Arch Phys Med Rehabil. 1993 Apr;74(4):445-7. Related Articles, Links
Sliwa JA, Lis S.
Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, Chicago, IL.
Dysphagia is a problem commonly treated and frequently diagnosed on the rehabilitation unit. It can be caused by trauma, injury, or diseases of the nervous system and can result in potentially serious and life threatening complications. The disruption of normal swallowing has also been reported to occur in psychiatric patients treated with psychotropic medication. Relatively unappreciated by physicians, and unreported by the rehabilitation patient, drug-induced dysphagia can likewise result in serious complications. This report describes a case of drug-induced dysphagia and aspiration pneumonia during the rehabilitation of a traumatically brain injured male who received psychotropic medication to control aggressive behavior. The course of his dysphagia was followed and documented both clinically and with videofluoroscopic studies.
Difficulty in swallowing (dysphagia): The literature suggests that 40% to 60% of nursing home patients experience some degree of difficulty swallowing.15 Many neurologic disorders produce dysphagia, and many drugs can also cause this problem. These drugs specifically include typical antipsychotics (e.g., clozapine, where the swallowing dysfunction is associated with drug-induced Parkinsonism and tardive dyskinesia--or both).
To differentiate between symptoms from the disorder and those that are drug-induced, carefully check the patient's history and conduct a swallowing evaluation, interview staff familiar with the patient's normal behavior, reduce or eliminate any drugs that can cause swallowing difficulty, regularly watch for symptom progression and, if possible, change prescriptions with careful titration.
Antihistamines and scopolamine are used for dysphagia in older adults due to degenerative neurological disorders. The side effects of these drugs may include urinary retention, blurry vision, rapid heartbeat, raised intraocular pressure, restlessness, irritability, and mental confusion.
Depending on the dose, it may also stimulate or depress the brain. Because the scopolamine patch comes only in one dose and cannot be cut, its use in the frail elderly and in small women may be limited. Side effects include irritated skin surrounding the patch as well as drowsiness, blurred vision, and dry mouth.
Long-term care patients are already at risk for esophageal mucosal damage and dysphagia because they may often be 1) lying down during drug administration, 2) taking multiple medications, or 3) unable to take enough fluid to swallow medication. A nasogastric tube may also cause esophageal spasms or irritability.
In addition, older adults often take certain high-risk medications, such as bisphosphonates and nonsteroidal anti-inflammatory drugs. And esophageal motility and saliva production decline with age. Finally, many older adults with neurologic disorders have pre-existing esophageal or swallowing disorders that may increase the likelihood of iatrogenic esophageal injuries.
In general, patients should be as upright as possible during drug administration and remain so for at least five to 10 minutes afterward. Pharmacists can play a pivotal role by identifying situations where there may be a higher likelihood of drug-induced dysphagia or esophageal injury and can recommend preventive and treatment strategies. (See also, "Evidence-Based Practice in LTC: The Facts about Dysphagia & Swallowing Studies," February 2003 Caring, p. 17.)
Excessive salivation (sialorrhea) & drooling: Drooling presents another distressing complication for people with neuromuscular diseases. In general, "the problem is not that they're making too much saliva, although that is the way it appears to the patient," said Jeffrey Rosenfeld, MD, chief of the division of neurology for the Carolinas Medical Center and director of the Carolinas Neuromuscular/Amyolateral Sclerosis Center in Charlotte, N.C. "They're drooling, and it's pooling. The problem is that they're not moving the saliva that they're making. All of the [available] treatments [cut] down the production of saliva, and it does work, but it works for a secondary reason."
It's important to seek causes of excessive salivation and drooling; for example, medications such as metoclopramide that affect the extrapyramidal nervous system. Treatments commonly prescribed for drooling in other populations include anticholinergic medications, such as glycopyrrolate (Robinul), atropine, and transdermal scopolamine. However, glycopyrrolate is not well tolerated in the elderly because of its anticholinergic side effects. Atropine is rarely used in long-term care because it can lead to dangerous anticholinergic side effects such as delirium and high fever.
