Management and Prevention of Constipation in ALS

Gema Ramos, RN, Care Services Coordinator, ALS United Greater Chicago

Constipation is defined as having a bowel movement fewer than three times per week generally with hard, dry stools, difficulty with elimination, and bloating. Unfortunately, constipation is a frequent complaint with ALS. It’s a symptom that’s not directly but indirectly brought about by ALS. To help manage or prevent constipation it is helpful to know the most common contributing factors.

Some of the possible causes and contributing factors to constipation in ALS in general are:

• Decreased physical activity because of a decrease in muscle strength and fatigue.
• Decreased dietary fiber intake due to changes in food choices due to chewing or swallowing difficulty.
• Decreased fluid intake because of difficulty swallowing liquids or decreased frequency of urination due to the need for more assistance going to the bathroom.
• Weakness in abdominal or pelvic muscles makes it more difficult to bear down and push the stool from the body.
• Medications to control saliva, (e.g., amitriptyline, atropine) or pain (e.g., codeine) which dry up the stool.

To help manage or prevent constipation here are some alternative non-medication recommendations:

• Stay well hydrated by increasing fluid intake including any non-alcoholic beverages, such as water, juices, milk, and thickened liquids— a liquid diet does not always contain much water, so drink plenty of water.  Aim for 8-9 cups of fluids per day. Try warm liquids, especially in the morning; Senna tea or microwaved prune juice can be helpful. It is important to establish good fluid intake before trying to increase fiber intake. High fiber intake without sufficient fluids may actually aggravate the problem
• Gradually increase dietary fiber intake including whole grain products (bread, cereals, pasta, brown rice), vegetables, fruit, legumes (dried peas, beans, lentils), and fiber supplements (bran, psyllium). Most of the fiber in fruits is found in the skin.  Fruits with edible seeds, such as strawberries, have the most fiber.  Eat bran cereal or add bran cereal to other foods.  Eat prunes (microwaved especially).
• Eat regular mealtimes
• Speaking to your doctor about adjusting certain medications that contribute to constipation
• Good bowel habits including not suppressing the urge for a bowel movement (“heeding the call of nature”)
• Using a “Squatty Potty” or simply propping up the legs on a trash can to elevate it. Having a bowel movement in the natural squat position opens the colon, making elimination faster and reduce straining.
• Going to see a physical therapist to have you or your caregiver learn colon massage or pelvic floor bowel management. Colon massage is an abdominal massage that when performed correctly, can help loosen up compacted fecal matter so the muscles in the colon can move the waste along in a more effective manner.

Here are two recipes that may be helpful:

Fruit Paste for Constipation

Ingredients:
1 pound pitted prunes
1 pound raisins
1 cup lemon juice
1 pound dried figs
1 cup brown sugar
3-4 oz pkg Senna Tea

Steep tea for 5 minutes in 3 ½ cups water and strain.  Add fruit to 2 cups of tea and boil for 5 minutes.  Add sugar and lemon juice and allow it to cool.  Blend in a food processor. Enjoy eating fruit paste straight off the spoon. Spread it on toast or add hot water and make a drink. If the fruit paste is not working (no bowel movements), then increase the amount of fruit paste each day. If the fruit paste induces very loose stools, cut down on the amount of fruit paste intake. Consider taking it every other day in some cases. This can be made and stored in the freezer in ice cube trays.

Prune Juice Cocktail

Mix together:
1 cup applesauce
1 cup oat bran or unprocessed wheat bran
1 cup of prune juice

Begin with 1-2 tablespoons each evening mixed with or followed by 6-8 oz cup of water or juice. This should help to soften and regulate your bowel movements within 2 weeks. If no change occurs, slowly increase serving to 3-4 tablespoons. This may be stored in your refrigerator or freezer. 1 to 2 tablespoon servings may be frozen in sectioned ice cube trays and thawed as needed.

Here are medication-related recommendations for managing constipation:

• Laxatives are often used for the treatment of constipation. Laxatives can be separated into four main headings: softeners, stimulants, bulking agents, and osmotic agents.
  • Stool softener: Docusate sodium, dosage of up to 500 mg daily. This medication brings more fluid into the bowel. These can take several days to take effect.
  • Stimulant laxatives: Senna, bisacodyl, or sodium picosulfate. These medications have a stimulant effect. These can take effect in approximately 6-12 hours. Glycerol suppositories act as a mild irritant to the lining of the rectum. These can take effect in 15-60 minutes.
  • Osmotic laxatives: Magnesium salts and Miralax (polyethylene glycol). These medications work to increase water absorption into the stool, making it softer, bulkier, and easier to pass. These can take effect in 1-3 days.
  • Bulking agents: Metamucil, Citrucel. People with ALS should exercise caution with bulk or fiber laxatives, especially if swallowing is difficult. Without adequate fluid intake, fiber laxatives can swell up in the throat, esophagus or intestine, creating a dangerous blockage. They also can gum up a feeding tube unless adequately flushed with water. Follow package directions carefully. These can take effect in 12-72 hours.

If these measures do not resolve the problem and/or you have not had a bowel movement in 4 days, please consult your physician.

Reference:

ALS Association Living with ALS Manuals: Managing Symptoms of ALS

“Amyotrophic Lateral Sclerosis: A Patient Care Guide for Clinicians” by Richard Bedlack and Hiroshi Mitsumoto

https://voice.ons.org/news-and-views/crush-constipation-with-this-old-time-recipehttps://www.hopkinsmedicine.org/johns_hopkins_bayview/_docs/medical_services/gynecology_obstetrics/bowel_regularity.pdf