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

Polymorphisms in ERBB4 and TACR1 associated with dry mouth in clozapine-treated patients

BACKGROUND

Sialorrhea is a common and uncomfortable adverse effect of clozapine, and its severity varies between patients. The aim of the study was to select broadly genes related to the regulation of salivation and study associations between sialorrhea and dry mouth and polymorphisms in the selected genes.

METHODS

The study population consists of 237 clozapine-treated patients, of which 172 were genotyped. Associations between sialorrhea and dry mouth with age, sex, BMI, smoking, clozapine dose, clozapine and norclozapine serum levels, and other comedication were studied. Genetic associations were analyzed with linear and logistic regression models explaining sialorrhea and dry mouth with each SNP added separately to the model as coefficients.

RESULTS

Clozapine dose, clozapine or norclozapine concentration and their ratio were not associated with sialorrhea or dryness of mouth. Valproate use (p = 0.013) and use of other antipsychotics (p = 0.015) combined with clozapine were associated with excessive salivation. No associations were found between studied polymorphisms and sialorrhea. In analyses explaining dry mouth with logistic regression with age and sex as coefficients, two proxy-SNPs were associated with dry mouth: epidermal growth factor receptor 4 (ERBB4) rs3942465 (adjusted p = 0.025) and tachykinin receptor 1 (TACR1) rs58933792 (adjusted p = 0.029).

CONCLUSION

Use of valproate or antipsychotic polypharmacy may increase the risk of sialorrhea. Genetic variations in ERBB4 and TACR1 might contribute to experienced dryness of mouth among patients treated with clozapine.

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.

Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations

Dysphagia is increasingly common in older adults; it is especially prevalent in long-term care settings. Patients with dysphagia likely require pharmacologic treatment for multiple comorbidities but may find it difficult or impossible to swallow oral medications. Administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia. However, inappropriate medication use and improper crushing technique can reduce the medication dose a patient receives, alter medication pharmacokinetics and pharmacodynamics, and compromise treatment efficacy and patient safety. Clinical judgment is needed to identify medications that can and cannot be crushed, select a crushing methodology and vehicle for administering crushed medications, and create a strategy for administering multiple medications. A coordinated effort from the entire care team-including physicians, pharmacists, nurses, advanced practice providers, speech therapists, patients, and caregivers-is necessary to develop and implement an individualized plan for administering medications to patients with dysphagia. This review details the current literature regarding the administration of medications that have been altered, such as by crushing tablets or opening capsules, for patients with dysphagia or who are receiving enteral feeding and provides recommendations on best practices.

Factors Associated with Malnutrition Risk in Residents of Long-Term Care Facilities in Mexico

OBJECTIVE

To investigate factors associated with the nutritional status in institutionalized Mexican older adults.

MATERIAL AND METHODS

In this cross-sectional study of residents in three long-term care facilities (LTCFs) in Monterrey, Mexico, a medical history, Mini-Mental State Examination, Barthel index, and geriatric depression scale, and Mini Nutritional Assessment (MNA) were performed. Risk of malnutrition and malnutrition status were defined as MNA 17-23.5 and <17, respectively.

RESULTS

Residents (n = 280) had a median age of 85 years and 72.1% were female. A total of 116 (41.4%) were at risk of malnutrition and 35 (12.5%) were malnourished. Having malnutrition or being at risk of malnutrition was associated with age (OR = 1.048), functional dependence (OR = 8.376), body mass index (BMI) <22 (OR = 7.518), cognitive impairment (OR = 2.210), urinary incontinence (OR = 2.397), previous stroke (OR = 2.870), Parkinson's disease (OR = 5.193), use of calcium channel blockers (OR = 3.706), and use of atypical antipsychotics (OR = 2.277). Having benign prostatic hyperplasia (OR = 0.067) or the use of angiotensin II receptor blockers (OR = 0.038) were related to being well-nourished.

CONCLUSIONS

In a population of residents of three LTCFs in Mexico, we found a high prevalence of malnutrition or being at risk of malnutrition. This underscores the need to implement guidelines for the prompt identification of this condition and further explanation of the factors identified as possibly related to malnutrition.

Mortality rates and proximal causes of death in patients with Lewy body dementia versus Alzheimer's disease: A longitudinal study using secondary care mental health records

BACKGROUND

Previous studies have shown reduced survival in Lewy body dementia (LBD) compared to Alzheimer's disease (AD), but the reasons for this are not known. We identified cause of death categories accounting for the reduced survival in LBD.

METHODS

We linked cohorts of patients with dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD) and AD, with proximal cause of death data. We examined mortality by dementia group and hazard ratios for each death category by dementia group in males and females separately. In a specific focus on the dementia group with the highest mortality rate versus reference, we examined cumulative incidence to identify the main causes of death accounting for the excess deaths.

