Do You Have To Be Accepted Into A Speech-Language Pathology Thickened Drinks – What Are They, Why Are They Needed and How Do I to Make Them?

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Thickened Drinks – What Are They, Why Are They Needed and How Do I to Make Them?

As a Speech Pathologist, I am often asked questions like this by family members of people who have recently been diagnosed with a swallowing difficulty. Most people have never heard of swallowing difficulties, let alone “Thickened Drinks”. Swallowing difficulties (also known as “Dysphagia”) are not common, but they can affect people of all ages. There are many known causes of dysphagia, but some of the most common are: stroke; cerebral palsy; Parkinson’s disease; head trauma; surgery and radiation therapy as a result of head or neck cancer; and changes in the nerves and muscles of the throat that make swallowing difficult for the elderly.

What are thickened fluids and why are they recommended?

If someone you know has been diagnosed with a swallowing difficulty, it is likely that they have been advised “boissons densates” or “thickened fluids”. Thickened drinks are basically normal drinks that have had a thickener specially formulated for them, to make them thicker than regular drinks (this is discussed later in the article). They are recommended by Speech Pathologists (also known as Speech Therapists or Speech and Language Therapists) for people who can no longer swallow normal fluids safely and who are at risk of having drinks in their lungs. The consequences of drinks entering the lungs can be a strong cough, suffocation or more serious risks, such as a chest infection and aspiration pneumonia. I recently worked with a woman who, just four months earlier, had been in the hospital with her third bout of aspiration pneumonia in less than 10 months. She had been prescribed fizzy drinks more than 12 months ago, but she was still drinking regular drinks at least once a day and small amounts of drinks were getting into her lungs. This was a problem, not only because of the fluid in his lungs, but because the natural bacteria in his mouth traveled with the fluid and into his lungs. Once this happens, it’s only a matter of time before the bacteria causes a chest infection known as aspiration pneumonia. Fortunately for this lady, she finally listened to the advice and only drank the large drinks that were recommended to her. She hasn’t had a recurrence of aspiration pneumonia since!

So what is so special about thickened drinks? One of the reasons for the work is because they travel more slowly in the throat and are easier for a person to control when swallowing. To get a better idea, imagine this – Someone starts pouring water from a cup and tells you to catch it in a bowl you are holding. Try to answer as quickly as possible, but there will probably be a delay between when they start pouring and when you move the cup to catch the water. This short delay will likely mean that some of the water lands on the floor. Now imagine someone pouring a thick drink, like a thick shake, from a cup. You’ll catch a lot more of this liquid because the thick shake flows more slowly out of the cup and gives you more time to react. This is similar to what happens when someone with a difficulty swallowing drinks water versus a large drink. When he drinks water, the muscles and nerves in his throat do not act quickly enough and some of the water can go into his lungs. But when they drink thick drinks, the fluid moves more slowly and this gives their body more time to control and direct the fluid away from their lungs and into their stomach. That’s one reason why thickened fluids work. As people with swallowing difficulties tend to have difficulty all day, every day, thickened fluids are intended to replace normal drinks. This means that people who have thickened fluids, in most cases, will not be able to drink normal drinks or until their Speech Pathologist advises otherwise. Therefore, when someone is on concentrated drinks, he should aim to drink as much as necessary to maintain normal hydration (1-2 liters).

The three levels of thickened fluids

When someone is diagnosed with a swallowing difficulty, a Speech Pathologist will recommend one of three different thickness levels. The level of thickness that is recommended varies from person to person. It depends on the severity of a person’s swallowing disorder. Generally, the worse the swallowing disorder, the thicker the drink. Recently, Speech Pathology Australia and the Dietitian Association of Australia have worked together to create the Australian Standards for texture-modified foods and fluids*. They have developed the following names and descriptions for the three major recognized thickened beverages:

Level 150 – Slightly thick

This level is the thinnest of all condensed fluids. It pours quickly from a cup (but slower than regular fluids) and has a fast, steady flow. You can drink drinks of this thickness level from a cup. Other names used to describe this thickness are: Level 1, Nectar Thick, Quarter Thick, Cream or Semi Thick.

