Intended for healthcare professionals

Practice Easily missed?

Constipation in people with learning disability

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c222 (Published 26 January 2010) Cite this as: BMJ 2010;340:c222
  1. Justin Coleman, senior general practitioner1,
  2. Geoffrey Spurling, senior lecturer2
  1. 1Inala Indigenous Health, 64 Wirraway Parade, Inala, QLD 4077, Australia
  2. 2Discipline for General Practice, Inala Indigenous Health
  1. Correspondence to: J Coleman colross{at}tpg.com.au

    Case scenario

    A 48 year old woman with mild intellectual impairment and epilepsy (for which she takes phenytoin) presented with left sided abdominal pain. She had mentioned this before but had denied constipation or diarrhoea. We found an archived radiograph showing moderate faecal loading. When pressed, she admitted not knowing what “constipation” meant and, in fact, had been manually evacuating but was too ashamed to tell anyone.

    Chronic constipation is surprisingly common in people with learning disability. Communication difficulties, the vagueness of the symptoms, and the presence of other priorities often mean that carers and clinicians miss looking for this problem.1

    How common is it?

    • In a randomly selected institutionalised adult population of 215 people with learning disability (IQ <50), 149 cases (69.3%) had constipation2

    • In children with severe disabilities, estimates of the prevalence of constipation vary from 26% to more than 50%3

    • People with learning disability are more likely to be taking drugs that are associated with constipation, such as anticonvulsants, benzodiazepines,2 and antipsychotics

    • Other factors associated with constipation in people with learning disability include reduced physical mobility and refusal to eat2

    • Some causes of learning disability, whether inherited (such as Down’s syndrome) or acquired (such as cerebral palsy), are strongly associated with constipation. In one study, 74% of children at a cerebral palsy outpatients clinic had chronic constipation.4 In comparison, a Canadian study of the general adult population showed a prevalence of around 15%5

    Why is it missed?

    The usual trigger for doctors to consider this diagnosis is the specific mention of constipation by the patient, or the communicated history of an abdominal symptom. Patients with learning disability may be unable to communicate these, to either their doctor or carer. In addition to more intuitive presentations such as overflow diarrhoea or urinary incontinence, pain from constipation may present as distress, sleep disturbance, or behavioural changes, including self harm.6 According to expert opinion, recognition of constipation in children with disability is commonly delayed, with symptoms often present for months or years beforehand.7 In a retrospective cohort of hospital deaths caused by intestinal obstruction, people with learning disability and constipation presented late and with minimal signs and symptoms.8

    Why does it matter?

    In patients who are less able to indicate the site of pain, or perhaps the very existence of pain, it is important to consider this very treatable cause of unnecessary suffering. Chronic constipation is also associated with urinary and faecal incontinence (further increasing the risk of social stigma), chronic nausea, rectal prolapse, anal fissures, haemorrhoids, the need for manual evacuation, and hospital admission for faecal impaction.3

    When people with learning disability were asked to rate their health problems, those listing constipation were more likely to have their health rated as poor.9 Learning disability predicted fatal intestinal obstruction, and chronic constipation was a risk factor for this in one hospital based study.8

    How is it diagnosed?

    Clinical features

    Actively consider constipation as a diagnosis in patients with learning disability. A focused history from the patient or carer regarding bowel habit (including faecal overflow) and abdominal pain is required, with careful attention to ensuring that the patient understands. We suggest that constipation be specifically considered during all learning disability checks as part of directed enhanced services in the United Kingdom.10 Faeces may be palpable on abdominal examination, and rectal examination may show impacted faeces or rectal complications such as fissures or prolapse.

    Investigations

    Abdominal radiography, although usually unnecessary in the general population, is often confirmatory and can be a useful investigation in people with learning disability.7

    How is it managed?

    Management principles include emptying the bowel and maintaining soft, lubricated stools in the long term (months, or even years if necessary). A small randomised controlled trial in neurologically impaired children showed that increasing dietary fibre significantly increases stool frequency and reduces painful defecation.11 Effective agents include polyethylene glycol (which provides benefit over long periods for chronic constipation, including faecal impaction),12 psyllium, and lactulose (on the basis of a systematic review of 20 commonly used agents).13 Rectal suppositories or enemas are necessary only occasionally and should be considered a last resort in children.14 Three before and after studies recommend regular toileting and behavioural treatments including rectal sensory biofeedback during defecation and psychological support,12 which may be especially important in people with learning disability. If available, health promotional materials with pictures and simple language are particularly helpful for those with learning disability.15

    Key points

    • People with learning disability are prone to constipation, often because of medication, reduced mobility, or refusal to eat

    • They may not communicate the typical symptoms to doctors and carers and sometimes present with apparently unrelated behavioural change; untreated constipation may cause unnecessary problems and occasionally even death

    • Doctors should actively consider and exclude the diagnosis of constipation in people with learning disability using history, abdominal examination, and, where necessary, abdominal radiography

    • Although ideally treatment should include increasing dietary fibre, laxatives are usually needed, sometimes for long periods

    Notes

    Cite this as: BMJ 2010;340:c222

    Footnotes

    • This is a series of occasional articles highlighting conditions that may be commoner than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, university lecturer in general practice, Department of Primary Health Care, University of Oxford, and Richard Lehman, general practitioner, Banbury. If you would like to suggest a topic for this series please email us (easilymissed.bmj{at}bmjgroup.com)

    • Contributors: JC wrote the larger portion of the manuscript and is guarantor. GS first suggested the article, helped write the initial draft, and helped at every stage of the rewriting and editing.

    • Funding: No special funding.

    • All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Not commissioned; externally peer reviewed.

    • Patient consent obtained.

    References

    View Abstract