REVIEW

The Impact of Aging and Medical Status on

Dysgeusia
Quratulain Syed, MD,a Kevin T. Hendler, DDS,a Kenneth Koncilja, MDb
a
Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, Ga; bCleveland Clinic, Cleveland, Ohio.

ABSTRACT

Disorders of taste and smell can cause an aversion to food in a sick patient and therefore affect his/her
ability to maintain optimal nutrition. This can lead to a reduced level of strength, muscle mass, function, and
quality of life. Additionally, reduced ability to differentiate between various intensities or concentrations of
a tastant can result in increased intake of salt and sugar and exacerbation of chronic diseases such as heart
failure and diabetes. These implications can be heightened in the elderly, who are particularly frail and are
challenged by polypharmacy and multiple comorbid conditions. In this article, we will review the preva-
lence, etiology, and management of taste disorders. Additionally, we will review the association between
taste and smell disorders and how disorders of smell can affect perception of taste.
Ó 2016 Elsevier Inc. All rights reserved.
The American Journal of Medicine (2016) 129, 753.e1-753.e6

KEYWORDS: Dysgeusia; Hospitalized elderly; Long-term care; Oral care; Polypharmacy; Weight loss

CLINICAL SCENARIO gastrointestinal endoscopy and a colonoscopy, which failed

Ms. Edwards is an 89-year-old female nursing home resi- to show any ulcers or evidence of malignancy.
dent admitted to an inpatient medicine service for failure to
thrive, severe malnutrition, loss of appetite, and a 25-pound TERMINOLOGY AND DEFINITIONS
weight loss in the past 6 months. Past medical history is
Taste disorders (dysgeusias) can be classified into qualita-
significant for osteoporosis, congestive heart failure, chronic
tive and quantitative disorders. The qualitative disorders
renal insufficiency, and hypothyroidism. She has been
include parageusia (inadequate or wrong taste perception
hospitalized twice during the past 6 months for exacerbation
elicited by a stimulus) and phantogeusia (presence of a
of heart failure, with resultant adjustment of her heart failure
persistent, unpleasant taste in the absence of any stimulus).
medication regimen. She notes a persistent loss of appetite
The quantitative disorders include ageusia (a complete loss
and lack of taste in her food for the past 6 months, pre-
of the ability to taste), hypogeusia (a partial loss of the
venting her from enjoying her food. She denies any diffi-
ability to taste), and hypergeusia (enhanced gustatory
culty swallowing, nausea, vomiting, or abdominal pain on
sensitivity).1 Burning mouth syndrome (BMS), also referred
eating. She also denies being depressed. Basic blood work
to as glossodynia or stomatodynia, is a sensation of spon-
indicated acute renal insufficiency due to dehydration,
taneous, continuous burning pain felt in the tongue or oral
which was corrected with intravenous fluids. Other blood
mucosa, commonly seen in postmenopausal women.
work including electrolytes, liver function, and thyroid
Impairment in sense of smell is called dysosmia and
function labs were unremarkable. She underwent an upper
complete loss of sense of smell is called anosmia.

Funding: None.
Conflict of Interest: None.
Authorship: All authors had access to the data and a role in writing the
manuscript.
Requests for reprints should be addressed to Quratulain Syed, MD,
Department of Medicine, Division of General Medicine and Geriatrics,
Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta,
GA 30303.
E-mail address: Quratulain.syed@emory.edu
PREVALENCE
The National Health and Nutrition Examination Survey
(NHANES) 2011-2012 reported that more than 5% of the
over 142 million US respondents experienced taste disorders,
and more than 10% experienced smell disorder in the past 12
months. Sex was not associated with the prevalence of either
disorder, but increasing age was associated with increasing

