The role of polypharmacy in swallowing: its implications for clinicians (2023)

The role of polypharmacy in swallowing: its implications for clinicians
By Lisa Milliken, MA, CCC-SLP
Current geriatric medicine
Bd. 11 Nr. 4 S. 14

Medications can add a significant risk of dysphagia based on multiple modes of action that can affect all phases of swallowing. One author shared that theReference to the doctor's tablelists dysphagia as a side effect of more than 160 drugs.1 Many of them pose a greater risk to the swallowing process than others.

The risk is increased in people over the age of 65 due to several factors. First, there are age-related pharmacokinetic and pharmacodynamic changes that affect drug sensitivity. For example, in a 70-year-old patient, the doctor can detect significant side effects of a drug that he does not see in a 45-year-old. The condition is further complicated by the fact that older people often have multiple comorbidities for which they take multiple medications. Therefore, although a single drug can produce symptoms of dysphagia, increasing the number of drugs used puts that individual at greater risk of drug interactions.2,3 All of these factors combine to result in a higher incidence of adverse drug reactions in the elderly population. .4.5

We often find elderly clients taking five or more medications for a variety of conditions and symptoms. And these are our healthy patients. However, once they have one or more chronic conditions, this list can grow exponentially.

Knowing how medications affect a patient's functional status is critical. Because the origin of dysphagia is often secondary to the effects of medications, the clinician must quickly identify the mode of action of each patient's medication and consider each medication's adverse drug events (ADEs) as well as the risk of drug interactions.

Aging affects sensitivity to drugs
Age-related changes lead to increased drug side effects in older people. Due to pharmacokinetic changes, there is a decrease in renal and hepatic clearance, which leads to an increase in the volume of distribution of fat-soluble drugs (prolongation of half-life). Similarly, pharmacodynamic changes often increase sensitivity to different classes of drugs, such as anticoagulants and cardiovascular and psychotropic drugs.6 These age-related changes in the kidneys, liver, and other organs affect the amount of drugs that work. And drugs that act on the central nervous system (CNS) will have a greater effect in older people, depending on changes in the blood-brain barrier.

To complicate the clinical picture, the nutritional status of the elderly, several chronic diseases, and functional and cognitive deficits are other age-related factors that can interfere with drug therapy. In general, older customers tend to lose muscle mass, which increases body fat and decreases body water. Cardiac output also decreases in older people. Kidney function gradually decreases and the effectiveness of the immune system decreases. Often these changes require reducing the dose of some drugs to maximize their benefits and avoid toxicity and side effects. These normal physiological changes that occur with age affect how medicines work in the body.

When working with older patients in long-term care and short-term rehabilitation, clinicians see a higher rate of cognitive decline due to the effects of medication. Such factors are crucial for decisions about treatment approaches and compensation strategies. Collaboration with interdisciplinary team members is critical to enable continuous follow-up and reporting, as well as accurate documentation and closure of clinical approaches.

ADE and drug interactions in the elderly
The prevalence of ADE in the elderly is of concern. In a 2012 study, older patients taking five or more medications were almost four times more likely to be hospitalized for ADE than younger people. nine or more drugs.8 The most common classes of drugs most commonly associated with ADEs include cardiovascular drugs, anticoagulants, NSAIDs, diuretics, antibiotics, anticonvulsants, benzodiazepines, and hypoglycemic drugs.

Similarly, drug-drug interactions are also higher in older adults.9,10 In a prospective cohort study of hospitalized older adults taking five or more drugs, the prevalence of a potential drug-drug interaction was 80%. Elderly people who take five to nine drugs have a 50 percent risk of drug interactions, and those who take 20 or more drugs have a 100 percent risk of drug interactions.9

To make matters worse, older people who take multiple medications also suffer from nutritional issues. One study found that 50% of elderly patients taking 10 or more medications were malnourished or at risk of malnutrition. of cholesterol, glucose and sodium.12

How drugs can affect swallowing
With this understanding of the complex effects of medications in older people, we can specifically look at how medications can affect the swallowing process.

