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Relieving Drug-Induced Xerostomia With Sorbet
Affiliations: Department of Nursing, Gonzaga University, Spokane, WA
Abstract: Many older adults living in nursing homes suffer from inadequate food intake secondary to xerostomia, or dry mouth. Persons with xerostomia have difficulty forming a food bolus, swallowing, and tasting food, all of which contribute to diminished nutritional intake. Xerostomia is often drug-induced, and the risk of its development increases as the number of drugs taken increases. Systemic therapies have had limited success in managing drug-induced xerostomia, as many are contraindicated in older adults due to their anticholinergic effects. Thus, alternative, easy to implement, cost-effective interventions aimed at stimulating salivation and decreasing the effects of xerostomia are needed for nursing home residents. This article describes a quality improvement program that has demonstrated how offering 2 ounces of sorbet prior to meals can help ameliorate drug-induced xerostomia and improve food intake among elderly nursing home residents. The author also discusses the relevant medications that contributed to xerostomia in the patients who either gained weight or lost weight during the study.
Key words: Nutrition, quality of life, quality of care, xerostomia, dry mouth.
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Long-term care settings grant access to skilled nursing care by registered nurses who provide ongoing evaluation of the residents’ health status; however, the provision of care in an institutional setting also involves challenges compared with home care or assisted living settings.1 Suominen and colleagues2 noted that as many as 85% of elderly persons living in nursing homes experience inadequate food intake, which can lead to weight loss and undernutrition, a form of malnutrition resulting from a reduced supply of food, or from the body’s inability to digest, assimilate, and utilize necessary nutrients. Although decreased appetite and decreased nutritional intake are common among many older adults, undernutrition is a significant problem in nursing homes, as it can lead to compromised quality of life, chronic disability, functional decline, increased healthcare utilization and related costs, increased morbidity, and even death.1 In particular, there is evidence that poor nutrition and weight loss in these settings ultimately may be due to inadequate food intake.3 Inadequate food intake is multifaceted; it can be caused by poor appetite, chronic disease, sensory loss, poor oral and dental health, and—notably among the nursing home population—polypharmacy, with a wide variety of xerogenic medications. This article reviews the medication classes that are associated with xerostomia in older adults, and in particular, their impact on nutritional intake. Effective relief from xerostomia is critical for improving nutritional intake, but decreasing or discontinuing the causative medications is not always possible. Current treatments for xerostomia have many limitations in older adults; therefore, an alternative strategy is needed. This article also describes the success of an intervention in which sugar-free sorbet was given to elderly nursing home residents prior to meals.
Pathophysiology and Etiology of Xerostomia
A challenging condition that negatively impacts food intake in older adults is xerostomia, also called dry mouth. Persons with xerostomia have difficulty forming a food bolus or swallowing, and they typically experience a diminished ability to taste food. The tastants (ie, any substance, such as salt, capable of eliciting gustatory excitation via stimulation of the sense of taste) travel through salivary secretions to interact with the taste buds on the tongue surface. Saliva plays an essential role in transporting the tastants to the buds. Taste stimuli (ie, tastants) that are water soluble are carried readily to the receptors, whereas others (primarily lipid-based) need soluble carrier proteins to arrive at the receptor, necessitating initial dissolution by saliva to facilitate adherence to the proteins. Any interference with either of these mechanisms will lead to inhibited, or absent, sensation of taste.
Affecting between 12% and 47% of the elderly,4 xerostomia can be temporary, developing from short-term antihistamine use, viral infections, dehydration, and anxiety, or it can be a long-standing condition caused by diseases that affect the salivary glands (eg, Sjögren syndrome,5 HIV, hepatitis C, cystic fibrosis, diabetes) or iatrogenic causes (eg, drugs, local radiation,5 chemotherapy).6,7 In the elderly population, xerostomia is more likely to be drug-induced because of the higher prevalence of complex drug regimens, with the risk of development increasing with the number of drugs that are taken.6 Nursing home residents take, on average, seven to eight different medications each month, and approximately one-third of residents take nine or more.6 Many of these medications have anticholinergic or sympathomimetic mechanisms of action, either of which can cause significant xerostomia.10 Hundreds of medications can cause xerostomia, including over-the-counter agents, as well as commonly prescribed medications for a myriad of chronic illnesses. A sample of the common medications whose side effects can affect nutritional intake are listed in Table 1.8,9
Limitations of Existing Treatments for Xerostomia
Treatment of drug-induced xerostomia has been primarily focused on palliative measures, such as salivary substitutes or stimulants (eg, sugar-free gum, candies, lubricating gels, mouthwashes).6 These products have limited effects because of the need to remove the salivary stimulant from the mouth during swallowing. Systemic therapies, such as pilocarpine and bethanechol, have had limited success in managing drug-induced xerostomia5 and are not without their own side-effect profiles, many of which can interfere with food intake. For instance, pilocarpine and bethanechol are associated with diarrhea, nausea, diaphoresis, and abdominal pain.11,12 Furthermore, these two drugs are frequently contraindicated in elderly patients due to their anticholinergic effects; contraindications include persons with asthma, chronic obstructive airway disease, heart disease, epilepsy, hyperthyroidism, and Parkinson’s disease.13,14 Thus, there is a need to seek alternative interventions, which are easy to implement and cost-effective, that can stimulate salivation and decrease the effects of xerostomia in long-term care residents.
