Yikes, I am not a doctor nor a scientist. I have come to realize after decades caring for our elderly that dysphagia is common. It's not treatable. Food/fluids will travel down the wrong "pipe" at times because the epiglottis has become weaker and more sloppy. Which do I want in my patient's lungs, solids or liquids? I've got a better chance at getting my patient to cough out thinner liquids than bulkier ones. I've tasted thickener. I always give my patients and or families the choice of thickener or not, but I list out the pros and cons of both. I rarely to never use thickener.
Dr Mandrola- the authors reported that it was the thick liquid group (not thin) who had a 0.92 odds ratio for mortality, and reduced risk for intubation, but higher odds of a respiratory complication. (If I am reading it right)
You wrote "The hazard ratio was 0.92, indicating that the thin liquid group had an 8% lower rate of death. ...Intubation was lower with thin liquids, but respiratory complications were higher with thin liquids."
I think you typed thin when you meant thick.
But I'm a Sensible Medicine fan through thick and thin.
One of my favorite JAMA IM “Less is More” articles from 2016 summarized the evidence for thickened liquids nicely, and had a great title “The Horrible Taste of Nectar and Honey—Inappropriate Use of Thickened Liquids in Dementia.” Of note, the evidence does include 1 RCT (negative but maybe underpowered)
Glad to hear from a radiologist in the comments! As an SLP I have to add that we’re missing a lot of relevant data about what happened to earn these patients a recommendation of thickened liquids in the first place. Were the patients identified as aspirating thin liquids on a VSS or FEES? A simple bedside swallow eval done by an SLP is unfortunately not adequate, even the best of us can’t reliably identify silent aspiration on a bedside swallow eval! So docs please don’t give us grief when we ask for the VSS order. And families please insist on a VSS or FEES if you’re not convinced of a swallowing disorder before agreeing to thickened liquids.. We need to know that those thickened liquids actually prevented aspiration. And also, thickened vs regular thin liquids is a false dichotomy. Look up the “Frasier Free Water Protocol”. This has been is use for over twenty years. Basically the recommendation is that even patients who “need” thickened liquids to prevent aspiration are allowed as much regular thin water as they want, provided that their mouth is kept super clean to decrease risk of aspiration pneumonia. This protocol does have a good evidence base to support it and might be an acceptable in between recommendation for some patients. As the SLP I always remind the families that we have to make the recommendation we believe is “safest” for the patient, but that they ultimately get to decide whether or not they want to follow our recommendations, acknowledging that thickened liquids or a pureed diet are significant quality of life issues. Thanks for covering this important quality of life issue!
My father who had dementia was put on thickened liquids after developing swallowing difficulty and some aspiration but proceeded to then have diarrhea because of the cellulose in the thickening agent. (and of course he was not able to make it to the bathroom so it was not a tenable situation) My sister stopped the thickened liquids.
Lot to unpack here. I'm SHOCKED. Shocked that you still read NY Times. I'm shocked that you thought NY Times reporter/contributor would convey anything close to truth. There should be a randomized control study on how many brain cells die after reading any NY Times article.
When my mother was put on thickened liquids she hated them. They tried to thicken the good take out coffee I bought for her when she was in rehab and I refused to allow it. That was the first time she smiled in weeks. When she went to assisted living my siblings and I all signed a letter stating that our mother did not want thickened liquids, and as long as she was allowed to drink any liquid she wanted, we would not hold the facility or its staff responsible for her aspirating. It worked. She did NOT die of aspiration or choking.
My mother was put on a thicker liquid and special food diet after being on a ventilator for 10 days post breaking 9 ribs on her right side. She already was a terrible patient, but was even more difficult when given water that essentially didn't quench thirst. She was under those restrictions until her release from rehabilitation 2 months later. Her first drink of coffee without it being as "thick as nector" was her favorite. Makes me wonder if the hours of her ranting about how she hated the food and the water was useless was all worth it.
