Constipation associated with Parkinson’s disease can damage wellbeing and restrict independence. Effective bowel care is essential to maximise people’s quality of life.
Gaye Kyle, MA, BA, RGN, is honorary lecturer, Thames Valley University and recognised teacher, University of Ulster.
Kyle G (2010) The physical, social and emotional effects of bowel dysfunction in Parkinson’s disease. Nursing Times; 106: 33, early online publication.
Bowel dysfunction in Parkinson’s disease can lead to embarrassment, social isolation and admission to long term care. Nurses need to understand the reasons why bowel dysfunction occurs and how to assess patients for this problem.
Keywords Parkinson’s disease, Bowel dysfunction, Bowel care
- This article has been double-blind peer reviewed
Some 60-80% of people with Parkinson’s disease (PD) suffer from constipation (Ueki and Otsuka, 2004) and bowel dysfunction in this group causes distress and disability and affects both self esteem and social participation.
PD is a common, progressive movement disorder affecting 3% of the population over 65 years (Ross et al, 2000). It is associated with the degeneration of dopaminergic neurons in the substantia nigra, leading to reduced levels of the neurotransmitter dopamine. People with PD classically present with the symptoms of bradykinesia, tremor, rigidity and rest tremor. These neurological symptoms may be referred to as Parkinsonism or Parkinson’s syndrome, which is further characterised by hypokinesia and postural instability.
Parkinsonism can be caused by drugs, as well as by conditions including multiple cerebral infarction and degenerative conditions such as progressive supra-nuclear palsy and multiple system atrophy (National Institute for Health and Clinical Excellence, 2006). Although PD is predominantly a movement disorder, other impairments often develop including depression and dementia.
The disease is incurable and associated with progressive disability and increased mortality. As it progresses patients face a multitude of problems that impact on bowel function, including immobility, functional dependence with associated functional incontinence, gastrointestinal problems and inability to communicate.
People with PD may live for more than 30 years with worsening symptoms that are compounded by the natural ageing process.
Quality of life
Health related quality of life (HRQoL) is a concept used to quantify the physical, social and psychological functioning that may be impaired by disease. It is a subjective term associated with personal wellbeing.
There is a lack of consensus about the definition of HRQoL and against what criteria this should be assessed. Ideally it should measure a condition from the patient’s perspective rather than from healthcare professionals’.
Irvine et al (2002) showed constipation had a clinically significant detrimental effect on HRQoL. It is suggested that its high prevalence and adverse effect on quality of life make it a major public health issue (Dennison et al, 2005). It appears that constipation affects patients’ overall wellbeing with symptom severity correlating negatively with perceived quality of life (Glia and Lindberg, 1997).
Understanding the physical, social and emotional effects of bowel dysfunction in PD may help healthcare professionals to develop a more therapeutic attitude towards bowel management.
The pathophysiology of the gastrointestinal tract in PD is complex involving autonomic, central and enteric nervous system dysfunction. Patients often experience excessive amounts of saliva in the mouth (sialorrhoea) due to dysphagia (impaired and infrequent swallowing). Studies suggest that dysphagia becomes more prevalent as the disease progresses (Pfeiffer, 2003).
Dysphagia has a direct impact on nutritional and fluid intake, and poor fluid and fibre intake together with diminished mobility can lead to the development of idiopathic constipation. The causes are outlined in Box 1. Inadequate nutrition and fluid intake can be addressed with the support of dietitians and speech and language therapists.
Box 1. Causes of idiopathic constipation
Simple (idiopathic/primary) constipation
Associated with lifestyle:
- Reduced dietary fibre;
- Reduced fluid intake;
- Reduced mobility;
- Environmental changes (such as lack of privacy, poor toileting posture).
Most common among older people: often the result of reduced mental and physical function. Dementia occurs in the latter stages of PD but may parallel motor progression from the disease outset.
Nutritional and fluid intake can be compromised by gastroparesis (delayed gastric emptying), which has symptoms of early satiety, abdominal discomfort, bloating and nausea. Pfeiffer (2003) suggested the presence of gastroparesis poses a potential hurdle to effective pharmacological treatment of PD as levodopa absorption occurs primarily in the proximal small intestine. Any delay in gastric emptying could result in a delayed response time to medication.
Delay in gastric emptying results in a weakened gastrocolic reflex. The large bowel has a peristaltic action only 5-6 times a day; these movements, known as gastrocolic reflex actions, are triggered by the distension of the stomach, usually occurring immediately after food has been ingested. The most powerful usually occur in the morning after breakfast and can help in the timing of defecation.
