Documente Academic
Documente Profesional
Documente Cultură
Introduction:
When we evaluate a person’s eating and swallowing function,
we have to put on our critical thinking caps, be detectives,
and collaborate with the team. To determine if there may be a
drug-induced dysphagia, we discuss symptoms and medications
with the patient/family/caregivers, medical team, psychiatrists,
pharmacists, and nurses. Lethargy, cognitive impairment,
inattention, distractibility, tremors, dry mouth, discoordination,
oral and pharyngeal delays in swallowing, food getting stuck,
burning sensation and odynophagia, drooling, dysphonia, weak
cough, aspiration, and inability to manage secretions could all
potentially be “blamed” on medications.
In this blog, I will cover some medications that Speech-
Language Pathologists (SLPs) working with adults should have
in their radar. First, I will discuss how Sinemet could relieve
symptoms of dysphagia in patients with Parkinson’s Disease
when used correctly. Second, I will cover three groups of
medications that could cause side effects which could elevate
risks for dysphagia and aspiration, particularly in geriatrics
(keep in mind the mnemonic of ABA).
Chlorpromazine (Thorazine)
Loxapine
Haloperidol (Haldol)
Lurasidone (Latuda)
Risperidone
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
Clozapine
Extrapyramidal symptoms
Neuroleptic Malignant Syndrome (NMS)
Drug-induced dysphagia
Potential Solutions:
The medical team frequently looks to Cogentin (Benzotropine)
as an antiparkinsonian medication to alleviate the parkinsonian
symptoms. However, this has significant anticholinergic side-
effects as noted above.
Discontinuation of the offending medications can lead to
resolution of the dysphagia, but it may take days to clear out of
the body and weeks for full resolution of the symptoms of the
drug-induced dysphagia. Haldol stays in the system after the
medication has been discontinued, with a half-life of 14-26
hours in IV form and 14-37 hours when given orally in
healthy individuals. It is metabolized in the liver and excreted
in the feces and urine. The elderly and/or those with liver and
kidney disease may have an even greater issue with slow
clearance of the medications.
Unfortunately, tardive dyskinesias (TD) can be persistent and
even irreversible, as the antiparkinsonian medications do not
resolve them. Per the FDA report above: “The risk (for
persistent TD) appears to be greater in elderly patients on high-
dose therapy, especially females.”
Conclusions:
In closing, I want to stress the fact that it may not be just one
medication that is the culprit for your patient’s difficulty eating
and swallowing. The medical team also needs to consider the
issue ofpolypharmacy. Regarding the issue of
polypharmacy, check out this interview with Dr Holly Holmes, from
University of Texas, Houston. She spoke on the implications of
polypharmacy in the elderly at the SIOG 2015 (International
Society of Geriatric Oncology). She notes that polypharmacy
may be taking over 5-10 medications, but the main issue is that
the patient may be “taking more drugs than is indicated.” She
notes that polypharmacy can cause falls, cognitive impairment,
and delirium.
Hospitalized elderly patients, especially those who are critically
ill, have an elevated risk for developing delirium (up to 56%
during hospitalization and up to 87% during ICU stay per Dr
Kennedy, 2015, October). Per Kennedy’s talk, hospitalized
patients over the age of 65 with delirium have increased
risks for complications within the hospitalization, such
as:
Benzodiazepines
Muscle relaxants (i.e., Flexeril)
Antihistamines (i.e., Diphenydramine, aka, Benedryl has a
long half-life and should be avoided in the elderly)
Tricyclic Antidepressants or TCAs (due to anticholinergic
effects, orthostatic hypotension, and sedation). Wilson &
Mottram (2004) noted the following common side effects with
TCAs: dry mouth, drowsiness, dizziness and lethargy. TCAs
have been replaced now by SSRIs (Selective serotonin
reuptake inhibitors, like Celexa and Prozac). However, SSRIs
may still cause nausea, vomiting, dizziness and drowsiness in
some elderly, per Wilson & Mottram (2004).
References:
Aldridge, K.J. & Taylor, N.F. (2012). Dysphagia is a common
and serious problem for adults with mental illness: a systematic
review. Dysphagia, 27, 124-137.
