Think Before You Thicken

By Kathleen Graham BSc (Hons) Speech and Language Therapy, Royal College of Speech and Language Therapists’ Senior Project Manager

Eating, drinking and swallowing difficulties are common in nursing home residents with around 50 – 75% of people experiencing a variety of symptoms. These can range from difficulty containing or moving food and drink around in the mouth, to food or drink entering the airway (aspiration), which can be associated with pneumonia and, potentially, death.

A common management option for people with difficulty swallowing drinks is the use of thickener. These are usually gum or starch based and may be in powder or gel form. The reason for their use is that if the drink is thicker, it travels more slowly through the mouth and throat giving the person more time to trigger a swallow, reducing the chance of it entering the open airway.

Due to widespread concern about the overuse of thickened fluids, the Royal College of Speech and Language Therapists (RCSLT) has created a position paper looking at the potential benefits and burdens of using thickener.

There are two key benefits. The first is that thickened fluids reduce drinks entering the airway and this is important as food or drink in the airway can lead to chest infections and pneumonia. The second is that some people prefer thickened drinks as it helps them to control the liquid in their mouth. As a result, they drink more fluids, and it can reduce distressing coughing when drinking.

However, when we look at the research into this area, we are unable to definitively conclude that thickened drinks either prevent or reduce swallowing related complications such as aspiration pneumonia, dehydration, or death.

Research has also found potential burdens associated with thickened drinks, including thirst, dehydration, reduced quality of life, altered bowel movements, increased risk of respiratory tract infections if thickened drinks were aspirated, and they may affect how some medications are adsorbed. Most people prefer not having thickened fluids.

In essence, the research has left many uncertain about the role of thickened fluids in the management of swallowing difficulties.

The RCSLT position paper highlights that thickened fluids are still a management option for people with swallowing difficulties. However, it also stresses the importance of a person-centred approach to its use.

Thickened fluids may be the most appropriate option for some people but the decision to use them should only be made after a thorough eating, drinking and swallowing assessment has been carried out by a dysphagia trained clinician – usually a speech and language therapist (SLT). Interventions to manage eating, drinking and swallowing difficulties are wide-ranging and it is often a complex decision-making process with the person, their family and care team to decide the most appropriate management plan. This can include having smaller sips through specialist cups; changes to the positioning of the body and head during swallowing; or rehabilitation plans to improve swallowing.

The RCSLT recommends that people on thickened fluids have long term follow-up appointments because of the potential burdens of treatment.

As care providers you should consider your service users and their potential swallowing needs.

Running through the following checklist will help you to do this:
• Is the person on thickened fluids and experiencing the potential burdens listed above?
• If someone is having swallowing difficulties, what steps have I taken to enable them to swallow more effectively?

For example, are they in an appropriate position; are they receiving regular good oral hygiene; have I tried them with different cups to avoid tipping their head back?
• Does this person need to be seen by a dysphagia trained practitioner?
• How can I communicate to my team that thickened fluids are not the only option to manage swallowing difficulties?
• How can I advocate for my service users to have timely access to eating, drinking and swallowing assessments?

The RCSLT has produced a useful information leaflet for people other than SLTs on the potential benefits and burdens of thickened fluids along with recommendations for usage. As Swallowing Awareness Day (#SwallowAware2024) is fast approaching on the 13 March, we encourage you to “think before you thicken,” and carefully consider people’s swallowing needs and how they can be best supported.