Thickened Liquids = Substandard Oral Fluid Intake = Dehydration. Is It Really That Simple? “Thickened liquids” generally elicits a negative reaction to those who have had experience with them. The altered taste, texture, and consistency of thickened liquids has long been thought to be the primary reason for substandard fluid intakes in patients with dysphagia who are restricted to thickened liquids. However, recent studies ... Article
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Article  |   June 15, 2016
Thickened Liquids = Substandard Oral Fluid Intake = Dehydration. Is It Really That Simple?
Author Affiliations & Notes
  • Anne McGrail
    Speech Pathology Department, Miami Valley Hospital, Dayton, OH
  • Disclosures
    Disclosures ×
  • Financial: The author has no relevant financial interests to disclose.
    Financial: The author has no relevant financial interests to disclose.×
  • Nonfinancial: The author has no relevant nonfinancial interests to disclose.
    Nonfinancial: The author has no relevant nonfinancial interests to disclose.×
Article Information
Swallowing, Dysphagia & Feeding Disorders / Part 2
Article   |   June 15, 2016
Thickened Liquids = Substandard Oral Fluid Intake = Dehydration. Is It Really That Simple?
Perspectives of the ASHA Special Interest Groups, June 2016, Vol. 1, 67-71. doi:10.1044/persp1.SIG13.67
History: Received October 6, 2015 , Revised December 17, 2015 , Accepted December 28, 2015
Perspectives of the ASHA Special Interest Groups, June 2016, Vol. 1, 67-71. doi:10.1044/persp1.SIG13.67
History: Received October 6, 2015; Revised December 17, 2015; Accepted December 28, 2015

“Thickened liquids” generally elicits a negative reaction to those who have had experience with them. The altered taste, texture, and consistency of thickened liquids has long been thought to be the primary reason for substandard fluid intakes in patients with dysphagia who are restricted to thickened liquids. However, recent studies suggest that individuals who have no restrictions on liquid consistency also exhibit substandard fluid intake. Factors including functional deficits post-stroke, environmental barriers, and the amount of fluids offered have been reported to influence oral fluid intake for hospitalized individuals regardless of liquid viscosity. While thickened liquids have received criticism for contributing to dehydration, another treatment in dysphagia, the “Water Protocol,” has generated a positive response in improving not only quality of life, but also hydration while maintaining respiratory health. Despite recent studies suggesting that aspirating water does not result in adverse events in individuals who are known to aspirate, there are many unreported variables that could alter the outcomes. Dysphagia severity, or more specifically, aspiration characteristics, may influence how well an individual tolerates a water protocol. Understanding the variables that can influence outcomes in dysphagia research is crucial before a treatment can be considered efficacious.

Thickened liquids have largely been viewed in a negative manner. Despite the immediate positive effect thickened liquids has on minimizing aspiration during instrumental examination (Logemann et al., 2008), the long-term efficacy of this treatment in preventing aspiration or development of aspiration pneumonia is no more or less effective than other compensatory strategies used with thin liquids (Robbins et al., 2008). Additionally, the literature is replete with evidence of altered taste and considerable variability in viscosity across brand of thickener, beverage type, beverage temperature, and time (Adeleye & Rachal, 2007; Dewar & Joyce, 2006; Horwarth, Ball, & Smith, 2005; Lotong, Chun, Chambers, & Garcia, 2003; Macqueen, Taubert, & Cotter, 2003; Matta, Chambers, Garcia, & Helverson, 2006). To further cast a negative light, reports of patient dissatisfaction with thickened liquids, as well as overwhelming evidence of poor fluid intake associated with thickened liquids, is abundant (Finestone, Foley, Woodbury, & Greene-Finestone, 2001; Garon, Engle, & Ormiston, 1997; Horwarth et al., 2005; Macqueen et al., 2003; McGrail & Kelchner, 2012; Whelan, 2001). Although each of these points are worthy of discussion, the role thickened liquids plays in the development of dehydration is becoming more and more crucial given the burden dehydration and associated medical conditions (e.g., urinary tract infection) have on health care spending (Xiao, Barber, & Campbell, 2004).
