How should xerostomia and dry throat be treated in an elderly patient?

Treatment of Xerostomia and Dry Throat in Elderly Patients

Begin with topical interventions including cold water sprays, cold water swabs, and mouth/lip moisturizers as first-line therapy, as this "bundle" approach significantly reduces xerostomia intensity and distress in elderly patients. 1

Immediate Non-Pharmacological Interventions

Topical Moisture Therapy (First-Line)

• Apply a combination of cold sterile water sprays, cold sterile water swabs, and mouth/lip moisturizers, as this bundled intervention significantly decreased both thirst intensity and distress in randomized trials 1
• Use frozen gauze pads with normal saline or ice chips, which are significantly more effective than wet gauze alone for reducing xerostomia 1
• Apply topical products containing olive oil, betaine, and xylitol, which have demonstrated effectiveness for relieving dry mouth 1

Critical Products to Avoid

• Never use lemon-glycerin swabs, as they produce an acidic pH, dry oral tissues, cause irreversible enamel softening and erosion, and paradoxically exhaust salivary mechanisms over time, leading to worsened xerostomia 1

Humidification for Oxygen-Dependent Patients

• For non-intubated patients receiving high-flow oxygen therapy, use heated humidifiers rather than bubble humidifiers, as this significantly lowers mouth and throat dryness 1

Hydration Management

Adequate Fluid Intake

• Ensure women consume at least 1.6 L of fluids daily and men consume at least 2.0 L daily, as aging dampens thirst sensation and impairs kidney concentration ability, while adequate hydration maintains saliva production necessary for oral comfort 2
• Water, milk, tea, coffee, and unsweetened fruit juice all contribute to fluid intake 2
• For underweight or frail patients, recommend milky drinks that provide energy and protein alongside hydration 2

Medication Review and Optimization

Identify and Modify Causative Medications

• Review all medications for anticholinergic properties (psychotropic agents, antihistamines) and diuretics, as these are the most prevalent causes of xerostomia in elderly patients 3, 4
• Altering anticholinergic agents plays an important role in management and should be prioritized when clinically feasible 4
• Consider that acetylcholinesterase inhibitors can worsen xerostomia by altering the oral environment 2

Pharmacological Interventions

Salivary Stimulants (For Patients with Residual Gland Function)

• Pilocarpine hydrochloride 5 mg orally three times daily is FDA-approved for xerostomia, with the option to increase to 10 mg three times daily if tolerated 5
• After 6 weeks of treatment, statistically significant global improvement of dry mouth occurs compared to placebo, with patients reporting improved ability to speak without water, sleep without drinking water, and swallow food without drinking 5
• The most common adverse events are sweating (the most common cause of withdrawal at 12% with 10 mg dose), nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 5
• Salivary stimulants appear more beneficial than saliva substitutes in patients with residual salivary gland function 4

Artificial Saliva Substitutes (For Patients Without Residual Function)

• Oxygenated glycerol triester (OGT) saliva substitute spray shows the strongest evidence of effectiveness compared to electrolyte sprays, with approximately a 2-point improvement on a 10-point visual analogue scale for mouth dryness 6
• Consider artificial saliva substitutes for patients who have undergone head and neck radiation or have autoimmune diseases like Sjögren's syndrome with minimal residual gland function 3, 7

Addressing Underlying Systemic Causes

Screen for Common Etiologies

• Evaluate for chronic mouth breathing, dehydration, autoimmune diseases (Sjögren's syndrome), diabetes mellitus, nephritis, and thyroid dysfunction, as these systemic conditions can diminish salivation 3
• Proper management of underlying disease is essential before initiating symptomatic treatment 7

Preventing Oral Complications

Dental Referral and Preventive Care

• Refer all patients with chronic xerostomia to a dentist for preventive care, as they are at significantly increased risk for dental caries, dysgeusia, glossodynia, sialadenitis, cracking and fissuring of the oral mucosa, and halitosis 3
• Xerostomia affects denture retention, mastication, and swallowing, requiring specialized dental management 3

Family Involvement in Care

Engage Family Members in Symptom Management

• Query family members about their interest in assisting with xerostomia-relieving measures, as they can provide simple mouth care and ice chips (if not contraindicated) 1
• Family members who are invited to provide care are almost twice as likely to perceive more respect, increased collaboration, greater support, and higher overall family-centered care 1

Critical Clinical Pitfalls

Common Errors to Avoid

• Do not assume xerostomia is a natural consequence of aging—it is most commonly caused by medications, systemic disease, or radiation therapy, not aging itself 3, 8
• Do not rely solely on objective tests of salivary flow, as there is little correlation between patient symptoms and objective measurements; clinical management should be based on patient symptoms 4
• Avoid using lemon-glycerin swabs despite their historical popularity, as they worsen xerostomia over time 1

Quality of Life Considerations

Impact on Daily Function

• Recognize that chronic xerostomia has a debilitating effect on the integrity of hard and soft tissues of the mouth, causing difficulty in speaking, tasting, eating, swallowing, and denture retention 8
• Effective management can significantly enhance quality of life for xerostomia sufferers when approached in a compassionate, understanding manner 8