Bowel woes can be treated easily, but some do not seek help. Lea Wee reports
For two years until last year, the social lives of Mr Tan (not his real name) and his wife were ruled by his bowel habits. Mr Tan, who is in his early 70s, had been having constipation since he was diagnosed with Parkinson’s disease in 2009. He used to be so afraid of the excruciating pain of blocked bowels that he would spend one to two hours in the bathroom throughout the day, trying to defaecate. He avoided going out because of the pain. His wife, too, stopped going out to meet friends as she did not want to leave him alone at home. Another Parkinson’s disease sufferer, Mr C. E. Fung, 75, also said he did not feel like going out because constipation gave him an uncomfortable feeling in his lower abdomen. He said: “It also made my bowel press on my bladder, making me feel like going to the loo all the time.”
Overseas data shows that at least one in two patients with Parkinson’s disease experiences constipation, said Dr Tay Kay Yaw, a consultant at the Department of Neurology at the National Neuroscience Institute. The prevalence of chronic constipation in the general population is about one in four. About three in every 1,000 people above the age of 50 have Parkinson’s disease. The total number of sufferers is expected to grow with an ageing population. Parkinson’s disease is a neurodegenerative disorder that often leads to tremors and problems with balance, walking and coordination. It can affect nerve cells in the gut. This slows down the normal movement of the gut, which explains why patients with Parkinson’s disease are more prone to constipation, said Dr Tay. Chronic constipation is generally defined as the presence of either straining and hard stool or a defaecation frequency of less than three times a week for at least a quarter of the time over several months.
But it is easy to overlook the problem of constipation in Parkinson’s disease because patients and medical staff tend to focus more on visible problems such as tremors, said Ms Jessie Tan, a nurse clinician (continence) at Khoo Teck Puat Hospital. She said: “Many patients also do not know there is a link between Parkinson’s disease and constipation and think constipation is caused by ageing.” By the time they turn up at the continence clinic, they often would not have passed motion for more than a week. She said: “The whole of their large bowel would be packed with hard stool and they would be in considerable pain and discomfort.” Nurses often have to clear the large bowel manually with their gloved fingers, a procedure which can take about a hour. If left untreated, chronic constipation can have a big impact on a patient’s quality of life, said Dr Tay. It can cause stomachache, bloatedness, poor appetite and even what is called a toxic megacolon, in which the gut becomes dilated and emergency surgery may be needed. Dr Tay said chronic constipation in Parkinson’s patients can also slow down the movement of food out of the stomach. This, in turn, slows down the absorption of medication for Parkinson’s disease, such as levodopa, and reduces its efficacy in treating the motor symptoms of the condition.
The good news is that chronic constipation is as treatable in Parkinson’s patients as it is for the general population, said Dr Tay. The doctor may prescribe laxatives, such as macrogol and lactulose, to soften the stool and stool bulking agents, such as senna, to better control the stools. As the lack of exercise and fluid can aggravate the condition, it is important for Parkinson’s patients to exercise regularly – at least four to five times a week for 40 minutes each time – and to drink at least 1.5 litres of water a day. Patients who experience tremors in their hands may find it difficult to drink fluid without spilling it, but this should not stop them from doing it, said Ms Tan. She said: “Without drinking adequate water, bran, a type of insoluble fibre, bulks up and hardens the stool, which makes the constipation worse.”
Having a balanced diet, with two servings of fruit and vegetables to provide enough soluble fibre and adequate fluid, can create soft stool which is easier to pass out, said Ms Tan. But these measures will not be enough to solve all constipation problems, especially for Parkinson’s patients, she added. The disease can affect the bowel, anal and pelvic floor muscles, so that patients cannot coordinate these muscles properly to push out the stools. Patients may need to learn pelvic floor exercises to retrain their muscles to contract and relax at the right time while defaecating. The tremors can also cause the patients’ legs to shake while they are sitting on the toilet bowl, making it difficult for them to maintain a downward pressure in their abdomens while defaecating.
To increase the abdominal pressure, patients can learn the brace technique, in which they place their feet flat on the ground or on a small stool, rest their forearms on their thighs and keep their mouths closed. Eager to put an end to his pain, Mr Tan has been following all these tips since last year. He now spends only 15 minutes in the toilet every morning after breakfast. Mr Fung, too, sought medical help and was given a rectal laxative, which he inserts every three days. He also does exercises, such as yoga and qigong, a few times a week. He said: “Now, I am not afraid to go out of the house.”