Constipation, Pt. 4: Treatment

In this series of blogs about constipation, we’ve discussed causes, prevention and identifying its presence in someone living with dementia where communication is a problem. This last blog is about treatment. Our friends, Ellen and Ben are back to help us with this.

Once Ellen has indentified that Ben is feeling constipated, she becomes much more diligent about preventative measures, making sure Ben eats lots of fiber, drinks adequate fluids and gets plenty of exercise.

In addition, she increases his preventative laxatives. He normally takes a mild osmotic laxative every other day and a stool softener every other evening. She increases this to once a day for both. Remember, each person is different. Others may need even more, or less. These laxatives are gentle enough that you can experiment with them without much fear of them being harmful. However, they should never be used without consulting the doctor first. The doctor should approve of the dosage change when constipation is suspected as well.

If Ellen catches the constipation early, this may be all she needs to do. However, if she misses the first signs and the bowel may become impacted. That is, the stool hardens and plugs up the bowel so that nothing, or very little can pass. Ben’s body simply can’t function properly when this happens and so it is quite serious, and often extremely painful. Symptoms of impaction are similar to those of constipation only stronger:

• Severe bloating
• Abdominal pain, often severe
• Nausea and vomiting
• Headaches.

In addition, there may be what seems to be mild diarrhea. Actually, this is the small amount of stool that is seeping out from around the blockage.

Enemas and suppositories can sometimes help, but Ben, like many people living with dementia, can’t hold the enema or the suppository in long enough to do much good. Partly this is due to poor muscle control and partly it is due to his inability to understand why he should do so in the first place.

It is sometimes possible to put on a glove and try to dig out an impaction if it is low in the colon. This requires a knowledgeable “nurse” and a compliant “patient” because the inner tissues of one’s rectum are easily torn. Ellen was once a caregiver in a nursing home and so she knows how to do this and Ben is willing to lie still and let her try this.

If Ellen’s excavation efforts don’t work, her next course of action is to take Ben to the ER, where the nurses are skilled at dealing with this problem and have more resources at hand for doing so than she does at home. In fact, once an impaction is suspected, an immediate ER visit is likely the best course of action for most people. You want this painful, possibly deadly condition dealt with as quickly as possible.

Once the impaction has been broken up and evacuated, expect more diarrhea. This is the stool that has been backed up above the impaction. Once it is out, the bowel can return to normal functioning. That’s when Ellen returns Ben to his preventative dosages of laxatives.

For even more information click here for a very through article by Alzheimer Scotland.

For more information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson's and Lewy Body Dementia

 Helen and James Whitworth are not doctors, lawyers or social workers. As informed caregivers, they share the information here for educational purposes only. It should never be used instead of a professional's advice.

Constipation, Pt. 3: Identification

This series of blogs are about constipation. The first discussed its causes and risk factors and how they can combine to make constipation an even worse problem. The second blog identified prevention as the first line of defense and discusses a variety of ways to decrease the risk of constipation. This blog is about ways to identify its presence even when the person living with dementia is unable to do more than know that they hurt or feel uncomfortable.

Jim has graciously allowed me to use his ongoing issues with constipation as examples in the previous blogs. However, we have an advantage that dementia care partners often don’t have. Jim doesn’t have dementia. He can use abstract thinking to identify early symptoms, compare them with previous experiences and come up with some valid conclusions about what is going on. Then, with the help of his own private nurse (me!), he can make conscious choices about how to deal with these symptoms. Finally, he can follow through even when the treatment is uncomfortable, bothersome or annoying because he is able understand that what he is doing is going to help him in the long run. These are all things that our friend, Ben, can seldom if ever do.

Ben has dementia. With his limited abstract thinking, he can seldom compare or make conscious choices. He lives in the present, with little thought of the future and only his residual feelings reminding him of the past. Since the strongest of these feelings are usually negative, they are seldom helpful. Jim can say, “I feel bloated,” and recognize that as an early constipation symptom. Ben just feels uncomfortable but probably can’t recognize why. Nor is he able to compare this uncomfortable feeling with past feelings and recognize it as “bloating” or as a warning sign of impending constipation.