When elderly are hospitalized or in rehab, they often have interventions forced on them. So much for informed consent. Glad she was a difficult patient if informed consent was not given. More people need to be difficult unless informed consent is adequately obtained
Did they assess the baseline nutritional status of each group Prealbumin, LBM etc?
Were the TL group more undernourished?
Since almost every “swallowing evaluation” I’ve ever ordered results is some form of swallowing disorder what wound they have to prescribe if TL isn’t an option?
I always believed someone or someones carefully studied this. Sounds like it was part of a Consensus Statement.
My late father gave me some advice. It was “don’t grow old”.
A lot of patients give me that same advice; my response is "the alternative is not a good one"
I agree that if you have concerns about swallow and get a swallow study, frequently get abnormal results. Often the best advice is just to make sure patient fully awake/alert, sitting up straight, tuck chin a bit, and swallow!
I always had difficulty swallowing the thickened liquid routine (bad pun intended). I believe the problem with swallowing in elderly people is neurological. I wondered if it wasn't possible that thicker liquids might be more difficult to clear with coughing than water or other "thin" liquids. I don't know the answer but, if that is the case, we could be doing more harm than good with the thicker liquids. In any case, it would be nice to have at least some indication that a given practice is not counter-productive before declaring it to be "standard of care".
At least the authors did, and/or the JAMA editors insisted that they do. However, that’s fairly faint praise.
Agree that what is needed is a proper trial from which we can make conclusions about causality (ie proper RCT) to answer this question.
However, what makes me curious is that we DIDN’T actually need this observational study to come to the realization of the need of an RCT to answer this question. They should have known even before they started (just as we would have known before they started) that this project would not provide a conclusive answer. In fact, we can DEFINITIVELY say this about ANY observational study. Alas, journals need stuff to publish, and academics need stuff to put on their CV….so this sort of thing will no doubt continue.
Agree with the overall point. So much of what we do is not properly proven to be of benefit. There are many many many more clinical questions than there are answers with RCT. It doesn’t mean nihilism, as we often need to make clinical decisions for patients absent all the evidence we would like to have. But it does mean we should be far less dogmatic about many of the things we do. The best part of what the authors did here was to decide to examine one such dogma.
Sorry to say, but one size does not fit all. That is why they call it the “practice” of medicine. There are so many syndromes, diseases, and oral anatomical issues related to swallowing difficulties that clinical experience and open dialogue with family and caregivers is much more practical.
Agree that you practice to the needs of individual patients, but that practice should still be guided by the evidence (generated based on the average patient) whenever possible. Otherwise, as JMM as said in the past, you’d be no different than a shaman.
Many things have yet to be known ie proven. When 50% of the people who receive Remdesivir seem to recover from Covid faster, even though it has toxic side effects, it is still an option in this country. The WHO recommends against it. Do the doctors who give it know that? Hummm.
"all patients had suspicion of swallowing issues". Sounds like they did not have formal swallowing studies. Our speech therapists study patients and then base recommendations based on findings. Of course, some or many of their recommendations are not based on RCT but at least they stratify the risk.
"This cohort study emphasizes the need for prospective studies that evaluate whether thick liquids are associated with improved clinical outcomes in hospitalized patients with dementia and dysphagia."
How many times have I seen that at the end of the paper; the problem is many of those studies never get done so we are left with suggestive studies to influence practice.
My local witch doctor and voodoo priestess offer many remedies that have no trials or real science behind them. I wonder why they usually seem to work?
Therapeutic fashion is the perfect phrase here. So many things that fit in that category and stick around for ages because they "make sense" or seem mechanistically plausible.
Yikes, I am not a doctor nor a scientist. I have come to realize after decades caring for our elderly that dysphagia is common. It's not treatable. Food/fluids will travel down the wrong "pipe" at times because the epiglottis has become weaker and more sloppy. Which do I want in my patient's lungs, solids or liquids? I've got a better chance at getting my patient to cough out thinner liquids than bulkier ones. I've tasted thickener. I always give my patients and or families the choice of thickener or not, but I list out the pros and cons of both. I rarely to never use thickener.
