By Amy M. Collins, associate editor
Last October, I wrote a blog post about my grandmother, who is 85 and suffering from the first stages of Alzheimer’s disease, and about the failure of many providers to assess and treat the underlying cause of a sudden and extreme acceleration of her dementia symptoms (mania, agitation, and violence, along with nonstop, nonsensical talking).
The post generated a slew of comments on both the blog and Facebook, with over 20 nurses suggesting the probable cause for her symptoms to be fecal impaction or urinary tract infection. They were right. But several physicians and specialists had been shockingly wrong, diagnosing her with everything from closet alcoholism to VERY-late-onset bipolar disorder.
My grandmother did, in fact, have a severe fecal impaction, finally diagnosed—after several weeks of family turmoil—by a nurse in an ED. She was treated, and within a few weeks her symptoms slowly dissipated. I’m happy to say that she’s now back to her sweet and gentle self, with no memory of the episodes she herself would have deemed crazy.
Although her Alzheimer’s symptoms are still heartbreaking (she recently introduced me to a fellow assisted-living resident as her ‘special friend’ instead of her granddaughter), she isn’t agitated, hallucinating, accusing people of stealing, or showing other signs of the previous mania. At a recent family visit, she spoke of her plans to attend a luau at her facility, and requested a grass skirt!
Chronic constipation in the elderly isn’t a rare occurrence, especially in patients with dementia, but unfortunately the outcome may not always be as favorable as in the case of my grandmother. Our August CE by Leah Craft and Joseph A. Prahlow, “From Fecal Impaction to Colon Perforation,” describes the case of a woman in her 70s, nonverbal and suffering from Alzheimer’s disease, who developed a fecal impaction and eventually died.
Although the woman had trouble communicating, for several days she moaned and pointed to her back—but wasn’t brought to the hospital right away. Even after she was hospitalized, and despite interventions, subsequent stercoral perforation of the sigmoid colon resulted in peritonitis, sepsis, and death. The authors suggest that the patient might still be alive if the changes in her behavior had been recognized as signs of pain and if constipation had been considered.
According to the article, people with cognitive impairment have an increased risk of constipation, fecal impaction, and stercoral perforation. Immobility, a decreased awareness of thirst, and difficulty in communicating pain and discomfort can all contribute.
In my grandmother’s case, her worsening short-term memory loss makes it hard for her to remember what time of day it is, whether or not she’s eaten, and whether or not she’s used the bathroom. To prevent her experience from repeating itself, the caregivers at her facility have now added a stool softener as part of her daily care plan.
Considering the parallels to my own personal experience, the case in the article truly touched me. And I’ll always be grateful to the nurse who correctly diagnosed my grandmother’s problem before it was too late. With people living longer and the likelihood of cognitive impairment or dementia increasing with age, all health care providers should be aware of the risk of fecal impaction and its potentially deleterious outcome. The August CE provides excellent information on fecal impaction and the added challenge of dementia, ways to avoid colon perforation, and the nurse’s role in managing constipation in the elderly.