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[Dysphagia] Medicare changes, thickened liquids/dehydration
I am responding to Irene Campbell-Taylor's posting about the above topic (original post is pasted below for reference).
Several questions/assertions:
1. MANY geriatric patients in nursing homes are dehydrated. The use of thickened liquids isn't the primary cause of dehydration--there are many causes. Patient choice is one of them: I have had many a patient tell me, "I can't drink much water. Then I'll have to go to the restroom and no one will help me get there." May I assert that quality of patient care also plays a role in dehydration, more than we realize.
2. Even patients NOT on thickened liquids in the nursing home often are not routinely being offered hydration (again, the issue of quality of patient care). Some falls are caused by residents trying to procure water on their own, who lose their balance and fall.
3. While use of thickened liquids doesn't "prevent" aspiration (most of us aspirate our own saliva during sleep...patients with dysphagia may aspirate their own secretions routinely), their use can decrease the risk of aspiration especially in patients with frank aspiration of thin liquids. SLP's who utilize the Modified Barium Swallow study to establish safest diet texture are following best practice. Would you prefer that SLP's be sued when a patient ends up in the hospital with aspiration pneumonia? Really, this is more likely than a family member suing us because we recommended thickened liquids, which led to dehydration caused by blood pressure fluctuations that resulted in the patient falling (quite a chain of causal links there, each of which is challenging to trace to one of the many possible causes).
4. It is true that thickened liquids do not provide hydration that is equivalent to plain water. However, by frequently offering thickened liquids to patients, they can obtain hydration. When facilities don't ensure that patients on thickened liquids are "pushed fluids," that isn't the fault of the SLP (although we certainly need to be providing the appropriate staff education). There are also some newer thickening agents that provide more "free water" per cc than the older thickening powders (one example--Simply Thick gel). There are many aspects of the use of thickened liquids to be considered, and many ways to improve our use of them, rather than simply discontinuing their use as suggested in this posting.
5. I would like to see the studies supporting the claim that dysphagia patients on thickened liquids have a higher incidence of falls than patients not on thickened liquids. Please give citations so we can all read and be aware of the research.
Thank you for an interesting post.
Brenda Abraham, MA, CCC-SLP
dysphagia-request at dysphagia.com wrote:
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Today's Topics:
1. Medicare changes (Irene Campbell-Taylor)
2. Off topic: aphasia (Irene Campbell-Taylor)
3. Policies re:use of mittens to prevent NG pulling and the
ethical implications (Coman Leah (5PV) West Essex PCT)
4. Use of mittens (Irene Campbell-Taylor)
5. Awareness in vegetative state. (Irene Campbell-Taylor)
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Message: 1
Date: Mon, 20 Aug 2007 17:58:31 -0700 (PDT)
From: Irene Campbell-Taylor
Subject: [Dysphagia] Medicare changes
To: dysphagia at b9.com
Message-ID: <537252.98204.qm at web30204.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
Medicare has announced it will stop paying hospitals for treatment of eight conditions that result from preventable errors, actually ?errors that could have been reasonably prevented.?.
The conditions are catheter-associated urinary tract and vascular infections, pressure ulcers, objects left during surgery, air embolism, blood incompatibility, mediastinitis and falls. The agency said it is also considering adding other conditions, such as S. aureus septicemia, ventilator-associated pneumonia, and C. difficile-associated disease, to the list.
Unless the conditions are present on admission, the extra cost of treating them won?t be reimbursed beginning with discharges occurring on or after October 1, 2008. The rules state that "The hospital cannot bill the beneficiary for any charges associated with the hospital-acquired complication."
While not immediately apparent, the one that most affects persons with swallowing dysfunction is falls. As long as thickened fluids are used extensively, we now know that, at least in the elderly, these lead to dehydration and certainly don't prevent aspiration. This dehydration, in turn, commonly causes hemodynamic instability with repeated falls, often causing hip fractures, head trauma etc. The acting Deputy Director of Medicare is quoted as saying,? ?if a patient goes into a hospital with pneumonia, we don?t want them to leave with a broken arm.? The latter would be mild compared to the subdural hematomas, fractured hips etc. that often result in acute care hospitalization, increased infection and, at the very least, worsened condition if not death. Falling because of blood pressure fluctuations due to dehydration is one of the major hazards of the elderly in nursing homes. Knowingly contributing to it by the use of thickened fluids is, at the very least, poor
management and it is only a matter of time before at least one family catches on and sues.
