Things We Do for No Reason: The Use of Thickened Liquids in Treating Hospitalized Adult Patients with Dysphagia

Abstract

The "Things We Do for No Reason" (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. CLINICAL SCENARIOA 74-year-old man with Alzheimer's dementia and chronic dysphagia with a history of aspiration pneumonia presents with urinary tract infection, hypovolemia, and hypernatremia. He has been on thickened liquids at home for the past several months. As his overall condition improves with intravenous fluids and antibiotics, he requests to drink thin liquids.

An Interactive Workshop on Managing Dysphagia in Older Adults With Dementia

“…We aimed to increase confidence around stopping the use of these interventions and having discussions with patients and families around the risks, benefits, and alternatives such as postural modifications and coached eating. 9,12 We found no similar interventions described in the literature. An extensive search found educational material primarily related to oral health, as well as one publication targeted at medical student history taking around dysphagia, as opposed to diagnosis and management.…”

“…However, increasing evidence suggests that these dietary modifications do not lead to decreases in harmful sequelae of aspiration, such as pneumonia, yet may have potential adverse side effects. 9 Initial evidence for the efficacy of thickened liquids in preventing aspiration came from videofluoroscopic studies that showed a reduction of aspiration events with nectar and pudding boluses, findings that have been replicated with other populations in further studies. 10 , 11 However, it was unclear what the clinical correlation was until a 2008 study by Robbins and colleagues that compared ingestion of thickened liquids (nectar and honey thick) with ingestion of thin liquid with postural intervention (chin tuck).…”

“… 12 Further studies supported that those with access to free water had no more risk of developing pneumonia than those without. 9 , 13 , 14 However, the modified diets showed evidence of potential harm in the form of increased risk of urinary tract infection and dehydration, and studies that have looked at quality-of-life scores have shown significant reduction for those on thickened liquid diets. 13 Additionally, there are no data looking at the effect of texture modification of food (e.g., mechanical soft, puree) on incidence of aspiration pneumonia or other sequalae of aspiration.…”

Bridging the Gap Between the Intensive Care Unit and the Acute Medical Care Unit

“…Patients with suspected dysphagia are often prescribed dysphagia diets, which generally lack evidence for reducing aspiration and may lead to dehydration, weight loss, and poor quality of life. 35,36 Previous literature has also shown that 40% of patients in the hospital are malnourished. 37 Addressing dysphagia in early ICU aftercare is critical to prevent dietary restrictions, reduce adverse events, and improve quality of life for ICU survivors.…”

Management of Dehydration in Patients Suffering Swallowing Difficulties

“…It is important to note that thickened liquids and adapted food consistencies are only a start to increase the quality of life of the dysphagic patients, as they work as a motivation tool and prepare them to eventually swallow food and fluid with normal consistency. Given the disadvantages of the use of thickened fluids and adapted food consistencies (which may lead to insufficient nutritional and fluid intake), it is important to control the progression of the dysphagia in order to adapt the food/drink consistency and protect the patient from being restricted to a certain consistency for too long [30].…”