Ayela Spiro, Nutrition Scientist, British Nutrition Foundation
Adequate hydration is necessary for survival. Every cell, tissue and organ requires water to function. However ensuring adequate hydration can be a particularly challenging area in the care of service users with dysphagia, i.e. those with swallowing difficulties.
Older residents with dysphagia are at greater risk of dehydration
For the frailer elderly, the ability to reach for or pour a drink can be frustratingly challenging and they may be reluctant to ask for help from busy staff. The prevalence of dysphagia is higher in older service users, and alongside other comorbidities more commonly seen with increasing age such as stroke, there is typically a greater dependence on others for assistance, making it more difficult to access appropriate liquids. Other issues associated with the physiological ageing process, including reduced kidney function, reduced total body water and altered thirst perception, are often amplified in older individuals with dysphagia. In addition, elderly individuals commonly use multiple medications, and these can further challenge hydration status, for example with detrimental side effects like a dry mouth, which further exacerbates difficulty swallowing.
Service users drinking thickened fluids may drink less compared to those drinking regular fluids
The drinks that we consume daily without much thought, such as water, tea, coffee, juice or milk, are all fast-flowing liquids. Yet these can pose a risk to safe swallowing. Thickened liquids (e.g. fluids thickened with powder or bought pre-thickened) are typically prescribed for people with dysphagia. However, dissatisfaction with, and inaccessibility to, thickened liquids can result in poor compliance. Studies have shown that individuals required to drink thickened fluids are less likely to meet their daily fluid requirements and are more likely to be dehydrated than those receiving regular fluids. Thickened liquids are a necessity rather than a choice for swallowing safety. It may well be that a combination of acceptability, taste and satiety factors affect sufficiency of intake, and further efforts are required to improve intake.
So how do we try to ensure that service users with dysphagia are adequately hydrated without exposing them to the risks of choking and aspiration (liquids entering the airway)?
Some steps that could be useful include:
- Early identification programmes – Screening programmes and early referrals to appropriate staff like speech and language therapists (SLTs) and dietitians
- A multidisciplinary team approach to care including care staff and caterers, as well as pharmacists, nurses, dietitians, occupational therapists and SLTs. For example, pharmacists can give advice with regards the optimal administration of medication, occupational therapists can provide valuable support to help users with positioning and feeding strategies and dietitians can provide valuable information on methods of increasing intake
- Keeping an eye on the next generation thickeners that may improve compliance and safety, although these may have a higher cost implication. The next generation clear gel thickeners typically result in better appearance and flavour, and more reproducible consistency and stability
- Oral moisture protocols can improve comfort. Mouth wetting is an important requirement to satisfy the feeling of ‘thirst’. This is thought to be a combination of increased oral moisture provided by the liquid and increase in saliva as stimulated by the liquid. Thickened liquids, however, do not provide this ‘mouth wetting’ quality. One way to combat this is to use a water atomiser to mist the oral cavity
- Liquids can also be provided through foods such as soups, pureed fruit and yoghurts
- Look for novel ways to increase fluid intake like always providing fluids with oral medications, using signs and reminders and pairing fluid intakes with a regular activity e.g. after bathing or after physiotherapy. Use of symbols, such as a water droplet logo where fluid intake needs to be maximised, can help staff identify those most in need of assistance to meet their daily fluid requirements
Meeting the hydration needs of patients with dysphagia requiring thickened fluids remains challenging. It is important to find products which not only can match the individual swallowing capacities but that address personal preferences.
While early identification and intervention are imperative in dysphagia management, more emphasis must be placed on improving patient compliance through continued efforts to make thickened liquids more palatable and accessible for individuals with dysphagia.
It is always a timely reminder as the summer approaches and the climate becomes warmer that adequate intake of fluid is important. Dehydration increases the risk of renal failure, falls, impaired mental status, constipation, urinary tract infection, respiratory infection, decreased muscle strength and pressure sores. If you have service users with dysphagia that are struggling to consume adequate fluids to support their health, do seek appropriate advice (e.g. from SLTs).
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