Whelehans Health Blog

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

This is a continuation from last week. There are two general treatment types of dysphagia, one for ‘high’ dysphagia and one for ‘low’ dysphagia.

Treatment of oropharyngeal or ‘high’ dysphagia

There is no complete cure for ‘high’ dysphagia as neurological problems are not easily fixed.  If you exclude dysphagia resulting from Parkinson’s disease (which can be controlled by medication), there are three general treatment types for ‘high’ dysphagia:

• Swallowing therapy is where a speech and language therapist (SaLT) teaches the patient different swallowing techniques.
• Dietary changes (eg) eating softer foods.
• Feeding tubes, provides nutrition short term while person is trying to recover swallowing function or more long term if swallowing is no longer possible

I only discuss dietary changes in more detail here due to space constraint  

Dietary changes
A dietician or nutritionist can help here. Dysphagia patients may benefit from food additives which thicken liquids (available from pharmacies). The increase in thickness can help swallowing function. (eg) Nutilis^®, Think & Easy^®. Reducing the volume of mouthfuls can make swallowing easier. For dysphagia related to neurological problems, administering meals during times of maximal attentiveness helps. Some find it difficult to manipulate, swallow and clear thick liquid textures such as milk shakes and honey. Others have issues swallowing foods which are dry, crispy chewy or stringy.

Taste
Strong flavours like sweet, sour, spicy or salty tastes help stimulate saliva production, swallow and chew. Bland flavours are best avoided.

Temperature
Food is best served at hot or cold temperatures instead of being tepid or at room temperature as hot or cold food stimulates the swallowing reflex better. Cold foods known to stimulate sensory input (if tolerated) include ice cubes and ice cream. Exceptions should be made for those with reduced oral sensation (eg. due to nerve damage) as extremes in temperature run the risk of burning or numbing the oral area.

Texture
Liquids should be thickened to enable formation of a bolus in the mouth allowing easier swallow. Foods that crumble or fall apart in the mouth are difficult to swallow so best avoided. Density and shape are also important. Jelly is often used as it slips down easily. Apple-sauce can prove difficult to swallow as it does not maintain a single strong lump in the mouth. Canned fruit, Jelly and ice cubes may be more manageable.

Consistency
Easy chewed does not automatically mean easy swallowed. Softer foods like porridge (which can be made thicker depending on need), soft peaches and thickened pureed fruits are easier to swallow as they hold shape in the mouth for longer thus stimulating the swallow reflex. Liquids are the most difficult to swallow as unlike solids they do not form a bolus (solid lump) so do not give a strong swallowing stimulus. Avoid using fluids to wash food down as again this causes confusing stimuli and increases aspiration risk.

Mucus Production
Milk products are known to form excess mucus which is difficult to clear and swallow. Chocolate can stimulate mucus secretions in some patients. Yoghurt, cheese and cottage cheese can be added to the diet instead of milk if milk is increasing mucous production.

Treatment oesophageal or ‘low’ dysphagia

Surgery
Dilation is a common surgical procedure to treat obstruction and involves small balloon being placed inside the oesophagus. The balloon is then inflated to gradually widen the oesophagus before balloon deflation and removal.

Botulinum toxin
Botulinum toxin is used for treatment of achalasia (condition where oesophageal muscles become stiff thus causing difficulty passing food and drink to stomach). Botulinum toxin in tiny doses can paralyze stiff muscles that prevent food moving down the oesophagus.

This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

Dysphagia is the medical term for poor swallow. Dysphagia is usually a complication of other conditions including stroke, mouth cancer, throat cancer and gastro-oesophageal reflux disease (GORD). The risk from fluid or food particles aspirating into the lungs is a serious complication that can cause serious or even fatal consequences including lung infection (aspiration pneumonia).

Types of dysphagia

There are two general classifications of dysphagia. The first type is Oropharyngeal dysphagia (also known as high dysphagia). This is where swallowing problems result from mouth or throat problems. The second type is Oesophageal dysphagia (also known as low dysphagia). This is where swallowing problems result from oesophageal problems. Low dysphagia can be due to a blockage in the oesophagus and surgery is often the treatment option. High dysphagia is due to problems with nerves and muscles that control swallow. High dysphagia is more challenging to treat than low dysphagia.

Symptoms

Difficulty or inability to swallow; Pain when swallowing; Coughing or gagging when swallowing; Choking when trying to swallow; Sensation of food being stuck in throat or chest; Food coming back up; Unexplained weight loss; Frequent lung infections (due to aspiration of food and drink into the lungs which can lead to pneumonia).

