Thickened liquids have had a lot of publicity lately in social media. They’ve been a large part of dysphagia management. Sometimes, it can be argued that the use of thickened liquids occurs more frequently than other compensation or management techniques.
- “Texture modification has become one of the most common forms of intervention for dysphagia and is widely considered important for promoting safe and efficient swallowing.” (Steele and Miller 2010)
Often, products or research is aimed at reducing the use or need of thickening liquids. The Provale cup is one such product that only allows the patient 5-10 ml per drink, which may or may not be a safer amount of thin or nectar thick liquids.
There is a lot to look at when looking into thickened liquids. The physical cost is definitely an issue. Thickener is not cheap. My friend Vince Clark calculated the cost of pre-thickened liquids and posted the following on Facebook:
When we look at the cost of Thickened liquids:
- Per Day: 9 x .34 = $3.06
- Week: $21.42
- Month: $85.68
- Year: $1116.90
These are the costs of a single organization. An individual purchasing thickener may pay double.
We also need to look at how thick we’re recommending for our patients. Many times and research back that maybe nectar thick is enough. Dr. Leder looked at patients that aspirated thin liquids and found that these same patients had 100% successful swallows with both nectar and honey thick liquids indicating that nectar thick may be adequate to promote safe swallowing. (Leder et al 2012)
There has been research leading to the fact that maybe we shouldn’t thicken liquids. Dr. Logemann et al found honey thick liquids were the most effective in eliminating aspiration when compared to nectar thick liquids and a chin tuck.However, when aspirated, honey thick liquids had the most significant impact causing pneumonia, longer hospital stays or death. (Protocol 201).
There are times patients are seen for a Modified Barium Swallow Study (MBSS), they penetrate with both thin and nectar so they are placed on honey thick liquids. Perhaps the debate should not be an all or nothing, thickened liquids or no thickened liquids, but look at the whole patient and make the decision with them. Always consider those patients that aspirate thin liquids during the MBSS, return home, continue to drink thin liquids and never die from aspiration pneumonia like we sometimes teach them will happen when they aspirate.
My interpretation of this research into my very real daily job is that I need to consider the whole patient and that some patients just need those thickened liquids. They’re not going anywhere anytime soon.
In fact, thickened liquids can be great therapeutically. Dr. Bonnie Martin-Harris has done quite a bit of research while developing the Modified Barium Swallow Impairment Profile (MBSImP) and has found that using a nectar consistency during the Modified Barium Swallow Study (MBSS) there is more significant pharyngeal movement during the swallow. There are also studies looking at how adding “weight” to the bolus can be an effective therapeutic strategy.
We need to be careful in interpretation of research. Just because an article came out that says not to use thickened liquids at all, don’t go and throw out all your thickener. (Wallace, this article, 2016).
The cost is not only monetary, but also in our patient’s health, satisfaction and quality of life. We all have or have had that patient that just really doesn’t mind thickened liquids. They drink the liquids, they may not be turning cartwheels with thickened liquids but they tolerate them. Some patients know it’s short-term and once they rehabilitate their swallowing function they may be able to resume thins.
We also have or have had those patients that just outright refuse thickened liquids. They don’t like the texture or the consistency. This may be the patient that says, “I know I need them but they taste like snot.” (A former patient on thickened liquids circa 2011.) This may also be the patient that refuses to follow your recommendations or just stops drinking all-together.
There always has to be a balance and a consideration for hydration, overall health, respiratory health and patient satisfaction. I’m not talking the survey the patient gets and rates you on a scale from 1-whatever. I’m talking about their everyday, I’m happy with my life satisfaction.
Always look at your patient as a whole. Look at their respiratory system, their overall health, history, cognition and if able create a plan with that patient.
I have completed many MBSS’s with many patients over my years. “Remember, the person is here because they have been having difficulty with their swallow. I’m guessing this isn’t the first or last time they have or will aspirate.” (Wallace at every MBSS when the radiologist is ready to quit because the patient aspirated.)
Remember those elders at the SNF that are put on thickened liquids and remain on honey thick liquids for the rest of their days. These may be the same people you say wandering the halls, stealing drinks at the water cooler, stealing drinks from the tables in the dining room or sneaking drinks from the bathroom sink.
Steele, C. M., & Miller, A. J. (2010). Sensory input pathways and mechanisms in swallowing: a review. Dysphagia, 25(4), 323-333.
Robbins, J., Hind, J., & Logemann, J. (2004). An ongoing randomized clinical trial in dysphagia. Journal of communication disorders, 37(5), 425-435.
Leder, S. B., Judson, B. L., Sliwinski, E., & Madson, L. (2013). Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: nectar is enough. Dysphagia, 28(1), 58-62.