[Dysphagia] reflux and feeding tubes

[wabeach at hsc.vcu.edu (wabeach@hsc.vcu.edu)]

Just a brief thought. Living wills are not adequate to determine how
aggressive medical management should be since they only obtain when
the patient is terminally ill. A durable medical power of attorney,
held by someone who will honor your wishes, is required to ensure that
in non-terminal cases your wishes (whatever they are) will be carried
out. State laws vary so make sure that you cover situations like PVS
(which is not terminal so would not be covered by living wills).

Woodford A. Beach, Ph.D., CCC/SP
Senior Speech Pathologist
Adjunct Asst. Professor, Neurology & PM&R 
Asst. Clinical Professor, Otolaryngology/Head & Neck Surgery 
Virginia Commonwealth University Medical Center 
Richmond, VA 23298 
Phone: 804-828-0207 
Fax: 804-828-8281 

-------------------
> Its so sad to me that we are universally not recognizing how
inappropriate 
> it is to tube-feed an individual with advanced Alzheimer's.  It
certainly 
> makes me want to make sure my living will, and that of my family's
is ready 
> to go!  All the literature is so clear in this area-- why is it
still 
> happening when these poor folks end up hospitalized...
> 
> Additionally, we can't as dysphagia therapists treat any one without
knowing 
> a great deal about the esophagus, what symptoms are consistent with 
> esophageal dysphagia, and what recommendations would be
contraindicated for 
> a person with esophageal problems (how about meds in applesauce
without any 
> fluids before or after in someone with a severe motility disorder???
yikes). 
> For anyone out there still wanting to say, "that's not my part of
the 
> body... leave it to GI" a terrible disservice is being done.  No, we
don't 
> treat esophageal problems, but we can educate, properly
differentiate 
> oropharyngeal vs esophageal symptoms and make sure what we recommend
is 
> appropriate in the least!
> 
> By the way, here's what ASHA has to say about it in case you think
the above 
> is out of our scope of practice for the SLP.  See--
> American Speech-Language-
> 
> Hearing Association. (2004). Guidelines for Speechlanguage
> 
> pathologists performing videofluoroscopic
> 
> swallowing studies. ASHA Supplement 24, pp. 77?92.
> 
> 
> Julie Huffman
> ----- Original Message ----- 
> From: <Drirenect@aol.com>
> To: <malindam@samhealth.org>; <dysphagia@b9.com>
> Sent: Wednesday, February 08, 2006 9:38 AM
> Subject: Re: [Dysphagia] reflux and feeding tubes
> 
> 
> It is unfortunate that many if not most of the difficulties
associated with
> swallowing in the patient with advanced dementing illness are
exacerbated if
> not  caused by the use of anticholinergic, dopamine antagonist 
> antipsychotics.
> This  has been apparent for decades but only now getting more
attention. 
> SLPs
> could  contribute significantly to the literature on the causes of
death -
> among them  the malnutrition and dehydration that go along with
decreased 
> intake
> of food as  a result of the side efects of these medications. The 
> contribution
> of these meds  to mortality is high:
> 
> Dec. 2, 2005
> N Engl J Med. 2005;353:2335-2341 ? Conventional antipsychotics are
at  least
> as likely as atypical agents to increase the risk for death among
elderly
> persons, and they should not replace atypical agents discontinued in

