Like drinking paste

I saw a patient last Monday for a review in the hospital. Reading through the progress notes I felt an gradually increasing feeling of dread. Every professional from the night nurse to the geriatrician had noted “hates thickened H2O!” What if I reviewed her and she wasn’t safe for thickened fluids?

A very recent review has confirmed the common knowledge that thickened fluids are effective at reducing aspiration in dysphagic clients. To the final-year Speech Pathology student, the acute clinician seems to be in charge of two levers: which texture and which thickness. Superior clinicians look beyond this two-dimensional measure to attempt to tailor a diet to patient’s needs, expertly balancing nutritional and hydration needs with swallowing safety.thickened fluids

Texture-modified foods and thickened fluids have had standard definitions in Australia since 2007. However, these standards “were not intended to address the nutritional adequacy nor patient acceptability” of them [1]. During their development, some clinicians pushed for more gradations, but it was noted that Clinicians could always “use their clinical judgement to prescribe any additional textures on a case-by-case basis.” [emphasis mine] It’s always more complicated than simply matching a patient to a texture/thickness.

SP’s don’t really have responsibility for ensuring adequate nutrition and hydration – this job belongs to dieticians (in the Multidisciplinary model anyway). This may mean SPs are sometimes less aware of the outcomes of their decisions.

Why don’t people like pasty fluids?

  • Acute patients (not on a stroke ward) appear to prefer pre-thickened fluids rather than power-thickened fluids (I agree with them! Powder thickener is foul) [2]
  • A small study suggested than extended care patients on pre-thickened fluids had better nutritional outcomes than those on power-thickened fluids [3]
  • A review by Cichero suggests that this ‘preference’ boils down to two factors: “physiological expectations that thick fluids will make them feel full”, i.e. 300mL of thickened water feels like more than 300mL of thin water; and the fact that thickening suppresses flavour, which reduced the desire to drink more [4].

Clinical Practice

A review of Australian practice (surveying SPs, nurses and dieticians) from 2014 found that while 98% of those surveyed supplied thickened fluids to their patients (82% using pre-thickened fluids) [5]. Only 17% routinely monitor fluid-intake for their patients on thickened fluids (8% never did this!). 9% believed their patients drank enough, and 51% thought their patients on thickened fluids did not drink enough!

Interestingly, one-third of the SPs did not know how hydration was measured. The authors note that “some
may argue it is not the role of a speech pathologist to know about optimum fluid intake and how hydration is monitored, the counter argument is that the speech pathologist, who prescribes the thickened fluid, should be aware of the impact this will have on an individual’s fluid intake and potential health complications.”

Unsurprisingly the most common strategies for addressing poor-fluid-intake was ‘pushing’ (87%) the patient to drink more, supplementary methods such as IV (66%), education (64%) and dietetics/medical referral. Encouragingly, SPs would offer different flavours, or offer foods with higher fluid contents. 14% implemented free-water protocols (I’ll talk about these in a later post).

Apparently a good technique is to set “small but regular targets for fluid intake throughout the day with increased monitoring.”

Conclusion

When I saw the patient, it became thankfully clear that she simply didn’t like thickened water, not thickened fluids in general. She tried a thickened juice and deemed it acceptable – hopefully her intake will increase from here!

References

  1. Dietitians Association of, A., & The Speech Pathology Association of Australia, L. (2007). Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition & Dietetics, 64, S53-S76. doi: 10.1111/j.1747-0080.2007.00153.x
  2. Whelan, K. (2001). Inadequate fluid intakes in dysphagic acute stroke. Clinical Nutrition, 20(5), 423-428. doi: 10.1054/clnu.2001.0467
  3. McCormick, S. E., Stafford, K. M., Saqib, G., Chroinin, D. N., & Power, D. (2008). The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration. Age and Ageing, 37(6), 714-715. doi: 10.1093/ageing/afn204
  4. Cichero, J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition Journal, 12, 54. doi: 10.1186/1475-2891-12-54
  5. Murray, J., Doeltgen, S., Miller, M., & Scholten, I. (2014). A survey of thickened fluid prescribing and monitoring practices of Australian health professionals. Journal of Evaluation in Clinical Practice, 20(5), 596-600. doi: 10.1111/jep.12154
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