Jim can say, “I have the same kind of abdominal pain I have had in the past when I was constipated.” Ben, who used to be a great conversationalist, doesn’t talk much anymore, but he can tell his wife, Ellen, that “I hurt,” or “I feel bad” although he can seldom explain how or where. More often, he simply strikes out at the discomfort with angry behaviors directed towards Ellen, whom he identifies as the source for all that happens to him, good or bad.

Naturally, Ellen prefers to deal with the constipation before the behavior starts if possible. To this end, she:

• Uses a calendar hanging inside their bathroom cupboard to check off when Ben moves his bowels. Thus, she can catch a change in his normal routine quickly and act before it becomes serious.
• Is especially alert during those times when constipation is most likely to occur such as during travel, when routines get messed up and in warm weather when the body needs more fluid.

If Ben does become constipated, he probably won’t be able to tell Ellen. But she has become an expert at playing detective and watching for non-verbal cues such as:

• Moaning and groaning and the cradling of his abdominal area.
• The sudden appearance of dementia symptoms such as hallucinations, agitation, mania, agitation, verbal or physical violence, nonsensical talking, active dreams or delusions. With Ben, she knows that his active dreams usually get worse when he starts feeling constipated, or when he has a UTI, another “hidden” complication, which can cause abdominal pain and acting out behaviors.
• A sudden increase of already present dementia symptoms. Ben had regular hallucinations but they are usually benign. When they start getting scarier, Ellen starts looking for a physical problem.

Next, Ellen has to do some sorting out. Like most people living with dementia, urinary tract infections (UTIs) are also very common causes of acting out behaviors. Therefore, if there are no changes in his bathroom routine, Ellen’s first guess is a UTI. She acts on that, getting a urine test and going from there. If there are changes in his bathroom routine, or if the UTI has been ruled out, Ellen moves on to look for signs of constipation:

• Does his abdomen look bloated?
• Is he holding his head or showing in other ways that his head hurts? Usually headaches and nausea don’t occur until the constipation is so serious that there may be an impaction. However, Ellen has learned to pay attention to when Ben complains of a headache, or starts showing non-verbal signs of one. With him the headaches can come early, while he is still no more than a little bloated. Every person is different and each care partner soon learns what their loved one’s danger signals are.
• Does he flinch or pull away when she gently touches various areas of his abdomen. She asks “Does it hurt here?” “Here?” or “Here?” but she depends more on his non-verbal signs of distress to tell her where it hurts most.
• Has he lost his appetite? If Ben is feeling bloated, he may not be hungry at times when he’d normally be eager to eat or he might reject food he usually loves.
• Does he act like he wants to throw up, or is he actually vomiting? Like headaches, nausea usually doesn’t occur until the constipation is so serious that there may be an impaction. Therefore, if he is exhibiting these signs, Ellen needs to be seriously concerned and might consider an ER visit.

The final blog in this series is about what to do when constipation occurs. It will be published on Nov. 23, two weeks from now. Next week's blog is about preparing for the Thanksgiving holiday.

For more information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson's and Lewy Body Dementia

 Helen and James Whitworth are not doctors, lawyers or social workers. As informed caregivers, they share the information here for educational purposes only. It should never be used instead of a professional's advice.

Constipation, Pt 2: Prevention

The last blog was about being aware that constipation is not just a condition of dementia but can be caused by other conditions as well. I used Jim’s history of Crohn’s disease as an example but named others such as diabetes as well. However, constipation, even without the complication of anything else can be very serious.

