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Author: Krueger, Zachary J.

Title: Acceptance and Intake of a New Thickened Beverage Product

The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial

completion of the requirements for the

Graduate Degree/ Major: Food and Nutritional Sciences

Research Advisor: Maren Hegsted, Ph.D.

Submission Term/Year: Spring, 2014

Number of Pages: 57

Style Manual Used: American Psychological Association, 6th edition

I understand that this research report must be officially approved by the Graduate School and that an electronic copy of the approved version will be made available through the University Library website

I attest that the research report is my original work (that any copyrightable materials have been used with the permission of the original authors), and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office.

My research advisor has approved the content and quality of this paper.

STUDENT:

NAME Zachary J. Krueger DATE: April 21, 2014

ADVISOR: (Committee Chair if MS Plan A or EdS Thesis or Field Project/Problem):

NAME Dr. Maren Hegsted DATE: April 21, 2014

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This section for MS Plan A Thesis or EdS Thesis/Field Project papers only

Committee members (other than your advisor who is listed in the section above)

1. CMTE MEMBER’S NAME: Patricia Knisley DATE:

2. CMTE MEMBER’S NAME: Sally Dresdow DATE:

3. CMTE MEMBER’S NAME: DATE:

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This section to be completed by the Graduate School

This final research report has been approved by the Graduate School.

Director, Office of Graduate Studies: DATE:

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Krueger, Zachary J Acceptance and Intake of a New Thickened Beverage Product

Abstract

INTRODUCTION: The study conducted was to determine any significant findings concerning

acceptability and intake differences between Thick-It Aquacare H20 thickened beverage and

other thickened beverages currently utilized at nursing care facilities. SUBJECTS: Five facilities

participated with a total of n=17 subjects across all facilities. METHODS: The nine-week study

was divided into three phases of three weeks each. Phase 1 involved establishing a baseline daily

intake average, Phase 2 involved switching residents to Thick-It Aquacare H20 thickened

beverage, and Phase 3 was a return to the normally used thickened beverage product at each

nursing care facility. Quantitative data of daily CC intake measurements were provided via

residents’ medical records with names withheld and resident identifiers utilized. DATA

ANALYSIS: Quantitative data was recorded and phase averages obtained. Subsequent Dunnett’s

T-Tests performed to provide significance between phase averages for each facility. Significant

results were p-value<.05. RESULTS: significant findings in 4 of 5 facilities showed both

increases and decreases between phases concerning average daily CC intake. CONCLUSION:

Factors other than type of thickened beverage appear to contribute to fluctuating daily CC

intakes in dysphagia residents. No significant preference between Thick-It Aquacare H20

product and other thickened beverage products exist in this sample population.

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Acknowledgments

Words of thanks and appreciation for all involved in the research process and to those

who contributed to bring the study to fruition. Thank you to Dr. Maren Hegsted, Patricia

Knisley, Dr. Sally Dresdow, Dr. Carol Seaborn, Dr. James Church, Drew Lehmann, and many

others who have helped in the writing process in any way. Special thanks goes out to all the

facilities, their administrators, dieticians, dietary and nursing staff, nursing home residents, and

families of residents whose cooperation allowed for the existence of this research. Most of all,

thank you to my parents Richard and Michelle, and to my wife Amber for constant emotional

support and understanding.

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Table of Contents

Abstract ........................................................................................................................................... 2

Chapter I: Introduction .................................................................................................................... 6

Statement of the Problem .................................................................................................... 6

Purpose of the Study ........................................................................................................... 6

Assumptions of the Study ................................................................................................... 7

Definition of Terms............................................................................................................. 7

Limitations of the Study...................................................................................................... 8

Methodology ....................................................................................................................... 8

Chapter II: Literature Review ....................................................................................................... 11

Causes of Dysphagia in the Elderly .................................................................................. 11

Symptoms of Dysphagia ................................................................................................... 14

Living with Dysphagia ...................................................................................................... 16

Treatments for Dysphagia ................................................................................................. 19

Causes of Dehydration in the Elderly ............................................................................... 23

Signs and Symptoms of Dehydration ............................................................................... 26

Treatment of Dehydration ................................................................................................. 28

Relationship between Dysphagia and Dehydration .......................................................... 31

Conclusion ........................................................................................................................ 35

Chapter III: Methodology ............................................................................................................. 37

Subject Selection and Description .................................................................................... 37

Data Collection Procedures ............................................................................................... 37

Data Analysis .................................................................................................................... 38

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Limitations ........................................................................................................................ 38

