Effect of a Minimal-Massive Intervention in Hospitalized Older Patients with Oropharyngeal Dysphagia: A Proof of Concept Study (1)

Dear Editor,

We have read with interest the letter from Hansen T et al. in response to our article and we want to make some comments. First, our intervention is not complex, it is very simple and is designed to be applied massively. To the specific question whether the results of the study by Martín et al (1) would change the conclusions of the systematic review by Beck et al (2), our consensus answer is yes because of 3 reasons:

1) The findings of the systematic review by Beck et al (2) concludes with “a weak recommendation against the use of texture modified liquids and good clinical practice pointing for the use of texture modified foods in patients with OD were made but this is based on the analysis of only two RCTs with patients over 50 years of age with dementia and Parkinson's disease, published in 2008. We believe this generalization is not acceptable.

2) Our intervention in older patients with OD admitted to a general hospital is not complex and it is based on our multiple studies on the diagnosis, pathophysiology, complications, and the effect of thickening agents in elderly patients with OD (3-15), the same phenotype as the patients included in the present study.

3) Regarding treatment, several studies have proved the separate therapeutic effect of the three elements of the Minimal-Massive Intervention (fluid viscosity, nutritional intervention, and oral health); the nutritional treatment is supported by a resolution by the European Council (16), the improvement of oral hygiene in older people is supported by the WHO (17), and the use of fluid thickening agents is supported by the European Society for Swallowing Disorders (ESSD) white paper (18) on fluid thickening. In its white paper, the ESSD concluded that there is evidence for increasing viscosity to reduce the risk of airway invasion and that it is a valid management strategy for OD. In addition, our strategy is supported by the European Union Geriatric Medicine Society and the ESSD in their white paper on OD as a geriatric syndrome (19).

Finally our hospital has been following this strategy, proving it is feasible and well accepted by patients and caregivers. Our study was performed by trained and experienced professionals in the screening and assessment of OD, malnutrition and oral hygiene and we have nearly 20 years experience in the management of older patients with OD (3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15). As stated in the conclusions, a randomized clinical trial including 400 older patients with dysphagia has been designed to validate the intervention and to support the results found in our proof of concept study. In conclusion, yes, we recommend the authors of this systematic review (2) first, to restrict their conclusions to the two phenotypes of patients they analyzed and not generalize to all older patients with dysphagia; and second, to follow scientific methodology, as we have proved the therapeutic effect of thickening agents in older patients with OD in several studies, and we challenge them to conduct clinical studies to refute these results. So, please look to the future, change your conclusions based on very old studies, and use the scientific method to develop your own clinical trials in your older patients. Please do it for the benefit of all older patients with OD.