Identifying hidden symptoms: Constipation & Parkinson's Disease
Dr. Amita Patel
Constipation is a common problem in Parkinson's disease, occurring in up to 60% of patients, and may occur even before motor symptoms appear. In the long term care setting, it is important for health care professionals to understand how the condition may present because it can be addressed successfully.
Constipation in the Parkinson's Patient
Patients with Parkinson's disease have decreased physical activity, which results in slowed colonic transit time resulting in constipation. Their widespread rigidity causes hypokinesia of abdominal muscles adding to the incidence of constipation.
Various mechanisms also contribute to this problem and can include degeneration of neurons in myenteric plexus of the colon with presence of Lewy bodies, weakness and lack of coordinated contraction of the muscles of the pelvic floor, contraction of abdominal muscles preventing straightening, and poor anorectal angle preventing passage of stool. Additionally, dystonic contractions of muscles, megacolon and volvulus can develop as well.
These patients may have paradoxical contractions of the external anal sphincter contraction during attempted bowel movements. This paradoxical contraction, which results in functional outlet obstruction, is likened to other dystonia seen in Parkinson's disease. Medications frequently prescribed to Parkinson's disease patients have adverse effects that can be a contributing factor for constipation, as well.
Patience and consistency – The trick to treating
Although randomized controlled trials of treatments for constipation in patients with Parkinson's disease are lacking, treatments can be generalized into pharmacological and non- pharmacological categories.
From a nonpharmacological perspective, patience and consistency is key to providing relief from constipation. Bowel training usually takes 2 to 3 months and the patient will likely see no change for the first week or two. Specifically, home care nurses or nursing home providers can encourage patients to defecate in the morning, especially 90 minutes after breakfast, to respond to the gastro-colic reflex.
Physical therapy is another important element in the treatment of Parkinson's disease. Increasing physical activity can improve colonic transit time and decrease constipation, with the added benefit of improved gait, posture and energy. People living with Parkinson's disease can be encouraged to walk, take guided yoga or tai chi, or even participate in water-based aerobic activities.
Dietary adjustments including increased water intake and increased dietary fiber to help relieve constipation can also be helpful. Further, a regular intake of probiotics, such as those found in yogurt, can improve stool consistency and bowel habits in these patients as well.
From a pharmacological perspective, there are several different categories of medications that may be appropriate for some Parkinson's disease patients ranging from bulk formers, stool softeners, laxatives and suppositories and enemas. Many are very inexpensive and easy to administer, which is a bonus for the Parkinson's disease patient who may be managing multiple medications already.
The following is a series of steps to restore normal bowel function. Working with their health care providers, patients should be instructed to begin with STEP 1 for two weeks. If there is no significant improvement after two weeks, items from STEP 2 and STEP 3, if needed, should be added to the established STEP 1 routine. STEP 4 and STEP 5 are to be used as a temporary last resort.
Step 1 – Diet and Fluid Intake
Eat meals at the same times each day and include fruits, vegetables, whole grain breads and cereals in daily meals. It's also important to drink at least 6-8 glasses (8 oz each) of fluid daily. I always advise drinking warm liquids on awakening and with breakfast. It's also important to establish a relaxed, regular time of the day for bowel moments.
Step 2- Bulk Formers
Bulk formers such as bran, Metamucil and Fibercon can be purchased without prescription. They are not habit forming and may be used daily. However, they need to be taken as directed, otherwise constipation may actually worsen. If a patient is taking a bulk former, then they should also be drinking 6-8 cups of liquid daily. When first starting a bulk former, do not increase the amount taken too quickly as gas formation or stomach fullness may result. Importantly, patients should be educated that patience is required. Bulk formers may take 2-3 months to correct constipation.
Step 3- Stool Softeners
Stool softeners such as Colace and Surfax can also be purchased without prescription. Like Bulk formers, stool softeners are not habit forming and can be used daily. Patients should start with one per day and increase to one each morning and evening if needed.
Step 4- Laxatives and Suppositories
Laxatives activate the bowel by chemical irritation and long-term use may harm the bowel.
Some laxatives, such as Ex- lax, Dulcolax, Feenamint, Correctal and Castor Oil are harsh and should not be used to establish a bowel program. However, mild laxatives may be used while establishing a bowel program. Milk of Magnesia, Doxidan, Pericolace and Senokot are mild and should be used sparingly. Another option, suppositories, provide rectal stimulation to empty the bowel and require stool to be present in the rectum to be effective. Suppositories may be needed to establish a bowel program. They may be used on a daily basis or every other day basis.
Step 5- Enemas
The use of enema is recommended when nothing else works. The bowel can easily become dependent on enemas.
Supporting the Parkinson's Patient
Constipation is not an uncommon problem in patients with Parkinson's disease. Several factors including decreased motility, co- morbid conditions, medications and dietary changes due to dysphagia may contribute to its developments. But, as noted above, treatment over time can work provided that the health care providers and people with Parkinson's are both patient and persistent. Finding the right combination of lifestyle modifications combined with select pharmacologic treatment can help patients find the relief they are seeking.
Noll, L. (2013). Management of Constipation in Patients with Parkinson Disease. Journal of Hospice and Palliative Nursing. 15(7), 388-389.
Diet Implications in PD Constipation. Retrieved from http://www.medscape.com/viewarticle/810992_9
National Parkinson's Foundation Handbook. Retrieved from http://www.parkinson.org/sites/default/files/Constipation%20in%20Parkinson%27s%20Disease.pdf
PD Center – UCSF Medical School. Retrieved from http://pdcenter.neurology.ucsf.edu/patients-guide/constipation-and-dietary-needs