Summary ........................................................................................................................... 39

Chapter IV: Results ....................................................................................................................... 40

Item Analysis .................................................................................................................... 40

Table 1: Thickened Beverage Intake Values (Mean ± SD and p-values) .........................41

Chapter V: Discussion .................................................................................................................. 43

Facility Comments ............................................................................................................ 45

Conclusions ....................................................................................................................... 47

Recommendations ............................................................................................................. 48

References ..................................................................................................................................... 49

Appendix: Original Data Values ................................................................................................... 57

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Chapter I: Introduction

Dysphagia, or difficulty swallowing, is a diagnoses and disease that affects many

residents that reside in skilled nursing care facilities. This disease is usually present with other

diagnoses that affect muscle coordination, brain activity, and a host of other abnormalities. Many

with dysphagia also need to be placed on a thickened liquid, to ensure better swallowing

mechanics under the circumstances, and to prevent aspiration of liquids that could lead to

compounded consequences such as aspiration pneumonia. While much has been done to research

the effects of dysphagia on the quality of life and health concerns of the affected individuals, a

lack of research exists on the acceptability and intake of thickened beverage products consumed

by those with dysphagia in these care environments.

Statement of the Problem

Currently there is a limited amount of research on the intakes of care center residents

with dysphagia with reference to type of thickening beverage product. It is undetermined

whether intake of thickened beverage products for dysphagia residents have shown to be

different if the type of thickened beverage product is changed.

Purpose of the Study

The purpose of the study is to determine the efficacy of the new thickened beverage

product, Thick-It Aquacare H20, in providing increased hydration status through increased

intake of a thickened beverage product. The product is being tested against products currently in

use at each respective facility.

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Assumptions of the Study

Assumptions must be made about the study to constitute an accurate representation of the

research effort. It is assumed that all data collections from the facilities are true and accurate, and

that the care facility workers are competent and that the charted information is valid. It is

assumed that there is no bias on either part of the researchers or care facility workers towards the

study or the participants in the study, so that the correct quantitative data will be recorded. It is

assumed that if no data was recorded for that day, or a zero was recorded, that it was on part of

the patient refusal, not on part of the facility staff failing to record a measurement. It is also

assumed that the care facility workers made every effort and attempt to ask the care facility

resident if he or she would like more of the product and to communicate with residents in a

fashion that not only promotes hydration, but is in accordance with facility policies.

Definition of Terms

Dysphagia. Difficulty or discomfort in swallowing, as a symptom of disease.

Deglutition. The action or process of swallowing.

Thickened beverage. A beverage thickened with a particular agent to provide

alternative viscosity.

Comorbidities. The simultaneous presence of two chronic diseases or conditions in a

patient.

CVA (Stroke). Stoppage of blood flow to part of the brain either by blockage or rupture

of a blood vessel.

Dementia. A chronic or persistent disorder of the mental processes caused by brain

disease or injury and marked by memory disorders, personality changes, and impaired reasoning.

CC’s. Abbreviation for “cubic centimeter”, a measurement of volume.

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Xerostomia. Is the subjective feeling of oral dryness, which is often (but not always)

associated with decreased function of the salivary glands.

Limitations of the Study

Many limitations exist in this study that must be taken into consideration when viewing

the validity of the information. Limitations of this study are that the population size is small, and

did not reach the threshold of 20 or more subjects to satisfy a “large” sample size from the

population. Many of the residents have varying conditions contributing to their reasons for being

in a care facility. These conditions may be associated with compounded by their dysphagia.

Cognitive abilities of the residents may influence their willingness to drink the new thickened

beverage product other than taste and texture alone. Some residents may not be able to

communicate their desire to have more of the thickened beverage. Nursing and dietary staff may

not be able to understand a request for more of the thickened beverage. Staff may not be

amenable to providing thickened beverage to those who want it due to schedule constraints.

Beverage intake rates may increase or decrease due to factors other than the product, such as

cognitive illness, physical illness, disinterest, etc. Intake amounts may vary greatly day to day

based on care facility resident preference. Some residents also were required to ingest ordered

supplements by the staff which would boost their CC intake; this would be unrelated to the new

thickened beverage product preference, but may have a bearing on total daily CC intake for that

day.

Methodology

After Institutional Review Board approval, five nursing care facilities were recruited

from the Chippewa Valley and surrounding areas to participate in the study. There were a

starting total of n=19 patients, and an ending number of 17 subjects. Two subjects did not

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complete the study; one due to improvement in health status, and another passed away before

completion of the study. All nursing home residents had some type of dysphagia extending from

various circumstances, and also were on some type of thickened beverage product; either honey

consistency or nectar consistency.