> response to
> the U.S. Food and Drug Administration (FDA) warning, according to
the 
> results
> of  a retrospective cohort study reported in the Dec. 1 issue of The
New
> England  Journal of Medicine.
> "Recently, the FDA issued an advisory stating that atypical
antipsychotic
> medications increase mortality among elderly patients," write Philip
S. 
> Wang,
> MD, DrPH, from the Brigham and Women's Hospital, Harvard Medical
School in
> Boston, Massachusetts, and colleagues. "However, the advisory did
not apply 
> to
> conventional antipsychotic medications; the risk of death with these
older
> agents is not known."
> This retrospective cohort study included 22,890 patients 65 years of
age or
> older who had drug insurance benefits in Pennsylvania and who began 
> receiving
> a  conventional or atypical antipsychotic medication between 1994
and 2003.
> The  investigators used analyses of mortality rates and Cox 
> proportional-hazards
>  models to compare the risk for death within 180 days, less than 40
days, 40
> to  79 days, and 80 to 180 days after starting therapy with an
antipsychotic
> drug.
> For all intervals studied, conventional antipsychotic medications
were
> associated with a significantly higher adjusted risk for death than
were 
> atypical
> antipsychotic medications (</=180 days: relative risk [RR], 1.37; 
95%
> confidence interval [CI], 1.27 - 1.49; <40 days: RR, 1.56; 95% CI,
1.37 - 
> 1.78; 40 -
> 79 days: RR, 1.37; 95% CI, 1.19 - 1.59; and 80 - 180 days: RR, 1.27;
 95% 
> CI,
> 1.14 - 1.41). This increased risk for death persisted in all
subgroups
> defined by the presence or absence of dementia or nursing home
residency.
> The greatest increases in risk occurred soon after therapy was
started and
> with higher dosages of conventional antipsychotic drugs. Increased
risks for
> conventional vs atypical antipsychotic medications persisted in
confirmatory
> analyses using propensity-score adjustment and instrumental-variable
> estimation.
> "If confirmed, these results suggest that conventional antipsychotic
> medications are at least as likely as atypical agents to increase
the risk 
> of  death
> among elderly persons and that conventional drugs should not be used
to
> replace atypical agents discontinued in response to the FDA
warning," the 
> authors
> write. "To place this magnitude of risk in perspective, only cancer,
> congestive heart failure, and HIV infection conferred greater
adjusted risks 
> in  our
> analyses."
> Study limitations include possible underestimation of mortality
resulting
> from the use of conventional agents, study based on nonexperimental
data, 
> lack
> of information on potential mechanisms through which conventional
> antipsychotic  medications might increase the risk for death in the
short 
> term, and lack
> of  data on the causes of death.
> "Beyond arousing new concern about conventional agents, our data
provide no
> guidance with regard to which pharmacologic or nonpharmacologic 
> interventions
> should be used to manage the many conditions and symptoms for which
> antipsychotic medications are used," the authors conclude.
"Traditionally, 
> the
> benefits and risks of treatments in the elderly have simply been 
> extrapolated  from
> studies involving younger populations. As the recent FDA advisory
and the
> results of this study show, such a practice can be misleading, given
the 
> unique
> needs and susceptibilities of older persons."
> The National Institute of Mental Health and the Agency for
Healthcare
> Research and Quality have disclosed that they supported this study.
> In an accompanying perspective, Wayne A. Ray, PhD, from the
Vanderbilt
> University School of Medicine in Nashville, Tennessee, notes that
the 
> relative
> efficacy and long-term safety, including effects on mortality, of
many 
> widely
> used medications, are poorly understood. He discusses methodologic 
> limitations
> of various approaches designed to fill this information gap.
> "Randomized trials would provide the most reliable data; however, in
the
> absence of material reform of the system for the approval of new
drugs, 
> there is
> little incentive to conduct such trials," Dr. Ray writes.
"Nonrandomized
> studies  can provide valuable information, as does the thoughtful
study by 
> Wang
> and  colleagues. However, observational studies of overall mortality
are
> particularly  susceptible to numerous biases and thus must be
conducted with 
> extreme
> care."
> 
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> 
Woodford A. Beach, Ph.D., CCC/SP
Senior Speech Language Pathologist, VCUMC
Adjunct Asst. Professor, Neurology
Adjunct Asst. Professor, PM&R
Asst. Clinical Professor, Otolaryngology/Head & Neck Surgery
Virginia Commonwealth University
Richmond, VA 23298