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Teachable Moment | Less Is More

The Horrible Taste of Nectar and Honey—Inappropriate Use of Thickened Liquids in Dementia A Teachable Moment

Christina Hao Wang, MD1; Blake Charlton, MD1; Jeffrey Kohlwes, MD, MPH1
[+] Author Affiliations
1Department of Internal Medicine, PRIME Residency Program, University of California and San Francisco Veterans Affairs Medical Center, San Francisco
JAMA Intern Med. 2016;176(6):735-736. doi:10.1001/jamainternmed.2016.1384.
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This Teachable Moment questions the routine use of thickened liquids to prevent pneumonia in patients with dementia.

Article InformationCorresponding Author: Christina Hao Wang, MD, Department of Internal Medicine, PRIME Residency Program, University of California and San Francisco Veterans Affairs Medical Center, 4150 Clement St, San Francisco, CA 94121 (hao.wang@ucsf.edu).

Published Online: May 2, 2016. doi:10.1001/jamainternmed.2016.1384.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient and her family for granting permission to publish this information.

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Also Meets CME requirements for:
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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Negative Title Detracts from Real Issue of Decision-Making in Dysphagia Management
Posted on September 15, 2016
Karen Sheffler, MS, CCC-SLP, BCS-S
Conflict of Interest: I am a medical Speech-Language Pathologist who works in acute care (adults/geriatrics), and I am the founder of SwallowStudy.com: Dysphagia Resource for Professionals & Patients.
I have not received any financial incentives to write this article. I had a fellow SLP request my writing assistance to respond to the article.
My desire is to raise awareness around the issues people face when they or loved ones have difficulty swallowing.
Disclosure on one link in my blog regarding Product Reviews of Thickened Liquids: I receive a small <3% commission on sales of thickened liquids through one company only (CWI Medical Products). The total amount I have received from this aspect of my website is $10. This information is disclosed on the website within the product review section. I also review products where I receive no commission.
Please see my in depth blog in response to Wang, Charlton, and Kohlwes (2016) at SwallowStudy.com: http://www.swallowstudy.com/?p=1819
It has received a lot of attention on Twitter and Facebook (@SwallowstudySLP).

I concluded the article with these calls to action:
1. SLPs need to market their dysphagia services better. We do not reflexively put people on thickened liquids. SLPs are not the bad guys who like to thicken liquids or make people Nil Per Os (NPO or nothing by mouth).
2. SLPs use patient-centered communication. SLPs discuss findings with the patient, caregivers, and medical team and pose recommendations as a spectrum of options from curative to palliative.
3. SLPs advocate for instrumental testing, when appropriate, to place people on the least restrictive diet and make sure that safe swallow strategies actually work. How risky are thin liquids? Does thickening the liquid work? SLPs further advocate for repeat testing, in order to return patients to thin liquids as quickly as possible after an acute illness or weakness has resolved.
4. The medical team, starting with the person’s primary care physician, needs to have discussions early on in the person’s degenerative disease regarding goals of care when eating and drinking becomes difficult.
5. The medical team needs to have in-depth and sit-down conversations with the patient and health care proxy (when applicable). The team should involve the Palliative Care service to help delineate the patient’s goals of care, as these conversations can be complex and lengthy. Is it in the patient’s goals of care to prevent aspiration and aspiration pneumonia at all costs? Would small changes make a big difference in the person’s quality of life (e.g., water between meals or having ice cream)?
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