[Dysphagia] reflux and feeding tubes

[Drirenect at aol.com (Drirenect@aol.com)]

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."