Dr Mandrola- the authors reported that it was the thick liquid group (not thin) who had a 0.92 odds ratio for mortality, and reduced risk for intubation, but higher odds of a respiratory complication. (If I am reading it right)
You wrote "The hazard ratio was 0.92, indicating that the thin liquid group had an 8% lower rate of death. ...Intubation was lower with thin liquids, but respiratory complications were higher with thin liquids."
I think you typed thin when you meant thick.
But I'm a Sensible Medicine fan through thick and thin.
One of my favorite JAMA IM “Less is More” articles from 2016 summarized the evidence for thickened liquids nicely, and had a great title “The Horrible Taste of Nectar and Honey—Inappropriate Use of Thickened Liquids in Dementia.” Of note, the evidence does include 1 RCT (negative but maybe underpowered)
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2517923
It's also worth it to read the Invited Commentary from Eric Widera (worth to follow him on twitter/X! also known from its GeriPal Podcast): https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2818202
I just made a new Twitter friend! Thanks for the shout out
Glad to hear from a radiologist in the comments! As an SLP I have to add that we’re missing a lot of relevant data about what happened to earn these patients a recommendation of thickened liquids in the first place. Were the patients identified as aspirating thin liquids on a VSS or FEES? A simple bedside swallow eval done by an SLP is unfortunately not adequate, even the best of us can’t reliably identify silent aspiration on a bedside swallow eval! So docs please don’t give us grief when we ask for the VSS order. And families please insist on a VSS or FEES if you’re not convinced of a swallowing disorder before agreeing to thickened liquids.. We need to know that those thickened liquids actually prevented aspiration. And also, thickened vs regular thin liquids is a false dichotomy. Look up the “Frasier Free Water Protocol”. This has been is use for over twenty years. Basically the recommendation is that even patients who “need” thickened liquids to prevent aspiration are allowed as much regular thin water as they want, provided that their mouth is kept super clean to decrease risk of aspiration pneumonia. This protocol does have a good evidence base to support it and might be an acceptable in between recommendation for some patients. As the SLP I always remind the families that we have to make the recommendation we believe is “safest” for the patient, but that they ultimately get to decide whether or not they want to follow our recommendations, acknowledging that thickened liquids or a pureed diet are significant quality of life issues. Thanks for covering this important quality of life issue!
My father who had dementia was put on thickened liquids after developing swallowing difficulty and some aspiration but proceeded to then have diarrhea because of the cellulose in the thickening agent. (and of course he was not able to make it to the bathroom so it was not a tenable situation) My sister stopped the thickened liquids.
Lot to unpack here. I'm SHOCKED. Shocked that you still read NY Times. I'm shocked that you thought NY Times reporter/contributor would convey anything close to truth. There should be a randomized control study on how many brain cells die after reading any NY Times article.
When my mother was put on thickened liquids she hated them. They tried to thicken the good take out coffee I bought for her when she was in rehab and I refused to allow it. That was the first time she smiled in weeks. When she went to assisted living my siblings and I all signed a letter stating that our mother did not want thickened liquids, and as long as she was allowed to drink any liquid she wanted, we would not hold the facility or its staff responsible for her aspirating. It worked. She did NOT die of aspiration or choking.
Same experience with my dad. He was fine without that horrible stuff for his last couple years.
My mother was put on a thicker liquid and special food diet after being on a ventilator for 10 days post breaking 9 ribs on her right side. She already was a terrible patient, but was even more difficult when given water that essentially didn't quench thirst. She was under those restrictions until her release from rehabilitation 2 months later. Her first drink of coffee without it being as "thick as nector" was her favorite. Makes me wonder if the hours of her ranting about how she hated the food and the water was useless was all worth it.
