Dysphagia and "minimal mass interventions": ethics, management and value

Marco Inzitari

In recent times there is an increased risk that the relevant becomes unseen. I understand that readers are mainly from the world of health but did you know that in Barcelona, ​​at the end of September 2017, the European and world congress on swallowing disorders was organized? And that the current president of the European Society of Swallowing Disorders is very close to us because he’s Dr. Pere Clavé, gastroenterologist and academic director, teaching and innovation at the Hospital de Mataró?

I was fortunate to be invited to talk about Dysphagia in older people in this meeting, with the opportunity to review the advances in this area. I don’t aim to venture into any clinical treatise on Dysphagia, but I think it’s useful to disseminate some aspects that are in line with the "value practices" advocated by this blog.



Some reminders, to focus the theme:

The prevalence of this problem in the elderly is very high: depending on the type of population, it varies between 11% within the community, 30-90% in those hospitalized within acute care, 40-75% in those who live in a residence and more than 80% in populations with very frequent chronic diseases, such as dementia, Parkinson's disease or stroke. It’s obvious that it increases with frailty.

The consequences can be very serious: malnutrition, dehydration, respiratory complications such as pneumonitis and infections, which can cause prolonged hospitalizations, more readmissions and increased morbidity and mortality and, obviously, costs. There are also psychological consequences (anxiety, depression), worsening patients’ experience and, in general, worsening of quality of life. It must be remembered that pneumonias (in which Dysphagia is undoubtedly a relevant determinant) are a clear risk factor for a person with advanced dementia to end their days in an emergency department or hospitalized, as a research showed.

The most interesting thing is that, although the congress also had a specific research aspect on biomechanics and technology, there are things we can do now and here, both for the individual person in front of us and in terms of the management and organization of an institution. The two main steps are well summarized in a recent review of Dr. Clavé's group:

1. Implement protocols for screening and diagnosis of Dysphagia, which can be perfectly clinical and be performed by different types of health professionals, such as nurses, along with an assessment of the person's nutritional status.
2. Act with adapted interventions. Those that rely on more evidence that can be implemented on a large scale within the strategy called minimal-massive intervention (understood as ‘the minimum that should be done with great scope’) are basically three:

A. After the evaluation, the administration of liquids with thickeners, which makes them more viscous, virtually prevents episodes of aspiration. As a negative aspect, currently the thickeners in the market are not very pleasant (they have little palatability) and sometimes it’s difficult to swallow them. Result: adherence of 50%, with risk of complications and dehydration. In this regard, the industry is working very actively to find better practical solutions

B. Adaptation of the diet, for example, with crushed preparations of different consistencies and with adequate caloric and protein intake. It’s important to take care of the organoleptic properties (taste, smell, sight, touch), which generates a great interest even of Catalan haute cuisine (Ferran Adrià with the Alicia Foundation, or Carme Ruscalleda, who in the congress recommended the recipe for a fideuá (short pasta and seafood) meal for dysphagic people).

Regarding points A and B, we must also remember that each evaluation and intervention must be focused on the person and must be framed in the multiple problems of the elderly person, from their comprehensive assessment, and in the shared decisions, with good advanced planning.

C. Last pillar is taking care of oral hygiene and oral health. To do this you have to start from the base: brush your teeth and use an antiseptic, and then take care of the mouth as any adult would and go to the dentist if necessary.ç

Especially in relation to the last point (C), it’s convenient to make a reflection on ethics and management, which, fortunately, in this case are coherent. Why, in the elderly, things like this still seem superfluous, as if it were another category of people? On the other hand, if implementing such simple interventions can reduce the risk of some of the mentioned complications, however little, in a non-invasive and apparently low-cost way, would not it be convenient to prioritize them, when we do many more complex and expensive things

On the other side of the coin, it could be argued that implementing this type of intervention may require dedication and effort (time), with the added difficulty of having to foster cultural changes in people and caregivers, and practical and organizational changes in institutions, that almost always generate open resistance or inertia. Much easier, then, is to prescribe a pill, at least we will have done something for the person with Alzheimer's disease who lives in a residence. But maybe it’s better not to question ourselves about the value of this heroic act, as Dr. Varela well argues in his recent editorial on statins.