[Dysphagia] Fwd: Answer to Suzanne

[eripley at yahoo.com (Irene Campbell-Taylor)]

Irene Campbell-Taylor <eripley at yahoo.com> wrote:  Date: Fri, 1 Dec 2006 06:50:48 -0800 (PST)
From: Irene Campbell-Taylor <eripley at yahoo.com>
Subject: Answer to Suzanne
To: dysphagia at b9.com

  Suzanne,
  I hope the following addresses your questions.
  First of all, let me make a clarification.  The literature and clinical experience make it clear that aspiration pneumonia is most often caused by:
  1)      Aspiration of saliva from a colonized oropharynx and
  2)      Unidentified inhalation of reflux followed within days by a bacterial superinfection due to aspirated saliva.
  It is unfortunate that patients with PD were chosen since they have comorbidities that undoubtedly affected the process.  Esophageal dysmotility is endemic to PD so that the incidence/prevalence of pneumonitis as opposed to pneumonia, is high.
  Patients with PD are so affected by this dysmotility that it alters the delivery and, therefore the effect, of sinemet.  This adds another uncontrolled variable.
  When persons with PD become obviously demented, the disease has progressed so that, by definition, their Hoehn-Yahr scale number alters. It is doubtful that there are PD patients without dementia since, even in the early stages, there is a subtle but definite frontal cognitive deficit.  This is one of the reasons that dysarthria therapy in PD does not work ? the patients either cannot remember the instructions or, more probably, are overwhelmed by the pressure of frontal impulsivity. For PD patients with obvious dementia, one wonders how they would be expected to understand, follow and remember instructions re ?chin tuck?. 
              One would also have to be sure not to include patients with Lewy body disease, who are often misdiagnosed as PD. The accurate diagnosis of dementia requires much more than the application of a scale.  I have given such scales to patients who were on opiate drugs, aphasic, hearing impaired, and to normals who were intoxicated, drugged, severely fatigued.  All scored as ?demented?.
  . I cannot find evidence that medications were counted in the variance. If they were not, this would be a significant omission.
  Aspiration on 3ml as opposed to cup drinking is a very different process.  It is difficult to infer the reasoning behind this criterion.
              In patients who were seen to aspirate, it does not appear to have been taken into consideration that they were aspirating their own saliva nor whether or not they were receiving good/poor/no mouth care. This is a significant confounding variable since it is impossible to state with any certainty what the cause of  any pneumonia might have been, bearing in mind that aspiration pneumonia is a very difficult diagnosis to make in the first place, especially in the elderly.
              The reason for inclusion of patients with gastrostomy is not clear.
  The results as shown in the presentation slides are ambiguous.  There seems to be increased risk with age and both chin ?down? and thickened liquid. There follows a slide that says ?Older patients had a lower aspiration rate.?
   
  Major findings:
  ?Long term results show that despite differential effect of interventions on immediate elimination of aspiration in videofluoroscopic suite
the three month incidence of pneumonia was similar for chin down posture compared to liquids (nectar, honey). 
  In other words, what you see on VFSS does not translate to the real world. This has been described so many times that it does not require repetition.
              Dehydration was more frequent in subjects on thickened liquids.  I think this has been pointed out innumerable times over the past five to ten years based on the literature and clinical experience.
              The overall message : It is not true that the thicker the liquid the safer the swallow 
?Not true in patients who aspirate thick liquids ?  i.e. patients DO aspirate thick liquids and they have ?WORSE health outcomes?.
   
              I am obliged to repeat the question I have asked many times, ?Why use thickened liquids at all??  These results may force an increased awareness and use of hypodermoclysis  as it occurs in other countries.


Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com


Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com