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Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).
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PMID:[Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly]. 1962 4

This represents the third clinical update based on presentations at the American Medical Directors Association (AMDA) annual meeting. Topics covered this year include hypertension, heart failure, cachexia, dehydration, falls, depression, constipation, and aspiration pneumonia.
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PMID:Clinical update on nursing home medicine: 2009. 1980 52

ABSTRACT Body packers are people who illegally carry drugs, mostly cocaine as well as opium and/or heroin, concealed within their bodies. The packets are inserted in the mouth, rectum, or vagina in order to get across borders without being detected. In this presentation we report a case of an opium body packer and review the available scientific literature by focusing on mechanisms of toxicity and treatment approach. The patient was a 35-year-old man who had lethargy, respiratory depression, tachycardia, normal blood pressure, hyperthermia, and pinpoint pupils on presentation. No past medical history was obtained and the only positive history was his travel from Afghanistan 2 days earlier, which he had given to emergency personnel before arriving at our hospital. Complete blood cells and kidney and liver tests were all in normal range. In the emergency department, the patient was treated with oxygen, naloxone, and hypertonic glucose. One dose of activated charcoal (1 g/kg) was administered orally. After intravenous injection of naloxone (4 mg), the lethargy, respiratory depression, and miosis were resolved. The patient was admitted to the intensive care unit and 90 min after admission, the patient redeveloped respiratory distress and lost consciousness. He was intubated and mechanically ventilated due to the suspicious of body packing. Plain abdominal x-ray showed multiple packets throughout the gastrointestinal tract; 81 packets were removed by surgery and three of them were left due to leaking. After removing the packets, the patient was treated conservatively. He suffered a pulmonary infection (aspiration pneumonia) and he regained consciousness after 4 days. Upon recovery the patient was seen by a psychiatrist prior to going to prison. Surgery is recommended for body packers who have significant signs or symptoms.
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PMID:A case report of opium body packer; review of the treatment protocols and mechanisms of poisoning. 2002 Sep 70

With the increasing size of the elderly population and evolving imaging technology, silent brain infarction (SBI) has garnered attention from both the public and the physicians. Over 20% of the elderly exhibit SBI, and the prevalence of SBI increases steadily with age, ie, 30%-40% in those older than 70 years. Well-known cardiovascular risk factors such as hypertension has been identified as a risk factor of SBI (odds ratio [OR] = 3.47) Besides this, blood pressure (BP) reactivity to mental stress, morning BP surges, and orthostatic BP changes have been demonstrated to contribute to the presence of SBI. Further, a metabolic syndrome not only as a whole syndrome (OR =2.18) but also as individual components could have an influence on SBI. Increased C-reactive protein and interleukin-6, coronary artery disease, body mass index, and alcohol consumption have also been associated with SBI. The ORs and possible mechanisms have been discussed in this article. Overt stroke, dementia, depression, and aspiration pneumonia were all associated with SBI. (overt stroke: hazard ratio [HR] =1.9, 95% confidence interval [CI]: 1.2-2.8; dementia: HR =2.26, 95% CI: 1.09-4.70). We also looked into their close relationship with SBI in this review.
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PMID:Risk of "silent stroke" in patients older than 60 years: risk assessment and clinical perspectives. 2085 71

Management of cough in the elderly with a deteriorated physical and mental status has received little focus. Since an aged population is rapidly increasing in developed countries, the research in this population are warranted. Cough reflex sensitivity in the elderly was shown to be hypersensitive, normosensitive and hyposensitive. The hypersensitive cough reflex is mostly due to gastro-esophageal reflux in nursing home patients. Impaired cough reflex sensitivity is assumed to play a crucial role in the development of pneumonia in the elderly. A marked depression of cough reflex sensitivity is reported in elderly patients with aspiration pneumonia. The impairment of the cough reflex in patients with aspiration pneumonia can involve both cortical facilitatory pathways for cough and medullary reflex pathways. We found the urge-to-cough in patients with aspiration pneumonia was also down-regulated, suggesting the involvement of supramedullary dysfunction in the etiology of aspiration pneumonia in the elderly. In order to prevent aspiration pneumonia in the elderly, restoration of cough reflex sensitivity is essential. We found several methods to restore cough reflex sensitivity in the elderly. They also improved the swallowing reflex, another important airway protective reflex, in the elderly. In the treatment of aspiration pneumonia, one of the most challenging steps is the start of eating for patients who usually fast at the time of hospitalization. By combining the methods to restore the cough reflex sensitivity and swallowing reflex, we developed a protocol to start eating in the elderly patients with aspiration pneumonia. Using the protocol, we reduced the incidence of re-aspiration due to start of eating in patients with aspiration pneumonia to one third of the patients without the protocol.
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PMID:Cough in the elderly: a novel strategy for preventing aspiration pneumonia. 2093 3

