Covert dysphagia and recurrent pneumonia related to antipsychotic treatment
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* Jonathan T. Stewart

A 65-year-old man with a lifelong history of paranoid schizophrenia had been treated with 50 mg of risperidone microspheres every 2 weeks for the past 10 years and had tolerated this therapy well. Approximately 1 year ago some drooling and a modest resting tremor developed, but there were no other signs of parkinsonism. He also experienced gradually worsening pleural effusion. Six months after these symptoms developed, he experienced 3 prolonged hospital admissions for aspiration pneumonia over a period of 2 months. A swallowing evaluation at that time revealed severe oropharyngeal dysphagia, and a percutaneous endoscopic gastrostomy tube was placed. Owing to concerns of possible antipsychotic-induced dysphagia, risperidone was discontinued and substituted with 400 mg/d of quetiapine. The patient’s condition improved over the subsequent 3 months, with no further pneumonia and advancement back to a regular diet. The pleural effusion resolved; it was probably a para-pneumonic effusion related to chronic silent microaspiration.

There is growing evidence that antipsychotic treatment is an important risk factor for the development of pneumonia, both in geriatric1–5 and in younger populations.5,6 Although the mechanisms of this association have not been entirely elucidated, antipsychotic-induced dysphagia likely plays a major role.1,7 Antipsychotic-induced dysphagia is a common but often unappreciated problem. Regan and colleagues, 8 for example, reported a prevalence of 23% in a group of 60 hospitalized patients with schizophrenia, and a dose-related association between antipsychotics and dysphagia has been well established.9

Healthy individuals commonly aspirate small amounts of oral secretions, but sometimes aspirate food and drink.10 Aspiration pneumonia ensues only when the amount of aspirate (or the virulence of the bacteria aspirated) overwhelms the patient’s defenses.10,11 Laryngeal closure during the pharyngeal phase of swallowing is a critical defence that minimizes the quantity of aspirate. It is known that antipsychotics, including second-generation agents, can profoundly affect the oral and pharyngeal phases of swallowing.12–14 Changes in the pharyngeal phase of swallowing are most predictive of aspiration and include delayed, slowed and incomplete laryngeal elevation (and therefore glottic closure); poor pharyngeal peristalsis; and pooling in the piriform sinuses with subsequent spillover into the airway.13,14 These changes may occur even in the absence of any other signs of parkinsonism and may occur with any first-or second-generation antipsychotic.7 Other mechanisms, including sedation, 1–7 xerostomia1–4,6,7 and possibly immune dysfunction,4,5 have been implicated in the association with pneumonia, but drug-induced pseudo-parkinsonism is likely foremost.

Although drug-induced parkinsonism is the most important mechanism leading to aspiration, it is not the only one. Dystonic reactions and tardive dyskinesia can both affect swallowing and lead to aspiration.7 Drug-induced xerostomia may lead to difficulties with swallowing and ultimately to aspiration.7 Conversely, clozapine-induced sialorrhea is a risk factor for aspiration pneumonia.15 Finally, abnormal eating and swallowing habits, predominantly fast eating and taking inappropriately large boluses, have been reported in individuals with schizophrenia for more than 60 years, well before antipsychotics were in common use.7,16,17 These behaviours often lead to choking, acute asphyxia and aspiration pneumonia.

Management of patients taking antipsychotics who show evidence of aspiration or experience recurrent pneumonia begins with careful evaluation. If the cause is not obvious, evaluation by a speech pathologist can be of great help. Management of aspiration or recurrent pneumonia related to drug-induced parkinsonism usually begins with an attempt to minimize the antipsychotic dosage or to switch to an agent with less extensive dopaminergic blockade (either from a first- to a second-generation agent, or to another agent within the same class). There are numerous reports supporting this strategy, 18–20 although some larger studies have suggested equal risk of pneumonia (but not necessarily of dysphagia) with first- and second-generation agents.1,2,4,5 There have also been reports of successful treatment with either an anticholinergic agent21 or with amantadine.18 No studies have specifically addressed feeding or dietary modifications, but most authors believe that modifications similar to those made for patients with Parkinson disease are reasonable.7 These include thickening liquids, eating fully upright, tucking the chin before swallowing, minimizing distractions and encouraging smaller bites and sips ( using volume control cups, straws and utensils).7

## References

1.  Trifiro G, Gambassi G, Sen EF, et al.Association of community-acquired pneumonia with antipsychotic drug use in elderly patients: a nested case-control study.Ann Intern Med 2010;152:418–25.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.7326/0003-4819-152-7-201004060-00006&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=20368647&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 
    
    [Web of Science](http://jpn.ca/lookup/external-ref?access_num=000276386900002&link_type=ISI) 

2.  Aparasu RR, Chatterjee S, Chen H.Risk of pneumonia in elderly nursing home residents using typical versus atypical antipsychotics.Ann Pharmacother 2013;47:464–74.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1345/aph.1R510&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=23548651&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

3.  Mehta S, Pulungan Z, Jones BT, et al.Comparative safety of atypical antipsychotics and the risk of pneumonia in the elderly.Pharmacoepidemiol Drug Saf 2015;24:1271–80.
    