The next thing will be pneumonias resulting from unnecessary enteral feeding.
Let?s not continue these practices.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
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Message: 2
Date: Mon, 20 Aug 2007 18:46:51 -0700 (PDT)
From: Irene Campbell-Taylor
Subject: [Dysphagia] Off topic: aphasia
To: dysphagia at b9.com
Message-ID: <506484.5725.qm at web30210.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
At a recent workshop I gave, one of the atendees told me of remarkable improvement ina patient, completely non-verbal six years post insult with LCVA?R hemiplegia until put on Aricept. Found the following of interest:
A more recent double-blind RCT by Berthier and colleagues9 cited by Lennihan, suggested that donepezil might be of value for stroke patients with chronic (ie, lasting 1 year or longer) aphasia. Greater improvements were seen in Western Aphasia Battery and Psycholinguistic Assessment of Language Processing in Aphasia scale scores in treated patients compared with controls (6.4 vs 3.5 and 4.6 vs 21.0, respectively). Patients only received 2 hours per week of standard language therapy in this study.
A randomized, placebo-controlled study of donepezil in poststroke aphasia NEUROLOGY 2006;67:1687-1689
M. L. Berthier, MD, PhD, C. Green, PhD, C. Higueras, PhD, I. Fern?ndez, PhD, J. Hinojosa, PhD and M. C. Mart?n, PhD
We studied 26 patients in a randomized, placebo-controlled, double-blind parallel trial to evaluate the efficacy and safety of donepezil in chronic poststroke aphasia. Donepezil (10 mg/day) improved aphasia severity at endpoint (week 16) relative to placebo (p = 0.037).
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
------------------------------
Message: 3
Date: Tue, 21 Aug 2007 11:03:58 +0100
From: "Coman Leah (5PV) West Essex PCT"
Subject: [Dysphagia] Policies re:use of mittens to prevent NG pulling
and the ethical implications
To: "dysphagia at dysphagia.com"
Message-ID:
Content-Type: text/plain; charset="us-ascii"
A colleague of mine would like to know whether anyone has a policy regarding the use of mittens to prevent NG pulling and the ethical implications. Any responses would be greatly appreciated.
Kind Regards
Leah
Leah Coman
Specialist Speech & Language Therapist - Voice / Head & Neck
West Essex Primary Care Trust
-----Original Message-----
From: dysphagia-bounces at dysphagia.com
[mailto:dysphagia-bounces at dysphagia.com]On Behalf Of
dysphagia-request at dysphagia.com
Sent: 14 August 2007 19:00
To: dysphagia at dysphagia.com
Subject: Dysphagia Digest, Vol 45, Issue 10
Send Dysphagia mailing list submissions to
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When replying, please edit your Subject line so it is more specific
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Today's Topics:
1. Re: Huntington fact sheets (Cameron, Sharon (R3))
----------------------------------------------------------------------
Message: 1
Date: Tue, 14 Aug 2007 09:46:46 -0300
From: "Cameron, Sharon \(R3\)"
Subject: Re: [Dysphagia] Huntington fact sheets
To: "Clarke-Goertz, Kim \(PAPHR\)" , "dysphagia
listserv" , "Division 13 Discussion List"
Message-ID:
Content-Type: text/plain; charset="utf-8"
Huntington Society of Canada has a physician's guide that is quite
comprehensive. There is info on swallowing, nutrition and dysarthria.
http://www.huntingtonsociety.ca/english/pdf/Physicians_Guide.pdf
Sharon
-----Original Message-----
From: dysphagia-bounces at dysphagia.com
[mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Clarke-Goertz, Kim
(PAPHR)
Sent: Thursday, August 09, 2007 12:21 PM
To: dysphagia listserv; Division 13 Discussion List
Subject: [Dysphagia] Huntington fact sheets
Does anyone know of/have fact sheets pertaining to dysphagia and enteral
feeding in persons with Huntington's disease?
I recently read some excerpts from a HD resource book. I plan to
re-vamp the pages a bit to organize the information better from my
perspective, however, in the interest of not re-inventing the wheel and
wanting to be comprehensive, I was wondering if anyone out there had any
info sheets they could share or point me in the direction of.