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Causes  

Neurological causes

Damage to the brain or the nervous system may interfere with nerves that enable the swallowing reflex which can lead to dysphagia. Neurological causes of dysphagia can include stroke, Parkinson’s disease, cerebral palsy, multiple sclerosis and motor neuron disease

Obstruction

Conditions that cause blockage or narrowing of the throat and oesophagus often affect swallow. Examples include Oral cancer or Lung cancer; Cleft palate; Radiotherapy (can cause scar tissue which may narrow the throat and oesophagus); Gastro-oesophageal reflux disease (GORD) and Infections (eg.)  tuberculosis, herpes simplex

Muscular conditions

Caused by the muscles of the oesophagus not functioning properly. Muscular conditions which cause dysphagia include scleroderma and achalasia. Muscles tend to weaken with aging which is a reason it is more common in the older population. However dysphagia should not be accepted as a natural part of aging.

Dry mouth

Dry mouth can exacerbate swallowing problems. A detailed review of medications is advised if medication is suspected to be causing dry mouth. Medications that can cause dry mouth include anticholinergics (eg. some drugs used for depression, schizophrenia, urinary incontinence, vomiting amongst others), antihistamines and certain blood pressure medication (diuretics, beta blockers, ace-inhibitors, calcium channel blockers) so a review by your GP or pharmacist may be advised.

Diagnosing dysphagia 

If a GP suspects dysphagia, he/she has the option of referring to an ear, nose and throat (ENT) specialist. Diagnosis of dysphagia means (1) Finding an exact location of the swallowing problem (‘high’ or ‘low’ dysphagia?) (2) Determining how swallowing ability is affected. Apart from a detailed medical history, other diagnostic techniques include:

Water-swallow test

This provides an initial assessment of swallowing abilities. You swallow 150ml of water as quickly you can; the length it takes to drink this glass of water and number of swallows is recorded to determine extent of the issue.

Barium swallow test

Patient swallows a barium meal so doctors can assess for swallow ability and location of the problem (as barium is seen clearly on X-ray and video footage can be taken).

Endoscopy

An endoscope (small, flexible camera) is passed down the throat and into the oesophagus. The endoscopy can detect scar tissue or cancerous tumours brought on by gastro-oesophageal reflux disease (GORD).

To be continued next week I discuss treatment

This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

This is the conclusion to last week’s article.

Treatment

No treatment is required if flat feet do not cause problems. Well-fitted shoes, especially extra-broad fitting types of shoes can help. For people suffering from over-pronated feet, a special insole, which prevents feet rolling over too much, can ease the problems. These specialised insoles can be advised on by a chiropodist or a physiotherapist. These insoles are also called orthotics and are available in pharmacies. A more permanent solution is a customized orthotic, whereby an orthotic is specifically designed for your foot. Measurements for this type of insole are taken, by your chartered physiotherapist, from a plaster cast of your foot or by stepping into a foam box. These are then sent on to a lab where the custom insole will be created.

If pain occurs, rest, ice and over-the-counter non-steroidal anti-inflammatories, or NSAIDS (eg. ibuprofen) can give temporary relief. Children with an abnormal foot that has not developed properly may require an operation to straighten the foot or to separate bones that have fused. Luckily operations are rarely needed as these are rare causes of flat feet in children. Other actions that can help include wearing footwear with lower heels and wide toes, losing weight if appropriate and doing appropriate exercises that strengthen muscles in the feet which can include walking barefoot, exercises called toe curls (flexing the toes) and heel raises (standing on tiptoes).

Heel cord stretching exercises

These stretch and lengthen the achilles tendon and posterior calf muscles. Your physiotherapist is best for advising on appropriate exercises.

How to do:

Stand facing a wall with your hands on the wall at about eye level. Put the leg needing stretching about a step behind the other leg. Keeping the back heel on the floor, bend the front knee until you can feel a stretch in the back leg. Hold the stretch for 15 to 30 seconds. Repeat 2 to 4 times. You should aim to do this exercise 3 to 4 times a day.

Health Step Physiotherapy

Health Step Physiotherapy, at Whelehans Pharmacy is operated by Chartered Physiotherapist, Kevin Conneely MISCP. Kevin can advise and offer treatment for flat feet. Kevin offers reduced physiotherapy rates for under-18s, students with valid student ID and for Over 65’s. He offers reduced rates for affiliated sports clubs and other groups. Contact Kevin on 087 4626 093 to advice or call Whelehans at 04493 34591 to book an appointment.

Our Chiropodist James Pedley can also advise on flat feet in adults and children; to book his clinic for adults or children call 04493 34591 and he also has reduced rates for children and over 60’s.

This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

During childhood, usually between the ages of 3 and 10, we develop a space (arch) on the inner side of our feet where the bottom of the foot is off the ground. People with a low arch or who have no arch are classified as having flat feet, sometimes referred to as having "fallen arches".

Causes

Flat feet can run in families, and both feet are usually affected. Occasionally, flat feet are due to a problem in the way the foot forms in the womb, in this situation, the feet are stiff and flat and the problem is usually noticeable during childhood.

Another form of the problem is when the foot has a tendency to roll inwards too much while standing or walking. This can be due to weak ligaments in the heel joint or at the base of the big toe. "Pronation" or "over-pronated foot" is a term for excessive rolling of the feet. 

