Aging Persons with Intellectual Developmental Disorders (IDD): Constipation KEYPOINTS A major medical conditions that commonly is seen among persons with IDD and may lead to serious complications is constipation. Adults with intellectual disabilities have intellectual functional limitations that occur prior to the age of 18 years. Adults with developmental disabilities have functional limitations in 3 or more areas of life activity (self-care, language, mobility, self-direction, capacity for independent living) Schlock et al, 2010. OVERVIEW Stool should be soft, passed easily out of the bowel Constipation should be considered if o Stool is hard and dry in consistency. o Stool elimination is painful and difficult to pass. Etiology: Persons with IDD may have several risk factors that predispose them to constipation: Birth defects (i.e. spinal bifida) can affect bowel and elimination function. Dietary habits inadequate fluid intake and low fiber intake leading to hard stool. Medication administration may affect stool transit in the intestines (i.e. anti-convulsants, antipsychotics, benzodiazepines). Neuromuscular disorders may cause muscular weakness and influence posture and movement. Swallowing disorders may limit amount of fluid intake leading to hard stools. Toileting habits may influence bowel function and routine such as lack of privacy and/or lack of equipment to assist with toileting (i.e. commode chair) ASSESSMENT Healthcare providers should include the following information in their History of Present Illness (HPI): Describe the baseline or normal bowel habits of the adult. How long has the adult been having difficulty passing stool? Identify the last bowel movement date. Ascertain if the adult has flatulence.
Ascertain if the adult is in pain, if the adult is non-verbal, has there been a change in behaviors, routines, or ability to function at baseline? Describe the current bowel management program. If applicable, describe previous constipation bowel management interventions and the success of the different plans of care. As with older adults with cognitive impairment, history often is ascertained from the caregiver. Pay particular attention to atypical clinical manifestations which can often be the only signs/symptoms that the older adult with IDD is constipated or having complications from constipation: Anorexia decreased food and fluid intake Change in daily function, routine or change in behavior Excessive time on the commode Grunting or straining when trying to have a bowel movement Caregiver s may be able to utilize the Bristol Stool Chart to provide information regarding stool characteristics: Lewis & Heaton, (1997)
Physical Assessment: GI System absence or diminished of bowel sounds, anal skin area irritation, bloating, distention, flatulence, painful hemorrhoids, pain on palpation, rectal bleeding, rigidity on palpation, vomiting Neurological System behavioral changes, change in daily routine, change in level of consciousness (lethargic, decreased verbalization), decrease in functional abilities Skin dehydration and poor skin turgor Atypical clinical manifestations may include fever, seizure, pneumonia DIAGNOSIS Diagnosis of constipation in persons with IDD may be challenging due to atypical presentation. Diagnosis should include or consider the following: History and physical examination Laboratory test o Basic Metabolic Panel o Complete Blood Count o Stool for occult blood, perhaps microscopic evaluation o If history indicates, thyroid panel to rule out hypothyroidism Imaging o Flat and upright abdominal radiograph o Barium enema o CT scan o MRI o Ultrasonography o Sigmoidoscopy Rule out potential complications: Bowel Obstruction (can be life threatening) Fecal Impaction Intestinal Perforation (can be life threatening) Rectal Prolapse
INTERVENTION Prevention Allow time and privacy for healthy bowel habits Dietary Interventions include o High fiber intake (20-35 grams/day) o Encourage fluid intake Exercise Record bowel frequency and stool consistency Intervention Non-pharmaceutical interventions include: Dietary o Increase fluid intake Manual modalities o Disimpaction o Enemas Pharmaceutical interventions include: Bulking agents Laxatives Osmotic agents Stool softeners Suppositories (daily)
REFERENCES Health guidelines for adults with an intellectual disability. Available at: http://www.intellectualdisability.info/how-to../health-guidelines-for-adults-with-an-intellectualdisability#constipation Lewis SJ, Heaton KW (1997). Stool form scale as a useful guide to intestinal transit time. Scand. J. Gastroenterol. 32 (9): 920 4. Office of Training and Professional Development (2011, October 15). The Fatal Four: Constipation: A Major Challenge that Impacts People with Developmental Disabilities. Division of Developmental Disabilities Services 4(9), pp 1-2. Schalock, RL, Borthw9ck-Duff, SA, Bradley VJ, et al. (2010). Intellectual Disability: Definition, Classification and Systems of Supports. (11 th ed). Washington DC: American Association on Intellectual and Developmental Disabilities. Smith, MA, & Escude, CL (2015). Intellectual and Developmental Disabilities. The Clinical Advisor, February:49-58.