HELPING PATIENTS THROUGH THICK & THIN (LIQUIDS) Presented By - PowerPoint PPT Presentation

HELPING PATIENTS THROUGH THICK & THIN (LIQUIDS) Presented By Hillary Cooper, M.A., CCC-SLP

ABOUT ME • President & Co-Founder of the Dysphagia Outreach Project • Owner of North Louisiana Swallow Solutions, a mobile FEES company • Owner of SLPstuff.com • Mentor of The Medical SLP Collective • Mom of 2 boys (age 18 and 4) • Wife of a Really Lucky Man • Never bored

A SPECIAL THANK YOU I’d like to extend a very special thank you to Rebecca Brown and Kristen West for helping me gather this (and more) information as part of this lecture and to help further the mission of The Dysphagia Outreach Project. Rebecca Brown Kristen West

COMPENSATION VS REHABILITATION Compensation Techniques Dysphagia Intervention Rehabilitation T echniques

COMPENSATION VS. REHABILITATION • Compensation Techniques*: • Thickening liquids • Breath Hold • Chin Tuck/Chin Down • 3 second Prep • Head Rotation to the Weak Side • Sour Bolus • Head Tilt to the Strong Side • Dry Swallow • Posterior Head Tilt • Alternate Liquids/Solids • Bolus size restriction • Carbonated Liquids • Texture modification • Super/Supraglottic Swallow *Not a comprehensive list….

WE MUST ALWAYS TEST COMPENSATION DURING INSTRUMENTATION!

COMPENSATION VS. REHABILITATION • Dysphagia Rehabilitation Techniques*: • Strengthening Exercises • MDTP • Swallow Optimization Therapy • Swallowing Boot Camp Approaches • MD Anderson Swallowing Boot Camp • Intensive Dysphagia Rehabilitation (Malandraki, 2018) • Oromyofunctional Therapy • Trismus Management *Not a comprehensive list….

COMPENSATION VS REHABILITATION • Additional Dysphagia Rehabilitation Tools/Techniques*: • Respiratory Muscle Strength Training (RMST) • IOPI or Tongueometer • Neuromuscular Electrical Stimulation (NMES) • sEMG Biofeedback • Endoscopic Biofeedback • Manual Therapy/Myofascial Release • Lymphedema Management *Not a comprehensive list….

AND BACK TO THE ORIGINAL TOPIC…

TO THICKEN OR NOT TO THICKEN According to Dysphagia Following Stroke (Daniels & Huckabee, 2014), a few key points to consider when deciding to recommend thickened liquids include: 1. Patient Satisfaction/Quality of Life: • Your patient’s lack of compliance with a recommended diet (puree, thickened) is directly related to the dissatisfaction of the food/liquid preparation (Colony, 2005) Used with Permission from Theresa Richard, M.A., CCC-SLP, BCS-S www.mobiledysphagiadiagnostics.com/blog

TO THICKEN OR NOT TO THICKEN 2. The Risk/Benefit ratio: • Aspiration • There is an INCREASED incidence of pneumonia in patients receiving honey-thick liquid compared to nectar-thick or thin with a chin tuck. (Robbins et al., 2008) • Dependency for feeding and oral care, the number of decayed teeth, and tube feedings are more predictive of aspiration pneumonia (Langmore et al., 1998) <--- (This "Predictors of Aspiration" paper is a must-read for anyone working in SNFs and struggling with the ultimatum to thicken or not to thicken) Used with Permission from Theresa Richard, M.A., CCC-SLP, BCS-S www.mobiledysphagiadiagnostics.com/blog

TO THICKEN OR NOT TO THICKEN 2. The Risk/Benefit ratio: • Dehydration • The issue is not with the actual thickening agent causing dehydration, rather it is a palatability issue with the patient drinking less than they would if it weren't thickened. • The free water protocol may be your best bet if dehydration is a concern. Used with Permission from Theresa Richard, M.A., CCC-SLP, BCS-S www.mobiledysphagiadiagnostics.com/blog

SO WHY DO WE USE THICKENERS? • Thickened liquids serve to slow down the movement of the bolus from the oral cavity into the pharynx. • In SOME patients with dysphagia, the slowed transit into the pharynx MAY result in a safer swallow.

TO THICKEN OR NOT TO THICKEN Used with Permission from Theresa Richard, M.A., CCC-SLP, BCS-S www.mobiledysphagiadiagnostics.com/blog

THICKENING & EBP* • Miles et al (2018) tells us that patients may be more likely to silently aspirate thickened liquids than thin liquids. • This is why getting that instrumental assessment is so important! • Nativ-Zeltzer (2018) tells us that: • (1) aspiration of thickener can lead to pulmonary injury • (2) aspiration of modified cornstarch thickener is worse on lung tissues than aspiration of xanthan gum thickener and aspiration of xanthan gum is worse than aspiration of plain water • Robbins (2008) tells us that there is an increased risk of aspiration pneumonia development with use of honey thickened liquids. *Not a comprehensive list….

