Dietary Management of Constipation in Aged Care

The term constipation refers to difficulty during defecation and infrequent bowel movements over an extended period of time. Symptoms include hard/dry stool, bloating and abdominal pain. Definitions of normal bowel function vary, but frequency can range between three times per week to three times per day. Older adults tend to determine constipation based on symptoms like pain, stool hardness or straining rather than frequency alone. Constipation can be a common issue amongst aged care resident’s, there is a link between ageing and the likelihood of constipation for those who are 70 years or older. Lifestyle issues can also contribute to constipation particularly the following:

 Risk Factors

  • Low-fibre diet – as fibre is indigestible, it adds bulk to the faeces, making it more easily pushed along the digestive tract. There are two broad types of fibre; soluble and insoluble. Soluble fibre helps to soften the faeces. Good sources of soluble fibre include legumes, fruits and vegetables. Insoluble fibre adds bulk to the faeces, helping it to move more quickly through the bowel. Good sources of insoluble fibre are in wheat bran, wholegrain breads and cereals. A lack of fibre can increase the risk of constipation.
  • Insufficient fluids – the fibre in faeces will only plump and soften up with water. Constipation can occur from a high-fibre diet if insufficient water is consumed.
  • Lack of regular exercise – living a sedentary lifestyle or being restricted in movement due to a disability or physical impairment are common causes of constipation.
  • A tendency to ‘put off’ going to the toilet – ignoring the urge to go means that more water will be extracted from the stools, making them difficult to pass. Regularly ignoring this urge may make the body less sensitive to normal signals to go to the toilet.
  • Some medications – such as narcotics (particularly codeine), antidepressants, iron supplements, calcium-channel blockers (antihypertensives, particularly verapamil) and non-magnesium antacids are known to slow bowel movements.
  • Illness – a period of illness, particularly an illness resulting in hospitalisation and bed-rest, typically results in constipation. Factors include change in routine, reduced food intake, pain (especially after abdominal surgery), and pain-relief medication such as morphine.

Medical causes of constipation

Underlying medical problems can cause constipation such as:

  • ‘Slow transit’
  • Anal fissure
  • Obstruction
  • Hernia
  • Abdominal or gynaecological surgery
  • Irritable bowel syndrome
  • Problems of the endocrine system
  • Tumour
  • Diseases of the central nervous system

Complications of chronic constipation can be serious such as impaction, incontinence, prolapse or haemorrhoids. It is therefore important to reduce lifestyle risks as possible.

Nutrition considerations for the treatment for constipation

The management of constipation must be individualised according to each person’s needs. Treatment will depend on the cause, but nutritional strategies could include:

Increasing fibre intake –A general recommendation for those over 70 years is 25-30g of fibre every day. Good sources of fibre include wholegrain cereals, fruits, vegetables and legumes. For some individuals foods such as milk, cheese, white rice, white flour and red meat can contribute to constipation and therefore intake should be monitored.

Tips to increase fibre intake in aged care:

  • Encourage wholemeal or wholegrain bread with meals
  • Encourage a high fibre cereal such as Porridge, All-bran, Weetbix or Muesli.
  • Ensure residents are consuming at least 2 serves of fruit each day. This could be consumed with Breakfast, as a dessert or as a mid meal snack
  • Order extra vegetables or salad with the main meal
  • Encourage high fibre mid meal snacks such as fruit, wholegrain toast with peanut butter, fruit and bran muffins etc.
  • To supplement fibre intake – add a ‘High Fibre’ mix to Breakfast. See below for an example recipe –

High Fibre Mix

  1. Combine ¼ cup of unprocessed bran with ½ cup of stewed prunes and ½ cup of pureed apple.
  2. Makes 10 x 2 tablespoon serves.
  3. Encourage residents to consume 2 tablespoons per day

Increase fluid intake – Encourage residents to drink regularly, not only at meals but in between meals. Staff should offer fluids whenever they enter a resident’s room. For residents at risk of a low fluid intake, monitor consumption using a fluid balance chart.

Fibre supplements – these may be helpful if the person is reluctant or unable to include more wholegrain foods, fresh fruits or vegetables. As fibre supplements can aggravate or cause constipation, always check with the doctor or dietitian when using them.

Exercise – one of the many benefits of regular exercise is improved bowel motility. Ideally, exercise should be taken every day for about 30 minutes. People with a condition that affects mobility need to be as active as possible each day, as every little bit of regular exercise helps. Consult with your facility physiotherapist for strategies to help individuals increase activity.

Other important considerations should include:

  • Treatment for underlying disorder
  • Laxatives
  • Removal of the impacted faeces
  • Regular toileting and education

In many cases constipation can be prevented through education, dietary changes and lifestyle modifications. It is therefore important for all residents’ at risk to have a bowel management plan where medical staff, nursing, dietetics and food service are working together to provide nutritional, lifestyle and medical interventions to help maintain bowel health.

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References: Better Health Channel – http://www.betterhealth.vic.gov.au/