Level 400 – Moderately thick

This layer is the second thickest of all condensed fluids. It is similar to the thickness of a thick shake (but a thick shake becomes thinner when melted, so people on this level of thickness cannot drink thick shakes!). Drinks of this thickness pour slowly from a cup and have a slow flow. As it is thick, the best way to have this drink is with a spoon. Other names used to describe this thickness are: Level 2, Honey Thick, Half Thick or Thick.

Level 900 – Extremely Thick

This level is the thickest of all thickened fluids in the new thickness guide. Drinks of this thickness cannot be poured from a cup into the mouth, as they have a very small flow. Drinks of this thickness are so thick that they keep their shape on the spoon and so the use of a spoon to have them is the best method. Other names used to describe the thickness of this drink are: Level 3, Pudding Thick, Full Thick, Mousse or Extra Thick.

How to buy or make thickened fluids?

You have two options, you can buy pre-made thickened drinks or you can make your own thickened drinks using a powdered thickener. Many people also use a combination of the two – so you get the benefit of both options.

Thick pre-mixed drinks

The first option is to buy pre-mixed thickened fluids. These are available in single cups (sold individually or in cartons) or large bottles. Here are some advantages:

  • they do not require preparation and are ready to drink,
  • they do not need refrigeration until they are opened
  • have a long shelf life (6+ months)
  • you can be sure that the drinks have been prepared at the right thickness and are not too liquid or too thick

These products are particularly attractive to people who are elderly or who have a disability and are not able to prepare drinks for themselves or do not have someone they can trust to do it well, every 1-2 days. The disadvantages of pre-packaged drinks are that they cost more than a simple thickening powder and some brands only manufacture a limited number of flavors. In Australia, we are lucky to have producers who have more than 20 flavors on their menu. However, if you are not based in Australia, you may have to search online to find products that suit you.

Make your own thickened drinks

The second option is that you can make thickened fluids using a specialized powder thickener that can come in small cans up to large, economical boxes. These thickeners are specially formulated for people with swallowing disorders. Thickeners such as wheat flour or Karicare are not recommended for thickening drinks. The reasons for this are:

  • It is difficult to obtain drinks at the correct consistency with these products
  • they often dramatically change the taste of the drinks that are put
  • they can be difficult to mix at all
  • drinks can change in consistency (becoming thicker or thinner) with time or as the surrounding temperature changes. This could result in the drink becoming thinner or too thick or sticky and therefore unsuitable for drinking.

One benefit of using specialist thickener powder is that it is cheaper and more economical than buying pre-mixed drinks and you can add it to any flavored drink you choose (including beer and wine!!). A disadvantage of using a thickener powder is that many people, especially the elderly or those with a disability may have difficulty mixing the drink at the correct thickness level. If a drink is too liquid, it puts a person at risk of having the drink go down the throat and then go into the lungs. If the drink is too thick, it may not be appetizing and a person may drink less than this and therefore be at risk of dehydration. Also, drinks that have been pre-mixed using a powder thickener only last a short time in the fridge – typically 1-2 days.

Some final points about thickening powder. Since not all thickeners in powder can be used to thicken hot drinks (and you think you would like to thicken hot drinks like tea), be sure to look for this information when making your choice. Also, if you decide to buy a specialized spice pot, you will find the recipes on the back of the container. They are quite easy to find and follow. Each package normally has three recipes that describe how to make the drink at each of the three recommended thickness levels. For example, if you are on Level 150 – Slightly thick, the recipe could order to add 1 spoon of powder to 200 mL of liquid, then mix. Just remember, if you’re not sure which level of thickness applies to you or your family member, don’t guess, it could be risky for the person drinking – especially if the drink is too thin. Just ask your dietitian or pathologist to talk.

As you can see, there are many things to understand about the use and preparation of thickened drinks, but you have many choices and it’s just a matter of finding what suits you or your family member in terms of price , ease of use and taste.

References: * Dietetic Association of Australia and the Speech Pathology Association of Australia Limited (2007). Texture-modified food and thickened fluids as used for individuals with dysphagia: Australian standardized labels and definitions. Nutrition & Dietetics64 (Suppl. 2): p553-576

(c) Copyright – Katie Prendergast. All rights reserved worldwide.

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