Join NARA friends in Advocating for Quality of Life for Seniors

Written by: Melissa Moffitt, MS, CCC-SLP
Progressive Senior Solutions, LLC

As a Speech Language Pathologist (SLP) and a lover of food, I find myself passionate about diet modifications in our senior population. An absurd number of residents in SNFs and Senior Living communities are on altered diets. As a new SLP in a SNF over 10 years ago, I was out to save my patients and eliminate any occurrence of aspiration. As a seasoned SLP with experience across the continuum, including SNF, AL/IL, and Home Health, my personal goal is to let them EAT, DRINK & BE MERRY!

Let’s talk statistics. Studies estimate close to 30% of seniors in Skilled Nursing facilities are on thickened liquids. Although thickened liquids can improve swallow safety, they also present unintended consequences, such as dehydration, impaired release of medications, etc. We all know the impact of dehydration on seniors including falls, altered mental status, constipation, etc. Many patients on thickened liquids feel constant thirst due to the thickness of liquids. Seniors are highly susceptible to dehydrations due to lack of thirst without adding thickened liquids to the equation. Studies indicate that between 50% to 92% of nursing home residents have inadequate fluid intakes while nearly 30% of hospital admissions of LTC seniors was due to dehydration. What are we doing to prevent these hospitalizations and maintain hydration and safe swallow function in our senior population? In my humble opinion, 95% of seniors dislike thickened liquids. Have we assessed liquids that are nectar thick in their original consistency such as tomato juice, buttermilk, smoothies, just to name a few, would meet the viscosity of a nectar thickened liquid. An additional consequence relates to medication’s inability to release effectively. Liquids thickened to as little as 150 mPa.s impairs drug release, therefore affecting medication absorption. Medications are essential for seniors. Meds maintain blood pressure, manage cardiac conditions, ensure adequate blood glucose levels for diabetics, and so on. Hydration is essential.

Let’s talk semantics and compensatory strategies. Instead of writing the infamous “no cornbread” order, why not write an order for “cornbread with milk.” Instead of ordering a pureed diet, why not order cream based soups, mashed potatoes, pudding, applesauce, etc, all of which are pureed in their original texture. Could a less restrictive diet be tolerated if distractions were reduced or if a chin tuck was used effectively? One study shows there was no difference in rates of pneumonia between the chin-tuck posture and thickened liquid intervention. What about adding broth, sauce, or gravy to foods to aid in bolus formation? There are multiple strategies Speech Pathologists use to assess increased safety versus altering diet texture and consistency.

And finally, and most importantly, let’s talk quality of life. My goal is to get you to think outside the box. What would you want as a 70, 80, or 90 year old? Would you want to eliminate every possible risk for aspiration or would you desire to eat the foods you enjoy while being as safe as possible? A quick reminder: we all aspirate at times. Fortunately, most of us have a fully functioning cough reflex. Instead of viewing coughing as a sign of aspiration, should we further assess the strength of the cough to ensure it is adequate to clear liquids? Instead of focusing on diet modifications, would we be serving our seniors better with compensatory strategies vs strict diet modifications?

Thickened liquids serve a purpose. However, thickened liquids aren’t the answer in all situations. Similarly, pureed diet may be most appropriate for the senior who experiences discomfort due to oral hypersensitivity secondary to dementia, while it may not be the most appropriate diet for a senior who is cognitively intact. We must address unintended consequences when recommending altered liquid consistencies and diet and determine the safest way to EAT, DRINK & BE MERRY! Whether you’re an SLP, PT, OT, or any other ancillary service provider, challenge your teams to focus on quality of life and unintended consequences related to dehydration and lack of adequate nutrition.

Resources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660277/
http://www.geripal.org/2015/01/do-thickened-liquids-help-people-with-dysphagia.html
https://www.medscape.com/viewarticle/567678
Mentes, J.C. and K. Culp, Reducing hydration-linked events in nursing home residents. Clin Nurs Res, 2003. 12(3): p. 210-25; discussion p. 226-8