POP QUIZ TIME!!! How many major TYPES (not brands) of products are currently used for thickening liquids for individuals with dysphagia across settings? A. Two B. Three C. Four D. Five E. Six F. Seven G. Eight

THE ANSWER IS G. EIGHT!

TYPES OF THICKENERS Types of Thickeners Modified Food Starch/Cornstarch Gelmix (tapioca starch & carob bean gum) Xanthan Gum Gel Infant Rice Cereal Xanthan Gum Powder Infant Oatmeal Purathick (tapioca starch & tara gum) Food Puree/Baby Food/Yogurt Note: Although individuals with dysphagia and family members may get *creative* with their thickening products, these are the types that are most currently used in medical settings across the lifespan. Items I’ve heard used include regular all purpose flour, potato flakes, agar agar, regular cornstarch, regular tapioca flour, and regular xanthan gum powder.

MODIFIED FOOD STARCH/CORNSTARCH Typical Ingredients Modified food starch; Modified Cornstarch, Maltodextrin (varies by brand) Common Brands Thick-It Original; Concentrated Thick-It2; Resource ThickenUp; Walgreens Thick Now Powder; Hormel Thick&Easy; CVS Instant Food Thickener Age Range for Safe Use Age 1+ Hot/Cold Liquids Can be used with both hot & cold liquids. Does not work well with carbonated liquids. Palatability Often mixes up with clumps in it. Can taste “grainy” or “bitter” Liquids become cloudy Continues to thicken over time as it sits Cost $10-$20 per package Shelf Life 2.5 years or more (unopened) Special Diet Considerations Kosher Pareve, Vegetarian Contraindications/Allergies Gluten free (typically) Avoid if sensitive to cornstarch or corn derivatives Other Considerations May increase pulmonary injury if aspirated (Nativ-Zeltzer, 2019); Diabetic individuals need to account for the thickener in their diet because it metabolizes like sugar.

XANTHAN GUM GEL T ypical Ingredients Xanthan Gum, Water, Soluble Fiber, Glucono Delta-lactone, Gellan Gum, Potassium Sorbate, Calcium Chloride, Citric Acid, Sodium Citrate, Guar Gum, Pectin Common Brands SimplyThick EasyMix Age Range for Safe Use >12 years old (packet says “do not use in infants or children under the age of 12 without consulting a healthcare professional) *some pediatric medical teams may consider off label usage Hot/Cold Liquids Works with both hot and cold & carbonated liquids. Can be frozen into ice. Does not continue to thicken over time. Palatability Smooth, gel consistency with no lumps or graininess. Consistency is stable over time. Cost $40-$70 per package Shelf Life 12 months after manufacture date Special Diet Considerations Certified Kosher Contraindications/Allergies Not for use in individuals at high risk of necrotizing enterocolitis (NEC) Free of major known allergens Other Considerations Contains 1g soluble fiber per 4oz serving (nectar thick) Contains no more than 1g carbs per 4oz serving (nectar thick) Contains 20mg sodium per 4 oz serving (nectar thick)

XANTHAN GUM POWDER T ypical Ingredients Maltodextrin, Xanthan gum, Erythritol, Carageenan, Ascorbic Acid (varies by brand) Common Brands Clear DysphagiaAide, Thick-It Clear, Resource ThickenUp Clear, Hormel Thick & Easy Clear Age Range for Safe Use Recommended for children over age 3 Hot/Cold Liquids Works with both hot & cold and carbonated liquids. Can be frozen into ice. Does not continue to thicken over time. Palatability More difficult to mix appropriately, but if done properly mixes into a smooth gel consistency. If not mixed appropriately, consistency may contain some small clumps of powder. Cost $10-$30 per container Shelf Life 18 months - 3 years (varies by manufacturer) Special Diet Considerations Kosher Contraindications/Allergies Gluten Free, Lactose Free, Corn Free Other Considerations Contains no more than 1g carbs per 4oz serving (nectar thick)

PURATHICK T ypical Ingredients Organic Tapioca Maltodextrin, Organic Tara Gum, Calcium Carbonate Common Brands Purathick Age Range for Safe Use Not for use with infants under 1 year old. Hot/Cold Liquids Works with hot and cold liquids Liquids will continue to thicken over time. Cold liquids thicken slower over time than hot liquids. Not recommended for carbonated beverages. Palatability More difficult to mix appropriately, but if done properly with a shaker cup it mixes into a smooth gel consistency. If not mixed appropriately, consistency may contain some small clumps of powder. Cost $20 per container Shelf Life 2 years after manufacturing date (unopened) 30 days after opening Special Diet Considerations Kosher Pareve, Vegan Contraindications/Allergies Do not use if patient has galactosemia (rare) or allergy to galactomannans is suspected. Other Considerations Non-GMO, Organic