Enteric nervous system abnormalities (within the peripheral nervous system) or central nervous system degeneration or a combination of both in PD can lead to prolonged bowel transit time resulting in constipation. Studies indicate that slow bowel transit time is the major cause of decreased stool frequency (Sakakibara et al, 2003). As a result faeces remain in the colon for a prolonged period, leading to considerable water absorption so the stool becomes hard and dry.
Complications of persistent or poorly managed constipation are haemorrhoids, faecal impaction with or without spurious overflow, urinary incontinence, urinary tract infection, rectal bleeding, general weakness and psychological problems.
Faecal impaction describes the condition when constipation has become so severe that a large mass of faeces cannot be passed. These then accumulate in the rectum and may back up in the sigmoid colon and even as far as the transverse and ascending colon. In an attempt to soften hard impacted faeces the bowel produces mucus and this can result in faecal impaction with overflow, known as spurious diarrhoea. Healthcare workers often confuse the overflow caused by faecal impaction with genuine diarrhoea and omit laxatives rather than evaluate laxative therapy.
The appearance of faecal impaction with overflow can be distinguished from diarrhoea because of its high mucus content and small scybala (rounded, hard masses of faeces). It has a characteristic “sweet” offensive smell due to bacterial fermentation. Diarrhoea from intestinal hurry has had minimal bacterial activity and decomposition and therefore it has a sharp, acidic smell and often contains remnants of undigested food.
Constipation is the most important cause of faecal incontinence in frail older people with PD. Faecal impaction with overflow incontinence contributes to older people being moved into care homes (Harari, 2002) and can be a symptom of end stage dementia (Potter and Wagg, 2005).
Posture for defecation
Adopting the correct posture for defecation raises the intra abdominal pressure through contraction of the diaphragm and abdominal muscles. Intra abdominal pressure can be further increased by initiating the Valsalva manoeuvre. This involves inhaling and forcing the diaphragm and chest muscles against a closed glottis to increase both the intra thoracic and intra abdominal pressure and causing pressure in the rectum to rise. At the same time the pressures exerted by the internal and external anal sphincters decrease. This mechanism is important, as rectal pressure must be higher than anal pressure for defecation to be effective. Relaxation of the puborectalis muscle then occurs, which widens and lowers the anorectal angle with perineal descent allowing faeces to pass more easily into the anal canal. Coordination between the abdominal contraction and pelvic floor relaxation is vital to the process of defecation.
Patients with PD have a less pronounced increase in abdominal pressure on coughing and during the Valsalva manoeuvre (Sakakibara et al, 2003) and experience a lack of synergy between the pelvic floor skeletal muscle (puborectalis muscle) and the anal sphincter muscle. The inappropriate contraction of the puborectalis and external sphincter muscles results in excessive straining, sometimes accompanied by pain and often a sense of incomplete evacuation.
Functional incontinence occurs when people are unable to reach the toilet in time due to limited mobility, poor dexterity, difficulty in communicating that they need to use the toilet and poor vision. Functional problems are significant for older people with PD who depend on others to help them with their toileting needs (Harari, 2004). Some may have normal bowel function but delays in going to the toilet will eventually lead to harder stools that are difficult to evacuate, ultimately leading to faecal impaction. Table 1 outlines examples of functional disability.
Over 40% of patients with PD experience depression (National Collaborating Centre for Chronic Conditions, 2006). Evidence is emerging that depression can be considered an intrinsic part of PD rather than a reaction to disability (Allain et al, 2000). Pharmacological treatments for depression in PD are complex with some antidepressants causing agitation and worsening symptoms of the disease (Chen, 2004). The constipating side effect of all antidepressants presents an additional problem. Table 2 outlines these and other causes of iatrogenic constipation caused by pharmacological agents.
Constipation is a significant problem for people with PD but they may be reluctant to discuss their bowel problems. This suggests that healthcare professionals need to adopt a more proactive approach (Kaye et al, 2006). There is a strong argument for using a risk assessment tool for constipation to facilitate clinical decision making by acting as an aide mémoire.
The importance of using a risk assessment tool for constipation is well documented (Royal College of Nursing, 2008; Kyle, 2006; Richmond, 2003). This is endorsed by the Royal College of Physicians (Potter et al, 2002), which stated that the identification of risk factors for constipation in older patients is critical to achieving effective management of constipation. The NICE (2007) guideline on faecal incontinence advocated a proactive approach to bowel care for older, seriously ill patients.
