Swallowing Disorders in Schizophrenia

Dopamine D2 receptor antagonism of antipsychotics and the risk of death due to choking

The risk of fatal choking for people with schizophrenia and associations with antipsychotic medication are largely unknown. Therefore, we calculated the choking-related standardized mortality ratio for schizophrenia relative to the general population (SMRchoking). We also computed adjusted hazard ratios (aHR) of choking-related mortality for antipsychotics in a nationwide cohort of patients with schizophrenia (N = 59,916). SMRchoking was 20.5 (95 % confidence interval (CI)=17.1-23.9). The aHR was 1.74 (95 %CI=1.19-2.55) for strong dopamine 2-antagonists. For other antipsychotics, CIs included 1. Importantly, aHRs were particularly high for high dose categories of strong dopamine D2 receptor (D2R) antagonists. In conclusion, a schizophrenia diagnosis is associated with a 20-fold risk of death due to choking. This risk is elevated during use of strong D2R antagonist antipsychotics, particularly when prescribed in high dosages.

The Oropharyngeal Dysphagia Screening Test for Patients and Professionals: Validation in Cognitive Impairment and in Severe Mental Illness

Dysphagia is a symptom that appears with high prevalence in persons diagnosed with dementia, intellectual disability, or severe mental illness. Risk of aspiration pneumonia or even death is very high in these populations. However, screening for dysphagia risk in these patients is complicated by the fact that most of them suffer from cognitive impairments and behavioral manifestations that hinder the assessment process using the existing screening tests. The aim of this study was to validate the Oropharyngeal Dysphagia Screening Test for Patients and Professionals, in patients with cognitive impairment (dementia/intellectual disability) or with severe mental illness (schizophrenia and other psychotic disorders, bipolar disorder, or major depressive disorder). For this purpose, 148 institutionalized patients were evaluated by professionals responsible for their food intake. The Oropharyngeal Dysphagia Screening Test for Patients and Professionals was used to assess its validity in screening for oropharyngeal dysphagia in patients with cognitive impairments and in patients with severe mental illness. Also, the Eating Assessment Tool-10 and the Swallowing Disturbance Questionnaire were used for convergent reliability procedures. Four comparison groups were established: patients with cognitive impairment with and without oropharyngeal dysphagia, and patients with severe mental illness with and without oropharyngeal dysphagia. Results from the Oropharyngeal Dysphagia Screening Test for Patients and Professionals adequately distinguished between groups with and without dysphagia, in addition to presenting adequate levels of convergent validity and reliability. These results were obtained from other-reports (professionals responsible for patients' food intake), using a simple, quickly applied test that does not require the use of food in patients with an altered cognitive state or with severe mental illness. With this study we expand the validity of the Oropharyngeal Dysphagia Screening Test for Patients and Professionals in populations with severe cognitive deficits and mental illness in which there is a great deficiency of oropharyngeal dysphagia screening instruments.

Evaluating Monitoring Guidelines of Clozapine-Induced Adverse Effects: a Systematic Review

BACKGROUND AND OBJECTIVES

Despite the evidence that no other antipsychotic is effective as clozapine for the treatment of resistant schizophrenia, it is associated with various metabolic, neuroendocrine, cardiovascular, and gastrointestinal adverse effects. Guidelines aiming to address the monitoring of clozapine's (serious) adverse effects can be helpful to prevent and treat these effects. However, many of these guidelines seem to lack one or more important monitoring recommendations. We aimed to systematically review the content and quality of existing monitoring guidelines/recommendations for clozapine-induced adverse effects.

METHODS

A comprehensive and systematic literature search, using the MEDLINE, Embase, Web of Science, and Cochrane databases, was conducted for guidelines/recommendations on the monitoring of clozapine-induced adverse events, published between January 2004 and April 2023 (last search 16 April 2023). Only peer-reviewed published guidelines reporting on the comprehensive monitoring of all major clozapine-induced adverse effects and including evidence-based recommendations, developed after the year 2004, were included. Studies reporting on the monitoring of adverse effects of clozapine without being a formal guideline, guidelines reporting on the monitoring of one or a limited number of adverse effects of clozapine, guidelines that were not peer reviewed or published, expert opinion papers without formal consensus guideline development, or guidelines developed before the year 2004, were excluded. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool was used to evaluate the guidelines/recommendations' quality.

RESULTS

Only one guideline met the inclusion criteria. This consensus statement made recommendations for hematological monitoring, and the monitoring of metabolic, cardiac, and three other adverse effects. Highest scores for the qualitative assessment were found for the domains "scope and purpose" (66.7%), "clarity of presentation" (44.4%), and "editorial independence" (66.7%). Lowest scores were found for "rigor of development" (14.6%) and "applicability" (0%).

