An Important Note About Liquids, Hydration And Dysphagia
Hydration is vital to maintaining healthy body functions. Usually 6 - 8 cups of liquid is recommended but varies with age, activity, & current health. Water is your body's principal chemical component and makes up about 60 percent of your body weight. Every system in your body depends on water. As the most plentiful substance in the human body, water is also the most plentiful nutrient in the diet. For some dysphagia patients, keeping adequate hydration may prove to be problematic because the thin liquids may be more difficult to swallow, or deemed unsafe to swallow. As with every physician, SLP's also learn differently and thereby practice by their beliefs differently. There is a big debate on using thickening agents vs. finding other alternatives to keep the patient hydrated while swallowing safely.
When making a decision for therapy or treatment, it's not one size fits all. There are a lot of components that come into play. Although my feeling is that thickening agents is widely over - diagnosed, I have used them and will continue to use them when necessary as a last resort. These thickening agents are referred to as "honey thick", "nectar thick", and "pudding thick". If you've ever had the displeasure of tasting any of them (and if you are an SLP, I highly recommend you do so you can put yourself in your patients shoes), they are, how can I put this, just plain awful!!! I've had patients tell me that they would rather choke then to continue drinking them.
Should your therapist recommend you or your loved ones' diet to contain thickened liquids fluid, the fluid can be easier to swallow once thickened, however, is it really safer? Thickening liquids alters the swallow physiology making it easier to swallow. Carbonated liquids are also found to be safer than thin liquids as well as thicker liquids (Logemann 2008). Robbins et. al. (2005) 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 physically easier to swallow (better for laryngeal function), it may not be safer. What does that sentence mean? Let's break it down. Logemann (2008) 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 patients' quality of life and hydration."
Dehydration may be caused by inadequate intake in relation to fluid requirements or excessive fluid losses due to fever, increased urine output, diarrhea, draining wounds, fistulas, environmental temperatures, or vomiting. Water deficiency is characterized by dark urine, decreased skin firmness, xerostomia (also known as dry mouth), dry lips, and mucous membranes, headache, a coated wrinkled tongue, dry or sunken eyes, weight loss, a lowered body temperature and increased serum sodium, albumin, blood urea nitrogen (BUN and creatinine values. Thirst is often the first sign of the need for more hydration.
If the patient has current upper respiratory infections and has pharyngeal dysphagia, we as SLP's must make sure the balance of hydration and safety are completed. The only way to be 100% positive the patient has pharyngeal dysphagia and is possibly penetrating or aspirating is with visual confirmation (instrumentation assessment). Even if there are no penetration/aspiration events during the assessment, the SLP can see other things that are possible to cause such an event, meaning a skilled SLP will know to look for other symptoms. Aspiration alone is not sufficient to cause pneumonia. Aspiration of small amounts of saliva occurs during sleep in almost half of normal subjects. Aspiration pneumonia is thought to occur when the lungs natural defense are overwhelmed when excessive and/or toxic gastric contents are aspirated leading to a localized infection. Those patients who aspirate over 10% of the test bolus or who have severe oral and/or pharyngeal motility problems on VMBS studies are considered at high risk for pneumonia. The severity of aspiration correlates with the risk of developing pneumonia.
That said, when we make treatment recommendations, they are based on a hole host of information to keep the patient safe and comfortable. Hydration is a vital part of that treatment plan. If one recommends one of the thickened liquids or an altered diet and the patient is not drinking or eating the recommended diet, then the treatment plan needs to be revisited so the patient will eat and drink. The patients health will continue to decline without adequate nutrition and liquids which feeds the body.
When making a decision for therapy or treatment, it's not one size fits all. There are a lot of components that come into play. Although my feeling is that thickening agents is widely over - diagnosed, I have used them and will continue to use them when necessary as a last resort. These thickening agents are referred to as "honey thick", "nectar thick", and "pudding thick". If you've ever had the displeasure of tasting any of them (and if you are an SLP, I highly recommend you do so you can put yourself in your patients shoes), they are, how can I put this, just plain awful!!! I've had patients tell me that they would rather choke then to continue drinking them.
Should your therapist recommend you or your loved ones' diet to contain thickened liquids fluid, the fluid can be easier to swallow once thickened, however, is it really safer? Thickening liquids alters the swallow physiology making it easier to swallow. Carbonated liquids are also found to be safer than thin liquids as well as thicker liquids (Logemann 2008). Robbins et. al. (2005) 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 physically easier to swallow (better for laryngeal function), it may not be safer. What does that sentence mean? Let's break it down. Logemann (2008) 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 patients' quality of life and hydration."