0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjmed.2016.02.003
753.e2 The American Journal of Medicine, Vol 129, No 7, July 2016

prevalence of both taste and smell disorders.2 Additionally, ethmoid bone prior to dissemination on the surface of the
taste disorders are more prevalent in hospitalized and insti- olfactory bulb. This makes it highly vulnerable to injury
tutionalized older adults compared with those living in the during head trauma. In this situation, a complete loss of
community.3,4 Glazar et al5 reported taste disturbance in sense of smell is more common.
13.9% of institutionalized individuals, compared with 3.2%
of community-dwelling individuals.5 Aging can affect gus-
ETIOLOGY
tatory function, as observed by
increasing of electrogustometry Impairment in Sense of
thresholds and reduction in density CLINICAL SIGNIFICANCE
Olfaction and its Effect on
of fungiform papillae.6 Numerous
Dysgeusia is fairly prevalent in older
medication conditions and sur-
Taste
adults, especially those admitted to Because the taste sensations are
geries (summarized in Table 1 and
hospitals or residing in long-term care conducted by 3 major nerves, a
elaborated below in the article) are
facilities. complete loss of taste (ageusia) is
also associated with dysgeusia.

Dysgeusia can impact a patient’s enjoy- very rare and occurs in only 3% of
all patients with dysgeusia.1
ment of food, overall nutritional status,
Among those patients presenting
ANATOMY and management of chronic diseases. for evaluation of loss of taste and
Gustatory receptor cells are present

Review of medications and attention to smell, 70% report loss of smell
in the taste buds on the dorsal and
oral health should be prioritized in pa- alone or in addition to loss of
lateral surfaces of the tongue, the
tients presenting with dysgeusia. taste. Less than 10% report an
soft palate, uvula, larynx, pharynx,
isolated loss of taste, while only
epiglottis, and esophagus. These
4% have a solitary measurable
receptor cells are innervated by
loss in gustation.1,7 Therefore, olfactory symptoms should
afferent neurons and are able to regenerate with a half-life of
be explored and olfactory function be evaluated in patients
about 15 days. Transduction of the 5 taste stimuli—acid, salt,
presenting with a complaint of loss of taste.
bitter, sweet, and umami (a pleasant savory taste imparted by
glutamate)—occurs by different chemical transmission sys-
tems. Taste sensations are transported via 3 cranial nerves: Genetic
cranial nerve VII innervates the anterior third of the tongue In a study involving patients with phantogeusia, there was
and the palate; cranial nerve IX innervates the back of the increased expression rate of some of the T2R taste receptor
tongue; and cranial nerve X innervates the oropharynx and the genes compared with controls, hinting that increased
pharyngeal portion of the epiglottis. Additional taste receptors expression of taste receptor genes may be involved in the
are found in the small intestine. The trigeminal nerve (cranial pathogenesis of phantogeusia.8
nerve V) is also involved in the transfer of sensations such as
the temperature, texture, and spiciness of food. The brain Postoperative
stem, thalamus, and the anterior insula play a key role in the Middle ear surgeries with resultant transection of the chorda
processing of the taste information by the central nervous tympani nerve can result in gustatory impairment.9 Addi-
7
system. Due to involvement of multiple nerve tracts, it’s tionally, tonsillectomies, dental procedures such as extrac-
rather difficult to completely lose the sense of taste. tions and treatment of abscessed teeth, and wearing dental
Olfaction, on the other hand, relies only on the olfactory prostheses can contribute to phantogeusia and glossodynia.1
nerve, and its axons pass through the cribriform plate of the There have been case reports of ageusia after the use of
laryngeal mask airways for surgery, and compression of the
lingual nerve has been hypothesized as the cause. Local
Table 1 Chronic Medical Conditions Contributing to Dysgeusia
anesthetic injected near the inferior alveolar nerve during
Sinusitis/upper respiratory infections dental procedures has been reported to cause ipsilateral loss of
Chronic hepatitis C taste and atrophy of fungiform papillae. However, these
Chronic kidney disease symptoms have been noted to resolve in a few months.10
Diabetes mellitus
Heart diseases
Thyroid disorders, esp. hypothyroidism Medications
Cognitive disorders/dementias Numerous medicines are excreted in saliva by carrier-mediated
Parkinson disease transport or passive diffusion.11 They can affect sense of taste
Malignancies by various mechanisms including drugereceptor interaction,
Dental/oral: periodontal disease, dental caries, oropharyngeal disturbance of action potential propagation in cell membranes
candidiasis of afferent and efferent neurons, and alteration of the neuro-
Mental health disorders and epilepsy
transmitter function. Additionally, limiting the access of taste
chemicals to sensing receptors due to mucosal dryness, closing
Syed et al The Impact of Aging and Medical Status on Dysgeusia 753.e3