The nine week study was divided into three phases, each phase lasting three weeks. The

first phase established a baseline of CC intake values by collecting daily CC intakes by person on

the thickened beverage product currently being used by the facility. The second phase was to

replace the original thickened beverage product with Thick-It Aqua-Care H20, provided by

Precision Foods Inc. The types of thickened beverages included orange juice, apple juice,

cranberry juice, caffeinated and decaffeinated coffee, and water. All types of thickened beverage

products were available in both nectar and honey consistency to the facilities. Total daily CC

intake values were recorded to obtain any difference in values between Phase 1 and Phase 2 data.

The final phase involved the facilities reverting to their normal thickened beverage product, and

to evaluate data to determine any significant difference between Phase 2 and Phase 3 data. P-

values were also monitored between the originally used thickened beverage product in both

Phases 1 and 3 to look for significant differences in those phases, as a way to help explain

deviation from predicted results.

Evaluation of data was used by permission from the patient’s daily CC intake medical

records provided by the facilities. No names or patient identifiers were used to identify the

individuals. Residents were coded with numbers by the investigators, along with coding for each

nursing home facility. CC data values were given to the researchers by the nursing home staff, as

part of their job is to accurately and consistently measure CC value intakes for all meals in those

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on thickened beverages with dysphagia. These official medical records were the basis for

quantitative data and any results inferred from those data values.

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Chapter II: Literature Review

Care facilities are facing many challenges today with reference to their residents’ health

needs. One of the diagnoses that presents as a challenge either by itself, but most often

concurrent with other diagnoses, is dysphagia, or difficulty swallowing. Dysphagia has been

linked to a number of other diseases and serious complications that can result as dysphagia is

presented and progresses. According to the United States Agency for Healthcare Policy and

Research, (1999) almost 40% of people living in assisted living or nursing homes have some

type of dysphasic presentation. Dysphagia can have a direct role in influencing the hydration

status of a resident, and therefore impact their quality of life. While diagnosing dysphagia in

care facility residents may be perceived as simple and potentially understood, following through

on treatment for this diagnosis can prove to be a herculean task dependent on the abilities of the

resident and other conditions presented with dysphagia. Thickened beverages have been on the

market for some time, and new products claim to be more effective concerning increased intake.

Because of the relationship between dysphagia and dehydration, and the known risks associated

with dehydration, thickened liquids are essential in some cases to provide the needed hydration

to the resident’s diet.

Causes of Dysphagia in the Elderly

Dysphagia has been a prevalent disease in care facilities. Although the complications

from dysphagia may be better-known, identifying the causes of dysphagia are equally important.

Many causes have been identified, although all incidences of dysphagia may not have a

definitive causal agent.

Of the causes of dysphagia, the most prevalent ones are those associated with other

diseases. According to Hoy et. al. (2013) in their study concerning causes of dysphagia in a

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tertiary care swallowing center, the most prevalent dysphagia cause was gastroesophageal reflux,

comprising 27% of the cause of dysphagia. Following gastroesophageal reflux, postirradiation

dysphagia followed with 14% of the cause in the cohort, and 11% of the cause was attributed to

cricopharyngeus muscle dysfunction. Interestingly enough, in the study by Hoy et. al. (2013),

13% of the cases of dysphagia had a cause labeled “undetermined.” A factor proposed by Cartee

(1995) may help explain some of the undetermined causes of dysphagia, where he states that

muscle disuse in the aging population could contribute to muscular atrophy.

Another predominant factor that leads to dysphagia and decreased swallowing function is

a cerebrovascular accident, or CVA, also commonly referred to as a stroke. According to

Corcoran (2005), approximately 45% of patients admitted to a hospital unit with a

cerebrovascular accident as the primary diagnosis will also have concurrent diagnosis of

dysphagia. Martino et. al. (2005) report that as many as 78% of stroke patients have dysphagia.

Therefore, it is important to learn about the effects of stroke on a patient’s swallowing function

in order to effectively treat dysphagia patients in this special population.

