedy' to prevent bowel problems. Proponents of colon cleansing believe that toxins build up in the gut causing a variety of health problems including arthritis, allergies, and asthma. The marketing materials promise many health benefits such as removing toxins, promoting healthy intestinal bacteria, enhancing the immune system, preventing colon cancer by cleansing all organs of toxins, removing ‘toxic waste matter’ from intestines, and boosting energy levels. Presently the Federal Trade Commission is investigating claims made by Internet sites selling some colon cleansers for deceptive advertising.

There is little scientific evidence to support or refute the benefits of colon cleansing. Most gI specialists say it is generally unnecessary because the digestive system and bowel naturally eliminate waste material and bacteria. The body does not require enemas or special diets or pills to do this. Colon cleansing can be potentially harmful—especially for the elderly. These products increase the risk of dehydration and can cause an unsafe rise in electrolytes which can be dangerous in individuals with kidney or heart disease.

Pearls for Practice

Changes in bowel habits can lead to increased health anxiety, constipation, or diarrhea. Food service is usually the first culprit when constipation or diarrhea presents. If several patients/residents who have eaten the same foods develop diarrhea, foodborne illness may be suspect.

Some patients/residents have a long history of either chronic constipation or diarrhea. Prevention strategies, which may include diet, need to be addressed in the care plan. Well-meaning friends and families may want to try ‘home remedies’ for the family members of constipation and diarrhea. These ‘remedies’ may not be helpful and are possibly harmful. CDMs should consult with the rD and physician before encouraging families to try ‘home remedies.’

By Mary D. Litchford, PhD, RD, LDN

Mary D. Litchford, PhD, RD, LDN is a nationally-recognized speaker and the author of various articles and books, including Common Denominators of Declining Nutritional Status.