Thickening drinks is a common way to manage and treat dysphagia. But there are problems with thickened drinks. In this short article, we briefly explain what those problems are.
Problems With Thickened Drinks
Thickening drinks can reduce the risk of aspiration. But drinks that are too thick can increase the risk of post-swallow residue remaining in the throat which may then be aspirated. Different people with dysphagia require drinks of different thicknesses to enable them to swallow safely. Because of this, it’s important to provide drinks of the correct consistency for each individual – not too thin and not too thick. But there are several issues that make this difficult to achieve.
Confusing Number Of Thickness Levels And Names Globally
The number of different levels of thickness, and the range of thickness within each level, differs from country to country. But there are usually four or five different levels of thickness (including un-thickened liquid) that are prescribed for people who have difficulty swallowing.
There is a wide range of names for these levels currently in use throughout the world, such as thin, normal, regular, slightly thick, mildly thick, moderately thick, medium thick, thick, other thick, extra thick, extremely thick, nectar, honey, syrup, custard, pudding, Level 150, Level 400, Level 900, Stage 1, Stage 2, Stage 3.
Many of these names lack specificity and are open to interpretation which may cause confusion among clinicians, carers and people with dysphagia. This can lead to drinks being prepared to an incorrect consistency.
Different Instructions From Thickener Manufacturers
Another problem with thickened drinks is that the different manufacturers of the thickening agents provide different instructions.
During our testing, we found that most instructions were based on adding thickener to 100ml of liquid but some are based on 200ml and one was based on 150ml. One manufacturer implies that adding two scoops of their thickener per 100ml of liquid can produce drinks of three different thicknesses!
This can cause further confusion among clinicians, carers and people with dysphagia.
More Problems With Thickened Drinks
It can take several minutes for a drink to reach the correct consistency after thickener has been added. Before this, the drink may be too thin.
Some thickeners continue to thicken the drink slowly over time. So a drink that was at the correct consistency initially can become too thick if not drunk soon after the thickener has been added.
Amylase, an enzyme in saliva, can break down starch. So if a drink thickened with a starch-based thickener is partially drunk, then left for a while, it can become too thin.
Different liquids (e.g. milk, orange juice, coffee) and drinks at different temperatures (e.g. chilled, room temperature and hot) can require different amounts of thickener to reach the same consistency. This is explained in more detail here: www.iddsi.org/News/Special-Features/Why-Temperature-Is-So-Important
Sometimes not all the thickener is completely mixed in to the drink with some forming in to lumps. The drink will then be too thin.
Human Error When Thickening Drinks
Currently there is no practical, reliable, cost-effective way to accurately test that a drink is at the prescribed consistency once the thickener has been mixed in. This problem is exacerbated by:
- The different names used to describe the different levels of thickness are not specific and are subject to interpretation.
- The different instructions for use provided by different manufacturers may cause further confusion.
- Different drinks at different temperatures may require different amounts of thickener to achieve the same level of thickness.
- The thickness of a drink may alter over time.
All this can cause confusion among clinicians, carers and people with dysphagia which leads to errors:
“Fewer than 50% of health professionals checked that texture modified food or thickened liquids were of the correct consistency before serving.” 1
“Visual inspection or observation was the most common assessment method for determining correct food texture or liquid thickness.” 1
“Thickeners are often mixed incorrectly by carers and the required fluid viscosity may not be achieved.” 2
Failures to adhere to Speech and Language Therapist guidelines regarding modifying food and drinks have been documented.3-7
This is a serious problem as such errors can be fatal:
“Noncompliance with recommendations about dysphagia management is associated with adverse outcomes. There was a high mortality rate and aspiration pneumonia was a common cause of death .” 8
“Confusion and miscommunication regarding diet textures and drink consistencies has resulted in increased risk of illness and even death.” 9
In our next article we’ll look at how the IDDSI Framework addresses some of these problems with thickened drinks.
Have you experienced problems with thickened drinks? Please feel free to leave a response below.
References
- www.viscgo.com/IDDSI_poster_Mar_2015.pdf
- Chadwick D, et al. Carer knowledge of dysphagia management strategies. Int J Lang Commun Disord2002; 37: 345–357.
- Chadwick D, et al. Adherence to eating and drinking guidelines for adults with intellectual disabilities and dysphagia. Am J Ment Retard2003; 108 (3): 202–211.
- Chadwick D, et al. Barriers to caregiver compliance with eating and drinking recommendations for adults with intellectual disabilities and dysphagia. J Appl Res Intellect Disabil2006; 19 (2): 153–162.
- Crawford H, et al. Compliance with dysphagia recommendations by carers of adults with intellectual impairment. Dysphagia2007; 22 (4): 326–334.
- Vivanti A, et al. Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. J Hum Nutr Diet2009; 22 (2): 148–155.
- Whelan K. Inadequate fluid intakes in dysphagic acute stroke. Clin Nutr2001; 20 (5): 423–428
- Low J, et al. The effect of compliance on clinical outcomes for patients with dysphagia on videoflouroscopy. Dysphagia2001; 16: 123-127
- www.iddsi.org/framework/what-is-dysphagia