Therefore, the best solution is to prevent the constipation in the first place.
To help prevent constipation,

Avoid refined grains, including white rice, and choose whole grains, especially bran, instead.
Avoid processed foods, including pasta (which Jim loves!) and choose fresh and cooked vegetables (which Jim isn’t as fond of!) instead. These high-fiber foods foster digestion by drawing fluid into the intestinal tract. Warning: if like Jim, Crohn’s is an issue, fiber that is too rough can be problematic. He still adds fiber but avoids foods like popcorn with its rough husks.
Avoid greasy fast foods like burgers and fries. Fatty foods and proteins are low in fiber and take longer to digest. It isn’t so much that they cause constipation as that they take the place of foods that prevent it. Choose nuts, beans and fish instead. If you have a problem getting enough fiber in your loved one’s diet naturally, consider a fiber supplement such as Metamucil or FiberCon.
Avoid processed (white) sugar and bakery items like cookies and cakes. Most people living with dementia love sweets and so avoiding these is often difficult—especially when they make such great bribes! However, these items are triple constipation risks: they are low in fiber, low in fluid and high in fat. Choose fruits instead.

Avoid green bananas but choose ripe bananas. Green bananas are constipating, but ripe ones are great sources of fiber. This is actually true for most fruit although it is especially strong with bananas. Dried fruit make great snacks and have even more fiber than fresh fruit. However, they also have more calories. Remember that old saying about an apple a day keeping the doctor away? You didn’t know they were talking about constipation, did you?

Avoid cheese and ice cream. Choose yogurt and fruit sherbets instead. (Most dairy products are constipating, but yogurt is fermented and has those healthy probiotics.) Also consider fermented foods, such as sauerkraut, kimchi, and miso, all of which contain healthy bacteria and probiotics that assist with digestion. Consider adding a daily probiotic supplement as well.

Avoid cold drinks, including water. Choose warm water instead. Drinking a glassful every morning activates digestion, helps to avoid indigestion and stimulates blood flow. This was a big issue for Jim. He felt good that he was finally drinking more water and then I suggested that he drink WARM water…something he had considered unpalatable in the past. Like a good patient, he manned up and now he drinks it regularly, at least when constipation threatens, although he still doesn’t enjoy it.

Coffee is a stimulant and can foster the digestive process. However, it is also a diuretic which can decrease fluids. Don’t avoid, but drink only a limited amount.

In addition, be sure to exercise regularly and drink water all day long. As we said in the last blog, these two especially can both be issues for summer travelers like us.

Help your loved one to set up a bathroom routine, where you encourage them to move their bowels at the same time of the day, every day. Be especially alert when this routine is broken, as it often is with travel.

Consider a daily routine of a combination of an osmatic laxative, such as Miralax, milk of magnesia or Citroma and stool softeners. The osmatics soften the stool by drawing fluid into the colon from nearby tissue and the stool softeners draw fluid already in the colon into the stool to soften it further. What works for each person varies. Some people need to take both every day. Jim learned that a daily dose of these could lead to diarrhea for him, but that using just the osmatics every other day kept him regular most of the time. Like Jim, you will probably have to learn by experimenting. However, check with the doctor before you start. These laxatives are mild, but they are still drugs and may conflict with something else your loved one is taking.

The next blog is about how to identify the presence of constipation is present in a person with a limited ability to recognize why they are uncomfortable or to communicate this easily to their care partner.

For more information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson's and Lewy Body Dementia

Helen and James Whitworth are not doctors, lawyers or social workers. As informed caregivers, they share the information here for educational purposes only. It should never be used instead of a professional's advice.

Constipation, Pt. 1: Causes

Constipation is a big issue with dementia, especially LBD, where a compromised autonomic nervous system can slow down the whole digestion process. In fact, it is often one of the first symptoms that care partners remember, looking back. Of course, they didn’t connect it with LBD at that time. This was the case with Jim’s first wife, Annie. She had chronic constipation for years before she had any cognitive evidence of dementia. In fact, it was so bad that she chose to have an elective surgical procedure to improve it.

If she and Jim had known what he knows now, they would never have Bene that. But back in the late 1990’s very little was known about LBD and neither they nor any of their doctors thought to connect constipation with dementia. Nor did they consider the risk of surgery for someone who was already exhibiting more than one symptom that we know now warns of LBD: her constipation and active dreams—and age, which is the most common risk factor of all. It was after that surgery that she started having hallucinations and Jim took over the cooking after one too many “burnt offerings.” Once a skilled cook, Annie was no longer safe around a stove.

