Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence

Context Patients with dysphagia are at increased risk for aspiration pneumonia. Contribution This trial involved 515 adults with dementia or Parkinson disease and videofluoroscopically demonstrated aspiration. Participants were randomly assigned to d... show more

Context Patients with dysphagia are at increased risk for aspiration pneumonia. Contribution This trial involved 515 adults with dementia or Parkinson disease and videofluoroscopically demonstrated aspiration. Participants were randomly assigned to drink thin liquids with a chin-down posture or to drink nectar- or honey-thick liquids in a head-neutral position. At 3 months, the cumulative incidence of pneumonia was about 10%, 8%, and 15% in the thin, nectar-thick, and honey-thick liquid groups. Dehydration was more common with thick than thin liquids. Caution Findings were inconclusive. The incidence of pneumonia was lower than expected, and confidence bounds around differences between groups were wide. The Editors Swallowing disorders are associated with increased morbidity and mortality. An estimated 18 million adults will require care for dysphagia-related malnutrition, dehydration, pneumonia, and reductions in quality of life by 2010 (13). Patients with dysphagia have an increased incidence of aspiration pneumonia because the aspirated material is heavily colonized with bacteria. Pneumonia is the fifth leading cause of infectious death in the United States among persons age 65 years or older and the third leading cause of death for persons age 85 years or older (4). One hospital admission for pneumonia is estimated to cost $7166 (5). Rates of hospital discharge for Medicare beneficiaries with pneumonia as a primary diagnosis have increased by 93.5% in the past decade (6), along with length of stay and death rates (4). Liquid aspiration is the most common type of aspiration in elderly persons (1). Relative risk for pneumonia is highest in patients with dementia, followed by those who are institutionalized (7). As many as 50% of patients with parkinsonism are estimated to have dysphagia (8), and one third aspirate silentlythat is, with no external sign (such as coughing) to eject material or alert caregivers (9). Many short- and long-term care facilities use thickened liquid diets to treat aspiration (10). In these diets, thin liquids (for example, water, tea, and coffee) are eliminated, even in the absence of efficacy data, at a substantial cost in financial and quality-of-life terms. It costs approximately $200 per month for an individual to drink thickened liquids (11, 12). A common alternative to thickened liquids is use of a chin-down posture (1317). Welch and coworkers (13) noted that posterior shift of anterior pharyngeal structures with the chin-down posture improved airway protection. Whereas previous studies have provided a basis for the widespread clinical use of chin-down posture, none has provided long-term health outcome data. Results from a previously reported portion of this study (18) demonstrated that short-term elimination of aspiration during the videofluorographic swallowing evaluation occurred most often with honey-thick liquids, followed by nectar-thick liquids and chin-down position. We sought to compare the effectiveness of chin-down posture and thickened liquids (nectar thick and honey thick) on the incidence of pneumonia in participants with dementia or Parkinson disease during 3 months of treatment. Methods Design The study design and methods are described in detail elsewhere (19). In brief, between enrollment initiation on 9 June 1998 and closure on 16 September 2005, 47 acute-care hospitals and 79 subacute residential facilities combined their patients to enroll 515 participants, a total that was 65 participants short of the recruitment goal. Follow-up was completed on 9 December 2005. The Data and Safety Monitoring Committee recommended discontinuing enrollment, on the basis of a futility analysis suggesting that enrolling additional participants would not change the findings. Participants were enrolled in this 3-month follow-up study if they were observed to aspirate when swallowing 3 mL of thin liquids from a spoon or when drinking from a cup without an intervention during videofluoroscopy of swallowing. Aspiration was defined as barium observed below the vocal folds. Participants who qualified were then given boluses to perform 3 conditions in random order: thin liquid (15 centipoise) swallowed in a chin-down posture, nectar-thick liquid (300 centipoise) swallowed in a head-neutral position, and honey-thick liquid (3000 centipoise) swallowed in a head-neutral position. Participants who did equally well (all conditions eliminated aspiration) or equally poorly (no conditions eliminated aspiration) but wished to continue oral intake, despite being warned about risk for pneumonia, were randomly assigned to 1 of the conditions as an intervention and followed for 3 months. Participants who aspirated during 1 or 2 of the conditions were not randomly assigned. On-site speech-language pathologists, nurses, and direct care and dietary staff who completed rigorous training about facilitation of the chin-down posture and proper techniques to thicken liquids supervised administration of the interventions. The number of participants under supervision by a speech-language pathologist ranged from 1 to 93 (median, 4 participants). Clinicians were instructed to refrain from using concomitant active or compensatory interventions with participants during the study period. Research staff made monthly site visits to monitor protocol adherence. All participants or their representatives provided written informed consent. Each facility's institutional review board of record, as approved by the Office for Human Research Protections, Department of Health and Human Services, approved the study. Setting and Participants Inclusion criteria were a physician-identified diagnosis of dementia (Alzheimer type, single or multistroke type, or other nonresolving types) or Parkinson disease and patient age (50 to 95 years). Exclusion criteria were tobacco use in the past year, current alcohol abuse, history of head or neck cancer, insulin-dependent diabetes for 20 years or more, nasogastric show less