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Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

2008 Apr 01

Journal Article

Robbins, J.A.; Gensler, G.; Hind, J.; Logemann, J.A.; Lindblad, A.S.; Brandt, D.; Baum, H.; Lilienfeld, D.; Kosek, S.; Lundy, D.; Dikeman, K.; Kazandjian, M.; Gramigna, G.D.; McGarvey-Toler, S.; Gardner, P.J.Miller

Ann Intern Med






Aged; Aged, 80 and over; Deglutition Disorders; dementia; Drinking; Female; Frail Elderly; Honey; Humans; Incidence; Male; Middle Aged; Parkinson Disease; Patient Compliance; Pneumonia, Aspiration; Posture; Risk Factors

BACKGROUND: Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions.OBJECTIVE: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease.DESIGN: Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005.SETTING: 47 hospitals and 79 subacute care facilities.PATIENTS: 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months.INTERVENTION: Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position.MEASUREMENTS: The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators.RESULTS: 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%).LIMITATIONS: A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs.CONCLUSION: No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

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