Traumatic Brain Injury, abbreviated TBI, is also associated with loss of neurocognitive

function. (Bullinger, 2002). Depending on the part of the brain affected during the event,

dysphagia could lead to difficulty handling food and decreased quality of life concerning

nutrition and satiety. As stated by Kowlakowsky-Hayner, Murphy, and Carmine (2012),

dysphagia is common with sustained brain injury. Although it is most often discussed directly

after the sustained injury and upon admission, difficulty swallowing due to the event may persist

and become increasingly prevalent over time. In a study by Morgan (2010) concerning children

with traumatic brain injury (TBI), 46% of the 157 cases presented dysphagia along with the

sustained traumatic brain injury. In their findings using videofluoroscopy, Terré, and Mearin

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(2007) found 90% of those presenting with traumatic brain injury also had concurrent

swallowing difficulty of some kind. Moreover, 65% of the 48 patients had some type of impaired

gag reflex, and 44% of the subjects coughed during oral feeding.

Another common finding with dysphagia is some type of dementia in the elderly.

Because of the nature of dementia, dysphagia can be present due to neurological changes in the

body that are associated with the disease. Kyle (2011) states in his study that dysphagia can

develop, and in many cases, does develop in almost all cases of dementia. Easterling and

Robbins (2008) found that dysphagia occurs in almost half of the residents in nursing homes that

have concurrent dementia in one form or another. Because of the physiological changes in those

with dementia including loss of muscle function, Alzheimer’s disease and other forms of

dementia can play a significant role in reducing the swallowing function in an individual. For

example, Liepelt-Scarfone et. al. (2013) cite in their research concerning function of activities of

daily living (ADL’s) in patients presenting with Parkinson’s Disease that dementia worsened

activities of daily living on both a cognitive and physical basis. The results of the study by

Liepelt-Scarfone et. al. (2013) of 30 patients fulfilling the “Movement Disorders Society Task

Force—recommended, cognitive level-one criteria for dementia” showed worsening of function

related to communication, increase in postural instability and gait disorders.

Dementia encompasses a wide variety of disease and disorders and is present in both

early development and late phases of dementia, according to Benati, Coppola, and Delvecchio

(2009). These dementia diagnoses present with sometimes severe cognitive and physical

impairment. Physical aspects such as muscle rigidity and decrease in muscular function are not

the only factors that may attribute to dysphagia symptoms. Cognitive barriers may also play a

role in the swallowing aspects of nursing home residents, either in a standalone state or in

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conjunction with a physical impairment. Moreover, dementia is not the only significant diagnosis

in a resident in a care facility. Other diagnoses such as traumatic brain injury, stroke, and a

multitude of other diseases can compound the problem of residents acquiring significant caloric

intake and nutrients (vitamins and minerals).

Perhaps the one of the most overlooked causes of dysphagia in the elderly is simply the

aging process. Swallowing is a surprisingly complex process, (Hoy et. al., 2013), involving 26

pairs of muscles and 6 cranial nerves. The 26 pairs of muscles and 6 cranial nerves work in a

cohesive, coordinated fashion to develop a smooth transition of the bolus of food from the mouth

to the stomach, where digestion again resumes after passage through the esophagus. As people

age, their motility will naturally decrease. For example, Tracy et. al. (1989) demonstrated that

pharyngeal swallowing was delayed significantly longer in older test subjects than in younger

test subjects. It was determined that all of the test subjects in this study did not have had any

dysphagia or swallowing difficulty prior to the study; thereby, making the case for decreased

motility of bolus as a normal part of aging.

Symptoms of Dysphagia

Dysphagia is problematic for the elderly because it can lead to more serious health

problems including dehydration and aspiration pneumonia. Eisenstadt (2010) cites that

dysphagia related to stroke, dementia, and other factors increases the risk of aspiration

pneumonia. Because these impairing subsequent diagnoses reduce the quality of life of the

resident, it is important for one to identify and be familiar with the symptoms of dysphagia.

Holland et. al. (2011) presents the Sydney Swallow Questionnaire (SSQ) in his research

of 800 subjects from Manchester and Newcastle, (as cited in Wallace, Middleton, and Cook

(2000)) as a tool developed to assess dysphagia. In the SSQ, questions were administered to the

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individuals to determine severity of dysphagia and predictive factors of age-related dysphagia. In

the questionnaire, it lists symptoms of dysphagia. Symptoms can include but are not limited to

difficulty swallowing thin liquids, thick liquids, soft foods, hard foods, dry foods, saliva, and

difficulty initiating a swallow. Other symptoms of dysphagia include coughing or choking when

attempting to swallow any of the previously listed types of food or liquid, coughing up food, or

food going behind or up the nose when swallowed. Although Holland et. al. (2011) lists the

questionnaire for their own use as a tool, the questionnaire developed by Wallace K L,

Middleton S, Cook IJ (2000) serves as its own list of symptomatic dysphagia in the aged

population.

