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Focus on Geriatric and Adult Services

Food Textures & Liquid Consistencies

Published October 31, 2013 8:00 AM by Jennifer Kay-Williams

Speech therapists have conversations about food textures and liquid consistencies on a daily basis with everyone from patients to other therapists to family members and staff. I think that many of us relate to feeling like we are either repeating the same information over and over, and perhaps not really being "heard," or to feeling like everyone wants an easy answer.

Swallowing is quite complicated, right? Just like no two patients always need the exact same medication dosage or type and size of wheelchair, what patients can and should consume for both safety and nutrition/hydration should be  more patient-centered, and less of a "one size fits all" approach.

Have you ever worked in a building where anyone with any type of swallowing or feeding difficulty was placed on a pureed diet with thickened liquids for "safety?" Have you worked with staff that believe that any patient who coughs, ever, needs thickened liquids? How about family members who insist that diet textures cannot be upgraded because the patient "failed" a swallow study, or because "this is what the doctor ordered?"

I remember a patient on nectar thick liquids who wanted to use a straw due to positioning and decreased ability to pick up and drink from a cup. He had once had a swallow study in which he aspirated thin liquids via both a cup and a straw, but not nectar thick liquids; however, the SLP conducting the swallow study did not test nectar thick liquids via a straw. Because the nectar thick liquids were not tested with a straw, the family was sure that straws were unsafe with any consistency, and became quite upset that the patient was trying nectar liquids with a straw, and some of staff worried as well. Eventually, the patient gave up on trying straws because it entailed constantly educating staff and family, and was just too much trouble.

We SLPs know that swallow function is a bit different with a straw, and that thin liquids via a straw can move too quickly, causing coughing and increased risk of aspiration, but at some point, it seems to have become commonly accepted that nectar thick liquids cannot be taken via straw, ever. Sometimes they cannot ... but sometimes they can. I have more than one discussion with staff and families about this.

Taking a blanket or cookie-cutter approach to swallowing therapy and diet changes has, in my opinion, led to an epidemic of "one size fits all" treatment and diet modifications. Yes, safety is a big concern, and we so want to avoid aspiration, choking and other risks. Quality of life, food intake, and hydration are also very important, and if a patient can safely drink nectar thick liquids through a straw, why not allow him that? Sometimes, I think we make decisions based on fear of what could happen or of litigation, rather than on what the patient truly wants or on what the patient can do with patient-specific feeding and swallow protocols in place. Patient-centered protocols are definitely extra work and more time-consuming for staff, and might also include adaptive equipment.

We can never remove any risk of choking or aspiration from all patients; young, healthy people have choking incidents as well as do frail people who have dysphagia. Risks are inherent with any intake, and of course we try to reduce those risks through modifications. I would love to hear from other therapists about their decision-making process in diet modifications. Does your facility have a "blanket" policy on diet modifications for aptients with dysphagia? Are staff willing to accept patient specific recommendations? Do you have a Free Water Protocol in place?

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We understand what you are feeling with the continuous education to staff and family on dysphagia diets and swallow function.  However, we have found that success is built on the education provided to family and staff and keeping up with the pace of new techniques such as VitalStim therapy to improve swallow function. We have also done many trainings on positioning and diet textures.  We also do have the Free Frasier Water protocol in place and the protocol seems to improve resident compliance with diet modifications.  Providing pamphlets on the Free Frasier, swallow function, and diet textures has also seemed to help resident's, family, and staff understand what we do every day! We provide resident centered care, each person is individualized based on their swallow function, we do add things that are upgraded  to resident's diets as appropriate.  We have dysphagia diets 1-4 that the staff and family adhere to them pretty well.  We also have the ideals that if someone would like to have an upgraded diet item they may, as long it is documented.  If a resident would like to upgrade their diet despite our recommendations we do a Quality of Life order. I hope this response helps.  

Melanie Cannon, Geriatrics - Speech Pathologist, Nursing Home November 7, 2013 2:35 PM
Jamestown NY

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