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Eternal enigma geriatric constipation, glimpse of homeopathic approach

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KNOW Homoeopathy Journal Vol–2 & Issue-2, 18 October 2022, Published at at https://www.knowhomoeopathyjournal.com/2022/10/volume-2-issue-2.html, Pages: 86 to 96, Title: Eternal enigma geriatric constipation, glimpse of homeopathic approach , Authored By: Dr. Mohit A. Nanani (PG Scholar in Department of Practice of Medicine, Rajkot Homoeopathic Medical College, Rajkot, Gujarat, India)

Title: Eternal enigma geriatric constipation, glimpse of homeopathic approach

Authored By:- Dr. Mohit A. Nanani

PG Scholar in Department Of Practice Of Medicine Rajkot Homeopathic medical college, Rajkot, Gujarat, India


Received: 06/05/2022        Accepted: 24/05/2022        Published: 18/10/2022

© 2022 KNOW Homoeopathy Journal https://www.knowhomoeopathyjournal.com/p/copyright-policy.html

How to cite this article:

Nanani M A. Eternal enigma geriatric constipation, glimpse of homeopathic approach. KNOW Homoeopathy Journal, 2022; 2(2):86-96, available at https://www.knowhomoeopathyjournal.com/2022/10/eternal-engima-geriatric-constipation-glimpse-homoeopathic-approach.html


ABSTRACT        

Constipation is the most frequently suffered  by the geriatric age group characterized by infrequent incomplete defecation, lower abdominal fullness, hard stools, excessive straining and similar complaints. Sedentary lifestyle, low fiber diet and low fluid intake amongst the elderly enhance the incidence of constipation. Side effects of drugs and laxatives complicate the situation further. Constipation has become a major problem in elderly people due to various etiological factors also not responding to a conservative treatment, perhaps age related gut motility changes. Homeopathy is a holistic system of medicine based on the law of similia. Homeopathic approach by using Mother Tinctures, potentized drugs and repertory helps in managing constipation in elderly. Diet and Regimen plays an important role in constipation in elderly. Dr Hahnemann gives important indications for diet in regimen which can be applied in management of constipation in elderly. The aim is to enumerate Homeopathic approaches and their indications useful in managing constipation in elderly people.



Keywords: Constipation in elderly, Diet and regimen

INTRODUCTION

Constipation is a disorder of the gastrointestinal tract which is characterized by infrequent stool, difficulty in evacuating stool, abdominal pain, accompanied by straining stool or ineffectual urge.[1] The number of people suffering from constipation increases with age. Elderly people are found to be much more affected  in which female are more prone to be affected with constipation.[2] Indeed, certain factors like genetic predispositions, dietary fiber, medicinal side effects, amount of fluid intake, sedentary life without much mobility, socio-economic status plays important role in pathogenesis of constipation in old age.[1] There is also an important relation of constipation and quality of life of a person who is suffering from constipation.[7] Elderly people mostly take laxatives for avoiding daily disturbances in life due to discomfort but it is having temporary relief. Although after taking such conventional treatment, many people were not satisfied with this temporary relief.[4] They become cautious about being dependent on laxative use in their daily life. There are also certain common side effects of laxatives like diarrhea, abdominal pain, nausea, vomiting, and flatulence.[4] Homeopathy is a holistic system of medicine which is very effective in treatment of constipation. It is prescribed according to the totality of symptoms.[5] It is useful in the long term care of the elderly people suffering from such chronic diseases.[6] The aim of this article is to provide a glimpse of homeopathic medicines, some rare useful mother tinctures and repertorial approach, which are useful in treating constipation in elderly.


