January

Senna Pods: an old remedy for a common problem

In January I tend to reflect on the past year and remember my patients and the problems we went through together. I treat hundreds of patients, so I will not pretend that I remember them all. At times I find myself in situations when my patients or their loved ones approach me outside hospital, telling how much better they feel. I smile, I ask them to pass on my regards, and I am genuinely happy that someone is feeling good, whether a patient or not.

However some patients will stay in my memory forever. Sometimes it is their personality, sometimes they have to stay in hospital for so long that we become very close, but mostly it is because of the nature of their medical problems. Take Rita for example....

Rita, a 92-year-old lady, was admitted in September 2014 with confusion, hallucinations and worsening ability to walk: in the previous 24 hours she had become bedbound. Her daughter Suzan told me that her mother, despite her age, was very fit and independently mobile with the use of just one stick, and her symptoms developed over the course of 7 days and were getting worse. She was worried that her mother had had a stroke.

Rita underwent a full physical examination and a number of medical tests, including a brain scan. As many diseases in older people have unusual presentations (for example urine infections in younger patients will cause frequency and burning on passing water; in older patients they might cause a fall or confusion) it is important to consider several diagnoses. Rita had a slightly tender abdomen and her tests all came back within normal parameters. The tenderness in her abdomen prompted more questions and it turned out that Rita was started on a new blood pressure medicine about 3 weeks previously and Suzan noticed that mother had been struggling with her bowels since. Rita had not opened her bowels for several days.

Over the next 5 days Rita had enemas, various laxatives, fluid drips, and very large bowel movements. Most of her medicines were discontinued. Her confusion resolved. On day 6 she was walking again and on day 7 I discharged her from hospital with strict instructions how to manage her bowels.

Suzan called me 3 days later worried that constipation was back. I taught Suzan how to become her mother's "private physician". Prescribed medicines in older people might cause harm if one does not take into account how the patient feels on a particular day. For example water medicines can be taken every other day or omitted for a few days if an older person develops an infection and does not feel right for this or another reason (subsequently eating and drinking less). An infection, even a mild one, also lowers blood pressure, so those on blood pressure medicines should have their blood pressure checked and their medicines omitted or doses reduced.

Another week passed and Suzan reported back to me that Rita had changed her diet and they experimented with laxatives, including senna tablets, lactulose, fybogel, sometimes with undesired results, but eventually found the right combination. Rita also had her medicines reviewed and most drugs with constipating side effects were either substituted by another drug or stopped altogether.

As we get older our body reserves decline and even minor problems, such as flu or a change in medicines, can cause deterioration in our health completely out of proportion to the problem which caused it. Constipation is common enough and all of us suffer from it at some stage. Older people are at higher risk because with age we become less active, we start taking medicines, many with constipating side effects, we drink less, the contractions in the bowel wall slow down as well, and constipation can be life threatening just as a heart attack can be. There is not much we can do about some of these factors, but there are many that we can modify. Patients are becoming increasingly knowledgeable and check their own blood pressure or blood sugars. With constipation I ask patients to keep a daily bowel chart and actually watch what is being passed and change the laxatives accordingly. Patients on 5 or more medicines should have their medicines reviewed every 6 months. If constipation is already a problem, some medicines should be avoided. Lifestyle changes such as change in diet and increased physical activity are very important too.

By mid October Rita was completely back to her normal self and went on holiday to Spain with her daughter and son-in-law. I saw them again at the end of December: Rita was keeping well, although complained that her diet is boring and she missed her toast, bacon and eggs for breakfast, which she used to enjoy every day!

Rita is one of those patients I'll remember forever and when she gets it I hope that she'll show me her 100^th birthday card from the Queen.

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