Patients with difficulty swallowing being kept nil-by-mouth unnecessarily, says leading geriatrician

03 April 2019

A paper published today in Age and Ageing, the scientific journal of the British Geriatrics Society, warns that a widespread misperception of a preventable link between aspiration and pneumonia while eating and drinking in those with difficulty swallowing may lead to patients being kept nil-by-mouth unnecessarily.

Some people have an ‘unsafe swallow’ that is unlikely to improve due to problems like a stroke, a neurological condition such as Parkinson's disease, or frailty. ‘Risk feeding’ is generally used when such patients continue to eat and drink despite a perceived risk of choking or aspiration. In some cases, this is the person’s choice; in others, it may be because tube feeding is not clinically indicated or because eating and drinking is judged in the person’s best interests.

Past studies have found that patients with difficulty swallowing who develop pneumonia, even repeatedly, do not necessarily have aspiration pneumonia. Nil-by-mouth status, feeding tubes and modified diets cannot prevent secretions colonized by pathogenic bacteria being inhaled into the lungs, and these interventions have not been shown to reduce pneumonia. Despite the lack of evidence that it will help, some healthcare professionals continue to implement interventions like nil-by-mouth to reduce the risk of pneumonia.

Dr Shaun O’Keeffe, a consultant in geriatric and general medicine at Merlin Park University Hospital Galway, cautions in his Age and Ageing paper that although risk feeding policies are well intentioned in seeking to avoid unnecessary restriction of eating and drinking, they might serve to validate and perpetuate unwarranted professional anxieties.

Dr O’Keeffe commented “Many people’s swallowing abilities and preferences fluctuate, sometimes from hour to hour, and staff need to have, and be encouraged to use, common sense, flexibility and judgement in these circumstances. Staff anxiety about aspiration of food or fluid is common, and people may fear being criticised if there is an adverse outcome. The pervasiveness of the language of risk in healthcare now may encourage a risk-averse attitude among staff and disregard of what matters to patients, their families and carers. People need to be informed of the potential benefits and risks of continuing to eat and drink and can then weigh up this information in the context of their preferences and goals and decide how to proceed.“

Read the Age and Ageing paper The perils of ‘risk feeding