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Use of thickened fluids in long term care: Is there a better alternative?

“Winnie, Mr. B had excessive coughs when drinking his apple juice yesterday.  Can you assess if he would benefit from thickened fluids?”
 
This is the type of message I receive on a regular basis from nurses and other care team members.  The demographics in long term care have changed in the past few years: people are being admitted at a later age with more complicated medical conditions, such as dysphagia.
 
When I was still a new dietitian in long term care, swallowing assessment referrals would lead to me going to see a resident with a tray of foods and liquids in various textures and consistencies by my side.  During the bedside swallowing assessment, I would observe the resident to see if any relevant symptoms were presented and recommend the appropriate textures to help minimize the risk of aspiration and/or pneumonia.  This is a standard scenario in a clinical setting, but I felt like something was missing.

Thickening liquids has become the most frequent intervention in the long term care setting. Evidence from clinical studies has shown that increasing the viscosity of thin liquids can help slow the transit time of a bolus from the mouth to pharynx, which reduces the chance of it going down the airway. 

However, I still had two questions:
  • Should thickened liquids be the first intervention for older adults in care who have progressive neurological degenerating diseases and multiple co-morbidities?  
  • Will the use of thickened liquids increase the risk of developing secondary complications?  

These questions made me re-visit the approach I was using to manage the symptoms of dysphagia. Dehydration is the primary concern among people on thickened liquids due to poor acceptance.  Can you recall tasting thickened liquids for the first time? I still remember that sticky mouthfeel and it getting worse as the thickness increased. The unpleasant coating in my mouth never went away no matter how many glasses of thickened liquids I drank. 
 
I observed that many residents were refusing to drink the thickened fluids because of the change in appearance and flavours, especially honey-thick liquids.  Unfortunately, some facilities only provide honey-thick liquids as it was believed that thicker is always safer, regardless of what residents actually need. 

Thickened liquids are either starch-based or gum-based, which increases the nutrient density of the liquid and leads to delayed emptying. Since gum is a good source of dietary fiber, it also plays a role in reducing appetite and caloric intake. A study published by Cichero in 2013  looked at the impact of different thickeners on medications, satiety, and the bioavailability of water. The study showed that the aeration of liquids increases their volume, which may also contribute to the feeling of fullness and affect one’s nutritional intake.
 
Alternate strategies to thickened fluids 
 
Despite my efforts in searching for answers through clinical studies, best practices/guidelines from professional associations, and blogs by credible clinicians and practitioners, I could not find any data that actually looked at the impact of adults in residential care drinking thickened liquids on long term health outcomes. 
 
However, I did find the Frazier’s Water Protocol that helped me to create more practical care plans for my residents.  The Frazier Rehab Institute published this Free Water Protocol to overcome the challenges I was concerned about. The assumption is that water aspirated into the lungs will be absorbed into the body and not lead to aspiration pneumonia (because water has a neutral pH).  I discussed the implementation of this protocol with my interdisciplinary team and addressed potential concerns. 
 
Then, I started screening for residents on thin liquid restricted diets or NPO and performed further assessments with the team to determine if they were good candidates based on the protocol guideline.  Family members of residents who were well suited to the Free Water Protocol were contacted to ensure they were aware of the plan.  The overall hydration status and satisfaction level of residents put on this protocol has improved compared with our baseline records.
 
Lessons learned

Changing beliefs and practices is not easy. Health care team members sometimes place too much emphasis on food/liquid modification before considering other options.  There is no doubt that thickened liquids have a unique therapeutic role in managing dysphagia but other compensatory strategies like head and body positioning, thermal stimulation, and/or use of adaptive eating aids can also help to promote a safe swallow.  

Now, when I perform a bedside assessment, I keep the following things in mind:
  • Can these symptoms be corrected by using alternate compensatory strategies?
  • Is the resident a good candidate for the Free Water Protocol program after considering his or her medical history and physiological factors like mobility limitations and/or impairment?
  • Would the least thickness product work for this resident?  Does it have to be honey or spoon thick?
  • Would the resident benefit from any exercises to improve and/or strengthen the swallowing muscle to help regaining swallowing ability?

Risks can be minimized, but not eliminated. As dietitians, the experts in food and nutrition, we should recommend the least restrictive texture possible when developing a dysphagia management care plan, while ensuring ongoing assessment and evaluation to achieve a balance between safety and one’s quality of life.

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Editor’s note: Thanks to Winnie for sharing her story and passion for this area of dietetics with us!
 
Do you also work with patients with dysphagia? Consider joining the Dysphagia Assessment and Treatment Network  to promote sharing of expertise and resources to build capacity within Canadian Dietitians. DC also has a great position paper that discusses dysphagia assessment and management based on the principles and ideals of evidence-informed, interprofessional client-centred care.

Please share your questions and comments for Winnie below. 
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