CONCLUSIONS

Future guidelines should develop more comprehensive recommendations about specific clozapine-induced adverse effects, including constipation, myocarditis, tachycardia, and seizures, as well as include a rechallenge policy. There is an urgent need for well-developed, methodologically stringent, guidelines.

REGISTRATION

PROSPERO registration number, CRD42023402480.

Diagnostic Accuracy of Mann Assessment of Swallowing Ability for Predicting Dysphagia in Patients with Psychiatric Disorders

Dysphagia occurs in various diseases and constitutes a major concern in patients with psychiatric disorders. The Mann Assessment of Swallowing Ability (MASA) comprises 24 clinical parameters designed to identify swallowing disorders. One item in MASA, the "gag reflex", involves an unpleasant stimulus, which means that it is often omitted when the test is administered. The aims of this study were to determine the presence/absence of dysphagia in patients with psychiatric disorders using the MASA and determine its diagnostic accuracy when the gag reflex item was excluded in patients with psychiatric disorders. The study participants comprised patients admitted to a hospital psychiatric ward in whom dysphagia had been suspected based on oral intake status. The following items were determined: age, total MASA score (23 out of 24 items, giving a score out of 195 points), body mass index score, milligram equivalents of chlorpromazine, and the Food Intake Level Scale score. The patients were divided into two groups according to the presence or absence of swallowing problems as assessed by videoendoscopic or videofluoroscopic examination. The scores for each item investigated in the MASA, including the total score, were compared between the two groups. Receiver operating characteristic curve analysis was carried out to determine the optimum cut-off value. The total MASA score, which excluded the "gag reflex" item, was lower in the problematic swallowing group than in the non-problematic swallowing group. The MASA scores for cooperation, respiratory, dysphasia, tongue coordination, oral preparation, pharyngeal phase, and pharyngeal response tended to be lower in the problematic swallowing group. Furthermore, an optimum cut-off value of 169 points (sensitivity, 0.92; specificity, 0.68; likelihood ratio, 2.84) was identified. These results indicate that the cut-off MASA score is effective in screening for dysphagia, even when the "gag reflex" item is excluded.

Crushing the Contents of Valbenazine Capsules for Potential Addition to Soft Foods or Administration via Gastrostomy Tube

PURPOSE

One-capsule, once-daily valbenazine is approved for tardive dyskinesia and under evaluation for chorea associated with Huntington's disease, conditions in which patients often experience dysphagia. In vitro studies were conducted to assess the suitability of crushing the contents of valbenazine capsules (40 and 80 mg) for mixing with soft foods or liquids or administration via a gastrostomy tube (G-tube).

METHODS

In study 1, the dissolution of whole valbenazine capsules and crushed capsule contents were measured serially for 1 hour. In study 2, valbenazine recovery was evaluated after crushed contents were mixed with soft foods, buffer solutions (pH range, 1.2-6.8), and fed-state simulated gastric fluid. In study 3, valbenazine recovery was evaluated after crushed contents were dispersed in water and delivered via a G-tube. In studies 2 and 3, acceptable valbenazine recovery was 90% to 110%.

FINDINGS

Study 1 indicated rapid and complete drug release for whole valbenazine capsules and crushed capsule contents, with similar release at 10 minutes (whole, 94%-99%; crushed, 98%-100%) and 60 minutes (whole, 101%-103%; crushed, 101%-102%). Study 2 found acceptable valbenazine recovery within 2 hours of adding crushed capsule contents to tested foods, buffers, or fed-state simulated gastric fluid (recovery, 92%-102%). Study 3 found acceptable valbenazine recovery when crushed contents were added to cold or hot water and delivered via G-tube, with a water cup rinse to capture residual contents (recovery, 91%-97%).

IMPLICATIONS

These studies indicate the potential viability of valbenazine formulation(s) that can be added to soft foods or liquids or delivered via G-tube. Such formulations will be important for individuals who require treatment with a vesicular monoamine transporter 2 inhibitor but cannot swallow whole pills.

