[Dysphagia] reflux and feeding tubes

[Heidi.Bassani at amedd.army.mil (Bassani, Heidi D Ms WRAMC-Wash DC)]

First of all I'd like to say that I agree with you 100% that
tube-feeding an Alzheimer's pt is not at all something I would recommend
for ALL of the reasons that people have mentioned. And you are all
correct in being irritated by the ongoing practice. 

On a personal note, I'd like to say that I'm getting frustrated with the
fact that people aren't reading what I write but are instead
interpreting it to fit their agenda.  What I said was that in terms of
the REFLUX, that is an issue that GI should handle. Yes, we have the
obligation to inform the family of the difference between oropharyngeal
and esophageal problems, YES we have the obligation to inform the family
of the risks and benefit (or LACK THEREOF) of tube feeding these pt's
and all other issues involved, including nutrition to a point.  It is
ASBSOLUTELY our job to inform the pt and family of everything that they
need to know in order for them to make the ultimate decision.  IF you
are someone who is NOT doing this education, then you should not be a
practicing SLP!  However, it is not our job in a palliative pt to say,
"Keep him NPO and feed him through a tube" OR "he's gonna aspirate, but
feed him anyway." Those are decisions, not recommendations, and are to
be made by educated family members with their MD. Period.

Heidi

-----Original Message-----
From: juliespeech [mailto:speechhuffman@nc.rr.com] 
Sent: Wednesday, February 15, 2006 5:29 PM
To: dysphagia@b9.com
Subject: Re: [Dysphagia] reflux and feeding tubes

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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