Drugs that act on the CNS can cause dysphagia by lowering levels of arousal; direct suppression of brain stem swallowing function; induction of movement disorders, neuromuscular blockade and myopathy; altered oropharyngeal sensation; and disrupt production and salivation.1,13

Drugs that affect central neurotransmitter activity and depress the CNS can affect the anticipation phase and cause altered mental status, leading to confusion or sedation in patients; this in turn can impair their ability to visually recognize food or coordinate motor actions for self-feeding.1 The CNS neurotransmitters histamine, dopamine, acetylcholine, and gamma-aminobutyric acid can depress the CNS and have an adverse effect causing mental state changes. , impairment of cognition, reduction of consciousness and voluntary muscle control, and sedation of patients. Therefore, anticonvulsants, benzodiazepines, narcotics, and skeletal muscle relaxants put the patient at risk of dysphagia.14

Drugs that inhibit salivation can directly cause the development of dysphagia. Salivary secretion and flow are crucial factors for all phases of swallowing, from oral preparation to the oral phase. Salivary lubrication continues to play a key role in the early stages of the esophagus and through the upper digestive tract. Because there are more than 400 drugs that contain xerostomia as an adverse reaction, we observe a high number of elderly people with dysphagia due to frequent use of two or more drugs from this list. Some of the many drugs on this list are those with anticholinergic properties that block acetylcholine in the central and peripheral nervous systems.15

Other drug effects may affect gastrointestinal autonomic motility, including changes in gastric emptying, decreased lower esophageal sphincter function, and the development of esophagitis and stomatitis. Related gastrointestinal effects of drugs include those affecting appetite, taste, and smell. For example, antipsychotics and antihistamines inhibit acetylcholine to affect autonomic motility, and several classes of drugs have side effects such as altered smell and taste or changes in appetite.1,16

anticholinergic properties
It is well known that the peripheral effects of anticholinergic drugs include constipation, dry mouth, dry eyes, tachycardia, and urinary retention. And the CNS effects of these drugs with anticholinergic properties include agitation, confusion, delirium, falls, hallucinations, and cognitive dysfunction.17

Specifically related to dysphagia, anticholinergic drugs may cause or contribute to:

• Relaxation of the lower esophageal sphincter, which aggravates gastroesophageal reflux disease;

• dryness of the mucous membranes (mouth, nose) causing difficulty in forming a bolus or initiating swallowing;

• abnormal peristalsis due to anticholinergic effects on esophageal visceral smooth muscle;

• severe oral motor weakness and difficulty speaking;

• Impaired attention and cognitive impairment, reduced attention to food and voluntary movements in the preoral and oral phases; Y

• Inhibition of swallowing due to anticholinergic effects on esophageal smooth and striated muscle.1,18

Many drugs prescribed to older people have anticholinergic properties, including some antidepressants, muscle relaxants, antispasmodics, antihistamines, and tricyclic antidepressants. Drugs from these drug classes often have strong anticholinergic effects, and elderly patients are particularly susceptible to these effects, which can reach levels of toxicity more quickly, especially if a person takes more than one drug with these properties.

The effect of antipsychotic drugs on swallowing
Drugs in the antipsychotic class appear to have one of the longest lists of most debilitating side effects. And while these drugs may be most useful for certain psychiatric conditions like schizophrenia, they've also been commonly prescribed for other conditions like dementia and anxiety disorders, which does more harm than good. Significant side effects for the swallowing process are the anticholinergic effects already described and extrapyramidal disorders, also known as Parkinson's symptoms. Examples include tardive dyskinesia, bradykinesia, muscle rigidity, akathisia and dystonia. Tardive dyskinesia can significantly affect the preoral and oral stages of swallowing and include severe chewing difficulty and delayed onset of oral swallowing.19

