A 79 yr old man having right side paralysis he has done bed sore operation previously and having constipation. Now tell me how to treat constipation
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constipation treatment elderly bedridden stroke paralysis management 2024
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I now have comprehensive information to give a thorough, practical answer. Let me compile this for the clinical scenario — a 79-year-old man with right-sided paralysis (likely post-stroke), history of pressure sore surgery, and constipation.
Managing Constipation in a 79-Year-Old with Right-Sided Paralysis
This patient has several compounding risk factors for constipation:
- Immobility/paralysis — reduced physical activity slows colonic transit
- Post-stroke neurological changes — disrupted autonomic/enteric nerve signaling
- Advanced age — slower gut motility
- Post-surgical recovery — possible opioid use, reduced oral intake
- Bed-bound status — gravity and posture cannot assist defecation
Step 1: Rule Out Contributing Medications
Review his current drug list and stop or reduce if possible:
| Constipating Drug Class | Examples |
|---|---|
| Opioid analgesics | Morphine, tramadol (post-op pain) |
| Anticholinergics | Some antidepressants, bladder drugs |
| Calcium channel blockers | Amlodipine, nifedipine |
| Antacids with calcium/aluminium | Common OTC antacids |
| Iron supplements | Ferrous sulfate |
If he is on opioids post-operatively, always prescribe a laxative simultaneously — osmotic or stimulant type.
Step 2: Non-Drug (Lifestyle) Measures
These are first-line, though limited in a bed-bound patient:
- Fluids: Give at least 1.5 litres/day of water or warm fluids. A warm beverage (e.g., warm water or tea) in the morning stimulates the gastrocolic reflex.
- Dietary fibre: Soft, fibre-rich foods — oats, fruits (prunes, papaya, banana), cooked vegetables, daal. Prune juice is particularly effective in elderly patients.
- Positioning: Even if bed-bound, try sitting him upright at 45–90° after meals. If he can be transferred to a commode, a semi-squatting position with feet on a footstool greatly helps.
- Abdominal massage: Gentle clockwise circular massage (following the direction of the colon) for 10–15 minutes, 1–2 times a day — helps in neurogenic/post-stroke bowel.
- Bowel routine: Attempt defecation at a fixed time each day, ideally 30–60 minutes after breakfast (when the gastrocolic reflex is strongest).
- Passive limb exercises: Even passive range-of-motion exercises help slightly stimulate gut motility.
Step 3: Pharmacological (Laxative) Treatment
Use a stepwise approach:
🔹 First Line — Osmotic Laxatives (Preferred)
These draw water into the bowel and soften stool. Preferred over stimulants for long-term use.
| Drug | Dose | Notes |
|---|---|---|
| Polyethylene glycol (PEG / Macrogol) | 17 g (1 sachet) once daily in water | Safest, no electrolyte disturbance; first choice |
| Lactulose | 15–30 mL twice daily | Can cause bloating/gas; use if PEG unavailable |
| Milk of Magnesia (Magnesium hydroxide) | 15–30 mL daily | Avoid if kidney disease present |
🔹 Second Line — Stool Softeners (Emollients)
Add alongside osmotic laxatives especially if stool is very hard:
| Drug | Dose | Notes |
|---|---|---|
| Docusate sodium (Colace) | 100 mg once or twice daily orally | Softens stool; helps prevent straining |
🔹 Third Line — Stimulant Laxatives
Use short-term only (risk of dependence with prolonged use):
| Drug | Dose | Notes |
|---|---|---|
| Senna (Senokot) | 2 tablets once or twice daily | Stimulates myenteric plexus |
| Bisacodyl | 5–10 mg orally or 10 mg suppository | Suppository form useful if oral route is unreliable |
🔹 For Acute/Immediate Relief — Rectal Options
If no bowel movement for >3 days, use rectal intervention:
| Option | Method |
|---|---|
| Glycerin suppository | Insert per rectum; provides quick local stimulation |
| Bisacodyl suppository | 10 mg PR; effective within 15–60 minutes |
| Phosphate enema | Use cautiously (avoid in renal impairment, frail elderly) |
| Manual evacuation | Last resort if fecal impaction is confirmed — digital removal of impacted stool |
Step 4: Watch for Fecal Impaction
In a bed-bound elderly patient, fecal impaction is a serious risk. Signs include:
- Overflow "spurious diarrhoea" (liquid leaking around a hard mass)
- Abdominal distension
- Pain/discomfort and refusing food
- No formed stool for >5 days
If impaction is present: Start with a glycerin or bisacodyl suppository, then an oil-retention enema (arachis oil), followed by a phosphate enema. Manual disimpaction under sedation if needed.
Step 5: Maintenance Plan
Once bowel habits normalise, maintain with:
- PEG (Macrogol) daily — long-term safe osmotic laxative
- Prune juice daily in the morning
- Adequate hydration (1.5 L/day)
- Abdominal massage by caregiver daily
- Fixed toileting schedule — after breakfast every day
- Reassess any constipating medications regularly
Summary Table
| Priority | Intervention |
|---|---|
| Immediate | Glycerin suppository or bisacodyl suppository if no BM >3 days |
| Daily medication | PEG/Macrogol 17 g daily (osmotic laxative) |
| Add if hard stool | Docusate sodium 100 mg twice daily |
| Rescue | Senna 2 tabs at night if no effect with PEG |
| Diet | Prune juice, warm fluids, soft fibre foods |
| Routine | Bowel attempt 30 min after breakfast daily |
| Caregiver | Abdominal clockwise massage 10–15 min/day |
Important caution: Since this patient has had surgery for a bed sore (pressure ulcer), ensure he is adequately nourished and hydrated — both for wound healing and bowel function. Straining at stool should be minimised, as it increases pressure and can worsen pressure areas.
Sources: Katzung's Basic and Clinical Pharmacology, 16th Ed | Tintinalli's Emergency Medicine | ASCRS Constipation Guidelines 2024 | PMC: Constipation in Older Adults
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