Chronic Constipation

Dec 11, 2017

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Netflix is a nostalgia machine. During the summer, Eric found the show "Malcom in the Middle". It is about a smart kid who grows up in a semi-dysfunctional family in the suburbs in the 1990's. I liked how funny Brian Cranstone was pre-Breaking Bad, but I wasn't a kid in the 1990's. Then Eric found "The Goldbergs". Another smart kid growing up in the burbs, but now 1980's. This was my decade. I chuckle and get misty eyed every episode I watch with Eric. When did I get old enough that the decade I grew up in became a land long ago and far enough away to set TV shows in?

Nostalgia is like a milk shake. It is fun, but if you consume it too fast, your head hurts. I used to make milk shakes for the residents of St. Paul's Care Home. Okay, we called them milk shakes. The residents probably had other names for them. We would mix milk of magnesia, which is a white liquid and senna syrup, which is a dark brown liquid. The result kinda looked like a chocolate milk shake. It didn't smell great and it didn't taste great, but it did help care home residents poop. I don't think I've made up one of those milk shakes in 15 years now, and I really can't blame the residents for not liking them.

In care homes, often we have people on medications that make them constipated. And often care home residents can't do the simple things the rest of us can do to prevent constipation. Simple constipation is usually caused by lifestyle. Ignoring the urge to empty your bowels, and a low fibre diet often contribute to constipation. Other lifestyle factors like not drinking enough fluid, not eating breakfast, and not exercising may lead to constipation as well. The elderly are constipated more often than younger people, and women are constipated more often than men. Constipation can cause different symptoms in different people. Some commonly reported symptoms are difficulty and straining in passing a stool, uncomfortable abdominal bloating, cramping, headache, and lack of interest in food.

Prevention of simple constipation should begin by using non-drug measures. These measures include eating 15-30g of food fibre per day. This is actually quite difficult to achieve, so 10 g of fibre per day is a good minimum to strive for. A person should drink 6-8 glasses of water per day. There has been some debate lately if you really need that much water per day. In this case water really does help the fibre do its job. A person should respond to the urge to empty the bowels as soon as possible, but don't strain when on the toilet. Regular, moderate exercise is also good for you in many ways. Some of the reading I did said exercise is good at preventing constipation, but that is not definitive. But, as exercise is good for you in so many other ways, it is a good recommendation.

Constipation in the care home is so common, we often have people on chronic constipation medications. Docusate sodium and docusate calcium are very common choices. They are both stool softeners, and have been used in hospitals and care homes for over 50 years. Docusate is a surfactant, so that is very similar to soap. It breaks the surface tension of the stool which lets water in. That softens the stool, and makes it easier to pass. Or at least that is what we were taught in pharmacy school.

It seems lately that when the docusate studies were looked at, they weren't very well done. One docusate study done in 1968 only had 15 elderly patients in it. A study in 1998 compared docusate to psyllium in 170 patients. The patients on the psyllium did better helping with constipation. In 2010 researchers actively looked for docusate studies and only found one double blind placebo controlled trial that they thought was done well enough to write about. And that study only had 22 people in it. The Canadian Agency for Drug and Technologies in Health (CADTH) only found 5 relatively poorly done studies on docusate from 2004 to 2011. And unfortunately, those studies didn't find docusate to be any better than placebo at decreasing constipation or constipation symptoms.

What should we use instead of docusate? In the care homes, we are using PEG 3350 now. It has brand names like Restoralax and Lax-a-Day. It is a white powder you dissolve in water and drink. It has almost no taste, so much nicer to take than those old milkshakes of milk of magnesia and senna syrup. PEG 3350 is an osmotic laxative. That means it draws water into the bowl, and help everything just flush along. It is safe to use daily. It is safe to use in children, adults, the elderly and pregnant women.

Now Netflix has an original series called "Stranger Things" that Eric has watched. It is about a bunch of 12-13 year old boys in the mid-80's. That was me. They are science geeks and play Dungeons and Dragons. That was me. They live near a strange government research facility. I lived near a government nuclear research facility. As far as I can remember none of my friends were whisked off to the "upside down", but I think all this 80's nostalgia is getting a little too close to home.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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