In Annie’s case, dementia wasn’t even considered as the cause of her constipation. But issues with identifying a cause can be the reverse too. Once dementia is known to be present, it is all too easy to blame it for any problem that comes up, including constipation—and often you’d be right. However, as a substance-abuse nurse, I learned that “an alcoholic has the right to any disease known to man.” This applies to dementia too. There are many other causes of constipation besides dementia. Crohn’s disease, for example.

Fast forward twenty years, and Jim is now the one experiencing bouts of constipation. Although he doesn’t have dementia, he is well past 60 and age is the biggest risk factor for constipation. However, in his case, we think first of Crohn’s disease. He hasn’t had a bout of Crohn’s for a couple of years, but we still worry. This disease, sometimes called ‘arthritis of the intestine” inflames the bowel lining and shrinks its working space, making constipation a constant threat. We know that even if it isn’t involved yet, it might be if we don’t get the constipation under control.

There are many other conditions besides age and Crohn’s that increase constipation risks. I’ve already mentioned LBD. It and other Lewy body diseases like Parkinson’s impair the nerves that control the muscles in the bowel and make them less effective. So do other neurological problems such as multiple sclerosis and stroke (common with vascular dementia). Hypo-thryoidism, or an underactive thyroid gland, decreases hydration and fosters constipation. So does diabetes, very common with seniors in general and especially common with Alzheimer’s. Depression, especially common with LBD and often present in other dementias, can slow down everything, including the GI tract.

Lifestyle can also be a risk factor. The body requires exercise and adequate fluids to function properly and fiber to foster digestion. In our travels, exercise is sometimes limited, and not just when we are traveling from one spot to another. We’ve been in both very warm and very chilly areas. Both make it tempting to stay in our comfortable RV instead of getting out and exercising. Lack of exercise is also often an issue for a person living with dementia, especially if mobility is already a problem. Hydration can be too. Jim has had to learn to drink more water, something he never did as a younger man. This becomes especially important during warm weather. Our bodies need more then. We aren't as careful about what we eat when we travel either, making do with things like fast foods that seldom have much fiber.

Certain medications can also be constipating: sedatives, narcotics, certain antidepressants and those that lower blood pressure. Since many people living with dementia often take these drugs, a care partner needs to be aware of this and be alert for early signs of constipation. Better yet, work with the prescribing physician to use drugs that have less constipation risk…or find an alternative non-drug method of treatment.

OK, so now we know a little about the causes, but what care partners really want to know is how to prevent, identify and treat constipation. Keep tuned. That’s what the next blogs will be about.

For more information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson's and Lewy Body Dementia

Helen and James Whitworth are not doctors, lawyers or social workers. As informed caregivers, they share the information here for educational purposes only. It should never be used instead of a professional's advice.

Lewy Body Dementia Precursors

Last week the blog was about how dementia is a symptom of many different cognitive, or mental, dysfunctions, with the main players being Alzheimer's, Lewy body, Vascular and Frontotemporal dementia. Readers also learned that dementias like to hang out together and that even if a person is diagnosed with one kind, an autopsy will likely show that there was at least one more.

This week's blog is about the symptoms leading up to Lewy body dementia.

Like Alzheimer's disease (AD), LBD is caused by normal proteins that become damaged, and then, cause more damage. In the case of LBD, it is the alpha-synuclein proteins that "misfold" into Lewy bodies. These round sticky masses then attack certain neurotransmitters, the chemicals that pass information from neuron to neuron. While AD proteins tend to stay in the cerebral cortex, Lewy bodies migrate, and can spread throughout the nervous system. Thus, they cause a great variety of symptoms. What these symptoms are depends on where in the body the Lewy bodies are located.
One question we often hear is "What causes the proteins to misfold and turn into Lewy bodies?" Well, the answer to that appears to be two-fold. First, a person has to have the genetic tendency. And then they have to be exposed to an environmental toxin. (See the 11/7/14 blog, Genes and Environment, for a more thorough answer to this question. I'll also be talking about it again in a future blog about something called "telomeres.")