Thanks,
Kim
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Message: 4
Date: Tue, 21 Aug 2007 04:19:24 -0700 (PDT)
From: Irene Campbell-Taylor
Subject: [Dysphagia] Use of mittens
To: dysphagia at b9.com
Message-ID: <958948.17947.qm at web30214.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
Nursing homes, hospitals etc. are supposed to maintain a "least retrictive environment." but they seldom do.
See:
Journals of Gerontology Series B: Psychological Sciences and Social Sciences, Vol 55, Issue 1 S33-S40,
---------------------------------
ARTICLES
Deficiency citations for physical restraint use in nursing homes
NG Castle
Institute of Health, Health Care Policy, and Aging Research, New Brunswick, New Jersey, USA.
OBJECTIVES: The average percentage of residents restrained in nursing homes is approximately 20%.( These include vests, belts, mittens, and wrist and ankle. Restraints and Posey vests.) Facilities that do not meet Health Care Financing Administration standards for restraint use may be issued a deficiency citation. This article investigates which structure and process factors of nursing homes are associated with a deficiency citation for restraint use. METHODS: Nationally representative data from the 1997 On-line Survey Certification of Automated Records are used, first, to provide descriptive analyses, and second, for logistic regression analyses of structure and process factors associated with a deficiency citation for restraint use. RESULTS: A total of 2,321 facilities were found to have at least one restraint deficiency citation, and 14,703 had none. After controlling for seven other key variables, five structural factors and six process factors are significant. The
structural factors--larger bed size, for-profit ownership, and hospital based--were significantly associated with a higher likelihood of a deficiency citation for restraint use; whereas higher numbers of full-time equivalent specialists per resident and nurse aide training were significantly associated with a lower likelihood. The process factors--suctioning therapy, pain management, and bladder training--were significantly associated with a lower likelihood of a deficiency citation for restraint use; whereas intravenous therapy, higher use of catheters, and physical restraints were significantly associated with a higher likelihood of a deficiency citation. DISCUSSION: This analysis establishes linkages between structures and processes and the outcome of a deficiency citation for restraint use. The structural results may have some utility for regulators. They could be used to develop a specific program to target facilities most commonly found to have inappropriate
restraint use. The process results may have some utility for providers who could use the information to target residents for review of inappropriate restraint use.
Mental Health Outcomes and Physical Restraint Use in Nursing Homes
Nicholas G. Castle
Administration and Policy in Mental Health and Mental Health Services Research
Volume 33, Number 6 / November, 2006 pages 696-704
Abstract We investigate the nexus between mental health outcomes in nursing home residents and the use of physical restraints. Previous studies in this area used limited statistical tests such as correlations and t-tests, that could not account for potential biases, such as residents who become mentally disturbed may be most likely to be restrained. We use propensity matching models that are less susceptible to this bias and data from the Minimum Data Set, representing approximately 2,000 residents over a period of 6 years. Our results clearly show that restrained residents are more likely to become more impaired with respect to cognitive performance, depression, and social engagement. We conclude that if facilities reduce restraint use then the prevalence of resident mental health problems will also likely decline.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
------------------------------
Message: 5
Date: Tue, 21 Aug 2007 05:56:17 -0700 (PDT)
From: Irene Campbell-Taylor
Subject: [Dysphagia] Awareness in vegetative state.
To: dysphagia at b9.com
Message-ID: <327385.15989.qm at web30212.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
Using Functional Magnetic Resonance Imaging to Detect Covert Awareness in the Vegetative State
Adrian M. Owen, PhD; Martin R. Coleman, PhD; Melanie Boly, PhD; Matthew H. Davis, PhD; Steven Laureys, MD, PhD; John D. Pickard, MD, PhD
Arch Neurol. 2007;64:1098-1102.
The assessment of patients with disorders of consciousness, including the vegetative state, is difficult and depends frequently on subjective interpretations of the observed spontaneous and volitional behavior. For those patients who retain peripheral motor function, rigorous behavioral assessment supported by structural imaging and electrophysiological findings is usually sufficient to establish a patient's level of wakefulness and awareness. However, it is becoming increasingly apparent that in some patients damage to the peripheral motor system may prevent overt responses to command although the cognitive ability to perceive and understand such commands may remain intact. Recent advances in functional neuroimaging suggest a novel solution to this problem; in several cases, so-called activation studies have been used to identify residual cognitive function and conscious awareness in patients who are assumed to be in a vegetative state yet retain cognitive abilities that
have evaded detection using standard clinical methods.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
------------------------------
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End of Dysphagia Digest, Vol 45, Issue 15
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