Although dysphagia is a general term for “difficulty swallowing” it can be further

subdivided into specific types of dysphagia. In examining dysphagia, it would appear that three

main types of dysphagia exist in the care facility resident population. The first population would

be those that have dysphagia as a result from disease or disorder, such as discussed previously

concerning stroke, TBI, forms of dementia, and other diseases associated with dysphagia. The

second population of persons with dysphagia would be those having dysphagia resulting from

the normal aging process. Termed “senescent aging,” normal dysphagia and loss of some

motility in the gastrointestinal tract occurs as a result of normal aging. Tracy et. al. (1989)

explain some of the physiologic changes that occur to individuals including pharyngeal and

esophageal sphincter changes common in late adulthood. A third dysphagia may occur due to

lack of motility because of environmental factors. For example, Porter, Scully, and Hegarty

(2004) reference xerostomia, a condition of reduced salivary output that is caused by

mechanisms influenced through medication. Because many residents in care facilities may be on

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a host of medications, they may have environmental dysphagia through drug-induced

xerostomia.

The severity of dysphagia depends on how much swallowing function has been lost, the

ability to swallow thin and thick liquids, various textures and densities of foods, and presence of

coughing or regurgitation in attempting to swallow. The most severe types of dysphagia lead to

complete loss of motility. Severity of dysphagia may be tested on an individual basis to

determine what and how well a resident can swallow. In a more scientific approach Dick J

(1998) assessed ten main factors in developing an overall “severity score” for dysphagia. These

parameters included weight gain (or loss), oromotor patterns of movement, sensation relating to

oral hypersensitivity or hyposensitivity; oppositional behaviors, such as crying, vomiting, refusal

of food, care anxiety (distress shown while feeding), nutrition adequacy, potential for aspiration,

chest status (respiratory and cardiac health), texture appropriateness, and finally bowel habit.

Severity scoring was 0 to 5 scale for each of the 10 parameters; therefore, a score of 0 would

indicate absolutely no dysphagia, while a score of 50 would indicate extreme severity. Although

this severity scale was developed for pediatric dysphagia, it can be used in the aging population

as well.

Living with Dysphagia

Dysphagia can place limits on those with the diagnosis, and can result in not only

physical complications, but can influence the emotional and social aspects of one with difficulty

swallowing. Furthermore, many comorbidities are associated with dysphagia and can result from

the progression of the disease. (Van der Maarel-Wierink et. al., 2014) Living with dysphagia can

be a very distressing and seemingly hopeless situation. The individual may experience

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deterioration of their everyday life satisfaction, coupled with decreased quality of life in holistic

fashion.

Dysphagia places limits on individuals as a direct result of difficulty swallowing, or as an

indirect result of complications associated with dysphagia. Limits can also be placed on those

with dysphagia because the cause of their dysphagia may also have additional restrictions. For

example, in a very recent study by San Luis et. al. (2013) involving 236 middle cerebral artery

stroke victims, over one-third were admitted to palliative (end-of-life) care on an average of

three days following their first swallowing assessment. Dysphagia found in stroke incidences

could have been a partial cause in admittance to palliative care. This does not bode well for an

optimistic prognosis for cerebrovascular accident victims with concurrent dysphagia as a result

of the incident, since the rate of dysphagia in stroke victims as high as 45%-78%. (Corcoran,

2005; Martino et al., 2005)

With the diagnosis of dysphagia, residents’ abilities to communicate with others may

become limited. One of the causes of dysphagia can also be facial surgery, and as a result of

surgery, dysphagia can lead to communication disorders. In a study conducted by Starmer et. al.

(2014) post-operative dysphagia had a large predictive value of subsequent perceived facial

function and quality of life. In other words, the patients believed that their quality of life would

be decreased, and they would have less personal enjoyment due to the presence of dysphagia in

their lives. This is important as a number of emotional and social factors can contribute to

perceived quality of life, and dysphagia appears to have a significant influence on emotional

outlook.

Perhaps one of the most important ways in which dysphagia disrupts lifestyle is by

affecting emotional and social mindsets of individuals with the disease. Patients with dysphagia

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also have concurrent psychological complications including depression and anxiety.

(Verdonschot et. al., 2013) In the patients with oropharyngeal dysphagia, 37% of these subjects

showed clinical symptoms of anxiety, and 32.6% showed clinical symptoms of depression.