Dehydration may be caused by inadequate intake in relation to fluid requirements or excessive fluid losses due to fever, increased urine output, diarrhea, draining wounds, fistulas, environmental temperatures, or vomiting. Water deficiency is characterized by dark urine, decreased skin firmness, xerostomia (also known as dry mouth), dry lips, and mucous membranes, headache, a coated wrinkled tongue, dry or sunken eyes, weight loss, a lowered body temperature and increased serum sodium, albumin, blood urea nitrogen (BUN and creatinine values. Thirst is often the first sign of the need for more hydration.
If the patient has current upper respiratory infections and has pharyngeal dysphagia, we as SLP's must make sure the balance of hydration and safety are completed. The only way to be 100% positive the patient has pharyngeal dysphagia and is possibly penetrating or aspirating is with visual confirmation (instrumentation assessment). Even if there are no penetration/aspiration events during the assessment, the SLP can see other things that are possible to cause such an event, meaning a skilled SLP will know to look for other symptoms. Aspiration alone is not sufficient to cause pneumonia. Aspiration of small amounts of saliva occurs during sleep in almost half of normal subjects. Aspiration pneumonia is thought to occur when the lungs natural defense are overwhelmed when excessive and/or toxic gastric contents are aspirated leading to a localized infection. Those patients who aspirate over 10% of the test bolus or who have severe oral and/or pharyngeal motility problems on VMBS studies are considered at high risk for pneumonia. The severity of aspiration correlates with the risk of developing pneumonia.
That said, when we make treatment recommendations, they are based on a hole host of information to keep the patient safe and comfortable. Hydration is a vital part of that treatment plan. If one recommends one of the thickened liquids or an altered diet and the patient is not drinking or eating the recommended diet, then the treatment plan needs to be revisited so the patient will eat and drink. The patients health will continue to decline without adequate nutrition and liquids which feeds the body.
Keep Hydrating!!!!
Adequate fluid intake can be achieved through various interventions, even when on fluid restrictions, ESPECIALLY when on fluid restrictions!! Such interventions consist of one or more of the following while also focusing on treatment:
- Offering patients foods or liquids with noted higher fluid content such as vegetables or pureed vegetables, jello or pudding, and fruits or pureed fruits.
- Pleasure feeds such as above. Or Pleasure drinks.
- Fluids via Intravenously (IV)
- Fluids via feeding tube
- Frazier "Free Water" protocol
Dehydration
Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated.
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:
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.
- 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 must be present, but will result in pneumonia only if the aspirated material is pathogenic to the lungs and host resistance is compromised
- Aspiration during water drinking trials is a benign event; even massive entry may cause only transient respiratory changes (Feinberg, 1990)
- Incidence of aspiration pneumonia is not significantly different between patients who aspirate thin liquids and those who do not aspirate (Feinberg, et al, 1996)
- 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)
- Delayed swallow initiation and excess residue are only significant when occurring with pureed food, but not with liquids
- Several factors are highly predictive of development of aspiration pneumonia (Langmore, et al, 1998)
-Dependence for oral care (40%)
-Number of decayed teeth (34%)
-Tube feeding (27%)
-More than one medical diagnosis
-Number of medications prescribed
-Now Smoking
-Reduced activity level (43%)
-GER (28%)
-Esophageal dysmotility
-Aspiration of food
-Decreased pharyngeal transit time
- Of documented aspirators, only 38% developed pneumonia
- Dysphagia by itself, without the presence of one of the above predictors is not sufficient to cause pneumonia
- The role of dysphagia/aspiration in the development of pneumonia may be better understood by considering the colonization of pathogenic bacteria and the host resistance to the process
- Oral and dental disease may contribute to pneumonia by increasing levels of certain oral bacteria in the saliva, and/or by changing the composition of the salivary flora
- Changes in oral milieu occur secondary to xerostomia, medications, reduced oral care, changes in the patients LOC, and changes in the patients’ ability to clear the organisms mechanically, e.g. stroke. (Millns, et al., 2003)
- Aggressive oral care, when done frequently:
-Increases the desire to eat
-Increases oral awareness of food
-Decreases aspiration
-Increases oral movement of food
-Increases alertness
-Prepares the patient for the meal by increasing taste sensation/salivation
Instructions for the Patient for Thickening Liquids
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.
Xanthem Gum is a natural source that can be used as a thickener and is found in all supermarkets.
Xanthem Gum is a natural source that can be used as a thickener and is found in all supermarkets.
| instructionsforthickeningliqs_forpt.pdf |