    

4.  Tolppanen AM, Koponen M, Tanskanen A, et al.Antipsychotic use and risk of hospitalization or death due to pneumonia in persons with and those without Alzheimer disease.Chest 2016;150:1233–41.
    
    

5.  Nose M, Recla E, Trifiro G, et al.Antipsychotic drug exposure and risk of pneumonia: a systematic review and meta-analysis of observational studies.Pharmacoepidemiol Drug Saf 2015;24:812–20.
    
    

6.  Yang SY, Liao YT, Liu HC, et al.Antipsychotic drugs, mood stabilizers, and risk of pneumonia in bipolar disorder: a nationwide case-control study.J Clin Psychiatry 2013;74:e79–86.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.4088/JCP.12m07938&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=23419234&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

7.  Kulkarni DP, Kamath VD, Stewart JT.Swallowing disorders in schizophrenia.Dysphagia 2017;32:467–71.
    
    

8.  Regan J, Sowman R, Walsh I.Prevalence of dysphagia in acute and community mental health settings.Dysphagia 2006;21:95–101.
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=16763936&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

9.  Rudolph JL, Gardner KF, Gramigna GD, et al.Antipsychotics and oropharyngeal dysphagia in hospitalized older patients.J Clin Psychopharmacol 2008;28:532–5.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1097/JCP.0b013e318184c905&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=18794648&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 
    
    [Web of Science](http://jpn.ca/lookup/external-ref?access_num=000259427900009&link_type=ISI) 

10. Huffnagle GB, Dickson RP, Lukacs NW.The respiratory tract microbiome and lung inflammation: a two-way street.Mucosal Immunol 2017;10:299–306.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1038/mi.2016.108&link_type=DOI) 

11. Mason CM, Nelson S.Pulmonary host defenses and factors predisposing to lung infection.Clin Chest Med 2005;26:11–7.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1016/j.ccm.2004.10.018&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=15802161&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 
    
    [Web of Science](http://jpn.ca/lookup/external-ref?access_num=000228169800003&link_type=ISI) 

12. Bazemore PH, Tonkonogy J, Ananth R.Dysphagia in psychiatric patients: clinical and videofluoroscopic study.Dysphagia 1991;6:2–5.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1007/BF02503456&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=1884635&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

13. Leopold NA.Dysphagia in drug-induced parkinsonism: a case report.Dysphagia 1996;11:151–3.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1007/BF00417906&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=8721075&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

14. Sokoloff LG, Pavlakovic R.Neuroleptic-induced dysphagia.Dysphagia 1997;12:177–9.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1007/PL00009533&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=9294935&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 
    
    [Web of Science](http://jpn.ca/lookup/external-ref?access_num=A1997XR85500001&link_type=ISI) 

15. Stoecker ZR, George WT, O’Brien JB, et al.Clozapine usage increases the incidence of pneumonia compared with risperidone and the general population: a retrospective comparison of clozapine, risperidone, and the general population in a single hospital over 25 months.Int Clin Psychopharmacol 2017;32:155–60.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1097/YIC.0000000000000162&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=28059928&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

16. Fioritti A, Giaccotto L, Melega V.Choking incidents among psychiatric patients: retrospective analysis of thirty-one cases from the West Bologna psychiatric wards.Can J Psychiatry 1997;42:515–20.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1177/070674379704200509&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=9220116&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

17. Arieti S.Primitive oral habits and their interpretation.Interpretation of SchizophreniaNew YorkR Brunner1955361–70.
    
    

18. Tang KT, Hsieh MH.A case of schizophrenia with dysphagia successfully treated by a multidimensional approach.Gen Hosp Psychiatry 2010;32:e11–3.
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=21112445&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

19. Stewart JT.Dysphagia associated with risperidone therapy.Dysphagia 2003;18:274–5.
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=14571332&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

20. Dziewas R, Warnecke T, Schnabel M, et al.Neuroleptic-induced dysphagia: case report and literature review.Dysphagia 2007;22:63–7.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1007/s00455-006-9032-9&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=17024549&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom) 

21. Hayashi T, Nishikawa T, Koga I, et al.Life-threatening dysphagia following prolonged neuroleptic therapy.Clin Neuropharmacol 1997;20:77–81.
    
    [CrossRef](http://jpn.ca/lookup/external-ref?access_num=10.1097/00002826-199702000-00009&link_type=DOI) 
    
    [PubMed](http://jpn.ca/lookup/external-ref?access_num=9037576&link_type=MED&atom=%2Fjpn%2F43%2F2%2F143.atom)