PREVALENCE AND ETIOLOGICAL  FACTORS

The frequency of constipation all over the world on an average is 16% in which 33.5% were found to be in the old age group (60-110 years of age). Also females are more affected than male.[1][2][3] The elderly due to tooth loss or loose teeth  find difficulty in chewing, due to which patients take soft food. Anorexia, loss of interest in food and difficulty in swallowing lead to low fiber diet.[1] There is an important role of dietary fiber in giving bulk and volume to the faeces.[9] Pelvic floor dyssynergia, rectal prolapse, rectocele are frequently seen in the old age group which lead to constipation.[8]


TYPES OF CONSTIPATION

There are mainly two types of constipation we need to evaluate in any patient

1.      Organic or mechanical constipation

2.      Functional constipation

1. Organic constipation is due to mechanical obstruction of lumen of intestine due to following  causes:[10]

       Adhesions

       Intussusception

       Sigmoid volvulus

       Tumor

       Hernia

       Diverticulosis

2. Functional constipation is caused due to any of the functional disturbances other than anatomical etiology, causes of which are as follows:

       Simple  colono-stasis: Mainly occurs due to poor dietary habits, sedentary lifestyle with lack of physical exercise.[11]

       Neurogenic constipation: Occurs due to decreased sensitivity of rectal receptors in response to stretching  in old age and causes accumulation of feces in rectum without any urge. Also disorders of the lumbo-sacral part of the back in the spinal cord  can cause constipation in old age. In some cases motor dysfunction of vagus nerve or intramural nerve fibers supplying large intestine can cause constipation.[11]

       Muscular constipation: Muscles of the body like diaphragm, abdominal wall muscles, intestinal wall muscles, muscles contracting anus plays an important role in defecation.Weakness of muscles due to age or any systemic disorders like Scleroderma or Chagas disease can lead to constipation in old age.[11]

       Psychological constipation: some disorders like depression, anorexia nervosa, schizophrenia are seen in elderly people. The urge for defecation is ignored due to such disorders in old age.[11]

       Metabolic or endocrine constipation: The GI motor dysfunction leading to sluggishness of intestinal motility and transit time can be caused by thyroid disorders mainly hypothyroidism or myxedema.[12] Also in cases of hypercalcemia, secondary to hyperparathyroidism, constipation is the common symptom. Constipation is also commonly seen in diabetic patients.[13]


PATHOPHYSIOLOGY

The above mentioned etiological factors can be divided into primary and secondary causes of constipation. The primary causes consist of disturbances in colonic motility and functional defecation. It includes constipation without delayed colonic transit, constipation with delayed colonic transit and functional defecation disorders like puborectal or recto-anal dyssynergia. The secondary causes for constipation includes effects of medications, psychological disorders, metabolic disorders, systemic disorders, or neurological disorders.[14][15]

The patient is first examined and evaluated for any surgical organic or mechanical causes including secondary causes of constipation, and then primary causes come into picture.

1.      Constipation without delayed colonic transit: The word ‘transit’ means the ‘act of passing’, i.e. the process of passing stool from the colon. Constipation without delay means frequency of stool is  normal and there is no problem in passing stool across the colon but there is hard stool. Sometimes, the patient may complain of abdominal discomfort and / or psycho - social stress. Thus, this can be also called functional constipation. Treatment with laxatives and a high fiber diet is favorable in such circumstances. [16]

2.      Constipation with delayed colonic transit: Delayed colonic transit suggests colonic stasis which leads to infrequency of stool (less than once a week), abdominal heaviness and bloating. The cause is either neurological or muscular in origin.[16]

3.      The interstitial cells of cajal are the cells present in the muscular layer of the wall of the intestine which mediates neurotransmission as slow wave contraction of smooth muscles of intestine.[17] Thus, decrease in the number of these cells due to old age, or any systemic disorder can lead to delayed colonic transit.[16]

4.      Functional defecation disorder: The muscles of the pelvic floor i.e. puborectalis muscle and anal sphincters play a significant role in physiological process of defecation. Dyssynergia and incoordination of these muscles can lead to constipation. In such cases, high stimulation of laxative doses also fails and can cause hemorrhoids due to excessive straining.[16]


DIAGNOSIS

The clinical presentation and proper history taking is an important aid in evaluating any case of constipation. It helps to eliminate alarming signs of mechanical or organic causes and also malignant causes.

       Sometimes unexpected weight loss, other gastrointestinal complaints like nausea, vomiting, abdominal discomfort is accompanied with constipation.[18]

       Some neurological disorders like Parkinson's disease should also be evaluated which can also be responsible for constipation.

       What medications a patient is taking also has an effect on constipation. For example, opiates, anti-hypertensives like calcium channel blockers,  or antidepressants.

       For the diseases like hypercalcemia, hypothyroidism, any inflammatory disease laboratory investigations are useful for tracing the cause of constipation.

