Letters to the Editor
Zenker’s Diverticulum and Psychosis in the Elderly
Dear Editor:
Zenker’s diverticulum is a pouch protruding posteriorly above the upper esophageal sphincter (1). A small diverticulum may be asymptomatic, while a large one may produce dysphagia, food regurgitation, weight loss, and gastroesophageal reflux symptoms. Pneumonia has been reported as a complication in 12% of cases (2). I present the case of an elderly man whose recurrent complications of a Zenker’s diverticulum exacerbated a preexisting psychotic illness. I am not aware of any similar cases in the literature.
Case Report
A 70-year-old man presented with a several-year history of monthly exacerbations of psychotic symptoms. The episodes are characterized by the patient yelling and talking loudly to himself. As well, he displays agitation, poor attention, and disorientation as to date—and often year and at times, place—together with fluctuation in symptoms. He has a 50-year history of a psychotic illness and a diagnosis of chronic, undifferentiated schizophrenia. He currently receives olanzapine 20 mg daily at bedtime.
During the episodes of increased psychosis, physical examination and chest x-rays have revealed pneumonia; antibiotic treatment is followed by improvement in the agitation and psychosis. When a swallowing study was performed, the patient’s upper esophagus filled with the bolus, with evidence of a Zenker’s diverticulum.
This man’s recurrent episodes of increased psychosis are consistent with repeated episodes of delirium superimposed on his schizophrenia. The delirium appears to be associated with pneumonia that is in turn likely related to aspiration caused by the Zenker’s diverticulum. Delirium is a frequent complication of pneumonia, with increased morbidity and mortality in the elderly (3,4). Since fever is frequently absent, delirium may be the only manifestation of pneumonia in the elderly (5).
Treatment recommendations should take into account measures to prevent aspiration. These include a moist solid diet, using a chin-tuck head posture to drink thin liquids (which should be given separately from meals), and good oral hygiene to decrease oral bacteria and the risk of pneumonia if aspiration occurs. Consultation with a gastroenterologist is important to assess esophageal function. Surgical correction of the Zenker’s diverticulum is often not considered in the elderly, owing to concerns about increased surgical risk. Nevertheless, the surgery has been found to be safe and effective, with resolution of symptoms and improved quality of life for most patients (2).
References
1. Acker E. Zenker’s diverticulum. Dig Dis 1998;16:144–51.
2. Crescenzo DG, Trastek VF, Allen MS, Deschamps C, Pairolero PC. Zenker’s diverticulum in the elderly: is operation justified? Ann Thorac Surg 1998;66:347–50.
3. Curyto KJ, Johnson J, Ten Have T, Mossey J, Knott K, Katz IR. Survival of hospitalized elderly patients with delirium: a prospective study. Am J Geriatr Psychiatry 2001;9:141–7.
4. Bross MH, Tatum NO. Delirium in the elderly patient. Am Fam Physician 1994;50:1325–32.
5. Torres A, El-Ebiary M, Riquelme R, Ruiz M, Celis R. Community-acquired pneumonia in the elderly. Semin Respir Infect 1999;14:173–83.
JP Cooper, MD, FRCPC
Toronto, Ontario
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