Recurrent Transient Hypoxemia in a Schizophrenic Patient Caused by Upper Airway Foreign Body Obstruction by Watermelon

A woman in her 70s with schizophrenia experienced repeated episodes of limb tremors and hypoxemia. Even after admission, the same symptoms continued while in a supine position. However, her condition rapidly improved with bag valve mask ventilation. Although computed tomography suggested aspiration pneumonia, she had a strong cough reflex while performing bronchoscopy, and no residues were observed in the trachea. Following the bronchoscopy examination, the patient was prompted by a nurse and subsequently expelled a mass of watermelon from her oral cavity, which was identified as a watermelon eaten during breakfast on the day. She was diagnosed with aspiration pneumonia, and treatment with 2 g/day of cefotiam was initiated. The inflammatory response had improved, and she was transferred to another hospital for adjustment of psychiatric medications on the 10th day of admission. A study indicated that 77% of emergency medical staff experienced misdiagnosis or delayed diagnosis of patients with mental illnesses. In the present case, various biases and system factors were found to be involved in the diagnostic error. It is crucial to recognize the potential for diagnostic errors in managing patients with schizophrenia given the various biases that may come into play. Furthermore, patients with schizophrenia are at high risk of upper airway foreign body obstruction because of dysphagia or drug-induced effects. When transient hypoxemia is observed, a prompt assessment of the visible intraoral region and, if necessary, evaluation of the entire upper airway through imaging studies should be considered.

Orodispersible Films-Current State of the Art, Limitations, Advances and Future Perspectives

Orodispersible Films (ODFs) are drug delivery systems manufactured with a wide range of methods on a big scale or for customized medicines and small-scale pharmacy. Both ODFs and their fabrication methods have certain limitations. Many pharmaceutical companies and academic research centers across the world cooperate in order to cope with these issues and also to find new formulations for a wide array of APIs what could make their work profitable for them and beneficial for patients as well. The number of pending patent applications and granted patents with their innovative approaches makes the progress in the manufacturing of ODFs unquestionable. The number of commercially available ODFs is still growing. However, some of them were discontinued and are no longer available on the markets. This review aims to summarize currently marketed ODFs and those withdrawn from sale and also provides an insight into recently published studies concerning orodispersible films, emphasizing of utilized APIs. The work also highlights the attempts of scientific communities to overcome ODF's manufacturing methods limitations.

Improvement of catatonia-induced rapid respiratory failure with electroconvulsive therapy: A case report

We encountered a case of sudden respiratory failure during treatment of catatonia that required intensive care. Electroconvulsive therapy (ECT) was administered in the intensive care unit while the patient was under systemic control. The catatonia symptom was relieved, and respiratory failure improved. Although a proximal venous thrombus was observed, anticoagulation therapy was continued during ECT, and the patient was successfully treated without causing a pulmonary embolism. It is crucial to monitor the patient's physical and psychological symptoms because respiratory status may deteriorate rapidly in a catatonic state.

Schizophrenia, but not depression or bipolar affective disorder, adds additional risk of aspiration pneumonia among stroke survivors: A national cohort study in Taiwan

OBJECTIVE

Few studies have assessed the sex-specific and age-specific risk of aspiration pneumonia (AP) in patients with stroke and evaluated whether mental disorders may increase this risk. In this population-based cohort study, we investigated the sex-specific and age-specific risk of AP in association with stroke and the joint effects of stroke and mental disorders on the risk of AP.

METHODS

We included 23,288 patients with incident stroke admitted between 2005 and 2017 and 68,675 matched nonstroke controls. Information on mental disorders was obtained from medical claims data within the 3 years before the stroke incidence. Cox proportional hazards models considering death as a competing risk event were constructed to estimate the hazard ratio of AP incidence by the end of 2018 associated with stroke and selected mental disorders.

RESULTS

After ≤14 years of follow-up, AP incidence was higher in the patients with stroke than in the controls (11.30/1000 vs. 1.51/1000 person-years), representing a covariate-adjusted subdistribution hazard ratio (sHR) of 3.64, with no significant sex difference. The sHR significantly decreased with increasing age in both sexes. Stratified analyses indicated schizophrenia but not depression or bipolar affective disorder increased the risk of AP in the patients with stroke.

CONCLUSION

Compared with their corresponding counterparts, the patients with schizophrenia only, stroke only, and both stroke and schizophrenia had a significantly higher sHR of 4.01, 5.16, and 8.01, respectively. The risk of AP was higher in younger stroke patients than those older than 60 years. Moreover, schizophrenia was found to increase the risk of AP in patients with stroke.

Long-term prognosis and clinical course of choking-induced cardiac arrest in patients without the return of spontaneous circulation at hospital arrival: a population-based community study from the Shizuoka Kokuho Database

Background

The risk of choking increases with aging, and the number of cases of choking-induced cardiac arrest is increasing. However, few studies have examined the prognosis of choking-induced cardiac arrest. The aim of this study was to reveal the rates of survival and dependence on devices in the long term after choking-induced cardiac arrest.

Methods

We analyzed data from the Shizuoka Kokuho Database, which consists of claims data of approximately 2.2 million people, from April 2012 to September 2018. We selected patients with choking-induced cardiac arrest who received cardiopulmonary resuscitation in the hospital. Patients were excluded if they were less than 20 years old, had an upper airway tumor, received ventilation assistance, or received enteral nutrition in the month prior to cardiac arrest. The primary outcome was death, and the secondary outcomes were the rates of survival at 3-months and independence on devices. Descriptive statistics are presented and compared among age groups (20–64 years, 65–74 years, 75–84 years, 85 years and older), and survival time analysis (Kaplan-Meier method) was performed.