When elderly are hospitalized or in rehab, they often have interventions forced on them. So much for informed consent. Glad she was a difficult patient if informed consent was not given. More people need to be difficult unless informed consent is adequately obtained
Did they assess the baseline nutritional status of each group Prealbumin, LBM etc?
Were the TL group more undernourished?
Since almost every “swallowing evaluation” I’ve ever ordered results is some form of swallowing disorder what wound they have to prescribe if TL isn’t an option?
I always believed someone or someones carefully studied this. Sounds like it was part of a Consensus Statement.
My late father gave me some advice. It was “don’t grow old”.
A lot of patients give me that same advice; my response is "the alternative is not a good one"
I agree that if you have concerns about swallow and get a swallow study, frequently get abnormal results. Often the best advice is just to make sure patient fully awake/alert, sitting up straight, tuck chin a bit, and swallow!
I always had difficulty swallowing the thickened liquid routine (bad pun intended). I believe the problem with swallowing in elderly people is neurological. I wondered if it wasn't possible that thicker liquids might be more difficult to clear with coughing than water or other "thin" liquids. I don't know the answer but, if that is the case, we could be doing more harm than good with the thicker liquids. In any case, it would be nice to have at least some indication that a given practice is not counter-productive before declaring it to be "standard of care".
Can’t expect the lay press to get it right.
At least the authors did, and/or the JAMA editors insisted that they do. However, that’s fairly faint praise.
Agree that what is needed is a proper trial from which we can make conclusions about causality (ie proper RCT) to answer this question.
However, what makes me curious is that we DIDN’T actually need this observational study to come to the realization of the need of an RCT to answer this question. They should have known even before they started (just as we would have known before they started) that this project would not provide a conclusive answer. In fact, we can DEFINITIVELY say this about ANY observational study. Alas, journals need stuff to publish, and academics need stuff to put on their CV….so this sort of thing will no doubt continue.
Agree with the overall point. So much of what we do is not properly proven to be of benefit. There are many many many more clinical questions than there are answers with RCT. It doesn’t mean nihilism, as we often need to make clinical decisions for patients absent all the evidence we would like to have. But it does mean we should be far less dogmatic about many of the things we do. The best part of what the authors did here was to decide to examine one such dogma.
Sorry to say, but one size does not fit all. That is why they call it the “practice” of medicine. There are so many syndromes, diseases, and oral anatomical issues related to swallowing difficulties that clinical experience and open dialogue with family and caregivers is much more practical.
Agree that you practice to the needs of individual patients, but that practice should still be guided by the evidence (generated based on the average patient) whenever possible. Otherwise, as JMM as said in the past, you’d be no different than a shaman.
Many things have yet to be known ie proven. When 50% of the people who receive Remdesivir seem to recover from Covid faster, even though it has toxic side effects, it is still an option in this country. The WHO recommends against it. Do the doctors who give it know that? Hummm.
A real problem exacerbated by technology is that we all believe history began the day we were born. Even shaman have been found to be right.
A broken clock is “right” twice a day. I’d say shaman have a lower batting average.
I seem to recall the development of birth control pills came out of Native American “shaman” herbal medicine.
That’s why it’s better to try to have more things “proven” via adequately powered RCT, than fewer.
"all patients had suspicion of swallowing issues". Sounds like they did not have formal swallowing studies. Our speech therapists study patients and then base recommendations based on findings. Of course, some or many of their recommendations are not based on RCT but at least they stratify the risk.
"This cohort study emphasizes the need for prospective studies that evaluate whether thick liquids are associated with improved clinical outcomes in hospitalized patients with dementia and dysphagia."
How many times have I seen that at the end of the paper; the problem is many of those studies never get done so we are left with suggestive studies to influence practice.
My local witch doctor and voodoo priestess offer many remedies that have no trials or real science behind them. I wonder why they usually seem to work?
Therapeutic fashion is the perfect phrase here. So many things that fit in that category and stick around for ages because they "make sense" or seem mechanistically plausible.
Any thoughts on this study?
Ann Intern Med. 2008;148:509-518.