Reducing Constipation Medications in Clients with Intellectual Disabilities

My son, who has autism and is now 23 years old, has had lifelong struggles with constipation. However, in the last few years, it has become much worse. He also seems to become horribly irritable when he has not had a bowel movement in a few days. We try to encourage eating fruits and fiber, but it seems that his constipation is worsening despite all of our efforts. Are there any suggestions for how to approach this? Am I overreacting? I have heard that there is not one schedule for elimination, such as having a daily bowel movement, that is necessary for health, but I am worried we are moving in the wrong direction.

Answered by Maureen McBeth, BSN, RN, Dani Block, MBA, BSN, RN, CDE, Ibukun Olagunju, MSN, BSN, RN, and Lindsay Bly, M.S., CCC-SLP
Melmark

These authors were invited to answer this question as they treat individuals with complex medical and behavioral needs at a residential care center, and are experts at intervening in cases of chronic constipation.

Reducing Constipation Medications in Clients with Intellectual Disabilities Concerned parents, like yourself, are not overreacting to this issue. Indeed, constipation is a serious and common issue among individuals with developmental disabilities. Of course, periodic constipation is common and is not a cause for alarm. However, chronic and severe constipation has actually been associated with severe health consequences, which can lead to pain, bowel obstruction, difficulty ingesting food, severe challenging behaviors, and medical emergencies (Mayo Clinic, 2022). While constipation may be perceived as a nuisance, it can become a medical emergency. It can even lead to complications that are fatal, including intestinal obstructions.

Many issues contribute to constipation in clients with developmental disabilities. Lack of mobility, decreased intestinal motility, use of medications to help manage health conditions and reliance on others to ensure adequate oral intake can increase vulnerability to constipation. Constipation is exacerbated by a variety of neurological, muscular, and digestive system issues, all of which occur at higher rates in individuals with developmental and intellectual disabilities (Mayo Clinic, 2022). As noted on that site, “An increasing amount of literature evaluates colonic motility itself, with the suggestions that disruption in neural modulation or abnormal development of neuromuscular control may be implicated as an underlying cause.”

Much can be done to prevent and treat constipation. It is important to do so, as emergencies can otherwise occur. At Melmark, a residential setting for individuals with developmental disabilities, clients are monitored for the Fatal Four conditions: aspiration, constipation, dehydration, and seizures. Trainings are provided for staff to increase awareness of these conditions. We use Health Tracking systems to monitor hydration, bowel movements, and seizures. Aspiration precautions are in place for clients who are at risk. Individuals with developmental and intellectual disabilities are more severely and frequently affected by these four major health problems than the general population (Pennsylvania Department of Human Services, 2018). These medical conditions are frequently preventable or, at the very least, treatable with prompt medical intervention (Pennsylvania Department of Human Services, 2018).

The pattern presented in this case – the persistence of constipation from childhood to adulthood – is not uncommon. The presence of constipation seems to be the same in children and adults with intellectual disabilities, which would suggest that it does not develop over time but is present from early in life (Rubin & Crocker, 2006). Indeed, there is some consensus that the vulnerability to constipation is fairly universal in these individuals. Strategies are generally put in place for individuals who are exhibiting associated issues, to ensure a bowel obstruction does not occur. Nurses complete weekly abdominal assessments and track fluid intake based on nutritionist and PCP recommendations. Direct Support Professionals (DSPs) record the size and type of bowel movement using the Bristol Stool Chart daily. The most common preventative and treatment strategy is the use of fiber capsules, to increase fiber content and assist with motility and passage of stool.

A Novel Intervention for Constipation

In addition to these strategies, there may be a place for a nutritional intervention for chronic constipation. The following intervention was developed by our interdisciplinary team as both a prevention and an intervention strategy when high rates of constipation and related complications were noted as a recurring issue. Prior to this approach, clients at risk for or experiencing constipation were given fiber tablets on a daily basis. In an effort to improve constipation issues and reduce the amount of medication taken daily by clients, the team at Melmark discussed the possibility of replacing fiber capsule/powder supplements with Power Pudding. Power Pudding is a delicious combination of prunes, bran, applesauce, and prune juice blended to a pudding consistency. It is a natural way to add fiber to a diet. It is also generally liked by the clients and enjoyed as a snack by them.

