CASE: Food issues
Ms. A, age 62, has a 40-year history of paranoid schizophrenia, which has been well controlled with olanzapine, 20 mg/d, for many years. Two weeks ago, she stops taking her medication and is brought to a state-run psychiatric hospital by law enforcement officers because of worsening paranoia and hostility. She is disheveled, intermittently denudative, and confused. Ms. A has type II diabetes, gastroesophageal reflux disease, obesity (body mass index of 34.75 kg/m2), and poor dentition. She has no history of substance abuse.
During the first 2 days in the hospital Ms. A refuses to eat, stating that the food is “poisoned,” but accepts 1 oral dose of aripiprazole, 25 mg. On hospital day 3, Ms. A is less hostile and eats dinner with the other patients. A few minutes after beginning her meal, Ms. A abruptly stands up and puts her hands to her throat. She looks frightened, and cannot speak.
A staff member asks Ms. A if she is choking and she nods. Because the psychiatric hospital does not have an emergency room, the staff call 911, and a staff member gives Ms. A back blows, but no food is forced out. Next, nursing staff start abdominal thrusts (Heimlich maneuver) without success. Ms. A then loses consciousness and the staff lowers her to the ground. The nurse looks in Ms. A’s mouth, but can’t see what is blocking her throat. Attempts to provide rescue breathing are unproductive because a foreign body obstructs Ms. A’s airway. A staff member continues abdominal thrusts once Ms. A is on the ground. She has no pulse, and CPR is initiated.
Emergency medical technicians arrive within 7 minutes and suction a piece of hot dog from Ms. A’s trachea. She is then taken to a nearby emergency department, where neurologic examination reveals signs of brain death.
Ms. A dies a few days later. The cause of death is respiratory and cardiac failure secondary to choking and foreign body obstruction. A review of Ms. A’s history reveals she had past episodes of choking and a habit of rapidly ingesting large amounts of food (tachyphagia).
The authors’ observations
The term “café coronary” describes sudden unexpected death caused by airway obstruction by food.1 In 1975, Henry Heimlich described the abdominal thrusting maneuver recommended to prevent these fatalities.2 For more than a century, choking has been recognized as a cause of death in individuals with severe mental illness.3 An analysis of sudden deaths among psychiatric in-patients in Ireland found that choking accounted for 10% of deaths over 10 years.4 An Australian study reported that individuals with schizophrenia had 20-fold greater risk of death by choking than the general population.5 Another study found the mortality rate attributable to choking was 8-fold higher for psychiatric inpatients than the general population,6 and a study in the United States reported that for every 1,000 deaths among psychiatric inpatients, 0.6 were caused by asphyxia,7 which is 100 times greater than the general population reported in the same time.8
Physiological mechanisms associated with impaired swallowing include:
- dopamine blockade, which could produce central and peripheral impairment of swallowing9
- anticholinergic effect leading to impaired esophageal motility
- impaired gag reflex.10
Multiple factors increase mentally ill individuals’ risk of death by choking (Table 1).11 Patients with schizophrenia may exhibit impaired swallowing mechanism, irrespective of psychotropic medications.12 Schizophrenia patients also could exhibit pica behavior—persistent and culturally and developmentally inappropriate ingestion of non-nutritive substances. Examples of pica behavior include ingesting rolled can lids13 and coins14,15 and coprophagia.16 Pica behavior increases the risk for choking, and has been implicated in deaths of individuals with schizophrenia.17
Medications with dopamine blocking and anticholinergic effects may increase choking risk.18 These medications could produce extrapyramidal side effects and parkinsonism, which might impair swallowing. Psychotropic medications could increase appetite and food craving, which in turn may lead to overeating and tachyphagia. In addition, many individuals suffering from severe mental illness have poor dentition, which could make chewing food difficult.19 Psychiatric patients are more likely to be obese, which also increases the risk of choking.
Table 1
Risk factors for choking in mentally ill patients
| Age (>60) |
| Impaired swallowing (schizophrenia patients are at greater risk) |
| Parkinsonism |
| Poor dentition |
| Schizophrenia |
| Tachyphagia (rapid eating) |
| Tardive dyskinesia |
| Obesity |
| Source: Reference 11 |
OUTCOME: Prevention strategies
New Hampshire Hospital’s administration implemented a plan to increase the staff’s awareness of choking risks in mentally ill patients. Nurses complete nutrition screens along with the initial nursing database assessment on all patients during the admission process, and are encouraged to contact registered dieticians for a nutrition review and assessment if a psychiatric patient is thought to be at risk for choking. Registered dieticians work with nursing staff to promptly complete nutrition assessments and address eating-related problems.