Parkinson's, a not very poopy disease.

I have never liked to talk in detail about people's bowel movements. Maybe it is because I was toilet trained by 12 months of age, or maybe because we were a family of 8 with one toilet, and my mother always had right of way. And we did not discuss such subjects as a family – in fact my mother accused me of embarrassing the family doctor by asking him what a bowel movement was! But for the sake of my friends with Parkinson's I steeled myself to explore what is known about constipation in Parkinson's disease. What I discovered, both about bowel function and about Parkinson's disease, made the exploration well worthwhile.

So I will put a clothes pin on my nose and tell you all I have learned about this shitty subject.

Constipation is often the first sign of Parkinson's disease (PD), and a change in bowel habits may closely precede the motor symptoms (that is the body movement problems) of PD. Of course not everybody who is constipated has Parkinson's disease. But PD is one explanation for a change in bowel habits.

What do we call constipation? For regular people it is not having a shit as often as you feel you should. For the medical researcher, who needs a more precise and objective definition, it is:

in at least 12 weeks of the preceding 12 months:

1. 2 or fewer bowel movements per week, or

2. a frequent feeling of not having completed a bowel movement, or

3. frequently having to strain at stool, meaning you have to work hard at it to get it to come out., or

4. feeling of obstruction at the level of the anus (butt hole), or

5. hard stools in more than 1 in 4 evacuations.

Depending on what study you look at, it is estimated that between 20% and 80% of patients with Parkinson's disease (PWP's) are constipated.

There is a tremendous variation in the frequency with which normal (non-Parkinson's) people have bowel movements. Some people it is several times a day, for others only a few times a week. I saw in my children when they were babies an incredible variation in their stool frequency, from the one who was several times a day to the one for whom it once or twice a week and you might have to stabilize the perineum (put your hands around the anus to reinforce it ) to allow them to pass the stool. It depends on diet, on the level of tension in the home, on opportunity, and on toilet training and on genetics. When I was in medical school and went to see my family for holidays I might go the whole week without a bowel movement, then as soon as I was in my apartment and relaxed I just went back to normal.

However in Parkinson's disease it is a whole different ball game. PD is a degenerative disease of the nerve cells, and it affects the nerve cells in the bowel as well as those in the brain.

Here was my first discovery to do with bowel function. (Rather, I did not discover it, I just found out that it was known.) Some of the cells which cause peristalsis in the bowel, have been killed by apparently the same process that caused the Parkinson's disease. Because of the loss of neurons around the bowel, peristalsis, which moves the food around through the bowel and out the end, is impaired.(3) Not only that, but the co-ordination that causes the anal sphincter, the muscle around the anus which keeps it closed, to relax when you push down, loses its co-ordination so you end up pushing against a closed door.[1]

In normal people who are not constipated, it takes about 20 hours for waste material to pass through the colon or large bowel. Excess fluid is removed and the stool becomes firm. But if it stays too long it gets dry and hard, and it may not be easy for bowel peristalsis to move it along. This situation is called impaction. and may require medical intervention. If you have constipation and abdominal pain, it could be due to fecal impaction and you should get yourself to a doctor.

In constipated people without Parkinson's disease it may take 60 hours for stool to pass through the large bowel, but if they are treated with laxatives the transit time returns to a normal time. However with PWP's, almost whatever you do, you can't change the bowel transit time.

What should you do?[4] Once you are in trouble you should consult your doctor. You may need an enema, a suppository, or even manual disimpaction. If you are constipated and have abdominal pain you need to see a doctor right away. Some of my Parkinson's friends have had to go to the hospital on numerous occasions to be manually disimpacted. That is to say: have the stool removed by hand. This is painful and may require a general anaesthetic. The thing to do is to prevent yourself from getting into that state.

1. Fluids: The first thing is to make sure you are getting lots of fluid. For example, make sure you take a full glass of water with each dose of medicine. Unless there is a medical reason you cannot drink large volumes, you should aim for 8 glasses of water or other fluids per day.

2. Fibre: Next, increase the amount of fibre in your diet. The current recommendation() is 20 to 35 grams per day [b]. This is really a lot – you have to take the high fibre option for every thing you eat.

Lets look at how I did today:

Meal	Food	fibre
Breakfast
	All bran 1 cup	6 grams
	1 c milk	0
	apple	1.8
	orange	1
	raisins	0.2
	tea	0
Lunch	lasagne	.5
	salad	.5
Dinner	Bread, whole wheat 2 slices	6
	Tomato and lettuce	.2
	Ice cream pie	0
	Chicken	0
	Nuts, 50 g	8 g
total		24.2 grams

So even though I chose as many high fibre options as I could, I only got to 24 gram, the lower part of the target range.

Note that “all bran” cereal has psyllium added to artificially increase the fibre content (like Metamucil), and that the whole wheat bread and the nuts are the major contributors to the total. It takes real dedication to get the fibre up into this range.

4. Exercise: Get some exercise every day. This will help to keep things moving.

5. Laxatives: It is not recommended to take irritant laxatives such as senna every day. However you can add an osmotic laxative, such as polyethylene glycol (PEG) 3350. (Magnalax and others) An osmotic laxative remains in the bowel and is not absorbed from the digestive tract, and helps the stool to retain water by its osmotic pressure. Lactulose is also an osmotic laxative. PEG by itself has been shown to help with constipation in the elderly in general [4], and in Parkinson's patients although it does not normalize the colonic transit time it has been shown to reduce fecal impaction by keeping the stool soft. It can be taken up to twice a day.

If that is not enough Magnesium or milk of magnesia may be added. (Discuss this with your doctor first – if you have other medical problems like kidney disease this could be dangerous.) Magnesium can be titrated to give the required stool frequency.

If there is still a problem then more draconian measures such as suppositories or enemas . may be needed. These should be discussed with your doctor.

Around Christmas this year my husband decided to please our youngest by buying white bread instead of brown bread. It took a few weeks for me to develop severe constipation, with hard stool which really required pushing to get it out in spite of the fact that I had been taking a stool softener (ducosate 100 mg twice daily) all along.

I realized that I had to find a protocol that I could follow regularly to keep me out of trouble. I have added daily polyethylene glycol (PEG) to my regular medications. One dose every day at bedtime. (To cover the chemical taste I mix it with hot milk and Ovaltine or Horlicks (delicious)). Even that is not enough to keep me going, though there is no more hard stool. Now on the instruction of my doctor I am taking a magnesium tablet (each has about 100 mg elemental magnesium) every day, and that keeps me going. (Actually she told me to take three, but if I take the three I feel like I need to spend the whole day on the toilet.)

No doubt things may get trickier as time goes by. I will have to deal with that then.

Ah! Now I can take that clothes peg off my nose. I just have to figure a way to get everyone around me to stop talking about their shit!

Next: the gastrointestinal theory of Parkinson's disease.

References:

1. Kim, JS, et al, Anorectal dysfunction in Parkinson's disease, J Neuro Sci 310(2011)

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2. uptodate 2015

3.Cersosino M G et al, Pathological correlates of gastrointestinal dysfunction in Parkinson's disease, Neurobiology of Disease 46:559, 2012

4. Cosgrave,M, et al, 'Management of faecal incontinence and constipation in adults with neurological disorders, the Cochrane library, 2014, #1