The Norgine risk assessment tool for constipation is a fairly new development (Kyle, 2007a; 2007b). Minimum data exists on its validity or reliability and the absence of any other risk assessment tool for constipation has meant that it cannot be judged against a gold standard. The dynamic nature of the tool suggests it will evolve and change over time with further research. However, anecdotal evidence suggests the tool is raising the profile of constipation among healthcare workers.
PD and associated bowel problems mean that many people live with psychological and physical difficulties that reduce their quality of life. Healthcare professionals should develop a more proactive and evidence based approach to preventing constipation rather than continuing with the existing reactive response to this distressing symptom.
- Free copies of the Norgine risk assessment tool can be obtained from Norgine Pharmaceuticals. Please send your name and address to: Norgine Pharmaceuticals Ltd, Freepost (HA4696), Uxbridge, Middlesex UB9 6BR or email your details to firstname.lastname@example.org
- Click here for The World Health Organization Quality of Life(WHO-QOL)-BREF
Allain H et al (2000) Depression in Parkinson’s Disease. British Medical Journal; 320: 1287-1288.
Chen JJ (2004) Anxiety, depression and psychosis in Parkinson’s disease: unmet needs and treatment challenges. Neurologic Clinics; 22: (suppl 3), S63-S90.
Dennison C et al (2005) The health-related quality of life and economic burden of constipation. Parmacoeconomics; 23: 461-476.
Glia A, Lindberg G (1997) Quality of life in patients with different types of functional constipation. Scandinavian Journal of Gastroenterology; 32: 11, 1083-1089.
Harari D (2004) Bowel care in old age. In: Norton C, Chelvanayagam S (ed) (2004) BowelContinence Nursing. Beaconsfield: Beaconsfield Publishers Ltd.
Harari D (2002) Epidemiology and risk factors for bowel problems in older people. In: Potter JM et al (eds) (2002) Bowel Care in Older People: Research andPractice. London: Royal College of Physicians.
Irvine EJ et al (2002) Health-related quality of life in functional GI disorders: focus on constipation and resource utilisation. American Journal of Gastroenterology; 97: 1986-1993.
Kaye J et al (2006) Excess burden of constipation in Parkinson’s disease: a pilot study. Movement Disorders; 21: 8, 1270-1273.
Kyle G (2007a) Developing a constipation risk assessment tool. Continence UK; 1: 1, 38-45.
Kyle G (2007b) Norgine risk assessment tool for constipation.Nursing Times; 103: 47, 48-9.
Kyle G (2006) Assessment and treatment of older patients with constipation. Nursing Standard; 21: 8, 41-46.
National Collaborating Centre for Chronic Conditions (2006) Parkinson’s Disease: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care. London: Royal College of Physicians.
National Institute for Health and Clinical Excellence(2007) Faecal Incontinence: The Management of Faecal Incontinence in Adults. London: NICE. http://guidance.nice.org.uk/CG49
National Institute for Health and Clinical Excellence(2006) Parkinson’s Disease: Diagnosis and Management in Primary and Secondary Care. London: NICE. http://guidance.nice.org.uk/CG35
Pfeiffer RF (2003) Gastrointestinal dysfunction in Parkinson’s disease. Lancet Neurology; 2: 2, 107-116.
Potter JM et al (2002)Bowel Care in Older People: Research and Practice. London: Royal College of Physicians.
Potter J, Wagg A (2005) Management of bowel problems in older people: an update. Clinical Medicine; 5: 3, 289-295.
Royal College of Nursing (2008) Bowel Care, Including Digital Rectal Examination and Manual Removal of Faeces. London: RCN. [link http://www.nursingtimes.net/Binaries/0-4-1/4-1567634.pdf]
Richmond J (2003) Prevention of constipation through risk management. Nursing Standard; 17: 16, 39-46.
Ross GW et al (2000) Association of coffee and caffeine intake with the risk of Parkinson Disease.Journal of the American Medical Association; 283: 20, 2674-2679.
Sakakibara R et al (2003) Colonic transit time and rectoanal videomanometry in Parkinson’s disease. Journal of Neurology, Neurosurgery and Psychiatry; 74: 268-272.
Ueki A, Otsuka M (2004) Life style risks of Parkinson’s disease: association between decreased water intake and constipation. Journal of Neurology; 251: (Suppl 7), VII/18-VII/23.