       Digital rectal examination and anorectal manometry are useful diagnostic procedures for assessing dyssynergia of pelvic floor muscles.[18]

       To assess the colorectal cancer colonoscopy can be done only if alarming signs are presented clinically.[18]

Bristol stool chart helps to identify the stool for constipation in a much easier way for both patients and physicians. Bristol stool type 1, 2 mostly indicates constipation.[18]

 

Cabot Health, Bristol Stool Chart, CC BY-SA 3.0, via Wikimedia Commons


Rome IV Criteria For Functional Constipation [19]

According to Rome IV Criteria, a patient should be suffering from constipation since the last 3 months with symptom onset at least 6 months prior to diagnosis. Criteria for opioid-induced constipation (OIC) should be distinguished from the criteria for functional constipation because their symptoms do overlap with each other.

1.      Must include two or more of the following:

2.      Straining during more than ¼ (25%) of defecations

3.      Lumpy or hard stools (Bristol Stool Form Scale 1-2) more than ¼ (25%) of defecations

4.      Sensation of incomplete evacuation more than ¼ (25%) of defecations

5.      Sensation of anorectal obstruction/blockage more than ¼ (25%) of defecations

6.      Manual maneuvers to facilitate more than ¼ (25%) of defecations (e.g., digital evacuation, support of the pelvic floor)

7.      Fewer than three SBM per week

8.      Loose stools are rarely present without the use of laxatives

9.      Insufficient criteria for irritable bowel syndrome


HOMEOPATHIC MANAGEMENT

Homeopathic system of medicine is very effective in improving bowel movement and can be helpful in cases of constipation in elderly people. After evaluating the various alarming etiologies for constipation, homeopathic medicine can be used for long term care of chronic constipation patients of old age. Along with the medications,there is an important role of diet and regimen in managing constipation in elderly according to Dr Hahnemann.[20] In aphorism 259, Dr Hahnemann advises for careful investigation for any obstacle to cure in chronic diseases that are present due to errors in Diet and Regimen of patient, and remove it. Also in 261 Aphorism, Dr Hahnemann gives an idea about the most appropriate regimen, removal of obstacles for cure and ‘supply where necessary’.[20]

Thus removal of obstacles includes lifestyle modifications, which includes sedentary lifestyle with lack of exercise. Also supply of dietary fiber and plenty of liquids play an important role in preventing constipation in elderly.[21]

Some rare and  useful mother tinctures which can be used  for constipation in old age are as follows:

1)Cascara sagrada Q: Is a sacred bark, acts wonderfully as a tonic for constipation when used in material doses. There is muscular rheumatism of extremities  along with constipation.Dr John Henry Clarke mentioned it as a well known purgative due to its tonic effects on gastrointestinal tract in cases of chronic rheumatism with constipation. Hemorrhoids, abdominal colic and vomiting are some of its associated symptoms with constipation.[22][23]

2)  Senna Q:It acts as a tonic for cases of  constipation with flatulent colic. There is muscular weakness, accumulation of nitrogenous waste in the body with a broken down system. Stools are hard, tender,dark with burning in rectum.There are insufficient, incomplete, and unsatisfactory stools.[22]

3) Hydrastis Q:Mainly used in old age, when enema fails to act. Constipation which rumbling in the abdomen and gets aggravated after cathartics is the most useful medicine. ‘Goneness’ feeling in abdomen, no desire for stool, dull headache is found along with constipation.[23]

4)Cascarilla Q:  Cascarilla is a useful drug for constipation with a hard stool covered with mucus. Diarrhea alternating with hard, lumpy stool preceded by griping pain is seen. Nausea, vomiting along with constipation is also marked.[22]

  The most common indicated homeopathic medicines useful for constipation in elderly are as follows:

1.Alumina: Mainly used in old age with great debility and lack of vital heat. Old people with an inactive rectum, even soft stools pass with difficulty. There is painful urging long before the stool. Great straining is required for passing the stool.[22]

2.Antim crud: Diarrhea alternating with constipation especially of old people, aggravated by overeating.acids and baths. Usually such people have a tendency to grow fat. Thick white coating of the tongue is the keynote of this drug. Also painlessness, where it could be expected, is a marked feature found in this medicine.[22]