Proposed Intervention to Reduce Xerostomia
In a previous study, the consumption of sugar-free lemon-lime sorbet prior to meals was tested as a novel alternative to the usual treatment for xerostomia.15 Sugar-free lemon-lime sorbet is composed of water, lemon-lime juice, and a sugar substitute. The natural citric acid component in the sorbet has the ability to stimulate salivation by “irritating” or exciting the lingual nerve and corneal afferent fibers, as well as peripheral cutaneous nociceptors and central nociceptive neurons in the trigeminal complex.16
We describe a quality improvement program that has demonstrated how offering 2 ounces of sorbet prior to meals can help ameliorate drug-induced xerostomia and improve food intake among the elderly in nursing homes. The specific aim of this experiment was to test the effects of the intervention on resident food intake and body weight. We also examined the relevant medications that contributed to xerostomia in patients who either gained or lost weight during the study. A program aimed at increasing food intake among nursing home residents by reducing the effects of drug-induced xerostomia may enhance quality of life of older adults residing in nursing home facilities.
Methods
Using a pre–post design, 39 cognitively intact nursing home residents from two different facilities received 2 ounces of lemon-lime sorbet prior to lunch and dinner meals for a period of 6 weeks. As a comparison and prior to the intervention, participants spent an initial 6 weeks drinking 2 ounces of a non-citrus beverage before lunch and dinner meals.
Participants
Nursing staff at both facilities identified all residents who took at least two medications associated with xerostomia, and who met the following inclusion criteria: (1) age ≥65 years; (2) Mini-Mental State Examination (MMSE) score of 12 to 30, indicating moderate/mild or normal cognition; (3) residence in a nursing home and with meals taken in the main dining room; (4) positive screen for drug-induced xerostomia; and (5) ability to self-feed within an hour. The following residents were excluded from the study:
- Residents who scored lower than 12 on the MMSE
- Residents who did not screen positive for xerostomia
- Residents who were actively dying or receiving palliative or hospice care; enhancing oral nutrition is essential for health and longevity in a non-hospice setting;
- Residents with a history of head/neck radiation, salivary gland surgery, or Sjögren syndrome; any of these conditions can interfere with production of saliva, as well as nerve conduction along the afferent neural pathways, and they would unpredictably interfere with study results
- Residents with a diagnosis of dysphagia, as the condition may be intermittent and interfere with nutritional intake irrespective of medication profiles.17 It could not be adequately controlled for in the study setting.
- Residents with a diagnosis of major depression, as the condition may interfere with appetite or even with the normal pleasant physiologic sense of food intake.18 It could not be controlled for in the study setting.
- Residents who ate a pureed diet; consumption of pureed food does not require saliva to be involved in taste, as the oral nutrition is already mechanically dissolved prior to intake.
Each participant was screened for xerostomia using a three-step process: drug review, oral inspection, and subjective evaluation. Residents who took at least two xerogenic drugs, displayed three out of five visual indicators of xerostomia, and reported three out of six subjective symptoms of xerostomia were identified as suffering from xerostomia (a positive screen). Of those residents initially identified by nursing homes staff, 39 were recruited to participate in the study. Human subjects research approval from the Institutional Review Board was obtained through Gonzaga University’s Human Subjects Protection Program prior to initiation of the project.
Measures
A plate waste protocol was used to determine actual food intake for each participant during lunch and dinner meals over the 7 days prior to both the comparison and intervention periods. This accurate procedure uses a gram food scale to weigh and compare weights of original food servings to weights of the remaining foods left on the plate after meals.19 Each resident was weighed at baseline and upon completion of both the comparison and intervention periods; patients wore approximately the same amount of clothing at each weigh-in and were weighed at the same time of day.
Results
A total of 22 residents (11 from each site) completed both the comparison and intervention periods. All were aged 65 years or older, and 59% (n=13) were women. MMSE scores ranged from 12 to 29 (average, 20.6). All had screened positive for xerostomia. The number of medications prescribed that potentially could cause xerostomia ranged from two to six per resident (average, 3.3). Major drug categories implicated in affecting nutritional intake included antidepressants, analgesics, diuretics, anxiolytics, benzodiazepines, beta-blockers, and H2 blockers/proton-pump inhibitors (PPIs).
