By | March 27, 2019

How do you help a person with an intellectual disability achieve a higher quality of life?

Providing support, companionship, and dedicated, compassionate care can go a long way, but the Fatal Four can destroy any foundation you work to build. Dehydration, constipation, aspiration and seizures make up the Fatal Four. These conditions have the potential to severely impact a person’s quality of life and, in some cases, can be deadly.

Why is Constipation One of the IDD Fatal Four?

Nobody likes poop. At best, it’s something we don’t really have to think about very much. At worst, it can kill. Some people even say chronic constipation is what REALLY killed Elvis.

Constipation is generally defined as having no bowel movement in 3 days or having only 3 bowel movements a week. Everyone is different, though, so some people may be constipated even if they do not meet this standard.

In one review, individuals with intellectual and developmental disabilities (IDD) were 250 times as likely as the general population to receive repeating laxative prescriptions. The same review found that 33 percent to 50 percent of the IDD population experienced constipation.

Risk Factors for Constipation

Constipation is often rooted in lifestyle issues, but there are common medical contributors as well:

  • Dehydration
  • Not enough dietary fiber
  • Lack of muscle function/tone
  • Nerve problems or damage
  • Inactivity/immobility
  • Certain medications, including iron and calcium supplements
  • Surgery or hospitalization
  • Being female
  • Being elderly

Some medical conditions, including Crohn’s disease, multiple sclerosis, irritable bowel syndrome, pregnancy, and diabetes, can also contribute to constipation.

Some of these factors are common across the IDD population. For example, individuals with cerebral palsy and Down syndrome commonly have reduced muscle tone. A high percentage of the IDD community experiences limited mobility or uses multiple medications. Individuals with pica eat non-food substances, which can contribute to bowel blockages. As a result, constipation is quite common within the IDD population.

Note that dehydration – one of the contributors to constipation – is another of the Fatal Four conditions that disproportionately affect individuals with intellectual disability.

The Signs of Constipation

Constipation is uncomfortable, and you can likely recognize it in yourself quite easily. However, it can be difficult to tell if someone you support is constipated. Watch for the following:

  • Passing stools infrequently. Typically, fewer than 3 in a week or going longer than 3 days in between passing stools is a red flag.
  • Hard or lumpy stools. Normal stools are typically soft, but not loose, and form a sausage shape.
  • Straining on the toilet. Stool should pass comfortably and with relatively little effort.
  • Feeling like you still have to go. Individuals who are constipated may be able to pass a small amount of stool, but not empty their bowels.
  • Abdominal bloating or pain. This may be caused by gas trapped in the colon, or in severe cases by the stool itself backing up in the body.
  • Gas or liquid stool. Sometimes when feces are trapped in the colon, gas or liquid stool backs up and escapes around the blockage.

Treating Constipation

Individuals who experience minor or infrequent constipation can often manage it successfully with simple remedies.

  • Drinking prune or apple juice can soften stool and help it move through the body.
  • Feces may be able to move more easily through the body when a person squats. If the person is safely able to do so, consider helping them squat over the toilet on a footstool. You can purchase stools designed specifically for this purpose.
  • A gentle abdominal massage following the shape of the colon may help to move feces through the body.
  • Over-the-counter laxatives or suppositories may trigger a bowel movement. Note that in many service settings, you will require a doctor’s order to use even an over-the-counter treatment.

Complications From Constipation

The most severe – and unfortunately, a relatively common – complication from chronic or extended constipation is bowel impaction. Impaction means that the stools in the colon have hardened and become so solid and/or large that the body is not able to remove them. This can be deadly if not treated. Bowel impaction can cause toxins to build up in the body and could lead to a ruptured intestine.

A doctor will often use an x-ray image to diagnose impaction. Signs of impaction typically include:

  • Chronic or extended constipation
  • Watery or leaky diarrhea
  • An urge, but inability, to defecate
  • Stomach pain
  • Dehydration
  • Swollen, hard abdomen
  • Rectal bleeding

Treatment for impaction requires removing the trapped stool. An enema involves inserting fluid through the rectum into the bowel and may soften the stool enough for it to pass. If an enema is unsuccessful, the impaction will have to be physically removed by a doctor. In severe cases, surgery may be required.

