High dosage of aripiprazole-induced dysphagia

Mealtime difficulties in adults with mental health conditions: an integrative review

BACKGROUND

Dysphagia and choking are highly prevalent in adults with mental health conditions. However, there is scant research considering the personal experience of dysphagia for this population.

AIMS

To understand the evidence-base for strategies to involve the patient in recognition, assessment and treatment of mealtime difficulties.

METHODS

This integrative review synthesised the literature on the experience of dysphagia in patients with mental health conditions. Patient consultation led to co-designed search terms and eligibility criteria for a systematic search of five scientific databases following Prisma guidance. Quality assessment of the eligible studies and reflexive thematic analysis were completed.

RESULTS

31 studies were included for review. These included case reports, literature reviews and cross-sectional studies. Quality of evidence was weak and no intervention studies were identified. There was scant detail regarding the personal experience of dysphagia or choking. Themes identified related to biomedical perspectives, influencing factors presented without context, and decision-making led by clinicians.

CONCLUSIONS

Guidance on mental healthcare calls attention to under-diagnosis of physical co-morbidities and advocates patient inclusion. However, the patient voice in this population is rarely described regarding dysphagia. Further inclusive research is indicated to explore the impact of dysphagia and choking, and implications for interventions and outcome measures.

A comprehensive review of swallowing difficulties and dysphagia associated with antipsychotics in adults

INTRODUCTION

This is a comprehensive review of antipsychotic (AP)-induced dysphagia and its complications: choking and pneumonia. Areas covered: Four PubMed searches were completed in 2018. The limited literature includes: 1) 45 case reports of AP-induced dysphagia with pharmacological mechanisms, 2) a systematic review of APs as a risk factor for dysphagia, 3) reviews suggesting adult patients with intellectual disability (ID) and dementia are prone to dysphagia (APs are a risk factor among multiple others), 4) studies of the increased risk of choking in patients with mental illness (APs are a contributing factor), 5) naturalistic pneumonia studies suggesting that pneumonia may contribute to AP-increased death in dementia, and 6) naturalistic studies suggesting that pneumonia may be a major cause of morbidity and mortality in clozapine patients. Expert commentary: The 2005 Food and Drug Administration requirement that package inserts warn of AP-induced dysphagia jumpstarted this area, but current studies are limited by: 1) its naturalistic nature, 2) the lack of dysphagia studies of patients with IDs and dementia on APs, and 3) the assumed indirect association between dysphagia with choking and pneumonia. Future clozapine studies on pneumonia, if they lead to a package insert warning, may have high potential to save lives.

Systematic review of case reports of oropharyngeal dysphagia following the use of antipsychotics

OBJECTIVE

The purpose of this systematic review was to examine the effect of antipsychotic medication on dysphagia based on clinical case reports.

PATIENTS AND METHODS

Literature searches were performed using the electronic databases PubMed and Embase. In PubMed, we used the MeSH terms "antipsychotic agents" OR "tranquilizing agents" combined with "deglutition disorders" OR "deglutition". In Embase, we used the Emtree terms "neuroleptic agents" combined with "swallowing" OR "dysphagia". Two reviewers assessed the eligibility of each case independently.

RESULTS

A total of 1043 abstracts were retrieved, of which 36 cases met the inclusion criteria; 14 cases were related to typical antipsychotics and 22 to atypical antipsychotics. Dysphagia occurred together with extrapyramidal symptoms in half of the cases and was the only prominent symptom in the other half. The most common strategy against dysphagia was changing to another antipsychotic (n=13, 36.1%).

CONCLUSIONS

The data from this review indicate that antipsychotics can increase the prevalence of dysphagia.

Dysphagia with second-generation antipsychotics: A case report and review of the literature

Background:

All antipsychotics are associated with extrapyramidal symptoms (EPS). These can present as dysphagia, esophageal dysmotility, or aspiration, all of which may not be recognized as EPS.

Case Report:

A 62-year-old with schizophrenia, prescribed olanzapine 5 mg daily, presented agitated and endorsed difficulty swallowing. Speech therapy suggested her complaints were related to either reflux or dysmotility. Esophageal manometry showed her lower esophageal sphincter was not fully relaxing, and identified an esophagogastric junction outflow obstruction. Despite therapeutic dilation, oral intake remained poor. Following an increase in olanzapine, she developed EPS, her dysphagia worsened, and she was choking on food. Following a switch to aripiprazole her EPS and appetite improved, and she ceased complaining of dysphagia.

Discussion:

Dysphagia has been reported with first- and second-generation antipsychotics. A review of the second-generation antipsychotic literature identified case reports of dysphagia with clozapine (n = 5), risperidone (n = 5), olanzapine (n = 2), quetiapine (n = 2), aripiprazole (n = 1), and paliperidone (n = 1). Postulated mechanisms of antipsychotic-induced dysphagia include that it may be an extrapyramidal adverse reaction or related to anticholinergic effects of antipsychotics. Management of dysphagia includes discontinuing the antipsychotic, reducing the dose, dividing the dose, or switching to another antipsychotic. Complications of dysphagia include airway obstruction (eg, choking, asphyxia), aspiration pneumonia, and weight loss. Additional complications include dehydration, malnutrition, and nonadherence to oral medications.

Conclusion:

It is important to recognize symptoms of dysphagia and esophageal dysmotility in antipsychotic-treated patients. Intervention is necessary to prevent complications.

Swallowing Disorders in Schizophrenia

Disorders of swallowing are poorly characterized but quite common in schizophrenia. They are a source of considerable morbidity and mortality in this population, generally as a result of either acute asphyxia from airway obstruction or more insidious aspiration and pneumonia. The death rate from acute asphyxia may be as high as one hundred times that of the general population. Most swallowing disorders in schizophrenia seem to fall into one of two categories, changes in eating and swallowing due to the illness itself and changes related to psychotropic medications. Behavioral changes related to the illness are poorly understood and often involve eating too quickly or taking inappropriately large boluses of food. Iatrogenic problems are mostly related to drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia, but may also include xerostomia, sialorrhea, and changes related to sedation. This paper will provide an overview of common swallowing problems encountered in patients with schizophrenia, their pathophysiology, and management. While there is a scarcity of quality evidence in the literature, a thorough history and examination will generally elucidate the predominant problem or problems, often leading to effective management strategies.