Aspiration pneumonia related to dysphagia is known to be the leading cause of death in patients with Parkinson's disease (PD). We investigated the relationship between depressive states and dysphagia in patients with PD. A hundred and twenty-seven PD patients gave their informed consent and were enrolled in this study. We used the Beck Depression Inventory (BDI) questionnaire to determine the participants' depressive states, and also used a questionnaire to assess participants' state of dysphagia. Participants were divided into four groups according to their BDI score. We compared the PD patients with Swallowing Disturbances Questionnaire (SDQ) scores of more than or equal to 11 with the SDQ scores of less than 11 regarding depressive categories. A logistic regression analysis was conducted to calculate odds ratios (ORs) and their 95% confidence intervals (95%CI) adjusting for age, sex, disease duration, wearing-off phenomenon and severity of movement disorder. OR (95%CI) of depressive categories, in which the trivial class was set as a reference group, were 3.28 (0.93-11.55), 13.44 (3.10-58.16), 30.35 (5.65-162.97) in the mild class, the moderate class and the severe class, respectively. This study suggests that there may be a strong relationship between depressive states and dysphagia in patients with PD.
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PMID:Relationship between dysphagia and depressive states in patients with Parkinson's disease. 2145 55

Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).
 ...
PMID:Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly. 2209 17

Oropharyngeal dysphagia describes difficulty with eating and drinking. This benign statement does not reflect the personal, social, and economic costs of the condition. Dysphagia has an insidious nature in that it cannot be 'seen' like a hemiplegia or a broken limb. It is often a comorbid condition, most notably of stroke, and many other neurodegenerative disorders. Conservative estimates of annual hospital costs associated with dysphagia run to USD 547 million. Length of stay rises by 1.64 days. The true prevalence of dysphagia is difficult to determine as it has been reported as a function of care setting, disease state and country of investigation. However, extrapolating from the literature, prevalence rises with admission to hospital and affects 55% of those in aged care settings. Consequences of dysphagia include malnutrition, dehydration, aspiration pneumonia and potentially death. The mean cost for an aspiration pneumonia episode of care is USD 17,000, rising with the number of comorbid conditions. Whilst financial costs can be objectively counted, the despair, depression, and social isolation are more difficult to quantify. Both sufferers and their families bear the social and psychological burden of dysphagia. There may be a cost-effective role for screening and early identification of dysphagia, particularly in high-risk populations.
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PMID:Definition, prevalence and burden of oropharyngeal dysphagia: a serious problem among older adults worldwide and the impact on prognosis and hospital resources. 2305 95

Khat is a drug widely used in the Horn of Africa and the Arabian Peninsula. Khat leaves contain, among other substances, the psychoactive alkaloid cathinone, which induce central nervous system stimulation leading to euphoria, hyperactivity, restlessness, and insomnia. However, it also could cause psychological adverse effects such as lethargy, sleepiness, psychoses, and depression necessitating pharmacologic treatment. Here we report the case of a 35-year-old man from Somalia who became unconscious and developed aspiration pneumonia and subsequent ARDS after excessive consumption of khat leaves. His unconsciousness was possibly caused by the sleepiness developed after khat consumption and a benzodiazepine intake by the patient himself. Thus, khat-induced adverse effects should not primarily be treated pharmacologically, but patients should be urged to quit khat consumption in order to eliminate or, at least, reduce the severity of present psychological adverse effects.
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PMID:Development of ARDS after Excessive Kath Consumption: A Case Report. 2480 15

Dysphagia, or difficulty swallowing, affects more than 15 million Americans and can result in adverse and potentially fatal consequences, including poor quality of life, depression, dehydration, malnutrition, aspiration pneumonia, and airway obstruction. Although many treatment options are available, provision of thickened liquids is a common intervention for achieving slower, more controlled bolus manipulation and propulsion. To meet this therapeutic demand, commercially available products containing starch and/or gum-based components have been developed for use by patients and institutions. The nutrient content of thickened products has been neglected, although dysphagic patients are often at significant nutrition risk. Thus, there are no clinical guidelines for selection of thickened products based on patient characteristics. To consider whether such guidelines are warranted, it is necessary to quantify nutrition differences among common thickened beverages. An analysis was conducted to quantify energy, carbohydrate, and sodium provided through daily consumption of thickened beverages. To determine the relevance of these nutrition contributions in the context of total dietary intake, we compared values with dietary recommended intakes. This analysis revealed that there are substantial disparities in the nutrient content of thickened beverages. These differences suggest that product selection can be optimized based on patient-specific characteristics such as weight status and presence of comorbidities. Future research focusing on the effect of this strategy on patient outcomes will facilitate the development of evidence-based recommendations to elevate the standard of care for this population.
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PMID:Nutrient intake from thickened beverages and patient-specific implications for care. 2554 37


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