of taste pores, or altering the constituents of mucous or saliva
can also impact the sense of taste.12
A review of the Italian national database of spontaneous
adverse drug reactions (ADR) (Agenzia Italiana del Farm-
aco) from 1988-2008 showed that taste alteration alone was
reported in 75% of cases of ADRs, and both taste and smell
impairment were noted in 13% of ADRs. Macrolides,
antimycotics, fluoroquinolones, protein kinase inhibitors,
angiotensin-converting enzyme inhibitors, HMG-CoA
reductase inhibitors (statins), and proton pump inhibitors
were the leading culprits.12 Resolution of symptoms varied,
with improvement reported within days to a few months
after discontinuation of the offending medicine.
Antiretroviral medications have been associated with
dysgeusia in human immunodeficiency virus patients.13
Chemotherapeutic drugs used for treatment of cancers,
especially 5-fluorouracil and its oral analogs, have also been
associated with dysgeusias, with greater prevalence in the
elderly.14 Numerous other commonly prescribed drugs,
described in Table 2, can contribute to dysgeusia.
Nicotine
Smoking can affect taste acuity, as smokers have increased
electrogustometry thresholds and decreased vasculariza-
tion and density of fungiform papillae compared with
nonsmokers.15
Dementia
Patients with mild cognitive impairment and Alzheimer de-
mentia have increased impairment in olfaction and taste
compared with controls.16 Alzheimer dementia and vascular
dementia can affect the insula and therefore, taste cognition.17
Additionally, medications prescribed for management of
dementias (eg, cholinesterase inhibitors) can also contribute
to taste disturbance.
Up to 70% of patients with Parkinson disease experience
dysosmia,18 and 9% experience dysgeusia.19 Lewy body-
related degeneration has been observed in pathological ex-
amination of the olfactory bulbs in patients with Parkinson
disease, which can explain the strong association between
dysosmia and Parkinson disease.20 As taste information also
connects to the amygdala and hippocampus, patients with
Parkinson disease can experience dysgeusia. Additionally,
patients with Parkinson disease may have underlying
depression, poor oral hygiene, gastrointestinal disease, and
zinc deficiency, which may explain dysgeusia in absence of
dysosmia.
Endocrine Disorders
Diabetes can affect gustatory function. Diabetics have been
observed to have higher electrogustometric thresholds and
lower density of the fungiform papillae compared with age-
matched controls.21 This can affect their food choices and
glycemic control.
Both dysgeusia and dysosmia have been reported in pa-
tients with untreated hypothyroidism, with improvement in
symptoms after treatment of the thyroid disease.22 BMS has
also been reported in a few case series as a presenting
feature of hypothyroidism.23
Due to increased prevalence of BMS in postmenopausal
women, steroid dysregulation has also been hypothesized as
a possible contributor.20
Chronic Diseases
Upper respiratory disorders are frequently associated with
both taste and smell disorders. Up to 38% of individuals
with taste problems in NHANES 2011-2012 reported