Another treatment for drooling in the absence of a treatable cause is L-hyoscyamine (Levsin), which can also serve as an anticholinergic/antispasmodic. Levsin is given for Parkinson's disease to help reduce muscle rigidity and tremors and to help control excess sweating. It is contraindicated in those with kidney disease and has limited use in those with liver disease. Levsin must also be limited to short-term use because it is highly anticholinergic.16
Has anyone ever heard of putting a stroke patient on Parkinsons meds??My patient is on Sinemet AND Amantidene AND Zoloft (dry mouth and very poor appetite)...I have heard of putting CVA's on non-traditional meds for neuro stim (ie Ritalin...to increase alertness) but this lady had her stroke 11-4-03....comments appreciated....Spkez
Neurontin has a not totally undeserved reputation of beign realtively free of side effects. Not exactly or entirely true, obviously! Given that anybody can get any side effect listed on anything, not to mention the ones not listed :-), overall Neurontin is tolerated well by the vast majority who get it. I have had many people on very high doess with no side effects, and it is probably the single most effective agent out there for neuropathic pain. It is only an adjunct for seziures though in general. Bear in mind my population is mostly younger people with physical disabilities. I have not personally had anyone with dysphagia attributable to Neurontin, though have had several on Baclofen; have had 3-4 who are sedated on it and have to limit dose and 1-2 who stopped taking it. I curently have a young man on 900 mg TID currently wtih no problems, reducing it even to 800 brought back some pain and spasm in an affected extremity related to transverse myelitis. Someday perhaps there will be some science in regards to side effects beyond "one man's wonder drug is another man's poison." > Neurontin has one of the worst adverse side effects profiles around. > Number one - like many antileptics- is ataxia. Followed by, among > others: Visual disturbances of all kinds, amnesia, vomiting, > dysarthria, xerostomia, dysarthria, fatigue, headache and on and on. > These are particularly prominent in the elderly and those who are > neurologically vulnerable.
From the ADA site: Effects of Medication on Food Intake and Nutritional Status ORAL AND TASTE/SMELL EFFECTS Drug may impair salivary flow causing dry mouth and increased caries, stomatitis,glossitis. Tricyclic antidepressants such as amitriptyline (Elavil) cause dry mouth and sour or metallic taste. Drug may be secreted into the saliva;the antibiotic clarithromycin (Biaxin) enters the saliva causing a bitter taste. Drug may suppress natural oral bacteria resulting in oral candidiasis; Antibiotics, such as tetracycline, may result in oral yeast overgrowth i.e. candidiasis. Drug may cause dysgeusia (taste change); Antibiotic metronidazole (Flagyl) causes metallic taste in the mouth. Drug may damage rapidly proliferating cells; antineoplastics such as cisplatin or methotrexate cause stomatitis, glossitis, esophagitis. GASTROINTESTINAL EFFECTS Drug may irritate the stomach mucosa causing distress, nausea, vomiting, bleeding,ulceration; NSAIDS Anticholinergic drugs (antipsychotics, antidepressants, antihistamines) slow peristalsis causing constipation. Drug may destroy intestinal bacteria; Antibiotics (e.g. ciprofloxacin (Cipro) cause overgrowth of Clostridium difficile and result in pseudomembranous colitis. APPETITE CHANGES Drug may suppress appetite, e.g.SSRI antidepressant drugs such as fluoxetine (Prozac) may cause anorexia and weight loss. Drug may increase appetite, e.g.Tricyclic antidepressants and most antipsychotic drugs, such as amitriptyline(Elavil), olanzapine (Zyprexa) and clozapine (Clozaril), stimulate appetite and weight gain.
Can any meds HELP dysphagia?
Reduction of risk of pneumonia associated with use of angiotensin I converting enzyme inhibitors in elderly inpatients.
Okaishi K, Morimoto S, Fukuo K, Niinobu T, Hata S, Onishi T, Ogihara T.
Pneumonia is a major direct cause of death in the elderly. Although aspiration based on a reduced cough reflex is one of the causes of pneumonia in the elderly, there are few studies of angiotensin-I converting enzyme inhibitors (ACE inhibitors), which are antihypertensive drugs that induce cough, as a factor influencing the incidence of pneumonia in institutionalized elderly subjects. To assess the effect of ACE inhibitors and dihydropiridine calcium-channel blockers on the incidence of pneumonia, we conducted a hospital-based case-control study. Cases were 55 pneumonia patients aged > or = 65 years during a 1-year period. The controls were elderly subjects, frequency matched to the cases by age and gender (n = 220). Data were collected on known risk factors and on medication for hypertension, consisting of ACE inhibitors, calcium-channel blockers, and nonantihypertensive medication. The significance of differences in risk factors was analyzed using univariate and multivariate comparisons of cases and controls. After adjustment for potential confounding factors, the relative risk estimates for pneumonia were 0.38 (95% confidence interval [CI], 0.15-0.97) and 1.84 (95% CI, 0.89-3.78) for ACE inhibitors and calcium-channel blockers, respectively, relative to nonantihypertensive medication. The preventive effect of ACE inhibitors on pneumonia was apparent in long-acting ACE inhibitor users (0.24; 95% CI, 0.07-0.88). We conclude that ACE inhibitor use is an independent factor reducing risk of pneumonia among elderly inpatients.
Acid suppression - H2 blockers, PPIs. These do not treat reflux, just render it less acidic.
Gastric motility/speed up emptying - Cisapride off the general market, Reglan may work, Erythromycin is a potent motility agent if tolerated.
Treat constipation aggressively
Botox - may spread from cervical injection and cause weakness, may be used to treat cricopharyngeal spasm.
Baclofen - usually adverse, benzodiazepines may help
Effective treatment of Parkinson's may help
Esophageal injury due to swallowing pills may be a factor