I have long had a ‘thing’ about the unnecessary use of laxatives. Its time to stop assuming these are a necessary fact of life for those with profound and complex needs.
Chances are that if you support people with severe learning disability, you administered one of these today – Lactulose, Senokot, Movicol: the inevitable sticky syrup or fiddly sachet that features in the majority of prescribing. Because as we all know, people with learning disabilities usually need help to poo.
I apologise if the last sentence was offensive to the squeamish but I should really be apologising for its inaccuracy. You see, having a learning disability ought not to render you incapable of having healthy and regular bowel movements without resorting to medication.
So why is this such a common treatment in this client group?
To maintain a healthy toilet habit, your body needs to be functioning efficiently and dealing with the food you eat. The food needs to be fibrous and you need to be hydrated. It helps a lot if you are also physically active as this increases bowel function; good old gravity helps things move along. You should be avoiding things that bind you up (coffee, sugary cakes and biscuits, cheese, eggs, fizzy pop) and substituting them with wholegrains, fruit and vegetables, beans and pulses and lots of water.
Now read that paragraph again and think about the lifestyles of people with complex needs that you know. Would you say this describes their average diet and lifestyle options? Probably not.
Drink more
It is a fact that sufficient fluid intake is the most important element in avoiding constipation. A constipated person requires between 50 and 60ml of fluid per kg body weight per day. Based on the average adult male weight of around 80kg, that’s a fluid intake of 4 litres a day. How many of your service users drink that much water?
Diet and exercise
Now think about diet. For those with enlightened carers or who can manage a varied and interesting menu, this is less of a problem. But think about the diet of those with very severe disability; PEG feeds are milk based; soft diets are often based on mashed potato, sauces and gravies. Although mashed vegetables do get a look in, it tends to be less leafy and more root veg, as this is easier to puree.
Findings suggest that less than 10% of adults with learning disabilities in supported accommodation have sufficient intake of fruit and vegetables, and carers generally have poor knowledge of health and nutrition.
When it comes to being active and mobile, this client group is again disadvantaged. The lack of movement, recumbent posture and inability to use the toilet all contribute to the reduction in muscle movement of the bowel, resulting in sluggish and inactive digestive systems. Privacy, time and no interruptions lead to better outcomes for moving the bowel. Imagine having to ‘go’ with an audience – not ideal! Yet we often expect service users to do that as we linger in the bathroom.
Other reasons
There is of course a list of other factors that can lead to constipation in those with profound learning disability. Medication regimes can have side effects that cause this problem. Physical features where the body is immobile or contorted can interfere with the natural transit of food waste. Routines, if disrupted, can lead to reluctance to go to the toilet. So can changes in staff and regime.
In the Winterbourne View report, it was said that constipation was ‘rife and poorly managed.’ The most common medications in use in care establishments are laxatives, and the most common co-morbidity is constipation. What this says, is that medicating people is not working.
So next time you reach for the sticky bottles, have a bit of a rethink. Ask yourself if there are viable alternatives that can be tried; get some advice from a dietitian, talk to the OT or physiotherapist about positioning and using the toilet rather than continence pads with service users. Up the fluid intake across the board. It is not a given that laxatives are a necessary part of caring for those with profound disabilities. It’s a feature, but one we can try to challenge.
Ginny Tyler – QCS Expert Learning Disabilities Contributor