Table 2 Medications Contributing to Dysgeusia

Medication Groups Frequently Associated with Dysgeusia Common Medicines in the Groups Associated with Dysgeusia
Antimicrobial medicines Macrolides, fluoroquinolones, ampicillin, metronidazole, tetracycline,
trimethoprim-sulfamethoxazole, amphotericin B, terbinafine and other
antimycotic drugs
Angiotensin-converting enzyme (ACE) inhibitors Captopril, ramipril
Antiarrhythmic medications Amiodarone, procainamide
HMG-CoA reductase inhibitors (statins) Atorvastatin, simvastatin
Proton pump inhibitors (PPI)
Anti-retroviral medications Atazanavir, darunavir, and ritonavir
Anti-epileptic medications Carbamazepine, phenytoin, topiramate
Diuretics Acetazolamide
Dopamine precursor Levodopa
Protein kinase inhibitors Sunitinib, erlotinib, imatinib
Anticholinergic medicines Antispasmodics, antimuscarinics, tricyclic anti-depressants
Psychiatric medicines Lithium, aripiprazole
Gout medicines Colchicine, allopurinol
Muscle relaxants Baclofen
Endocrine medications Antithyroid medications, corticosteroids, levothyroxine
Chemotherapeutic agents 5-fluorouracil, cisplatin
753.e4
experiencing nasal congestion.2 Additionally, survey par-
ticipants with a history of heart failure, heart attack, liver
problems, and impaired vision reported increased taste
disturbance in the past 12 months compared with partici-
pants who did not have these medical conditions. This as-
sociation was valid even after adjustment for risk factors
including head or nasal injury or sinus infections.24
Dysgeusia, including metallic taste and impairment in
identification and intensity of different flavors, has also been
observed in individuals with chronic kidney disease and
chronic hepatitis C. Individuals with chronic hepatitis C
experience problems in identification and intensity of
different food flavors. Numerous hypotheses have been put
forth, including alteration in function of affected brain cells
in the taste area by the virus, and alteration in secretion of
neurotransmitters involved in taste perception.25
Uremic state in chronic kidney disease can affect salivary
flow leading to dry mouth and dysgeusia.26 Additionally,
medications and zinc deficiency can affect taste perception
in patients with chronic kidney disease.
The association between heart diseases and taste distur-
bance is usually due to concomitant renal dysfunction and
adverse effects of medications.
Electrolyte and Nutritional Deficiency
The principle nutrient deficiency commonly associated with
taste loss is that of zinc. A reduction in number and size of
taste buds in zinc-deficient animal models has been
demonstrated. However, this has not been consistently
verified in double-blind trials. Vitamin A deficiency has
been associated with atrophy of taste buds in animal models,
and vitamin B12 deficiency can lead to atrophic glossitis,
resulting in loss of taste sensation. Additionally, electrolyte
disturbances including hyponatremia have been reported to
cause taste disturbance.27
Oral/Dental Conditions
The mouth is the gateway for food into the body. Therefore,
changes in the oral cavity can have an impact on taste. Older
adults frequently have poor oral hygiene with increased
dental caries and periodontal disease. Poor oral health may
be more pronounced in institutionalized older adults where
access to dental care may be limited and daily oral hygiene
inadequate.27 Additionally, xerostomia (dry mouth) is
frequently experienced by patients taking numerous medi-
cations and patients with dehydration, diabetes, Sjögren
disease, and thyroid conditions.
Dental caries, periodontal disease, candidiasis, stomatitis,
dental-alveolar infections, xerostomia, tumors, and me-
chanical trauma can lead to taste disorders in the elderly.5,28
Dentures, especially those that do not fit well, can cause
traumatic ulcers, stomatitis, and fungal infections. Addi-
tionally, patients wearing dentures that cover the hard palate
report increased taste problems.29
The American Journal of Medicine, Vol 129, No 7, July 2016
Malignancies
Chemosensory dysfunction is fairly prevalent in individuals
with advanced malignancies. One study showed that 86% of
individuals with advanced cancer (defined as locally recur-
rent or metastatic) reported some degree of chemosensory
abnormality, especially persistent bad taste in the mouth and
taste distortion.30
Radioactive iodine therapy for thyroid cancers has been
shown to affect salivary flow, especially from parotid
glands, and high-dose radioactive iodine therapy has been
associated with increased oral pain and problems with taste
and chewing.31
Head and neck cancer patients treated with radiotherapy
or chemotherapeutic agents, or both, can develop altered
taste acuity, radiation-induced xerostomia, and dysphagia,