To better understand the effects of antipsychotics on swallowing, consider the presented case study of a 79-year-old man with Alzheimer's disease who was initially placed on Haldol and thioridazine for his aggressive behavior and later switched to loxapine, a typical antipsychotic. After a week, the patient began to choke and became constipated. A modified barium swallow study revealed moderate to severe oral pharyngeal dysphagia characterized by reduced chewing, tongue pumping, reduced tongue range of motion, reduced tongue base movement (probably due to muscle stiffness), reduced bolus control, delayed initiation of pharyngeal swallowing, reduced laryngeal movement, accumulation of debris in vallecules and piriformis after swallowing with penetration of these residues and silent aspiration of light liquids. Repeat study, more than two weeks after drug discontinuation, showed significant improvements.20

Drugs that affect the gastrointestinal system.
Medications can contribute to dysphagia by affecting appetite, taste, and smell. They can also cause significant xerostomia and mucositis. Several drugs can also cause esophageal and mucosal lesions, particularly in the elderly. All of these pharmacological effects are considered to contribute to dysphagia via the gastrointestinal system.

Drug-induced esophagitis is often referred to as tablet esophagitis and is commonly caused by antibiotics, potassium chloride supplements, NSAIDs, bisphosphonates, quinidine, and other sources such as aspirin, iron-containing products, and vitamin C products.

More than 70 commonly used drugs have been associated with drug-induced esophageal injury and esophagitis. Some factors that increase this risk are geriatric age, increased anatomical and motor abnormalities, decreased saliva production, taking medication in the supine position, inadequate fluid intake while taking medication, and drug use of more medication. Geriatric patients also have a higher prevalence of cardiac dilatation with concomitant mid-esophageal compression.21,22

Other Major Classes of Drugs
The list of drugs that contribute to swallowing disorders is extensive. The riskier drug classes include many other drug classes in addition to those already discussed, such as benzodiazepines, antidepressants, neuromuscular blockers, high-dose corticosteroids, and narcotics, to name a few. Of course, the magnitude of the effect of these drugs when swallowed is more significant when prescribed to people over 65 years of age.

The role of the healthcare provider
Older people are at increased risk of dysphagia due to the effects of various drugs. These drugs can affect different elements of swallowing, which can cause different problems that can trigger dysphagia from the preoral to the esophageal phase of dysphagia.

Physicians need to know which medications are common problems for older people and maintain an accurate medication history for each patient's prescription. From then on, the physician should be aware of the side effect profile of each drug and disease process that a patient may experience and what may increase the risk of certain drug interactions. Optimal treatments can then be planned; Compensatory strategies, education, and supportive care plans should be considered. Healthcare team members should also report any side effects to the prescribing physician, as appropriate.

When treating drug-induced esophagitis, the causative agent should be discontinued. If the drug cannot be stopped, strategies for treating dysphagia may include ensuring that the drug is taken with sufficient fluid, that the drug is taken in an upright position, that the drug is taken at least 30 minutes before lying down, and that the agents are offensive and other drugs are spaced to allow recovery time between doses.23

The doctor's most important role is to constantly review the prescription list for all clients, talk to them about the specific side effects they may be experiencing, and educate them about the potential of their medications to cause dysphagia and what they can do to to reduce the risks. . .

— Lisa Milliken, MA, CCC-SLP, is a speech therapist and educational specialist for Select Rehabilitation.

references
1. Carl LL, Johnson PR.Drugs and dysphagia: how drugs can affect eating and swallowing. Austin, TX: Pro-Ed; 2006.

2. Fulton MM, Allen ER. Polypharmacy in the elderly: a review of the literature.Nursing Practice J Am Acad. 2005;17(4):123.

3. Mallet L, Spinewine A, Huang A. The challenge of managing drug-drug interactions in the elderly.Lanzette. 2007;370(9582):185-191.

4. Lavan AH, Gallagher P. Predicting the risk of adverse drug reactions in older adults.Ther Adv Drug Safe. 2010;7(1):11-22.