Results

In total, 268 patients were analyzed, including 26 patients in the 20–64 age group, 33 patients in the 65–74 age group, 70 patients in the 75–84 age group, and 139 patients in the ≥85 age group. The overall 3-month survival rate was 5.6% (15/268). The 3-month survival rates were 3.8% (1/26) in the 20–64 age group, 15.2% (5/33) in the 65–74 age group, 8.6% (6/70) in the 75–84 age group, and 2.2% (3/139) in the ≥85 age group. The overall 12-month survival rate was 2.6% (7/268). Of the 7 patients who survived for 12 months, 3 received ventilation management and 5 received tube or intravenous feedings at 3 months. These survivors were still receiving ventilation assistance and tube feedings in the hospital and had not been discharged at 12 months.

Conclusions

The prognosis of choking-induced cardiac arrest was extremely poor when patients were not resuscitated before hospital arrival. Those who survived were mostly dependent on assistive devices. Additionally, none of the survivors dependent on assistive devices had discontinued the use of the devices at the long-term follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00676-8.

Movement Disorders and Mortality in Severely Mentally Ill Patients: The Curacao Extrapyramidal Syndromes Study XIV

BACKGROUND AND HYPOTHESIS

There is a substantial gap in life expectancy between patients with severe mental illness (SMI) and the general population and it is important to understand which factors contribute to this difference. Research suggests an association between tardive dyskinesia (TD) and mortality; however, results are inconclusive. In addition, studies investigating associations between parkinsonism or akathisia and mortality are rare. We hypothesized that TD would be a risk factor for mortality in patients with SMI.

STUDY DESIGN

We studied a cohort of 157 patients diagnosed predominantly with schizophrenia on the former Netherlands Antilles. TD, parkinsonism, and akathisia were assessed with rating scales on eight occasions over a period of 18 years. Twenty-four years after baseline, survival status and if applicable date of death were determined. Associations between movement disorders and survival were analyzed using Cox regression. Sex, age, antipsychotics, antidepressants and benzodiazepines at each measurement occasion were tested as covariates.

STUDY RESULTS

Parkinsonism was a significant risk factor with an HR of 1.02 per point on the motor subscale of the Unified Parkinson's Disease Rating Scale (range 0-56). TD and akathisia were not significantly associated with mortality.

CONCLUSIONS

Parkinsonism may be an important risk factor for mortality in SMI patients. This finding calls for more follow-up and intervention studies to confirm this finding and to explore whether treatment or prevention of parkinsonism can reduce excess mortality.

Psychopathological aspects of dysphagia: a systematic review on correlations with eating disorders and other psychiatric conditions

BACKGROUND

The effect of psychopathology on swallowing ability tends to be an overlooked issue in the assessment of dysphagic patients, possibly overshadowed by the given prominence to organic pathologies and the difficulties on the management of these patients. In addition, it should also be kept in mind that a great number of psychotropic drugs can affect swallowing adding problematic clinical issues in this area. Despite this, assessment of dysphagia should be considered as an extremely important issue, due to its impact on basic symptomatology, course of illness and quality of life.

OBJECTIVE

This review aims to be an overview of relevant data on psychopathology associated with dysphagia and impairment of swallowing function.

MATERIALS AND METHODS

An extensive bibliographic search was carried out in different medical databases (PubMed and Psycharticles) to comprehensively identify the most relevant publications available on dysphagia in eating disorders published until December 2020, according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) method. Research articles, either theoretical or empirical-based, published in peer-reviewed journals and in English language, were included. Case reports were also considered in the analysis when it was appropriate for completeness purposes. Titles and abstracts were reviewed according to the eligibility criteria.

RESULTS

In total, 260 published studies were identified and 40 were finally selected after removal of duplicates and relevance. Primarily we investigated the correlation between dysphagia and eating disorders, analysing the complex relationship between the two conditions. Then we provided an overview of the assessment of dysphagic symptoms in other psychiatric syndromes.

LIMITS

No exclusion criteria or statistical methods were applied nor was an assessment of study-level or outcome-level bias applicable for our purpose. The topic is vast and research bias could not be excluded; moreover, data available are heterogeneous and lacking systematic approach.

CONCLUSIONS

With this review, the authors want to provide an overview of the most considerable and clinically useful information about the topic, focusing on some key points to disentangle psychiatric components from the complexity of patient with dysphagia. It should be a relevant concern for all clinicians and should be always thoroughly assessed, considered its frequency in clinical practice and its implications in every kind of patients' morbidity, mortality and quality of life. Special attention should be paid to mentally ill patients, who might display complex and multiple comorbidities, as well as consequences of abnormal eating behaviours, occasionally exacerbated by psychotropic medications. More systematic studies are needed, while it seems clear that a multidisciplinary approach is pivotal in the assessment and management of dysphagic patients.

LEVEL OF EVIDENCE

Level I (evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies).

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.

Stabilometric analysis of neck orientations during mealtime by a wearable device for dysphagia patients

Postural changes are commonly used treatment to prevent the elderly from the risk of aspiration pneumonia. However, the evidence-based studies regarding effectiveness of this treatment remains unclear since no systematic method exists to measure constantly changing postures without disturbing usual eating behaviors. In this paper, using IMU system attached to a smart-phone based wearable technology, we analyzed data of the neck orientation angles obtained from the dysphagia patients and healthy adults during their mealtime and attempted to see if the obtained data can show differences regarding the dynamics of the angles.The result shows the possibilities to use the device to monitor neck orientations while the dysphagia patients eating their meals in daily lives.

End-of-Life Care for Persons Under Guardianship

CONTEXT

Guardians are surrogate decision makers appointed by a court when other health care decision-makers are unable, unwilling, or unavailable to make decisions. Prior studies suggest that persons under guardianship may experience delays in transitions of care.

OBJECTIVES

To compare quality of end-of-life care for persons under guardianship to a matched group on objective indicators and to identify narrative themes characterizing potential obstacles to quality end-of-life care.

METHODS

One hundred sixty-seven persons under guardianship who died between 2003 and 2019 within the Veterans Healthcare Administration in Massachusetts and Connecticut matched on a 1:1 basis to persons without guardians. The groups were compared on treatment specialty at death, days of hospice and intensive care unit care, and receipt of palliative care consultation. Additionally, patient narratives for those under guardianship with extended lengths in intensive care unit were subjected to qualitative analysis.

RESULTS

Overall, <1% were under guardianship. Within this sample of persons who died within the Veterans Health Administration, persons under guardianship were as likely as patients in the comparison group to receive palliative care consultation (odds ratio [CI] = 0.93 [.590-1.46], P = .359), but were more likely to have ethics consultation (odds ratio [CI] = 0.25 [0.66-0.92], P = .036) and have longer lengths of ICU admission (β = -.34, t = -2.70, P = .009). Qualitative findings suggest that issues related to family conflict, fluctuating medical course, and limitations in guardian authority may underlie extended lengths of stay.

CONCLUSION

Guardianship appears to be rare, and as a rule, those under guardianship have equal access to hospice and palliative care within Veterans Health Administration. Guardianship may be associated with health-care challenges in a small number of cases, and this may drive perceptions of adverse outcomes.

COVID-19 Infection-Related Weight Loss Decreases Eating/Swallowing Function in Schizophrenic Patients

Background: In older people with psychoneurological diseases, COVID-19 infection may be associated with a risk of developing or exacerbating dysphagia. The aim of the present study was to examine the relationship between eating/swallowing function and COVID-19 infection. Methods: Subjects were 44 inpatients with confirmed COVID-19 infection being treated for schizophrenia in a psychiatric ward. Eating function was assessed using the Food Intake Level Scale (FILS) before and after infection. We also evaluated age, comorbidities, COVID-19 hospital stay, obesity index, weight loss rate, and chlorpromazine equivalent. Results: Subjects had a mean age of 68.86 years. Pre-infection, 20 subjects had a FILS score of 7–9 (presence of eating/swallowing disorder) and 24 subjects had a score of 10 (normal). Eating function after infection resolution showed decreasing FILS score compared to that before infection in 14 subjects (74.14 years). Six subjects (79.3 years) transitioned from oral feeding to parenteral feeding. A ≥ 10% weight loss during infection treatment was significantly associated with decreased eating function and a transition to parenteral feeding. Chlorpromazine equivalents, comorbidities, and number of days of hospitalization showed no associations with decreased eating function. Conclusions: Preventing malnutrition during treatment for COVID-19 infection is important for improving post-infection life prognosis and maintaining quality of life (QOL).

Associations of Oral Health-Related Quality of Life with age, oral status, and oral function among psychiatric inpatients in Japan: a cross-sectional study

BACKGROUND

As the general population of Japan ages, the population of hospitalized psychiatric patients is also ageing. The purpose of this study was to investigate the associations of oral health-related quality of life (OHRQoL) with age and oral health, including oral and swallowing function, among psychiatric inpatients.