Review
Liquid Viscosity and Oral Fluid Intake
The literature unanimously reports substandard oral fluid intake in patients receiving thickened liquids (Finestone et al., 2001; Garon et al., 1997; McGrail & Kelchner, 2012; Whelan, 2001). Average fluid intakes ranged from as little as 455ml/day to 1210ml/day in acute/sub-acute post-stroke patients exhibiting dysphagia. In general, the lack of adequate fluid consumption was attributed to patients' dissatisfaction with thickened liquids, placing individuals restricted to thickened liquids at high risk for dehydration. While the association between thickened liquids and poor fluid intake is strong, McGrail and Kelchner (2012)  found that post-stroke patients consuming thin liquids also exhibited substandard fluid intake in comparison to a conservative fluid intake standard of 1500ml/day. One of ten post-stroke patients consuming thin liquids met the minimum standard intake of 1500ml/day; the remaining 9 patients were deficient (range of 158ml to 637ml below standard). Despite a significant difference in oral fluid intake between post-stroke patients consuming thickened liquids (947ml/day, +/-144ml) and post-stroke patients consuming thin, or unaltered liquids (1237ml/day, +/-442ml) p = 0.039; the actual difference between the 2 groups was 290 ml. This equates to approximately 9 ounces of fluid, or slightly more than 1 cup per day. These findings suggest that factors other than altered liquid viscosity influence oral fluid intake.
Functional Deficits and Oral Fluid Intake
Post-stroke sequelae can encompass a wide and varied range of motor, sensory, and cognitive-communicative deficits. These deficits, in terms of functional ability to facilitate adequate consumption of fluids, were investigated to determine their predictive value in oral fluid intake in post-stroke patients receiving thin liquids and post-stroke patients receiving thickened liquids (McGrail & Kelchner, 2015). The authors used admission Functional Independence Measure (FIM) scores for eating (self-feeding), communication, and cognition (memory and problem solving) as well as a 7-point severity rating scale for dysphagia to identify how well these functional deficits predict oral fluid intake in post-stroke patients. Level of dependence (FIM) for expression (communication) and severity of dysphagia did not significantly predict oral fluid intake for either group; however, FIM scores for eating (self-feeding) significantly predicted oral fluid for post-stroke patients receiving thin liquids (p = .05). This finding suggests that the more independent the patients are in feeding themselves, an increase in fluid intake would be seen. The FIM scores for cognition significantly predicted fluid intake for patients receiving thickened liquids (p = .0037), suggesting that as patients are more independent with problem solving, reasoning, and memory, fluid intake of thickened liquids would increase. These findings shed some insight into how functional deficits post-stroke can influence fluid intake aside from thickened liquids and/or dysphagia, and their influence should not be underestimated. However, factors related to the health care environment also contributed to poor fluid intake, particularly for individuals receiving thickened liquids.
Barriers to Oral Fluid Intake
Barriers to adequate intake during meals have been identified in hospital and long-term care facilities (Kayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999; Naithani, Whelan, Thomas, & Gulliford, 2010; Westergren, Karlsson, Andersson, Ohlsson, & Hallberg, 2001). Adequate time to consume meals/beverages, interruptions during meals, and inability to reach foods/beverages can certainly hinder adequate intake. When patients are dependent upon staff to bring them beverages, fluid intake can be dependent not only on how accessible the beverages are (e.g., within reach of the patient), but also upon the amount and how frequently fluids are offered. McGrail and Kelchner (2012)  reported that patients consuming thin liquids had beverages within reach 88% of the time during unannounced observations; whereas, patients consuming thickened liquids only had beverages within reach 56% of the time. This discrepancy may have been a reflection of the need for supervision during oral intake for those consuming thickened liquids. Regardless, limited access to beverages poses a problem and places the burden of responsibility on those caring for the patient. Additionally, the authors do not report the amount of fluid present (e.g., 240 ml versus 2400 ml); only if the patient was able to reach the beverage. Regardless of the proximity of the beverage to the patient, the amount of fluids present and/or offered can also have an impact on sufficient oral fluid intake.
McGrail and Kelchner (2015)  found that patients receiving thin liquids were offered significantly more fluids (mean = 2574ml; SD = +/- 737ml) than patients receiving thickened liquids (mean = 1588ml; SD +/- 302ml; p = 0.0002). Remarkably, those receiving thickened liquids were actually offered less than 1500 ml per day 50% of the time. Despite being offered less than the minimum fluid intake standard (1500 ml), patients receiving thickened liquids consumed similar proportions of the fluids offered when compared to patients receiving thin liquids; both consuming approximately 55–65% of what was offered. Fluid intake will always be substandard when inadequate amounts of fluids are offered. To compound this issue, oral fluid intake could suffer even more if patients do not like the beverage offered, regardless of viscosity. Simmons, Alessi, and Schnell (2001)  report improved oral intake of fluids when beverage preference was adhered to and beverages were offered more frequently in the long-term care setting. While additional research into environmental barriers to oral fluid intake is needed, it is crucial for speech-language pathologists (SLPs) to work in conjunction with other health care professionals in order to minimize the development of dehydration for patients who are at risk.
