People with swallowing difficulties are at risk of choking, dehydration and aspiration. A care home company developed training and compared the use of thickeners
In this article…
- Risks associated with swallowing difficulties
- Use of fluid thickeners to improve dysphagia care
- A training programme to improve staff dysphagia awareness
Bridget Penney is care specialist for Barchester Healthcare.
Penney B (2014) Use of fluid thickener to reduce dysphagia risk. Nursing Times; 110: 12, 16-18.
Swallowing difficulties are common among care home residents, and increase their risks of a range of conditions. A care home provider evaluated the use of fluid thickeners to reduce these risks, and implemented an initiative to improve understanding of dysphagia among both care and catering staff. This included changing the thickeners used and ensuring there was some consistency with regard to the terminology used related to food textures, as well as undertaking staff training.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Dysphagia puts people at risk of malnutrition, dehydration, choking and aspiration
- The use of prescribed thickeners in food and fluid promotes safety and can enhance quality of life
- Training for clinical and catering staff is key to understand modified diets and fluids
- Communication between key staff is vital to make sure modified fluids and diet are appropriate and consistent
- Involving all health professionals ensures a consistent approach to safety regarding people with dysphagia
The Francis report (Francis, 2013) states people must have access to food and drink that is palatable and in a suitable form for them to consume. However, it is estimated that, at any one time, over 50% of people in care homes will have an impaired ability to eat or drink safely (Hanson, 2013). Dysphagia - difficulty in swallowing - puts people at high risk of malnutrition, dehydration, aspiration pneumonia and choking.
A report by the Health Foundation (Lecko, 2013) found evidence suggesting a high rate of dehydration in older people, and varying studies report that 50-90%
of those living in a care home have inadequate fluid intakes. This may be due to a refusal to drink adequate fluids or an inability to drink without assistance. Although there is little research evidence to demonstrate a link between dysphagia and dehydration, clinical experience suggests one does exist.
In addition to the physical effects of dysphagia, the condition also has a negative effect on quality of life.
A key element in reducing the risk of choking and aspiration when drinking is to modify the texture of the fluid consumed by people with dysphagia. Thickened fluids are easier to swallow as they enter the pharynx slowly, allowing time for the pathway to the lungs to be closed off to avoid aspiration and choking. Commercially available powdered thickeners are prescribed to help make fluids safer to drink; many are made with starch but newer gum-based products are emerging.
Studies have shown that starch-based thickeners have an undesirable “starchy” flavour, are grainy in texture and cause lumping when mixed with fluid, making them less likely to be tolerated (Lotong et al, 2003). Fluids thickened with a starch-based product have also been shown to become thinner over time as the thickener is broken down by amylase, the enzyme found in saliva, posing a potential safety risk.
In contrast, gum-based thickeners have been shown to be more stable and maintain their thickness due to their amylase-resistant properties. They are also less grainy and are said to be more palatable when mixed in fluids (Mills, 2008).
Observation of the use of prescribed thickeners has highlighted variations in how they are used and in the terminology used to record individual required consistencies (McCormick et al, 2008). Phrases such as “just add enough until it looks right” or “add some more if it looks too thin” have been heard. Box 1 outlines correct use of fluid thickeners.
Improving dysphagia care
Barchester Healthcare provides care for people living in more than 200 care homes, many of whom have a diagnosed swallowing difficulty. We recognised the importance of ensuring they can drink safely and that we needed to introduce staff training and education on the issue.
We incorporated the Dysphagia Diet Food Texture Descriptors (National Patient Safety Agency et al, 2012) into our nutrition strategy to standardise terminology used by staff, but recognised that we needed to take a structured approach to education to ensure consistently high-quality care for people with dysphagia in all our homes. This would include information about dysphagia generally, followed by the correct use of thickening products.
Aims of the project
The main aims of the project were to:
- Reduce the risk of dehydration for people requiring thickened fluids; Train staff in the correct use of thickeners;
- Ensure that residents with dysphagia were receiving palatable fluids;
- Find out whether starch-based or gum-based products were preferred.
Forty Barchester Healthcare homes were asked to provide information about the number of people currently prescribed a thickener and what product this was. The majority had been prescribed a starch-based product by their GP and had been using this for some time. The need for modified food and fluids was discussed with our central hospitality operations manager, who confirmed that catering and hospitality staff were not always aware of the correct use of thickeners, which may increase risk for residents with dysphagia.
We decided to meet representatives from two key companies, one producing a starch-based thickener and one manufacturing a gum-based product. They were asked to outline their product, how it was used and the support their company could offer Barchester Healthcare and its homes. Use of a gum-based thickener is safer as it does not become thinner over time in the presence of saliva. The safety of our residents is paramount and we felt that if staff were using thickeners incorrectly, this safety could be compromised. The gum-based thickener is of a comparable cost to one that is starch based.
We chose to work with Nutricia and developed a plan to introduce its gum-based thickener (Nutilis Clear). This would involve extensive staff training in the correct use of products to ensure residents’ safety. We also needed to engage our key stakeholders including GPs, local speech and language therapists, residents with dysphagia and their families.
Teamwork is essential at mealtimes so residents with dysphagia can enjoy their meals safely. The training brought together clinical and catering staff from the homes who have key responsibility for nutrition and hydration. We hoped this would promote effective communication between the two areas and a clearer understanding of their roles and problem-solving skills.
A series of three-hour training sessions were attended by key staff from each home - these were mainly head chefs, senior nurses and care staff with a keen interest in nutritional issues. Each session was divided into an informative and lively overview of dysphagia, a comparison of starch-based and gum-based products with a practical demonstration, and tasting session. This was followed by a hands-on practical cooking and tasting workshop to discover how thickeners can be used in food to enhance the palatability of modified diets. The workshops were all well received.
Feedback suggested the training would result in:
- Effective communication within the homes;
- Correct use of the thickeners;
- Examination of the variety of meals and drinks that can be produced using a thickener.
The training sessions were followed by an evaluation of starch-based and gum-based thickeners with regard to mixing and ease of use. Nine homes were asked to participate in the evaluation and were assisted by Nutricia to gather data on use of both types of products. Although this was a small and non-scientific evaluation, the input from staff teams was consistent and professional. All home managers were asked to discuss the evaluation with local GPs and given a pro-forma letter to send to them. We felt that GP support for the evaluation was important to ensure continued use of the most suitable product after the evaluation; most GPs were happy to support the evaluation.
Individuals with dysphagia and their relatives were informed of the evaluation and had the opportunity to decline to participate if they wished. All were happy to join the evaluation, which took place in two stages: data was collected over three days during which the residents used their current starch-based thickener followed by three days when they used the gum-based thickener. All data was anonymous.
The acceptability, ease of use and mixing of both types of thickeners were assessed using staff questionnaires.
Results from the staff questionnaires showed that a gum-based thickener was clearer when mixed and easier to mix with fewer problems, and no “lumping” was reported (Table 1). The gum-based thickener also demonstrated a low incidence of drinks changing over time (for example, continuing to thicken).
Staff also reported being happy with the gum-based product and said residents preferred the texture, taste and appearance of that over the starch-based alternative. Staff felt it was easy and quick to mix and instructions were easy to follow.
As a result of the evaluation we decided to extend the training nationally across all our homes. A further evaluation of starch-based and gum-based thickeners is being explored to confirm our findings. This will help us to influence the prescribing of gum rather than starch-based products.
Implications for practice
We have continued to provide staff training with the support of Nutricia, and held a one-day seminar for senior clinical and catering staff to improve communication with the company and to foster ongoing support for the training initiatives around the country. The training sessions are viewed as essential for staff - although the numbers of residents using thickeners remains low, their safety and quality of life is paramount.
Staff feel empowered to improve nutritional practices to improve the quality of care for our residents with dysphagia, and are more aware of and confident in using the relevant screening tools and management guidelines available to them.
Implementation of change within any organisation must have the support of key people to drive it forward (Barnett, 2014) so it is crucial to select the right people to attend the training sessions. We are committed to staff development and this is crucial to the success of any new initiative. A whole-home approach to this initiative means all stakeholders can get involved with the provision of food and fluid, including managers, clinical staff, catering and hospitality staff, people with dysphagia and their relatives and friends.
All homes are encouraged to hold monthly multidisciplinary nutrition meetings to discuss issues and opportunities; we have also developed a training academy for chefs and the use of thickeners in food and fluid will now become a key element in their training.
The involvement of local GPs remains a focus and staff in all homes are encouraged to invite GPs to visit at mealtimes to demonstrate the use of thickeners and discuss the benefits of choosing a suitable gum-based product against the costs of hospitalisation and trauma of a person who has episodes of choking and aspiration. The focus on safety and palatability are two key areas that staff discuss with stakeholders in an attempt to maintain the quality of life of our residents.
Dysphagia is poorly understood by many frontline health professionals and this exposes people to avoidable discomfort, pain or even death. Practical education will help increase staff awareness and ensure thickeners are used consistently, thereby helping to improve safety.
The NHS is currently developing The Dysphagia Game, a new game-based learning programme to help improve dysphagia care. Barchester Healthcare has actively worked in partnership with the following organisations to develop this unique game-based training tool:
- NHS England;
- Royal College of Speech and Language Therapists;
- British Dietetic Association;
- British Association of Parenteral and Enteral Nutrition;
- National Nurses Nutrition Group;
- National Association of Care Catering;
- Focus Active Learning; and
The Dysphagia Game is a board game for face-to-face engagement in healthcare. An online app version is also available and can be played anywhere on any device.
Barnett E (2014) Compliance with NPSA Dysphagia Diet Texture Descriptors. The Dietitians’ Magazine; 4, 01.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office.
Hanson B (2013) Management of swallowing disorders using thickened drinks. Complete Nutrition; 13: 1; 33-35.
Lecko C (2013) Patient Safety and Nutrition and Hydration in the Elderly. The Health Foundation.
Lotong V et al (2003) Texture and flavor characteristics of beverages containing commercial thickening agents for dysphagia diets. Journal of Food Science; 68: 4, 1537-1541.
McCormick S et al (2008) The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration. Age and Ageing; 37: 6, 714-715.
Mills R (2008) Dysphagia management: using thickened liquids. The ASHA Leader; 14 October.
National Patient Safety Agency et al (2012) The Dysphagia Diet Food Texture Descriptors.