While over-pronated feet usually develop in childhood it can sometimes develop in adulthood. Flat feet may develop due to a ruptured tendon (which is rare), tear of the spring ligament (also rare), arthritis, nerve damage due to diabetes, or injury which leads to stiffness and distortion of the joints of the feet. Conditions of the nervous system or muscles including cerebral palsy, spina bifida or muscular dystrophy can cause flat feet as they can cause muscle weakness or lack of movement in the muscles. These conditions lead to feet becoming stiff which gets worse as the condition develops. Other contributing factors include shoes which limit toe movement such as high heels (walking barefoot may have a protective effect). Tight achilles tendon or calf muscles can make you more prone to flat feet. Obesity also can contribute to flat feet.

When is treatment needed?

Most flat feet do not cause any problem so no treatment is needed. Reasons to look for treatment include pain (not eased by any type of foot wear). Pain from flat feet can occur in a number of areas including inside the ankle, at arch of the foot, the outer-side of the foot, calf, knee, hip or back. Other reasons for treatment include wearing out shoes quickly, feet appear to be getting flatter, feet tire easily, swelling on the inside bottom of feet, feet are stiff and lack of feeling in the feet or weakness.

Health Step Physiotherapy

Health Step Physiotherapy, at Whelehans Pharmacy is operated by Chartered Physiotherapist, Kevin Conneely MISCP. Kevin can advise and offer treatment for flat feet. Kevin offers reduced physiotherapy rates for under-18s, students with valid student ID and for Over 65’s. He offers reduced rates for affiliated sports clubs and other groups. Contact Kevin on 087 4626 093 to advice or call Whelehans at 04493 34591 to book an appointment.

Our Chiropodist James Pedley can also advise on flat feet in adults and children; to book his clinic for adults or children call 04493 34591 and he also has reduced rates for children and over 60’s.

To be continued….next week I discuss treatment

This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans

ASK YOUR PHARMACIST

Long acting anti-psychotic injections (For Schizophrenia)

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

I previously discussed long-acting antipsychotic injections Westmeath Examiner due to a query from a person who is prescribed them for schizophrenia. First-generation antipsychotic (FGA) long-acting injections were introduced in the 1960s. The first of the second-generation antipsychotic long acting injections (LAI) (risperidone LAI) became available in 2002 and since then Xeplion^® (paliperidone) injection has come on the market. For the purpose of this article I refer to long-acting injection versions of antipsychotics as LAIs. This article discusses second-generation antipsychotic LAIs in a little more detail than I did in my previous Examiner article on LAIs.

Why used?

According to studies, approximately 40–60% of patients with schizophrenia do not take their medication regularly and in many cases refuse to take it at all. Long-acting injections are often prescribed when a patient is not taking their oral medication as prescribed. Many decide to use them as they offer the convenience of not taking a tablet every day and in some cases where a tablet did not work. LAIs require the attendance to a clinic for regular injection every 1–6 weeks.  This ensures the medication is given regularly and allows regular review of treatment. LAIs do not guarantee the patient will not relapse but they greatly reduce the risk.

Comparing Long-acting injectable antipsychotics (LAIs) to oral antipsychotics

A 2011 study published in the New England Journal of Medicines found that, in high-risk patients with schizophrenia and schizoaffective disorder, long-acting injectable risperidone did not provide great improvements to key outcomes such as psychiatric symptoms, quality of life or functioning when compared with oral antipsychotics (tablet versions). However, other studies have shown that LAIs give very favourable results when compared to oral antipsychotics and that they reduce hospitalisations by up to 34% when compared to oral antipsychotics and reduce relapses by between 10 and 30% when compared to oral antipsychotics.

Second-generation long-acting antipsychotic injections

Risperidone was the first of the second generation LAIs to be licensed in the UK and Ireland. The drug will not reach a therapeutic level for a few weeks after injection; therefore it is essential that the patient receive supplementary antipsychotic medication (tablet form) during the initial period of treatment following the first injection. It is administered into the gluteus (buttocks) or deltoid (upper arm) muscle every two weeks.

Xeplion^® (paliperidone) injection is the newest LAI; it only needs to be administered once monthly. Paliperidone is effective in relieving both positive symptoms (hallucinations, disturbances of thought, hostility) and negative symptoms (lack of emotion and social withdrawal) of schizophrenia, whereas older antipsychotics are usually less effective against the negative symptoms Paliperidone also relieves 'affective symptoms' that are associated with schizophrenia, such as depression, guilt feelings or anxiety.

For more information, call into Whelehans for a free copy of Eamonn’s comprehensive article on injections used for schizophrenia; he also discusses the older first-generation antipsychotic LAIs (commonly called ‘depot’ injections) such as Zuclopenthixol (Clopixol^®) such as Flupenthixol (Depixol^®). The information is also available at www.whelehans.ie. We also have a comprehensive article on schizophrenia.

This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans