1. The Good, The Bad, and The Ugly, About Thickened Liquids
Presented by:
Mobile dysphagia specialists

2. Why would a resident be on thickened liquids?
Resident has difficulty managing liquids due to a weak or in-coordinated tongue or a swallow reflex delay

3. Who makes the recommendations for thickened liquids?
Typically the speech pathologist, but nursing will sometimes downgrade a residents liquids when they are having difficulty swallowing and speech therapy is not available.

4. Prevent Aspiration Pneumonia
# 1 Goal of the speech Pathologist when treating a swallowing disorder….
Prevent Aspiration Pneumonia

5. Aspiration Pneumonia
Aspiration pneumonia occurs when food, saliva, liquids,or vomit is breathed into the lungs instead of being swallowed into the esophagus and stomach
Bacteria causes pneumonia, not the food, liquid, or saliva.
Even when we prescribe thickened liquids, the patient will still be aspirating their own secretions.

6. Aspiration Pneumonia (cont)
We all aspirate from time to time
When talking and eating
During sleep
Most people can tolerate some aspiration without getting aspiration pneumonia
Those at higher risk include: Asthmatics, residents with COPD, Parkinson’s and other respiratory disorders that would impede the residents ability to clear secretions
One of the top 5 diagnosis for hospital readmissions

7. What does aspiration look like?
MBSS video of aspiration

8. “1 out of 12 nursing home residents are on Thickened liquids”
How is this

9. Why so many residents on Thickened liquids?
Clinicians who have gone to school in the Midwest have been taught that the MBSS is the gold standard
Dr. Jerry Logemann, from Northwestern University , a clinician and researcher created the MBSS protocol.
Clinicians on the East and West coast are taught the FEES method as the gold standard in swallowing diagnostics.
The creator of the FEES protocol, Dr. Langford is from Boston Hospital.

10. Why so many Thickened Liquids? (cont)
Traditionally, speech pathologists had to make very conservative diet recommendations due to the limitations of the swallow evaluations available to us.
Bedside Swallow Evaluation (BSSE)
Modified Barium Swallow Study (MBSS)
Residents are not being re-evaluated once they are put on a modified diet in the hospital.
Reassessments are not completed due to resident being d/c’

11. Why so many thickened liquids (cont)?
Too difficult to send residents out to the hospital for swallowing re- assessments
Too difficult physically and or mentally
Too costly to send resident out for swallow re-assessment
Residents fall through the cracks.
“They’ve always been on that diet”
A resident on thickened liquids should receiving swallow therapy to treat the swallow problem or they should be on a “Frazier Water Protocol”

12. Thickened liquid types
Types of Thickened Liquids
Nectar Thick
Honey Thick
Pudding Thick

13. Side Effects of Thickened liquids

14. Side effects of Thickened Liquids
DEHYDRATION
“Tastes awful”….”Feels like swallowing a raw egg”
Residents wont drink the thickened liquid OR drink very little
Residents with dementia have a very hard time drinking thickened liquids

15. MORE REASONS TO GO TO THE HOSPITAL
Dehydration
Taste and texture of thickened liquids are unpleasant
Causes decrease in fluid consumption
Thickened liquids are less hydrating than regular liquids
Thickened liquids make you feel full so residents don’t want to drink as much liquid as they should
One of the top five diagnosis responsible for hospital readmissions…
Dehydration
Causes:
Confusion
UTI
Falls
Weakness/Decline in Function
MORE REASONS TO GO TO THE HOSPITAL
Most residents will not drink the thickened liquids
Residentuids with dementia typically will not drink thickened liquids because they think something is wrong with their drink.

16. “75% of Residents that are on thickened liquids are dehydrated”

17. Side Effects of Thickened Liquids (cont)
Creates Other Swallowing Problems Reduced Release of Medication Poor satiety of thirst Poor Quality of Life

18. The Cost of Thickened Liquids

19. Thicken LIquids Thickened liquids: $200 per month, $2400 per year
Enteral feeding:
Readmissions to hospital
Cost of pneumonia
Meds
Extra nursing care
Md visits
Psycho/Social
Res health

20. How effective are Thickened liquids?
In a study published in Annals of Internal Medicine (2008), patients that aspirated on thin liquids during a MBSS. (515 residents participated in the study). The patients were randomized to drink all liquids using a chin-down position or drink nectar-thick liquids. They looked at the mortality rate and adverse effects at 3 months.
There were no difference in rates of pneumonia between the chin-down-position, or incidence of pneumonia.
Drinking thinner nectar-thick liquids was associated with a lower incidence of pneumonia than drinking the thicker honey-thick liquids.
The combined outcome of at least 1 dehydration, uti, or fever event was more common in the group getting thickened liquid.