There are additional complications of constipation that are not generally life-threatening but can cause a great deal of discomfort.

  • Anal fissures. These small tears in the skin of the anus may provide an entry point for bacteria in the stool to move into the bloodstream. These fissures may become infected or cause pain when a person is trying to have a bowel movement.
  • Hemorrhoids. These are swollen veins in the rectum or anus, and they can bulge and cause pain or bleeding when defecating. Hemorrhoids can be caused by straining to defecate when a person is constipated.
  • Rectal prolapse. Straining may lead to the extrusion of a portion of the rectum through the anus.

These complications can cause pain when defecating. Unfortunately, this can cause a person to resist having bowel movements, which can in turn increase their risk for constipation.

9 Ways DSPs Can Prevent Constipation

The most effective means of dealing with constipation is to prevent it. Direct support professionals (DSPs) should use these nine tips to help reduce the risk for constipation among the individuals they support:

1) Encourage a well-balanced diet

A diet that contains plenty of fiber promotes the movement of fluids and materials through the digestive system. Some people may experience an increase in constipation when they eat a lot of dairy products or red meat. This could be due to individual sensitivity, or it may be that these products are taking the place of fiber in their diet.

2) Integrate physical activity into the day

Physical activity increases the motility of the digestive tract, and it can help prevent stool from becoming lodged in the intestines.

3) Try probiotics

Some studies have shown that probiotics, like the kinds commonly found in some varieties of yogurt, can improve a multitude of bowel problems, including constipation.

4) Be aware of sodium

Salt in the body can cause the intestines to absorb additional water, drying out the stool and increasing the risk of constipation.

5) Increase fluid intake

Constipation occurs when stools are dry, so increasing fluids can reduce or prevent constipation.

6) Discourage alcohol consumption

Alcohol increases dehydration, and therefore also the risk for constipation.

7) Track bowel movements

Among individuals with risk factors or a history of constipation, track the frequency, size, and consistency of bowel movements. This will enable you to identify possible constipation and intervene early. For individuals who use the toilet independently, consider helping them develop a tracking system that they can complete on their own.

8) Support regular bowel habits

Refraining from having a bowel movement leads to greater hardening of stool, which may cause constipation. Help the individuals you support develop routines, such as using the toilet at a certain time of day, to promote healthy bowel habits. Plan ahead to ensure that people will have opportunities to use the toilet when away from home. Unless absolutely necessary, never advise someone to “hold it.”

9) Consider stool softeners

Many individuals benefit from regular use of stool softeners or fiber supplements to make their stools easier to pass. Note that although many of these are available over the counter, in many service settings you will likely require a doctor’s order to use them.


If a person suffers from frequent constipation despite these strategies, it’s important to alert the person’s medical team. Constipation can be a warning sign of other health problems and may be caused by an underlying and resolvable medical issue.

Constipation stinks, but it doesn’t have to be deadly. Having more information available about this condition in the Fatal Four can help your organization better serve those at higher risk.

DSPs and other caregivers need to know how constipation and the rest of the Fatal Four – aspiration, dehydration, and seizures – interact and potentially cause other serious health problems. The only way to keep the Fatal Four from claiming more lives is education and prevention.


Additional Posts About The Fatal Four

Dehydration Signs and Risk Factors

Aspiration’s Dangers and Key Interventions

What You Need to Know About Seizures

Katy Kunst

IDD Content Writer

Katy Kunst received her Bachelor of Arts in Psychology from the University of North Carolina at Chapel Hill, and her Master of Business Administration from Elon University. She has 12 years of experience in the IDD field, including roles as a direct care provider, program director, and training facilitator. She has created and facilitated training on topics including non-violent crisis interventions, person-centered planning, cultural competence, quality service delivery, regulatory compliance, and a variety of topics related to IDD.


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