Advice and resources : Constipation in people with a learning disability

Constipation is when you can't poo.

It’s a common problem that affects people of all ages.

People with a learning disability are more likely to have constipation. 

Communication problems can mean it is difficult for the people who support them to spot it and get treatment.

Untreated constipation can lead to life-threatening complications if it is not treated. It’s important to be aware of the signs and symptoms, and how to prevent and treat it.

Time to contact their GP

If you’ve spotted one or more of the signs of constipation, you should contact the GP.

When you call the GP, make sure the receptionist knows you're calling about constipation for a person with a learning disability.

What causes constipation?

People with a learning disability can get constipated for the same reasons as anyone else, but they are at a higher risk.

Common causes include:

• poor diet, by not eating or drinks the right things
• lack of movement and exercise, which can slow digestion
• side effects of medications, like some antipsychotics, antidepressants, and anticonvulsants
• feeling anxious or depressed, as mental health issues can affect digestion

Some conditions linked to learning disabilities, such as Down’s syndrome or cerebral palsy, also put a person at higher risk of constipation, as well as common conditions like hypothyroidism, depression, and diabetes.

Environmental factors that can increase the likelihood of constipation include:

• not having the right toilet facilities
• no privacy 
• changes in daily routine or care
• ignoring the urge to go to the toilet

Impact of constipation

Constipation might not seem like a big deal, and it's usually easy to treat if you catch it early.

If it's left untreated, it can lead to more serious problems. In severe and rare cases, long-term constipation can be fatal.

Symptoms of serious constipation

People with serious constipation may have symptoms such as: 

• strong tummy (abdominal) pain
• cramps
• bloating
• rectal bleeding, caused by small tears in the anus (anal fissures), swollen veins in the rectum (haemorrhoids), or the rectum slipping out of place (rectal prolapse)
• loss of appetite
• nausea
• overflow diarrhoea, when when loose poo leaks around a blockage
• faecal impaction, which is a hard mass of poo stuck in the rectum
• faecal vomiting, which is vomiting due to a severe blockage
• twisting of the bowel, which can lead to a lack of blood flow (ischaemia) and a severe infection (septicaemia)

Symptoms of constipation can be missed in people with a learning disability, as some assume they could be caused by their behaviour.

It's important to consider physical problems like constipation if someone suddenly behaves in unusual ways or acts differently.

Chronic constipation can also seriously affect a person's mental health and quality of life. because of embarrassment, social isolation, and anxiety.

Research shows a link between chronic constipation and behavioural problems, including self-harm in people with a learning disability.

Tips to avoid constipation

We understand that you may often feel helpless when the person they care for has chronic constipation. There are practical steps you can take to help them. 

It might take some time, but you there are changes to daily life that you can take to help a person with a learning disability improve their bowel habits and reduce or even remove the need for laxatives.

Healthy eating and drinking 

Constipation is mainly caused by a lack of fibre, dehydration, and inactivity, so lifestyle changes around food and drink are often needed.

People with a learning disability in supported communities often have poor diets with not enough fruit and vegetables.

Simple dietary changes can increase fibre intake, but it's recommended to do this gradually to avoid bloating and gas.

A balanced diet should include:

• whole grains
• fruits
• vegetables
• pulses

Adults should aim for 18 to 30g of fibre per day.

Someone with constipation needs to drink 50 to 60ml of fluid like water per day, for every kilogram they weigh.

People who breathe through their mouth, sweat a lot, or drool may need more.

Foods like soups and yoghurts can also add to fluid intake. When not constipated, adults should drink 6 to 8 glasses of fluid a day.

Exercise

Lack of exercise slows down the natural movement of poo in the bowel, leading to constipation.

Adults with learning disabilities often have low activity levels compared to others, so think about physical activity which can help that person use their abdominal muscles work.

Toilet

You can make small changes so that the person feels comfortable and confident, such as:

• making sure the bathroom is clean, warm, and well ventilated
• giving them privacy, but let them know you can help
• removing distractions
• feeling well-balanced on the toilet seat

Sitting correctly can also help.

The right position is with your knees higher than your hips, leaning forwards with elbows on your knees, pushing out your abdomen, and keeping your back straight.

To help, you could:

• use the right toilet seating, by asking physiotherapists or occupational therapists for help
• use a footstool, so that they can use their feet for balance and push with their stomach muscles

Toilet routine

Bowel habit retraining can also help.

You can make sure they sit on the toilet first thing in the morning, after a warm drink, or about 30 minutes after eating a meal.

Follow this every time, to create a regular routine.

Encourage them to sit on the toilet for 10 minutes and reward them if they open their bowels during this time.

It's important that an individual can respond immediately to the sensation of needing to open their bowels, so people with mobility problems should have help to get to the toilet when they need it.

Physical health and medication review

It's important to check for health conditions that can cause constipation, like depression and thyroid deficiency.

These are usually treatable but can come on slowly and unnoticed.

People with a learning disability are more likely to take medications that cause constipation.

They should be on the least amount of medication needed to manage their condition. 

Any constipating medication should be adjusted, if possible.

Monitoring

You can keep track of the changes you've made, to see if they're working.

You can use a poo chart or diary to see how well the plan is working, and if you notice any issues that you need to speak to a GP about.

For example, more fibre in a diet can sometimes cause bloating but no improvement in bowel movements.

Waist measurements may be needed to monitor bloating where there are real concerns.

Monitoring is only useful if appropriate action is taken in response. There should be clear guidance on what action to take if concerns are identified.

Laxatives

Laxatives may be prescribed to help with lifestyle changes, or if the changes aren't quite working.

They can help manage constipation in the short term, but they shouldn't be used every single time.

Some laxatives can be habit-forming, meaning the bowel may start to depend on them, making the problem worse.

Using laxatives for too long, or too many times can cause issues such as:

• diarrhoea
• dehydration, which can lead to heart problems, kidney damage, and muscle issues
• dependency and rebound effects, which can make constipation worse
• carcinogenic (cancer-causing) effects in the long-term

Laxatives can become less effective over time. For many people with a learning disability, this leads to an additional type of laxative being prescribed.

Alternatives

There is some evidence which suggests people with a learning disability can be over reliant on laxatives.

If long-term use of laxatives is needed, other non-pharmacological approaches should always be considered.

Sessions using muscular training, abdominal massage, and diaphragmatic breathing together with laxatives have been shown to be more effective for chronic constipation.

Resources

NHS England

Visit the NHS England website to download help guides.

• Are you worried about your poo? (Easy read leaflet)
• Trouble pooing (constipation) – tips for healthy pooing (Easy read leaflet)
• Let’s talk about constipation (Leaflet for carers)
• Poo matters (Information for families and carers)