21. In a study with Parkinson’s patients who aspirated on thin liquids, 53% also aspirated on nectar thick liquids and 63% aspirated on honey thick.
No study available that shows thickened liquids prevent aspiration pneumonia.
If a patient is aspirating thin liquids, they will still aspirate their secretions.
Pneumonia is cased by the bacteria in your mouth, which is in your saliva
At the most, thickened liquids may lessen the amount of bacteria being introduced into the lungs.

22. #1 Most effective way of preventing aspiration Pneumonia
Modified diets and liquids? NO
Compensatory Strategies, i.e Chin tuck?
NPO/ G-tubes or Peg tubes?
Incorporate a well managed oral care program in your facility?
YES!!!

23. A note on oral Care:
“Approximately 1 in 10 cases of death from pneumonia may be prevented by improving oral hygiene”.
Plaque carries bacteria that if aspirated can cause pneumonia
Bacteria is also found in infected gums and bad/rotten teeth

24. It all starts with a test

25. Mbss vs Fees
Add video of MBSS and FEES demonstrating aspiration

26. FEES: the new Gold Standard in swallowing diagnostics
More accurate than MBSS
Portable
Real Food
Less thickened liquid recs
1/3 the cost of MBSS
Able to see entire swallow sequence
More diet upgrades

27. FEES effectiveness in preventing pneumonia
Hx of pneumonia before FEES
Hx of Pneumonia within 30 days after FEES No
Yes
Unknown
52% 2%
12%
26% 1% 7%

28. FEEs effectiveness in upgrading diets

29. Conclusions from FEES Research
Most of the NH residents with dysphagia, who were either NPO or PO were able to be upgraded in liquid and or diet safely
NPO residents at the time of FEES tended to remain NPO (69%), but some were able to be advanced to higher nutrition intake levels within NPO status, such as comfort feeding, therapeutic feeding or pleasure feeding (19%).
11% of the NH residents who at the time of the FEES were NPO and received new recommendations and follow up therapy, improved to PO intake within 30 days.
31% of NH residents who were PO-fed, after the FEES were able to advance their liquids and/or diets.
The incidence of pneumonia was significantly reduced clinically among NH residents wo received FEES assessments and new recommendations. 52% had no new pneumonia and 26% had no repeat pneumonia.
Research Questions:
Do outcomes from FEES significantly affect nutrition recommendations among nursing home residents
Do 30 –day nutrition intake outcomes differ significantly from previous FEEs recomendations?
Meaning, how accurate were the recs.

30. Decreasing Thickened liquids in your facility
1. Develop a system that for every resident that is admitted to your facility on a thickened liquid should be assessed by the SLP
If the SLP is not confident that this resident is able to be upgraded, she should order a FEES study to determine safest diet
Many will be ready for diet upgrades
When MBSS is done in the hospital, the resident is at their sickest
Patient is not in the hospital long enough to re eval swallow when patient was well

31. Decreasing Thickened liquids in your facility
2. Utilize FEES as your swallow diagnostic evaluation
FEES= fiberoptic endoscopic evaluation of swallowing
It’s a mobile service, they come to you
More accurate than a MBSS
100% accurate in identifying aspiration
More accurate in prescribing least restrictive diet
A third in cost compared to the MBSS

32. Decreasing Thickened Liquids in your facility (cont)
Implement an oral care program
Assign a nursing assistant whose only job is to provide oral care
Daily toothbrushing
Monitor gum health and coordinate dental care
Implement the Frazier Water Protocol
Residents who had daily mouth care providing by a nursing assistant whose only job was to provide oral care had 3 times less risk of dying from pneumonia than those that do not.

33. Quality of life!!
Eating and drinking is suppose to be a pleasurable experience
Enhances social interactions, fellowship and family events