which can lead to anorexia. However, with the use of
intensity-modulated radiotherapy in the treatment of head
and neck cancer, >80% of cancer survivors reported normal
or near-normal taste function at 3 and 5 years after intensity-
modulated radiotherapy.32
Mental Health Disorders and Epilepsy
Dysgeusia has been reported in depressed, nondelusional
patients.33 Impairment in suprathreshold measures of su-
crose taste intensities has been shown in patients with major
depression, compared with controls.34 Gustatory (and ol-
factory) hallucinations can also be a feature of psychiatric
disorders such as schizophrenia, schizoaffective disorder,
and bipolar disorder, or a manifestation of parietal, tempo-
ral, or temporoparietal partial seizures.35,36
EVALUATION AND MANAGEMENT OF TASTE
DISORDERS
It is important to screen for taste or smell disorders if your
patient is experiencing appetite problems and weight loss. A
proposed screening question has been adapted from the
NHANES 2011-2012 survey:
Have you experienced problems with taste or smell in the
past 12 months?
A detailed history should include questions about sali-
vary flow, problems with taste and smell, chewing prob-
lems, pain in the oral cavity, problems with teeth and
dentures, dental hygiene, and ear or upper respiratory
infections.
A loss of taste can be both regional and quality specific,
with different thresholds for different substances in different
regions of the tongue, palate, and pharynx. Primary care
physicians can use easily available stimuli such as sugar
(sweet), citric acid (acid), sodium chloride (salty), or
caffeine or quinine (bitter) to do a quick and objective taste
assessment in their office. A referral to an otolaryngologist
may be warranted for detailed evaluation.
Evaluation and management of upper respiratory in-
fections, oral candidiasis, and basic blood work to rule out
metabolic or endocrine disorders should be pursued.
Syed et al The Impact of Aging and Medical Status on Dysgeusia
Figure Schematic diagram of management of taste disorders. HbA1c ¼ glycated hemoglobin;
LFT ¼ liver function test; TSH ¼ thyroid-stimulating hormone.
A thorough review of medications can help identify
medications contributing to dysgeusia. Based on the
comorbidities and indication of the culprit medication, an
evaluation to stop the medicine or change to an alternative
medication with less taste distortion side effects may be
warranted. Taste-related side effects should be discussed as
part of the potential risks of prescribed medications prior to
initiation of therapy.
Many older adults lack private dental insurance, and
Medicare does not cover routine dental care. Medicaid
dental coverage for adults varies by state, with only about
one half of the states paying for preventive dental care or
restorative services.37 This greatly limits access to dental
care for low-income older adults who rely on Medicaid. A
dental referral for examination and treatment of oral disease
should be a priority when there is a complaint of altered
taste. This should also include evaluation and management
of dry mouth. Additionally, primary care physicians should
discuss the importance of good oral hygiene and the role of
good oral health in the overall health of an individual.
Currently there is insufficient evidence to recommend
zinc supplementation to improve taste perception or acuity
in zinc deficiency-related or idiopathic dysgeusia.38
FOLLOW-UP ON MS. EDWARDS
Ms. Edwards continued to eat poorly and complain of taste
impairment during her hospital stay. The inpatient medical
team reviewed her medications with the help of a clinical
pharmacist and identified numerous medicines including
lisinopril, atorvastatin, digoxin, levothyroxine, donepezil,
and oxybutynin, which may cause taste problems. Based on
clinical indication and weighing benefits and risks of treat-
ments, the team decided to stop donepezil and oxybutynin.
She was advised to see a dentist and her primary care physi-
cian upon discharge from the hospital. Her dentist diagnosed
753.e5
periodontal disease, which was treated. She saw a dietician
who educated her and her family on optimal nutrition and a
liberalized diet. Her primary care doctor and cardiologist
agreed to discontinue digoxin. Six months later, her appetite
had gradually improved and her weight stabilized.
This case highlights the importance of a multidisciplinary
approach to the management of taste disorders in older
adults (Figure) and how medical status, including oral
health and medications, can impact taste disorders.
Recognizing the causes of dysgeusia and knowing how to
treat this can have a great impact on general health and
overall well-being of patients.
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