These psychological manifestations are a clinical outcome of dysphagia, as negative outlook on

life and perceived decreased quality of life can be contributing factors to the lowering of mood

and rising of psychological problems such as anxiety and depression. (Verdonschot et. al., 2013)

Eating is a social arena in which individuals exchange ideas. If an individual is on some type of

treatment for their dysphagia, social interaction may be reduced due to the focus placed on

resolving complications of the disease. Avoidance of social situations may also occur if the

resident feels inadequate or embarrassed because of their dysphagia and inability to consume

certain foods or drinks.

The comorbidities of dysphagia have a significant impact on the quality of life of those

with difficulty swallowing. Cerebrovascular disease, TBI, dementia, and other diseases are

considered comorbidities when it comes to the resident presenting dysphagia symptoms and

diagnoses. Because of these added complications, the resident may have other difficulties in their

life that already act as stressors to their quality of life. As Serra-Prat et. al. (2012) state in their

research, nearly 19% of those in the study with oropharyngeal dysphagia were at risk for

malnutrition or had had an incidence of malnutrition in the last year. Dysphagia only compounds

the problem by not allowing easy access to nutrients needed for any potential healing to occur

and can accelerate decline in physical status.

A main concern for individuals who are diagnosed with dysphagia is aspiration

pneumonia. Besides the risk of declining strength, slower healing time, and reduction in

emotional state is the risk of aspiration pneumonia and even non-aspiration pneumonia. As Cabré

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et. al. (2014) found in a study with 2,359 elderly patients, 47.5% who were diagnosed with

dysphagia, that dysphagia is a relevant risk factor for readmission to a hospital for both

aspiration and non-aspiration pneumonia. The results found that the risk of readmission for

pneumonia in those without dysphagia averaged 3.67 per 100 patients, whereas the patients with

dysphagia averaged a 6.7 per 100 patient readmission rate for pneumonia.

Eisenstadt’s (2010) findings of a comprehensive literature search also support other

research that aspiration pneumonia is a common diagnosis in the elderly adult population, and

dysphagia increases the risk of aspiration, along with other common comorbidities outlined

above.

Treatments for Dysphagia

Although living with dysphagia can seem an insurmountable obstacle to the resident with

the diagnosis, as well as a challenge to the healthcare team providing assistance to the individual,

treatments do exist. Remarkable advancements in treatment practices for those with dysphagia

have allowed those individuals with difficulty swallowing to regain some independence, along

with physical, mental, and social improvements that lead to an overall upgrade in quality of life.

Several approaches to the treatment of dysphagia exist, and choosing which ones will be

utilized depend on the individual care plan for each dysphagia resident. Although many various

forms of treatment may exist, including environmental changes and modifications in eating

utensils, two of the most frequent methods of treating dysphagia are interventions with speech

therapy, and thickened beverage products. (Garcia et al., 2010)

Thickened liquids are a widely used intervention for those with dysphagia, in hopes of

preventing aspiration during deglutition (Cichero, 2013). There are five basic thickening agents

used in today’s products, including but not limited to xanthan gum, guar gum, locus bean gum,

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starch, and carrageenan. (Cichero, 2013). Each of these thickening agents are used to make a

more viscous, thickened consistency to help combat the negative effects of dysphagia. Although

each of these thickening agents have the same basic function, they do not all react in the body the

same way and may have different characteristics unique to each individual thickener.

Thickened liquids can be delivered in two basic methods to patients: either a pre-

thickened beverage that comes directly from a manufacturer, or a powder that is thickened at the

nursing facility. Moreover, there are three basic thickness categories in which a thickened liquid

can belong. (Health and Human Services Agency, 2010) A thickened liquid can be either nectar-

thick consistency, honey-thick consistency, or pudding-thick consistency. The thickness that is

prescribed to each individual depends on their swallowing capability and is determined by the

healthcare team, led by decisions from a registered dietician and sometimes in conjunction with

input from the speech therapy department.

Although the consistency of the thickened beverage is determined by the registered

dietician leading the rest of the care plan team, the choice to buy pre-thickened product versus

product that needs to be thickened at the facility may fall to another entity-- this is usually the

administration of the facility. The administration body must decide which approach is not only

more cost-effective, but also benefits the quality of life outcomes of the patients. As found by

Kotecki & Schmidt (2010), the choice to have commercially prepared beverages can present a

significant cost savings. This savings is highly dependent on the skills of the healthcare team and

the time it requires to prepare a thickened beverage. In their study, the researchers found that the

cost of preparing thickened beverage in-facility can range from $0.54 to $1.41 per unit based on

the wage of the person preparing to time ratio. When ordering a commercially prepared

thickened beverage product, there is a potential savings of nearly 60%. (Kotecki and Schmidt,

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2010). However, this is highly dependent on the skills of the preparer, as one who may be able to

prepare a thickened beverage within a rapid time period may prepare it at a lower cost than a

commercially ordered product.