3.Nux vomica: Constipation with irregular peristaltic action leading to ineffectual urge. Constriction of rectum with frequent ineffectual desire. Absence of desire to pass stool is contraindication of nux vomica. Alternate diarrhea and constipation after abuse of purgative, it is a very useful drug.[22

Opium: There is obstinate constipation with inactivity of intestines.There is spasmodic retention of feces in the intestine.The stools are composed of  hard, round,black balls with offensiveness. Hard and distended abdomen with no power to expel. The cases where the strongest purgatives failed.[22]

4.    Phytolacca: Constipation of old age with weak heart is a keynote. There is burning and griping pain in the abdomen. Bruised feeling in the epigastric region along with the constipation. Bleeding per rectum. Patient says bowels will not move without purgatives. Fullness of abdomen before stool.[22]]

5.    Selenium: Selenium metallicum is mainly useful in old age with great mental and physical debility. Debility after exhaustive diseases.Constipation with large stools accumulated in rectum. There is a desire for brandy and other strong drinks.[22]

Some useful rubrics most commonly used in clinical practice for constipation in elderly are as follows:[24]

1. Rectum; constipation; old people: aloe ALUM(3) alumn ambr ANT-C(4) ANT-S(3) ant-t arn BAR-C(3) BRY(3) calc calc-f CALC-P(3) CON(3) cycl ferr graph hep HYDR(3) ign KALI-M(3) LACH(3) lyc mag-m nat-m nit-ac NUX-V(3) nyct OP(4) PHOS(3) PHYT(3) PODO(3) PSOR(3) rhus-t ruta SEL(3) sep sil sil-mar SULPH(3) thuj vanad.

2. Rectum; constipation; peristaltic action, from irregular: NUX-V(4) SEL(3).

3. Rectum; constipation; prolapse, in: AESC(3) alum am-c AUR(3) bry COLL(3) ferr IGN(3) lyc med podo ruta sep sil stann sulph.

4. Rectum; constipation; drugs, purgatives, laxantia, after abuse of: agar aloe ant-c BRY(3) camph CHIN(3) coll COLOC(4) euph-l hep HYDR(3) lach(2) lyc m-aust nat-m NUX-V(4) OP(4) rham-f(2) ruta sel sep sil(2) sulph tarent thuj.

5. Rectum; constipation; sedentary habits agg.: aloe ALUM(3) AMBR(3) BRY(3) hydr iris LYC(3) NUX-V(4) OP(3) PLAT(4) PODO(3) SEP(3) SULPH(3).

6. Rectum; constipation; spinal cord complaints, in: alum arg-n caust nux-v phos PLB(3) sil sulph.

7. Rectum; constipation; stasis, from portal: absin AESC(4) aesc-g ALOE(3) card-m coll CROC(3) elaps fl-ac ham hep KALI-BI(3) KALI-M(3) lsd merc NUX-V(4) podo sep SULPH(4).

8. Rectum; constipation; stool; after; cathartics, induced only with: aur-m-n bar-m COLL(4) graph nux-v plb.

9. Rectum; constipation; urging; absent; accumulation of stool, until large: alum ANAC(3) BRY(3) meli NAT-M(3) OP(3) SANIC(3) SULPH(3).

10.  Rectum; constipation; urging; absent; accumulation of stool, until large: alum ANAC(3) BRY(3) meli NAT-M(3) OP(3) SANIC(3) SULPH(3).


CONCLUSION

Thus constipation is a ubiquitous malady  in elderly. Lifestyle and a low fiber diet plays an important role in it. The use of laxatives  and other medicinal side effects are found to be unfavorable after some extent. The Homeopathic system of Medicine provides many useful drugs and a repertorial approach, along with alterations in Diet and Regimen that can be useful in Managing Constipation in elderly.


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19. Appendix A:Rome IV Diagnostic criteria for FGIDs;C2 bowel Disorders;Functional constipation,Available from: https://theromefoundation.org/rome-iv/rome-iv-criteria/ 

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21.  U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2015–2020. 9th Ed. Published December 2020. Accessed July 15, 2021. www.dietaryguidelines.gov

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24.  Complete Repertory- Complete Dynamics



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