An Important Note About Liquids/Hydration
Hydration is vital to maintaining healthy body functions. Usually 6 to 8 cups of liquid (48-64 oz) intake are needed daily to maintain healthy body functions. For some dysphagia patients, this may present problems because thin liquid may be more difficult to swallow, or deemed 'unsafe' to swallow. You may be told that you are not allowed to drink any liquids at all, or that all of your liquids need to be thickened. So what happens next.......
Some patients may be recommended for fluids to be thickened to whats called 'nectar' thick or 'honey' thick. If you've ever had the opportunity to taste these thickened liquids, they are, how shall I put this, just plain awful! I've had patients literally tell me they would rather choke then continue drinking these thickened liquids (Usually not my patients however, because I often refrain from recommending thickened liquids in most cases). Should your therapist recommend your diet to contain thickened liquids, fluid can be easier to swallow once thickened. However, Robbins et al., (2008) research suggests chronic aspirators drinking honey thick liquids need three times longer to recover from pneumonia than those who aspirate thinner materials (thin liquids) concluding that thickened liquids, although may be easier to swallow, may not be safer. Logeman (2006) supports this statement in many of her research stating "the data to support the efficacy of these procedures is not strong and the use of thickened liquids can reduce the patient's quality of life and hydration".
Dehydration decreases salivary flow, which promotes altered colonization of the oropharynx and may lead to lethargy, mental confusion, increased aspiration, and possibly pneumonia. Dehydration makes the patient susceptible to infection by depressing the immune system. Close monitoring by the dysphagia team is required for anyone drinking less than 4 cups of thickened fluid a day or anyone not progressing to thin liquids within 4 weeks.
Some patients may be recommended for fluids to be thickened to whats called 'nectar' thick or 'honey' thick. If you've ever had the opportunity to taste these thickened liquids, they are, how shall I put this, just plain awful! I've had patients literally tell me they would rather choke then continue drinking these thickened liquids (Usually not my patients however, because I often refrain from recommending thickened liquids in most cases). Should your therapist recommend your diet to contain thickened liquids, fluid can be easier to swallow once thickened. However, Robbins et al., (2008) research suggests chronic aspirators drinking honey thick liquids need three times longer to recover from pneumonia than those who aspirate thinner materials (thin liquids) concluding that thickened liquids, although may be easier to swallow, may not be safer. Logeman (2006) supports this statement in many of her research stating "the data to support the efficacy of these procedures is not strong and the use of thickened liquids can reduce the patient's quality of life and hydration".
Dehydration decreases salivary flow, which promotes altered colonization of the oropharynx and may lead to lethargy, mental confusion, increased aspiration, and possibly pneumonia. Dehydration makes the patient susceptible to infection by depressing the immune system. Close monitoring by the dysphagia team is required for anyone drinking less than 4 cups of thickened fluid a day or anyone not progressing to thin liquids within 4 weeks.
Hydration
Adequate fluid intake can be achieved through various interventions, even when on fluid restrictions. Such interventions consist of one or more of the following:
- Offering patients foods or liquids with noted higher fluid content such as vegetables, jello or pudding, and pureed fruits.
- Fluids via Intravenously (IV)
- Fluids via feeding tube
- Frazier "Free Water" protocol
Frazier "Free Water"
This is provided in order for you to be informed of options so you can have a fully informed discussion with your therapist and your Physician. This is not posted on this website for you to take action without consent from your therapist. It is vitally important for you to have all of the facts and make an informed decision about your treatment protocol together. Please do not use the protocol without your therapist's permission. Therefore, the guidelines for the Frazier Water Protocol will not be posted on this website.
Water Protocol is based on several assumptions:
Dehydration
Aspiration Risks
This is provided in order for you to be informed of options so you can have a fully informed discussion with your therapist and your Physician. This is not posted on this website for you to take action without consent from your therapist. It is vitally important for you to have all of the facts and make an informed decision about your treatment protocol together. Please do not use the protocol without your therapist's permission. Therefore, the guidelines for the Frazier Water Protocol will not be posted on this website.
Water Protocol is based on several assumptions:
- aspiration of water poses little risk to the patient if oral bacteria associated with the development of aspiration pneumonia can be minimized
- allowing free water decreases the risk of dehydration
- allowing free water increases patient compliance with swallowing precautions and improves patient quality of life
- good oral hygiene is key ingredient of the water protocol and offers other benefits with regards to swallowing. Aggressive oral care is extremely important and refers to brush your teeth, tongue, gums and roof of mouth with toothbrush and toothpaste, and you floss; even if you are on a restricted diet.
Dehydration
- Xerostomia (dry mouth), which can significantly and negatively impact nutrient intake, reportedly affects more than 70% of the geriatric population
- Potential for reduction in health care spending related to avoidable hospitalizations in dehydrated patients could be as much as 1.14 billion dollars in 1999 (Xiao, Barber, & Campbell, 2004)
- “Dehydration costs Medicare $450 million dollars monthly.” Tufts University, 1994. Dehydration can lead to a variety of negative health consequences (Gross et al., 1992; Copeman, 2000; Kleiner, 1999)
- changes in drug effects
- infections
- poor wound healing
- pressure sores/ulcers
- decreased urine volume and urinary tract infections
- falls
- confusion and lethargy
- constipation/diarrhea
- altered cardiac function
- acute renal failure
- weakness
- declining/decreased nutritional intake
Aspiration Risks
- Risk of developing aspiration pneumonia is significantly greater if thick liquids or more solid consistencies are aspirated (Holas, DePippo, & Reding, 1994)
- When water enters the alveoli, it is taken up into the blood vessels and rapidly reabsorbed into the bloodstream
- Aspiration during water drinking trials is a benign event; even massive entry may cause only transient respiratory changes (Feinberg, 1990)
- The quantity and type of aspiration that can be safely tolerated by the lungs has not been clearly defined
- Clear liquids do not pose an aspiration pneumonia risk unless the pH is very high or very low, or if the quantity is great enough to cause asphyxiation. (Crossley & Thum, 1989)
Thickening Liquids
Although I feel that thickening patients' liquids is well overdiagnosed, I have noticed a concern when patients recommended to thicken their liquids are discharged and confused on how to do so correctly. The below is a nice handout you can give to patients who need such directions on thickening liquids.
| instructionsforthickeningliqs_forpt.pdf |