RESULTS

Hazard ratios for death were higher in PDD and DLB compared to AD, for both males and females. PDD males had the highest hazard ratio for death across the dementia comparison groups (HR 2.7, 95% CI 2.2-3.3). Compared with AD, hazard ratios for "nervous system" causes of death were significantly elevated in all LBD groups. Additional significant cause-of-death categories included aspiration pneumonia, genitourinary causes, other respiratory causes, circulatory and a "symptoms and signs" category in PDD males; other respiratory causes in DLB males; mental disorders in PDD females; and aspiration pneumonia, genitourinary and other respiratory causes in DLB females.

CONCLUSION

Further research and cohort development is required to investigate differences by age group, to extend cohort follow-up to the whole population and to investigate the risk-balance of interventions which may differ by dementia group.

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.

Risk Factors of Mortality from Foreign Bodies in the Respiratory Tract: The Japan Collaborative Cohort Study

Objective This study assessed the risk factors of mortality from foreign bodies in the respiratory tract using the Japan Collaborative Cohort Study for the Evaluation of Cancer Risk data. Methods Data of 110,585 participants 40-79 years old living in 45 areas in Japan were collected between 1988 and 2009. Mortality from foreign bodies in the respiratory tract was assessed in a multivariable-adjusted analysis using a Cox proportional hazard regression model. Results Among all participants, 202 deaths occurred from foreign bodies in the respiratory tract. In the multivariable-adjusted model, older age [50-59 (hazard ratio, 4.93; 95% confidence interval, 1.91-12.74), 60-69 (hazard ratio, 14.96, 6.01-37.25) and 70-79 (hazard ratio, 53.81; 95% confidence interval, 21.44-135.02) years old compared to 40-49 years old], male sex (hazard ratio, 2.34; 95% confidence interval, 1.54-3.54), a history of apoplexy (hazard ratio, 7.04; 95% confidence interval, 4.24-11.67) and the absence of a spouse (hazard ratio, 1.56; 95% confidence interval, 1.05-2.32) were associated with an increased risk of mortality from foreign bodies in the respiratory tract. Conclusions Older age, male sex, medical history of apoplexy and the absence of a spouse were potential risk factors of mortality from foreign bodies in the respiratory tract. Especially in elderly men, social connections, such as cohabitation or relationships, may be important for ensuring the early detection of asphyxia and preventing death due to foreign bodies in the respiratory tract.

Prevalence of oropharyngeal dysphagia in geriatric patients and real-life associations with diseases and drugs

Risk factors for oropharyngeal dysphagia (OD) in elderly patients are mainly central nervous system (CNS) and structural organic diseases or presbyphagia. We analysed the OD prevalence and association of OD with multimorbidity and polypharmacy using real-life data to complete this spectrum, with a focus on further and iatrogenic risk. This was a cross-sectional retrospective study based on a random sample of 200 patients admitted to a geriatric hospital. Data analysis included diagnoses, the detailed list of drugs, and an intense clinical investigation of swallowing according to Stanschus to screen for OD in each patient. The mean patient age was 84 ± 6.5 years. The prevalence of OD was 29.0%, without an effect of age, but a higher rate was found in men and in nursing home residents and an elevated risk of pneumonia. OD risk was slight in diabetes mellitus and COPD, and pronounced in CNS diseases. A relevant OD association was found, even after adjusting for CNS diseases, with antipsychotics, benzodiazepines, anti-Parkinson drugs, antidepressants, and antiepileptics. Further risk of OD was found with beta-blockers, alpha-blockers, opioids, antiemetics, antivertiginosa or antihistamines, metoclopramide, domperidone, anticholinergics, loop diuretics, urologics, and ophthalmics. From real-life data in patients with and without CNS diseases, we identified drug groups associated with a risk of aggravating/inducing OD. Restrictive indications for these drugs may be a preventative contribution, requiring implementation in dysphagia guidelines and an integrative dysphagia risk scale that considers all associated and cumulative medication risks in addition to diseases.

Review of Clinical Questions Submitted to Norwegian Drug Information Centres Concerning Administration and Dosage to Older Patients of Relevance to Patient-Centric Care

Patient-centric care entails optimising healthcare provision to patients based on their perspective and opinion. It involves appropriate treatment at a reasonable cost and a focus on patient characteristics in the decision-making process to make it more personally useful. The optimisation of medicines in the older population is a challenge due to physiological changes, comorbidity, and polypharmacy. Furthermore, patient-centric care is difficult to achieve due to the high proportion of patients with dementia and frailty. Decision support concerning the appropriateness of indication, formulation, dose, administration, co-prescribing, and length of treatment to older patients is frequently in demand. In the current study, we aimed to review clinical questions concerning administration and dosage to older patients of relevance to patient-centric care. We analysed questions concerning medicines to patients 65 years or older in the database of the network of Norwegian drug information centres from 2010 to 2020. The analysis included the distribution of drugs, diseases, and recurring topics among the questions. Through a Boolean search that combined the indexed categories of “older” and “administration and dosage”, we retrieved 84 question-answer pairs. Questions about psychotropic and cardiovascular drugs in relation to therapy, adverse drug reactions, and pharmacokinetics dominated, and more than 60% of the questions came from physicians. Topics relevant to patient-centric pharmacotherapy were drug withdrawal (10 questions), drug formulation (8 questions), drug initiation (8 questions), and switching drugs (5 questions). One question concerned drug withdrawal and switching, and one question drug formulation and switching. Answers provided decision support regarding appropriate formulations of drugs to patients with dementia who chew capsules or tablets, the use of parenteral administration in patients who refuse to take oral formulations, and the pharmacokinetics of transdermal or rectal drug administration. The results highlight the importance of including pharmacological factors in the assessment of the acceptability and appropriateness of oral and parenteral medicine to older patients.

