Practice Blog

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

A dietitian working in long term care discusses achieving a balance between safety and quality of life for residents.

WHHS-(1).jpgWinnie Hung is a consulting dietitian, with a Master of Public Health, based in Vancouver. She has been a long term care dietitian since 2009. Winnie received the BC Regional Morgan Medal Award from the Canadian Foundation for Dietetic Research in 2010 for her work in acknowledging the gap between theory and practice in menu planning for residents in care. Receiving this award helped deepen her commitment to improving the quality of food for this vulnerable population. You can follow Winnie on FacebookInstagram or Twitter or get in touch with her at


“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.

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. 
  1. Thanks for the great practice blog on thickened liquids. I agree! In our interest to provide "safe" care we may be inadvertently increasing other risks, such as dehydration.
    We've recently had conversation about this in our region, we need to look at hydration status carefully when thickened liquids are recommended.

    There is a recent opinion in JAMA that also may be of interest: The Horrible Taste of Nectar and Honey—
    Inappropriate Use of Thickened Liquids
    in Dementia, JAMA Internal Medicine June 2016 Volume 176, Number 6, p 735. This opinion raises the concern about thickened liquids for those with dementia.

    We are not trained in our region to recommend compensatory techniques (other than basic recommendations, like swallow twice!) or to recommend exercises. That's great that you have that additional tool available!

    Your blog reinforces that we have an important role in ensuring the care plan is correct and perhaps we need to revisit thick liquids depending on the individual's acceptance.
  2. Thanks for sharing your insights Winnie! This is a great example of the important role of dietitians in LTC - improving the health and quality of lift of clients through practical, evidence driven solutions.
  3. Thanks Winnie for your blog. I completely agree and feel if at all possible we should be trying to provide thickened fluids that are as-thin-as-safely possible for residents and patients. This is in accordance with the IDDSI systematic review findings that state that thickened fluids do help to minimize aspiration in those individuals that aspirate on thin fluids, HOWEVER, there is such a thing as too thick. In this review, they discuss the trade off between safety and efficiency of the swallow when fluids are too thick. Another (most) important part of the picture that you mention is the quality of life of those individuals requiring thickened fluids.
    Thin water protocols have been proven successful in rehab settings - there isn't much evidence in long term care, however, I think if the candidates are chosen properly and mouth care is a priority, then they can do well with thin water - and what a difference to quality of life that would make!!!! Thanks again for sharing your experience.
  4. I am so proud of You Winnie! Good job! I agree with you 100%. I often asked myself how much was I really harming the patient by trying so hard to be safe but I did to have the guts to change it... And I felt I was ruining the little life they had left giving them "gross water"and gross coffee! (Although, I always tried to get the family to sign a waiver form so that I could give the patient what they wanted.) I am so proud of your work! Good job!
  5. Karol Traviss wrote on article entitled, "Black Sheep Facility: No Thickened Fluids" in 1999 that was published in Practice. She told the story of how, at the hospital where she worked, they decided that 'thickened fluids' be interpreted as a request for nutrition assessment. Like Winnie, dietitians found other more palatable ways to deliver required fluids. From 1999 to 2016, it is interesting to observe how the reliance on thickened fluids has grown in practice; these two articles point to the need for greater exploration of this clinical situation.
    Catherine Morley, PDt, PhD, FDC
    Acadia University
  6. Great blog Winnie.
    I see this all too often. We start thickened fluids and find that the risks far outweigh the benefits, and switch back to thin d/t increased QOL.
    The Free Water Protocol sounds like a good idea. I'm curious if this would only be appropriate for residents with good oral hygiene/mouth care? Many of my residents who need thickened fluids cannot maintain or receive good mouth care which may increase their risk of respiratory infection. Should this be considered?
  7. Thank you for this excellent piece and the critical thinking you have demonstrated. I am disappointed (but not completely surprised) to learn that this issue is still out there in full force, as it was for colleagues and I back in the 1990's when commercially thickened fluids had come into common use. We had some similar thoughts back then (which I articulated in an article which I will send you). Karol

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