The main reason for thickened is that the increased viscosity lowers the risk of aspiration

of the liquid, working to prevent pneumonia and other complications associated with aspiration

of food and drink (Mills, 2008). By having a thickened liquid instead of a normal consistency,

the individual can receive important hydration through the delivery of water molecules bound to

a thickening agent. Because of the bonds to the thickening agent, there is a result of increased

viscosity, lessening the chance of aspiration into the lungs. The thickener also allows hydration

to ensue as Mills (2008) states, because body can pull the water away from the thickener. In fact,

Sharpe et. al. (2007) reports that both starch-based and gum-based thickeners indeed release

greater than 95% of the water bonded to them upon digestion, providing the necessary hydration

to the body of the consumer. This is important because the water being released, the individual

would become severely dehydrated and the thickened liquid would hold little to no value.

Thickened beverages are used to alleviate the risk of aspiration consequences while

promoting hydration effects. Speech therapy is another common treatment for those with

dysphagia. Speech therapy is a field that covers a variety of treatment methods, with thickened

beverage being just one avenue of treatment, usually coupled with other treatment routes.

Techniques used by speech therapists usually involve working with specific muscle

groups to strengthen the areas involved in swallowing. According to the American Speech-

Language-Hearing Association (ASHA, 2014), three main techniques are used to combat the

effects of dysphagia in adults. They may use exercises to improve muscle movement around the

affected area, postural positions and strategies to help the individual swallow in a more effective

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manner, and changes in dietary habits including liquid and food textures. Another interesting use

of technology in the practice of a speech therapist is to use surface electromyography to achieve

analysis of how difficult a swallowing action may be for an individual. In the study by O’kane et.

al. (2010), surface electromyography was used to measure swallowing activity in thirty

individuals, both young and elderly, to measure maximum effort in swallowing. By utilizing this

technique, the concept of using surface electromyography as a biofeedback mechanism was

established as a potentially effective tool in swallowing rehabilitation across varying ages and

volumes of bolus ingested.

With the vast differences of conditions that are present in those affected with dysphagia,

and the comorbidities associated with the diagnosis, a healthcare team must use a multifaceted

approach. A coordinated effort between dietary, speech, and nursing departments will promote

effective therapy and other modalities for the patient living with dysphagia. When there is a lack

of communication between departments, risks for patient harm may result, even in instances

concerning dysphagia. Garcia et. al. (2010) studied communication breakdown and

noncompliance. In the study of 42 health care providers, thickened beverages were not thickened

to appropriate viscosity. A lack of communication appeared to exist between both the nursing

staff and dietary, or possibly between either of these and the thickened beverage distributor.

Because the prescribed viscosities were not maintained due to inadequate training practices, a

risk for aspiration and subsequent complications could result. This lack of communication could

also be present between trainers and trainees in the health care environments of these healthcare

providers. With communication between departments involved in an individualized care plan,

dysphagia may be treated more effectively, resulting in increasing quality of life (Garcia et. al.,

23

2010). Individuals with difficulty swallowing need a coordinated effort between departments

involved in their care, to ensure the best safety and care practices are up to standards.

Causes of Dehydration in the Elderly

Dehydration is a major concern in the aging population. In nursing home facilities, the

elderly may experience additional obstacles compared with others of the same age that are not in

skilled nursing care facilities to remaining hydrated due to a barrage of comorbidities.

Dehydration is associated with increased mortality and morbidity in the elderly (Chassagne et.

al., 2006). Factors contributing to dehydration in the elderly population involve both biological

and environmental influences. By understanding when and how dehydration starts, one may be

better able to anticipate its surfacing and curtail the negative consequences associated with a lack

of hydration in the aging population.

Several causes of dehydration have been shown to have a significant impact in the

individual’s health status, and are of special concern to the studied population (Manz, 2005).

These causes can be standalone causes but generally work in conjunction with each other to

precipitate an overall dehydration status. Although many causes may exist, the focus is directed

to specific causes including general disease, TBI, dementia, thirst itself, and social and emotional

effects that may lead to dehydration.

In nursing care residents, dehydration is associated with a vast variety of diseases.