Balzer, K.M. (2000). Drug-induced dysphagia. International
Journal of MS Care, 2 (1), 40-50.
Brunbech, L. & Sabers, A. (2002). Effect of anti-epileptic drugs
on cognitive function in individuals with epilepsy: a comparative
view of new versus older agents. Drugs, 62 (4), 593-604.
Casey, D.E. (1993). Neuroleptic-induced acute extrapyramidal
syndromes and tardive dyskinesia.Psychiatric Clinics of North
America, 16 (3), 589-610.
Dziewas, R., et al. (2007). Neuroleptic-induced dysphagia: Case
report and literature review. Dysphagia, 22, 63-67.
Hughes, T.A.T, Shone, G, Lindsay, G. & Wiles, C.M. (1994).
Severe dysphagia associated with major tranquilizer
treatment. Postgrad Med Journal, 70, 581-583.
Fonda, D., Schwarz, J. & Clinnick, S. (1995). Parkinsonian
medication one hour before meals improves symptomatic
swallowing: Case study. Dysphagia, 10, 165-166.
Kalisvaart, K.J., et al. (2005). Haloperidol prophylaxis for elderly
hip-surgery patients at risk for delirium: A randomized placebo-
controlled study. Journal of the American Geriatrics Society,
53 (10), 1658-1666.
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-
5415.2005.53503.x/abstract
Kennedy, A. (2015, October). Delirium: Aka toxic/metabolic
encephalopathy. Session presented at Geriatric Conference
2015: Geriatric Syndromes in the Hospitalized Patient, Newton-
Wellesley Hospital, Newton, MA.
Larsen, K.A., Kelly, S.E., Stern, T.A., Bode, R.H., Price, L.L,
Hunter, D.J., et al. (2010). Administration of Olanzapine to
prevent postoperative delirium in elderly joint-replacement
patients: a randomized controlled trial. Psychosomatics, 51 (5),
409-
418.http://www.sciencedirect.com/science/article/pii/S0033318210707
234
Marks, Cheryl (2015, October). Pain Management in the
Older Adult. Session presented at Geriatric Conference 2015:
Geriatric Syndromes in the Hospitalized Patient, Newton-
Wellesley Hospital, Newton, MA.
Nagamine, T. (2008). Serum substance P levels in patients with
chronic schizophrenia treated with typical or atypical
antipsychotics. Neuropsychiatric Disease and Treatment, 4 (1),
289-294.
O’Neill, J.L. & Remington, T. (2003). Drug-induced esophageal
injuries and dysphagia. The Annals of Pharmacotherapy,
37, 1675-1684.
Priff, N. & Harold, C. (Eds.). (2005). Pharmacology: A 2-in-1
Reference for Nurses. Philadelphia, PA: Lippincott Williams &
Wilkins.
Servis, M. (1996, March). Managing agitated patients in a
general hospital, Western Journal of Medicine, 164 (3), 257-
258.
Sico, J.J. & Patwa, H. (2011). Risperidone-induced bulbar palsy-
like syndrome. Dysphagia, 26, 340-343.
Silwa, J. & Lis, S. (1993). Drug-induced dysphagia. Arch Phys
Med Rehab, 74, 445-447.
Sokoloff, L.G. & Pavloakovic, R. (1997). Neuroleptic-induced
dysphagia. Dysphagia, 12, 177-179.
Stroschus, B., & Allescher, H.D. (1993). Drug-induced
dysphagia. Dysphagia, 8, 154-159.
Wang, W. et al. (2012). Haloperidol prophylaxis decreases
delirium incidence in elderly patients after non-cardiac surgery:
A randomized controlled trial. Critical Care Medicine, 40 (3),
731-
739.http://journals.lww.com/ccmjournal/Abstract/2012/03000/Haloperi
dol_prophylaxis_decreases_delirium.4.aspx
Wilson, K. & Mottram, P. (2004). A comparison of side effects of
selective serotonin reuptake inhibitors and tricyclic
antidepressants in older depressed patients: A meta-
analysis. Int Journal of Geriatric Psychiatry, 19 (8), 754-62.
Share this: