I Can't Get No Salivation
Abstract & Commentary
By Allan J. Wilke, MD, MA, Chair, Department of Integrative Medicine, Ross University School of Medicine, Commonwealth of Dominica. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: Elders who ate sorbet before a meal ate more of the rest of their meal.
Source: Crogan NL. Managing xerostomia in nursing homes: Pilot testing of the Sorbet Increases Salivation intervention. J Am Med Dir Assoc 2011;12:212-216.
Xerostomia (dry mouth) is one of several contributors to malnutrition in the elderly.1 This pilot study from the University of Arizona's Center on Aging hypothesized that individuals suffering from xerostomia could stimulate salivation by consuming lemon-lime sorbet and that, subsequently, they would increase their food intake.
The study was conducted at a skilled nursing facility. Participants were residents who were taking ≥ 4 medications known to cause xerostomia and who met the following inclusion criteria: age ≥ 65 years, Mini Mental State Examination score ≥ 12, taking meals in the main dining room, and screened positive for xerostomia. Residents who were receiving palliative or hospice care, who had received head or neck radiotherapy, who had salivary gland surgery, or who had Sjögren syndrome were excluded. To confirm the presence of xerostomia, the subjects underwent a Modified Schirmer Test. This involves measuring saliva output with strips of filter paper, performed at baseline, and then three more times at 1-minute intervals after consuming water or sorbet. Sorbet, on average, produced more saliva than water.
Twenty residents were randomly selected; 12 agreed to participate, 8 female and 4 male. Two did not complete the study secondary to hospitalization. The study was conducted over 12 weeks. Each subject was given 2 ounces of sugar-free sorbet before lunch for two 3-week periods divided by a 6-week no-treatment period. (Patients with xerostomia are at high-risk for severe dental decay; hence, the use of a sugar-free sorbet.) Their lunch plates, filled with food, were weighed before serving and again after the meal to measure the amount of food consumed. Nine of the 10 residents ate more food during the sorbet weeks than the non-sorbet weeks, but in only one resident did the difference reach statistical significance. In that patient, the difference in weight of food eaten was about 7 grams.
Commentary
This is a very small study and not robust enough to draw any conclusions, but the intervention is so simple and appealing, we should pay attention to it. It is low-cost and would be easy to implement. Anything that confirms the wisdom of "Life is short; eat dessert first" is okay in my book, but "more food eaten" falls short of my desires for a primary endpoint. What about improved health status, or, at the very least, improved quality of life? A larger, more vigorous study should be undertaken.
Sorbet is simply a frozen sweetened water, pureed fruit, or juice concoction often served before the main course of a meal to cleanse the palate. I wonder if fruit other than lemons and limes would work as well, and whether sherbet (fruit and milk) would have a similar effect.
Xerostomia interferes with proper nutrition by diminishing the taste of food and making chewing and swallowing difficult. It usually is treated by correcting the underlying cause, or, when that is not possible, by sipping water frequently, eating ice chips, stimulating salivation, or replacing it with artificial saliva preparations containing hypromellose or methylcellulose. Sucking on sugar-free lozenges or candy, chewing gum, or administering pilocarpine or cevimeline can stimulate salivary flow, but those drugs have their own set of adverse effects.2
As interesting and potentially useful as this intervention could be, it begs the questions: Why were all of these patients on at least four drugs known to cause xerostomia? Shouldn't the first step be to do a diligent medication review and trim the list? Although there are several causes of xerostomia (e.g., radiation treatment of head and neck cancer, Sjögren syndrome, Parkinsonism, AIDS, and diabetes), most often it is the result of the drugs that we prescribe. Drugs that cause xerostomia are usually anticholingerics or antimuscarinics, although there are others (e.g., diuretics and benzodiazepines). These drugs have other unintended consequences.3 The mantra in the elderly should be "less is more." The fact that we can prescribe medication shouldn't compel us to do so.
References
1. Chapman IM. The anorexia of aging. Clin Geriatr Med 2007;23:735-756.
2. Atkinson JC, et al. Salivary hypofunction and xerostomia: Diagnosis and treatment. Dent Clin North Am 2005;49:309-326.
3. Wilke AJ. Are you prescribing loco weed? Internal Medicine Alert 2006;28:65-67.
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