METHODS

The subjects included 165 psychiatric inpatients in psychiatric hospitals in Japan. The General Oral Health Assessment Index (GOHAI) and the Eating Assessment Tool (EAT-10) were included in the questionnaire survey for the measurement of OHRQoL and the screening of dysphagia. A score ≥ 3 on the EAT-10 was defined as suspected dysphagia. Oral examinations and oral diadochokinesis (ODK) measurements for the tongue-lip motor function evaluation were conducted. The inpatients with acute psychiatric symptoms, moderate and severe dementia, and cognitive impairment that affected their ability to communicate and relate their feelings were excluded. A chi-squared test, the Mann-Whitney U test, and linear regression analysis were used for the analysis. The data were analysed at the 5% significance level.

RESULTS

A total of 100 (64.5%) psychiatric inpatients (mean age, 67.3 [SD, 14.5] years, 49% males, and 51% females) participated in this study. The means ± SDs for the decayed missing filled teeth (DMFT) index and GOHAI score were 20.6 ± 6 and 49.7 ± 7.9, respectively. The GOHAI score in the older age group (≥ 65 years) was significantly lower than that in the younger age group (< 65 years). The mean ODK scores were less than 3 times/s for all syllables. The percentage of the participants with suspected dysphagia was 45.0%. Tooth loss and suspected dysphagia were significantly associated with low GOHAI scores. The EAT-10 score was significantly correlated with the GOHAI score only after adjusting for age and sex (β = - 0.725, 95% CI - 0.97, - 0.64).

CONCLUSIONS

In hospitalized psychiatric patients, impaired oral health in the older subjects was more pronounced compared with that among general adults. Tooth loss and swallowing function were associated with OHRQoL. Therefore, oral care for the recovery of occlusal and swallowing functions may be needed to improve OHRQoL among psychiatric patients.

Chronic Microaspiration and Frailty: A Geriatric Smoking Gun?

Chronic microaspiration and diffuse aspiration bronchiolitis may account for some otherwise unexplained frailty in nursing home patients.

The Added Value of Liquid Antipsychotics: The Case of Quetiapine

Background:

Antipsychotic drugs are the cornerstone of schizophrenia treatment and are also indicated for other psychotic and mood disorders. Different antipsychotic drugs and their formulations are available, though liquid forms have been overlooked.

Methods

Herein the added value of liquid antipsychotics is reviewed, with a focus on the recently introduced liquid quetiapine, a frequently used antipsychotic.

Results

Liquid antipsychotics are easily administrated via the preferable oral route, while compliance under supervised administration is transparent. Liquid forms could be preferred in patients with swallowing difficulties, which are common in elderly patients and often concealed. In this population, the availability of liquid antipsychotics could prevent errors in medication administration, which could possibly render caregivers labile to any harm caused to the patient. Aspiration, however, remains a risk with liquid formulations. Common errors in medication administration are the omission of treatment and alteration of solid oral formulations. Regarding quetiapine, omission of treatment could be associated with non-adherence as well as discontinuation symptoms, while alteration of extended release formulation could alter its pharmacokinetics. Mildly agitated and cooperative patients are another target population of liquid antipsychotics, which can induce fast sedation avoiding involuntary intramuscular injections. The combination of sedative properties and low incidence of extrapyramidal symptoms makes liquid quetiapine a valuable option for these patients, yet the current evidence is limited.

Conclusion

The liquid form of quetiapine can facilitate pharmacotherapy of schizophrenia and can be defined as value added medicine bringing key benefits not only to the patients and caregivers but also to the health care system.

Asphyxia risk factors in adult psychiatric wards

PURPOSE

To identify factors for choking in psychiatric wards that can be easily screened.

DESIGN AND METHODS

Data were collected from patients admitted to the acute phase psychiatric wards who were assessed for swallowing function by dentists. We defined 47 and 102 patients of choking in the high- and low-risk groups, respectively.

FINDINGS

Through multivariate analysis, we identified basal metabolic index and two Drug-induced Extra-pyramidal Symptoms Scale items, bradykinesia and tremor, as independent choking factors.

PRACTICE IMPLICATIONS

Choking risk is related to patient tolerability rather than to the absolute severity of psychiatric symptoms or psychotropic dose.

Causes of Sudden Unexpected Death in Schizophrenia Patients: A Forensic Autopsy Population Study

BACKGROUND

Schizophrenia is a detrimental psychiatric disorder, with an increased mortality from natural and nonnatural causes.

METHODS

This study was a retrospective review of autopsy cases of all the individuals with history of schizophrenia investigated by the Office of the Chief Medical Examiner, State of Maryland, for a 5-year period from 2008 to 2012.

RESULT

A total of 391 schizophrenia patients were autopsied at the Office of the Chief Medical Examiner because they died suddenly and unexpectedly. Their age ranged from 15 to 100 years with the mean age of 49.5 years. Of the 391 deaths, 191 (48.8%) were white, 185 (47.3%) were African American, and 15 (3.9%) were either Hispanic or Asian. The male and female ratio was 1.5:1. The majority of deaths (64.2%) were caused by natural diseases, 12.0% deaths were accidents, 11.5% deaths were suicides, and 9.7% deaths were homicides. The manner of death remained undetermined in 38 cases (9.7%). Of the 251 natural deaths, 198 cases (78.9%) were owing to cardiovascular diseases. Cause of death was listed as cardiac arrhythmia in 11 cases. This diagnosis of cardiac arrhythmia was made by exclusion based on death scene investigation, review of medical history, complete autopsy, and toxicological tests. Drug intoxication was the second most common cause of death.

CONCLUSIONS

The study shows high fatality caused by cardiovascular diseases and drug intoxication among schizophrenia patients, which calls attention of the medical community to closely monitor the high risk factors of sudden death among schizophrenia patients.

Whiplash-Associated Dysphagia: Considerations of Potential Incidence and Mechanisms

Non-specific self-reports of dysphagia have been described in people with whiplash-associated disorders (WAD) following motor vehicle collision (MVC); however, incidence and mechanistic drivers remain poorly understood. Alterations in oropharyngeal dimensions on magnetic resonance imaging (MRI), along with heightened levels of stress, pain, and changes in stress-dependent microRNA expression (e.g., miR-320a) have been also associated with WAD, suggesting multi-factorial issues may underpin any potential swallowing changes. In this exploratory paper, we examine key biopsychosocial parameters in three patients with persistent WAD reporting swallowing change and three nominating full recovery after whiplash with no reported swallowing change. Parameters included (1) oropharyngeal volume with 3D MRI, (2) peritraumatic miR-320a expression, and (3) psychological distress. These factors were explored to highlight the complexity of patient presentation and propose future considerations in relation to a potential deglutition disorder following WAD. The three participants reporting changes in swallowing all had smaller oropharyngeal volumes at < 1 week and at 3 months post injury and lower levels of peritraumatic miR-320a. At 3 months post MVC, oropharyngeal volumes between groups indicated a large effect size (Hedge's g = 0.96). Higher levels of distress were reported at both time points for those with persistent symptomatology, including self-reported dysphagia, however, this was not featured in those nominating recovery. This paper considers current evidence for dysphagia as a potentially under-recognized feature of WAD and highlights the need for future, larger-scaled, multidimensional investigation into the incidence and mechanisms of whiplash-associated dysphagia.

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.

Morbidity burden and community-based palliative care are associated with rates of hospital use by people with schizophrenia in the last year of life: A population-based matched cohort study

Objective

People with schizophrenia face an increased risk of premature death from chronic diseases and injury. This study describes the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with receipt of community-based specialist palliative care and morbidity burden.

Method

A population-based retrospective matched cohort study of people who died from 01/01/2009 to 31/12/2013 with and without schizophrenia in Western Australia. Hospital inpatient, emergency department, death and community-based care data collections were linked at the person level. Rates of emergency department presentations and hospital admissions over the last year of life were estimated.

Results

Of the 63508 decedents, 1196 (1.9%) had a lifetime history of schizophrenia. After adjusting for confounders and averaging over the last year of life there was no difference in the overall rate of ED presentation between decedents with schizophrenia and the matched cohort (HR 1.09; 95%CI 0.99–1.19). However, amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to ED more often. Males with schizophrenia had the highest rates of emergency department use in the last year of life. Rates of hospital admission for decedents with schizophrenia were on average half (HR 0.53, 95%CI 0.44–0.65) that of the matched cohort although this varied by cause of death. Of all decedents with cancer, 27.5% of people with schizophrenia accessed community-based specialist palliative care compared to 40.4% of the matched cohort (p<0.001). Rates of hospital admissions for decedents with schizophrenia increased 50% (95% CI: 10%-110%) when enrolled in specialist palliative care.

Conclusion

In the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend emergency departments if male. Community-based specialist palliative care was associated with increased rates of hospital admissions.

Risk factors for pneumonia in patients with schizophrenia

AIM

Pneumonia is a major cause of death in patients with schizophrenia. Preventive strategies based on identifying the risk factors are needed to reduce pneumonia-related mortality. This study aimed to clarify the risk factors for pneumonia in patients with schizophrenia.

METHODS

We retrospectively reviewed the clinical files of consecutive patients with schizophrenia admitted to Tokyo Metropolitan Matsuzawa Hospital during a four-year period from January 2014 to December 2017. We analyzed the clinical differences between patients with and without pneumonia.

RESULTS

Of the 2209 patients enrolled, 101 (4.6%) received the diagnosis of pneumonia at the time of hospital admission while 2108 (95.4%) did not have pneumonia. Multivariable analysis to determine the risk factors related to pneumonia showed that the use of atypical antipsychotics had the highest odds ratio among the predictive factors (2.7; 95% confidence interval [CI] 1.0-17.7; P = 0.046), followed by a total chlorpromazine equivalent dose ≥600 mg (2.6; 95% CI 1.7-4.0; P < 0.001), body mass index <18.5 kg/m² (2.3; 95% CI 1.6-3.6; P < 0.001), smoking history (2.0; 95% CI 1.3-3.1; P < 0.001), and age ≥50 years (1.7; 95% CI 1.2-2.6; P = 0.002).

CONCLUSIONS

We found that advanced age, underweight, smoking habit, use of atypical antipsychotics, and large doses of antipsychotics were risk factors for pneumonia in patients with schizophrenia. Among these factors, it was unclear whether the use of antipsychotics was a direct cause of pneumonia due to is uncertain because our retrospective study design. However, our result might be a good basis of further study focused on reducing pneumonia-related fatalities in schizophrenic patients with pneumonia.

Risk of pleural empyema in patients with schizophrenia: a nationwide propensity-matched cohort study in Taiwan

OBJECTIVE

Thoracic infection and pneumonia are prevalent in patients with schizophrenia; however, it is unclear whether patients with schizophrenia are at an increased risk of developing pleural empyema.

DESIGN

A retrospective cohort study with propensity-matched cohorts with and without schizophrenia.

SETTING

Using the National Health Insurance Research Database of Taiwan.

PARTICIPANTS

We identified 55 888 patients with schizophrenia newly diagnosed in 2000-2011 and same number of individuals without schizophrenia as the comparison cohort, frequency matched by propensity scores estimated using age, sex, occupation, income, urbanisation, year of diagnosis and comorbidities.

PRIMARY OUTCOME MEASURES

We assessed incident pleural empyema by the end of 2011 and used the Cox proportional hazards model to calculate the schizophrenia cohort to comparison cohort HR of pleural empyema.

RESULTS

The overall incidence of pleural empyema was 2.44-fold greater in the schizophrenia cohort than in the comparison cohort (4.39vs1.80 per 10 000 person-years), with an adjusted HR of 2.87(95% CI 2.14 to 3.84). Stratified analyses by age, sex, occupation, income, urbanisation and comorbidity revealed significant hazards for pleural empyema associated with schizophrenia in all subgroups.

CONCLUSIONS

Patients with schizophrenia are at an increased risk of developing pleural empyema and require greater attention and appropriate support.

A particular case of accidental asphyxiation

The case reported involved a 60-year-old man with psychiatric illness who was found dead at his home. He was almost naked and showed signs of death by violent asphyxiation, which led to the suspicion of homicide. Autopsy findings showed foreign material in the trachea and larynx. However, the partially digested content in his stomach, the study of the gastric content and the microscopic analysis of the airways made it possible to define this as accidental death due to inhalation of material from a diaper. Toxicological analysis detected the presence of phenytoin, valproic acid, and phenobarbital in his blood, with values within the therapeutic ranges. This is certainly a peculiar case, as particularly evident after careful review of the literature on deaths by asphyxiation in psychiatric patients. Furthermore, this study highlights the importance of a full autopsy and microscopic evaluation of any foreign bodies.

Could the screening for correct oral health reduce the impact of death due to bolus asphyxia in adult patients? A forensic case report

INTRODUCTION

"Bolus death" or "Café Coronary syndrome" refers to death due to asphyxia caused by an occlusion of the upper airways due to food. In this kind of asphyxia, the food bolus obstructs the larynx or the bronchial branches. This kind of event often affects subjects with acute intoxication due to alcohol or drugs, or with edentulism and with neurological or psychiatric diseases.

CASE REPORT

An elderly woman, suffering from schizophrenia, was found dead in her house due to food bolus asphyxia. The post-mortem toxicological analysis on the deceased's biological fluids revealed the presence of tricyclic antidepressants, antipsychotics and neuroleptics. Study of the oral cavity showed the presence of partial edentulism and periodontal disease.

HYPOTHESIS

We hypothesize that this kind of asphyxia in adults can be prevented. We believe that there are two major preventable factors: edentulism and salivation disorders in elderly and neuropsychiatric patients. The primary prevention of these pathologies would deal with the basic physician, similarly to other screenings already effectively in place.

CONCLUSIONS

It is possible to prevent fatal asphyxia in subjects who suffer from this kind of diseases through appropriate screening. This prevention strategy would greatly reduce the amount of choking deaths in adults.