Multi-Disciplinary Approach to Maintaining Hydration
The debate about the role thickened liquids has in the development of dehydration will continue for the unforeseeable future, but how the health care team is addressing the problem of dehydration is of importance now. A collaborative effort among SLPs, dietitians, nurses, and physicians is crucial for identifying risk factors for insufficient oral fluid intake and being proactive in establishing a treatment plan to promote fluid intake. When patients exhibit decreased or fluctuating levels of alertness, parenteral, or enteral fluids may be necessary to meet fluid needs. However, when patients are able to actively participate, ensuring that adequate amounts of beverages of their choice are easily accessible is crucial. Patients whose food intake is greater than fluid may benefit from choices of fluid dense foods to promote sufficient fluid intake (Vivanti, Campbell, Suter, Hannan-Jones, & Hulcombe, 2009). Another treatment that has been recently reported to increase fluid intake for patients' restricted thickened liquids is the free water protocol (Carlaw et al., 2012).
Free Water Protocol
The Frazier Free Water Protocol, a well-known treatment in dysphagia developed by Panther and colleagues over 20 years ago, offers patients with dysphagia a means in which to enjoy thin water within a specified set of parameters. Patients who are able to initiate a swallow, but exhibit aspiration without distress (e.g., excessive coughing), are permitted to have unlimited water 30 minutes following a meal or medication, until their first bite of food or drink of thickened beverage. Aggressive oral care is provided to patients who are unable to complete their own care. More recently, Carlaw et al. (2012)  developed the GF Strong Water Protocol, which expanded upon the Frazier Free Water Protocol by establishing an algorithm identifying patients who are appropriate for the water protocol. Additionally, more stringent guidelines for oral hygiene/oral care for individuals who participate in the water protocol were developed, likely in response to the plethora of evidence linking poor oral hygiene/oral disease to aspiration pneumonia (Abe, Ishihara, Adachi, & Okuda, 2006; Abe et al., 2008; Sarin, Balasubramaniam, Corcoran, Laudenbach, & Stoopler, 2008; Yoneyama et al., 2002). No adverse events (e.g., aspiration pneumonia) and an increase in oral fluid intake was reported for 16 participants who participated in the pilot study (Carlaw et al., 2012). While the aforementioned study and those completed by Frey and Ramsberger (2011)  and Karagiannis, Chivers, and Karagiannis (2011)  have added to the current literature on the effects of water in aspirating adults, many questions remain unanswered.
Despite the algorithm established by Carlaw et al. (2012), the criteria for patient candidacy in participating in a water protocol remains ambiguous. Based upon the widely accepted criteria for participation in a water protocol, the individual must be able to initiate a swallow and not exhibit signs of distress as a result of the aspiration events. It would then stand to reason that regardless of dysphagia severity, including the amount, frequency, and consistencies of boluses aspirated on instrumental examination, any individual whose oral hygiene is good and maintained during the water protocol, and whose respiratory status is stable (e.g., no active pneumonia) would be a good candidate for the water protocol. Interestingly, prior research studies do not report dysphagia severity; or even confirm presence of aspiration during instrumental examination (Carlaw et al., 2012; Frey & Ramsberger, 2011; Karagiannis et al., 2011). If patients are aspirating small amounts infrequently, this could influence the outcomes in a positive manner (e.g., no adverse effects).
A retrospective study of 79 individuals with dysphagia who participated in a water protocol revealed interesting trends in aspiration characteristics (McGrail, 2015). A majority of participants (68%) aspirated only on thin liquids during the instrumental examination and 76% of all aspiration events were subjectively judged to be small amounts that traveled just below the level of the vocal folds. Individuals who aspirated on both thin and thickened liquids, or who were subjectively judged to aspirate grossly during instrumental examination, did not start the water protocol immediately following the instrumental assessment; (starting an average of 11 days, SD +/- 4.4 days later; McGrail, 2015). The delay in starting the water protocol possibly allowed time for improvement in swallowing function; therefore, possible skewing the results by conservatively selecting patients at lower risk of aspiration. Furthermore, Carlaw et al. (2012)  reported participants were encouraged to use strategies during water consumption that were found to be effective in preventing aspiration on thin liquids. If patients are using strategies during the water protocol to prevent aspiration, then it's possible we are assessing the efficacy of the strategies rather than how well patients are tolerating aspiration of water.
Conclusions
Barriers to oral fluid intake are widely prevalent in health care. While there are merits to the use of thickened liquids, this treatment has been overwhelmingly linked to poor fluid intake and dehydration. As a member of the health care team, SLPs need to acknowledge that factors aside from thickened liquids also contribute to this problem and work with the dietitians, nurses, and physicians to minimize the risk of dehydration associated with dysphagia. Additionally, allowing individuals with dysphagia the opportunity to drink thin/ unaltered water has improved the quality of life for many. However, before treatments are hailed as efficacious or not, continued investigation is imperative. The use of treatments such as “the water protocol” in health care facilities will continue to be scrutinized if SLPs are not diligent in enhancing our knowledge of factors that can influence the outcomes of our treatments.
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