Chronic Constipation. Annie, Jim Whitworth's first wife, and his original reason for being on this journey, had chronic constipation as a young woman. Her more conventional LBD symptoms of hallucinations and poor thinking skills didn't appear for almost a half century later. One thinks of LBD being a "brain disease" but it is more a "nerve" disease. Since there are more nerves in the gut than anywhere else in the body, except for the brain, it makes sense that one of the first places Lewy bodies may show up is in the intestinal tract, which isn't nearly so well protected.

REM Sleep Behavior Disorder (RBD). The chemical switch that prevents movement during sleep is situated on the brainstem in the pons. When Lewy bodies find their way here, they damage the switch and people act out their dreams. They can be very active, hence the very accurate description of "Active Dreams." About 50% of those with RBD go on to develop LBD eventually. See our 11/02/12 blog, Active Dreams, for more about RBD.

Parkinson's disease (PD). PD is a movement disorder that occurs when Lewy bodies in the midbrain attack dopamine, a neurotransmitter instrumental in fine motor control. From 60% to 80% of those with PD will eventually go on to experience dementia symptoms. Many people with PD also have Chronic Constipation and or RBD. The more of these "precursor symptoms" a person has, the more likely dementia is. See our books (below) for more about PD.

Hallucinations. When the Lewy bodies travel a little further into the brain, they find the cerebellum, which has a lot to do with making sense out of what a person sees. Here, Lewy bodies interfere with this process and cause a person to hallucinate, or see (or feel or hear) things that aren't really there. These hallucinations can appear very realistic. Even so, a person can usually understand that although they see the little bugs or green men or lady on the sofa, no one else does--at first. Then as the Lewy bodies move into the thought processing parts of the brain, they begin to believe their hallucinations are real. See our books (below) for more about hallucinations.

Mild Cognitive Impairment (MCI). The Lewy bodies have found the cerebral cortex, the area of the brain where the ability to think clearly and do tasks is stored, causing poor decisions or the fumbling of familiar tasks (MCI-LB). If Alzheimer's is involved, MCI may start with memory loss (MCI-AD). In either case, a person can still function and take care of themselves.

Dementia: MCI becomes "dementia" when it interferes with a person's ability to provide adequate and safe self-care. In the case of AD, symptoms usually have to do with memory about things: words, dates, events and such. With LBD, they have more to do with task memory: the ability to perform once easy tasks. Lewy bodies also mess with one's thinking skills and delusions become common. People with hallucinations now believe they are real.

Now, the thing to remember is that with LBD nothing is firm. Every person experiences LBD differently. Any one of these symptoms can occur without the other, or in almost any order, although at least one of them usually occurs prior to the dementia. Lewy bodies tend to travel in the way I've described, but they often don't. They may skip a symptom, such as PD, and move on to the next, or they may travel in a different order. In fact, about 50% of the time, a person with Lewy body dementia will NOT have experienced PD first, although eventually, they will usually have some motor issues. When this happens, it is called Dementia with Lewy bodies.

For a much more involved description of all of the above read our books (below).

Next week's blog will be more about the two types of Lewy body dementia...the kind that starts with PD and the kind that doesn't.

Acronyms:
LBD: Lewy body dementia
AD: Alzheimer's disease
RBD: REM sleep behavior disorder
PlwD: person living with dementia
PlwLBD: person living with LBD
DLB: dementia with Lewy bodies
PDD: Parkinson's disease with dementia
MCI: mild cognitive impairment
MCI-LB: the form of MCI that precedes LBD
MCI-AD: the form of MCI that precedes AD
BPSD: behavioral and psychological symptoms of dementia

For information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson's and Lewy Body Dementia

Helen and James Whitworth are not doctors, lawyers or social workers. As informed caregivers, they share the information here for educational purposes only. It should never be used instead of a professional's advice.

Next week's blog will be more about the two types of Lewy body dementia...the kind that starts with PD and the kind that doesn't.