Relationship between polypharmacy, xerostomia, gustatory sensitivity, and swallowing complaints in the elderly: A multidisciplinary approach

Oral dysfunctions are common in the elderly but the literature lacks a multidisciplinary approach on the relationship between polypharmacy, saliva flow, xerostomia, taste, and swallowing complaints. This cross-sectional study included 204 non-institutionalized elderly (>60 years; 123 women/81 men), free of severe disabilities and non-alcohol/tobacco consumers, from whom specific pharmacological therapies were evaluated, as well xerostomia (Xerostomia Inventory-XI) and swallowing complaints (EAT-10 questionnaire), salivary flow rate and gustatory sensitivity. Statistical analysis included Chi-square, Mann-Whitney, Two-way ANCOVA, and linear multiple regression. Polypharmacy (≥5 drugs daily), hyposalivation, and severe taste dysfunction were found in 18, 46, and 10% of the participants, respectively. Polypharmacy was related with xerostomia (p = .041) and swallowing complaints (p < .001; power = 94%), but not with taste dysfunction. Dry mouth complaint and higher risk of swallowing disorders were found in 50 and 12% of the elderly, respectively, and angiotensin-converting enzyme (ACE) inhibitors users (n = 36) showed higher EAT-10 scores (p = .038). Regression models showed that stimulated salivary flow rate was dependent on gender and diuretic use, while xerostomia scores were dependent on the number of medications and unstimulated saliva flow (p < .001). In conclusion, the results draw attention to the high frequency of oral and maxillofacial dysfunctions found in non-institutionalized elderly, especially polypharmacy, xerostomia and swallowing complaints, and the side effects of drugs that can disturb the oral functions, the acceptance of food, and the adherence to oral therapies.

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.

Diagnosis and Management of Esophagogastric Junction Outflow Obstruction

Esophagogastric junction outflow obstruction (EGJOO) is an abnormal topographic pattern seen on high-resolution manometry. EGJOO is characterized by an elevated median integrated relaxation pressure with intact or weak peristalsis, thus not meeting the criteria for achalasia. This diagnosis has a female predominance and is associated with varying presenting symptoms. EGJOO can be idiopathic or secondary. It is important to assess for secondary causes, including structural or medication-related ones. Cross-sectional imaging is recommended to rule out secondary causes; however, increasing evidence suggests that esophagogastroduodenoscopy and barium esophagram are usually sufficient. The disease course is variable, with up to three-quarters of patients experiencing spontaneous resolution of symptoms over 6 months. In patients who have mild symptoms, it is reasonable to observe and consider treatment if symptoms persist. Variable response has been seen in small studies with both medical treatment and botulinum toxin injection of the lower esophageal sphincter. For patients with significant symptoms and objective evidence of obstruction on imaging, targeted therapy of the lower esophageal sphincter should be considered via pneumatic dilation or myotomy.

Medications and Vocal Function

Medications can have innumerable direct and indirect effects on laryngeal hydration, vocal fold mucosal integrity, laryngeal muscle function, and laryngeal sensation. Effects, therefore, can be subtle and slowly progressive over time. This article delineates the general classes of medications that are known to cause alterations of vocal function, highlights medical history symptoms that may help raise suspicion for medication-related vocal changes, and presents recommendations for approaches to treatment of these issues.

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.

Dysphagia and pharmacotherapy in older adults

PURPOSE OF REVIEW

The review summarizes current knowledge and recent findings about how to practically apply medication in patients with dysphagia and how swallowing function may be positively or negatively affected by drugs.

RECENT FINDINGS

Oropharyngeal dysphagia is a major health problem in older persons and was recently classified as a geriatric syndrome. Although the knowledge about an effective diagnostic approach increased during the last years, comparatively little is known about how to effectively manage and treat dysphagia and hardly anything is implemented in clinical routine. Studies have shown a considerable lack of knowledge about the adequate modification of medication and demonstrated an increased rate of practical medication errors in patients with dysphagia. With regard to dysphagia therapy, two systematic reviews have identified neuroleptics as potentially harmful for swallowing function. The role of other candidates is controversial. Contrary to this, some pharmacological approaches may be future options for the treatment of dysphagia, with capsaicin currently being the most evaluated and potential one.

SUMMARY

More professional training and advice about the adequate management of medication in dysphagic patients is necessary for all healthcare professionals. Large observational and interventional studies are needed to identify and confirm the influence of pharmacological substances on the swallowing function.