A repeated-measures analysis of variance (ANOVA) was conducted to measure the effects of sorbet on resident food intake. Overall, it was found that the amount of liquids ingested during dinner was reduced significantly from 356 mL in the comparison period to 310 mL in the postintervention period (P=.002). Liquid intake with meals was inversely related to nutritional intake at the same meal. The amount of food ingested during the dinner meal increased significantly from 208 g in the comparison period to 253 g in the post-intervention period (P=.001).
Of the 22 residents who completed the study, 36% (n=8) gained weight, 45% (n=10) maintained their weight, and 18% (n=4) lost weight. Of the residents who gained weight, all of them were prescribed three or more xerogenic medications. Specifically, all residents who gained weight were taking an antidepressant. One resident was taking two antidepressants. Further, four of the eight residents were prescribed an analgesic, diuretic, anxiolytic/benzodiazepine, and/or an H2 blocker/PPI.
In evaluating the four residents who exhibited weight loss, the first was a 90-year-old resident who was admitted to hospice during the study, thus weight loss was an expected outcome. Of the three remaining residents, one was taking two antidepressants concomitantly, another was taking two separate diuretics, and the third resident was taking both a beta-blocker and a PPI concomitantly.
Discussion
In this study, we found a statistically significant improvement in residents’ food intake using a simple intervention that added a small amount of sugar-free sorbet prior to two daily meals. The presumed positive results were appreciated without any modification to the existing medication regimens of the study participants. Thus, the result is postulated to be from stimulation of saliva production. All residents were taking xerogenic medications, which have a known potential to negatively impact nutritional intake and overall nutrition. As discussed, the incidence of xerostomia is very high in older adults, with polypharmacy being the most common cause.8 Numerous drug classes that are utilized extensively in the elderly population can have untoward side effects, particularly anticholinergic activity, which may lead to xerostomia. Table 220,21 and Table 38,9 provide an overview of common pain medications and central nervous system medications that can affect nutritional intake.
In our study, several residents were taking multiple medications that are known to cause xerostomia. Without making any changes to the residents’ medication profiles, the addition of sorbet resulted in weight gain for 36% of the residents. There was a statistically significant increase in the quantity of food consumed, as well as a statistically significant decrease in the quantity of liquids consumed, the latter indicating that less liquid intake was required to facilitate mastication and swallowing. This is an important factor, as the intake of excess fluids with a meal can often cause early satiety and decreased caloric intake overall, further contributing to undernutrition. By stimulating salivation with a sour citrus sorbet, the need for fluids was reduced, while caloric intake was increased.
It is worth discussing the incidence of polypharmacy in the elderly, as it was illustrated in our study population. Residents were maintained on multiple psychotropic medications or diuretics in some cases. Medications with antihistaminergic activity not only cause xerostomia directly, they can cause confusion and sedation, both of which interfere with proper nutritional intake.9
Opioids have similar side effects, as well as the potential to elicit nausea and decreased gut motility, leading to early satiety.22 Anxiolytics are routinely prescribed in elderly patients for many reasons, such as insomnia and anxiety; however, this class of medications is considered inappropriate in the elderly population, according to Beers,9 due to their unreliable pharmacodynamics (eg, prolonged sedation), contribution to cognitive decline, and potential for additive sedation when used in conjunction with many other medications—most notably opioids and antihistamines.9
Limitations
The quality improvement program described herein was conducted at two eastern Washington nursing homes. As such, the results may not be applicable to other settings or populations. Additionally, when discussing the side-effect profile and pharmacotherapeutic effects of any medication, these effects are considered generalizable to the population. Individual variation in response to any medication is always possible.
Conclusion
Undernutrition in elderly adults has its roots in many unique causes, particularly among individuals who reside in institutional settings. Polypharmacy, feelings of loss of autonomy, concomitant medical disease, cognitive decline, and impaired mobility may all impact the intake of nutrients. In this study it was noteworthy that several residents were taking multiple medications that are known to have a negative impact on nutritional intake. Whereas discontinuation of many of these types of medications may not be feasible for most, we have shown that the simple addition of a calorie-free citrus sorbet prior to meals improves nutritional intake without the need to modify the medication profile. However, it is our hope that with education and acknowledgment on the part of prescribers as to the potential risks of reduced food intake inherent to many medication classes, greater consideration will be given before prescribing such therapies to residents of nursing homes.
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Disclosures: The author reports no relevant financial relationships.
Address correspondence to: Neva L. Crogan, PhD, 502 East Boone Avenue, Spokane, WA 99258; crogan@gonzaga.edu