Before beginning the trial of Power Pudding, clients tasted a sample of it to see if they would enjoy it. In the adult population who were offered the pudding, all verbal clients offered asked for more. Non-verbal clients showed enjoyment by smiles, lip smacking, and opening their mouths for more. In the children’s population, all individuals offered the trial have an ASD diagnosis. Among the children, some did refuse the pudding, which may have been a texture issue, which is common in ASD.

To prepare for the trial, the nursing staff obtained physicians’ orders to place fiber capsules/powder constipation medications on hold for a period of two weeks. Medications were replaced with Power Pudding in accordance with the medication script (daily, twice daily, and three times daily). Guardians unanimously gave consent and were excited at the prospect of decreasing the amount of daily medication (pills) taken by their loved ones.

What We Learned

We want to share a bit about some of our experiences implementing this protocol. To ensure there would be controlled monitoring, four to six clients were introduced to the pudding at a time. At the end of the trials, all but two clients were having consistent bowel movements. One was having an issue with loose stool. For that individual, the amount of power pudding changed from two 4 oz portions a day to one 4 oz portion every other day. The change in amount worked well for this client, who then reported consistent bowel movements. The other client who relied on daily enemas had no change in bowel movements with the addition of power pudding, and the medical doctor gave the order to discontinue. However, in all other cases, the Primary Care Physician gave discontinuation orders for fiber capsules/powder medications.

At present, approximately 30 clients have had reductions in the constipation medications, on average of about three fewer pills daily since February 2021. This is good news for clients who may be prescribed five to twenty-five pills due to their various diagnoses. Our dietary services provider makes power pudding and distributes to our clients’ residences 3 times a week.

While this intervention was applied in a residential setting, it can also be done at home. To assist in exploring whether this could reduce complications for learners in your care, the recipe is below (please adjust for smaller quantities).

Summary

Recipe for Reducing Constipation in autism Quality of life and medical wellness are essential outcomes for all human beings and should be a central focus in planning care for those with autism and other developmental disabilities. Issues in constipation are prevalent but are not always openly discussed. Constipation is a serious issue, both in terms of the discomfort it produces, and in terms of the serious associated health consequences. Treating constipation with fiber pills is an effective strategy, but also adds to the number of pills taken daily. Furthermore, it is better to derive fiber from food sources whenever possible. This project explored adding a high fiber daily pudding to the clients’ daily food intake as an alternative strategy. The intervention was successful in almost all cases. The pudding was desired by the participants. Such an intervention is simple and may help others with chronic constipation. As an additional note, it is important to attend to hydration, along with fiber rich foods. Hydration is very important for digestion. Parents should ask their doctor what their loved one’s daily fluid intake should be. They can then keep records to see if they are meeting that goal. Adequate hydration can help ease constipation, and may serve a preventative function.

Final words

It may be worth exploring the pudding intervention with your Primary Care Physician and your interdisciplinary team. If they agree to try it, you can first explore whether it would be something that your son would prefer and willingly ingest. Then, you can work to find the right dosage and frequency to aid in attaining regularity. In preparing to meet with a physician about this, it would be helpful to have information about frequency of bowel movements, about associated issues (straining, difficulty having a movement, behavioral avoidance of voiding, etc.). It also may help to provide information on typical food intake, including fruits, vegetables, and fiber.

References

Mayo Clinic. (2022). Intestinal obstruction. https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/syc-20351460

Mayo Clinic. (2022). Constipation. https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253

Pennsylvania Department of Human Services. (2018). The Fatal Four. retrieved 11-30-22. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.paproviders.org/wp-content/uploads/2018/08/Fatal-Four-Handout-Version-Begin-08-10-18-v2.pdf

Rubin, I. L., & Crocker, A. C. (2006). Developmental Disabilities: Delivery of Medical Care for Children and Adults. Baltimore, MD: Paul H. Brookes Publishing Co., Inc.

Authors’ Note: The authors would like to thank Carrie and her crew from Lintons, who make Power Pudding for the clients at Melmark.

Citation for this Article:

McBeth, M, Block, D., Olagunju I., & Bly, L. (2022). Clinical Corner: Reducing constipation medications in clients with intellectual disabilities. Science in Autism Treatment, 19(12).

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