5. O'Connor MN, O'Sullivan D, Gallagher PF, Eustace J, Byrne S, O'Mahony D. Prevention of hospital-acquired adverse drug reactions in the elderly using the Senior Prescription Screening Tool and the Screening Tool to Alert Correct Treatment Criteria : a cluster-randomized controlled trial.J Am Geriatr Soc. 2016;64(8):1558-1566.

6. Mangoni AA, Jackson SHD. Age-related changes in pharmacokinetics and pharmacodynamics: fundamentals and practical applications.Br J Clin Pharmacol. 2004;57(1):6-14.

7. Marcum ZA, Amuan ME, Hanlon JT, et al. Prevalence of unplanned hospitalizations due to adverse drug reactions among war veterans.J Am Geriatric Society. 2012;60(1):34-41.

8. Nguyen JK, Fouts MM, Kotabe SE, Lo E. Polypharmacy as a risk factor for adverse drug reactions in aged care home residents.Bin J Geriatr Pharmacother. 2006;4(1):36-41.

9. Maher RL, Hanlon JT, Hajjar ER. Clinical consequences of polypharmacy in the elderly.Opinion of a drug expert. 2014;13(1):57-65.

10. Doan J, Zakrzewski-Jakubiak H, Roy J, Turgeon J, Tannenbaum C. Prevalence and risk of potential cytochrome P450-mediated drug-drug interactions in elderly hospitalized patients with polypharmacy.Ana Pharma. 2013;47(3):324-332.

11. Jyrkka J, Enlund H, Lavikainen P, Sulkava R, Hartikainen S. Association of polypharmacy with nutritional status, functional capacity, and cognitive abilities over a three-year period in an elderly population.Safe pharmacoepidemiological drugs. 2010;20(5):514-522.

12. Heuberger RA, Caudell K. Polypharmacy and nutritional status in the elderly: a cross-sectional study.medication for old age. 2011;28(4):315-323.

13. Rofes L, Arreola V, Almirall J, et al. Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly.Praxis Res Gastroenterol. 2011;2011:818979.

14. Chang E, Ghosh N, Yanni D, Lee S, Alexandru D, Mozaffar T. A review of spasticity treatments: pharmacological and interventional approaches.Crit Rev Phys Rehabilitation Med. 2013;25(1-2):11-22.

15. Fusco S, Cariati D, Schepisi R, et al. Management of oral drug therapy in elderly patients with dysphagia. J Gerontol Geriatrics. 2016;64(1):9-20.

16. Salles N. Basic mechanisms of aging in the gastrointestinal tract.You said. 2007;25(2):112-117.

17. Ruxton K, Woodman RJ, Mangoni AA. Drugs with anticholinergic effects and cognitive impairment, falls, and all-cause mortality in the elderly: systematic review and meta-analysis.Br J Clin Pharmacol. 2015;80(2):209-220.

18. Nekl CG, Lintzenich CR, Leng X, Lever T, Butler SG. Effects of heavy swallowing on esophageal function in healthy adults.Neurogastroenterol Motil. 2012;24(3):252-256.

19. Bhat PS, Pardal PK, Diwakar M. Dysphagia due to tardive dyskinesia.Ind Psychiatry J. 2010;19(2):134-135.

20. Sokoloff LG, Pavlakovic R. Neuroleptic-induced dysphagia.Dysphagia. 1997;12(4):177-179.

21. Aparanji KP, Annavarappu S, Russell RO, Dharmarajan TS. Severe dysphagia due to drug-induced esophagitis: a preventable condition.Clin Geriatr. 2012;20(2):34-39.

22. Aslam M, Vaezi MF. Dysphagia in the elderly.Gastroenterol Hepatol. 2013;9(12):784-795.

23. Balzer KM. Drug-induced dysphagia.Int J MS Nursing. 2000;2(1):40-50.