Dehydration in susceptible individuals (including the elderly) can be associated with diseases

such as asthma, cardiovascular disease, cancer, diabetic hyperglycemia, and a host of other acute

medical conditions (Manz, 2005; Maughan, 2012). The conditions associated with dehydration

are serious and often times fatal. Coupled with the poor health conditions of some nursing care

facility residents, dehydration is prone to exacerbate worsening quality of life by adding

24

complications to the residents’ overall health. Another study by Belayachi et. al. (2012)

concerned aged patients (median age 70 years old) admitted to the intensive care unit.

Dehydration was also a significant cause for mortality in these patients while in the intensive

care unit.

Another cause of dehydration may be due changes in either the brain chemistry or

anatomy and physiology. TBI and forms of dementia can significantly impair one’s judgment so

that they do not have the ability to keep hydrated even when their physical state allows it. In an

example by Koopmans et. al. (2007), the researchers followed 890 patients, all with dementia, to

the end of their lives. Out of those patients in the 9-year study, the most important and common

cause of immediate death in those patients was indeed dehydration, accounting for 35.2% of all

patients with dementia in the study, and over 50% of those who survived all the way to the final

debilitating stage of dementia. Moreover, those who survived to the final phase of dementia were

significantly more likely to die of dehydration than of cardiovascular disease. This is important

because of the nature of dementia. Patients suffering from dementia may not be aware that they

have not drunk any liquids, or go further to state that they remember just taking a drink of liquid,

even though they have not and are not remembering correctly. Refusal of drink or memory and

cognition problems relating to dietary intake are common in those with dementia, and may help

explain the high prevalence of death from dehydration in this population.

TBI victims may have symptoms similar to that of dementia patients. Bullinger et. al.

(2002) relay that neurocognitive deficits develop in those with dementia. Much like the effects of

TBI on producing dysphagia, TBI can also produce memory and cognition loss and lead to

incoherent memories and loss of cognition relating to dietary intake.

25

Another important cause of dehydration, especially in the elderly, is considering thirst as

a separate entity that may not always be present. In addition to other disease and disability,

individuals in this population may not have the thirst reflex, or feel thirsty even when

dehydrated. As indicated by Mentes (2013), the elderly have a blunted thirst response, which is a

decreased sensitivity to thirst, resulting sometimes in lower fluid intake (Kenney & Chiu, 2001).

In older adults, thirst sensitivity is often decreased, leading to decreased fluid intake. This

subsequently results in a slower response to restore fluid balance in these individuals, which

means prolonged dehydration status. Mckinley et. al. (2007) explain this decreased sensitivity to

thirst as a change in satiation of thirst that come with aging. Even after inducing thirst in the

individuals and monitoring neural changes through cerebral blood flow and positron emission

tomography, the elderly still drank lower volumes of water when stimulated to be thirsty,

suggesting a lower volume to initiate satiation through liquid intake (McKinley et.al., 2007).

The final causes of dehydration in the elderly are social and emotional factors (Chia-Hui

Chen et. al., 2010). They can impact an individual’s mood, causing them to have a lessened

intake of liquids. Many elderly patients in nursing care facilities are diagnosed and live with

depression, anxiety, or other psychological disorders. Specifically depression has been linked to

a lower functional state, in which individuals may not be able or feel that they do not want to

care for themselves. This can include reduction in activities of daily living (ADL’s) including

eating and providing adequate liquid intake for oneself.

Chia-Hui Chen et. al. (2010) found that depressive symptoms are a risk factor for

malnutrition and dehydration. Other factors affecting components of geriatric syndrome include

cognitive, nutritional, and functional status, along with being female. While there is a complex

set of risk factors associated with decreased quality of life in the geriatric population, depressive

26

risk factors were found to be a significant influence to geriatric syndrome (Chia-Hui Chen et. al.,

2010). In a study by Onat et. al. (2014), over 50% of the elderly individuals had a risk for

depression. These depressive risk factors were also associated with decreased cognitive,

functional, and mental states. Laudisio et. al. (2014) found a definitive association between

chewing problems and depression in the elderly using multivariate logistic regression. If chewing

problems are associated with depression, potential association for intake of liquids and

depression could exist.

Signs and Symptoms of Dehydration

Although the causes for dehydration are cognitive, functional, and physical, they may be

examined and discovered before the dehydration becomes chronic and presents a potential life-

threatening risk to the individual. By identifying the signs and symptoms of dehydration, one

may better intervene on a timely basis to preclude delayed treatment.

Certain tests can be administered to assess hydration status in individuals. These tests are

usually administered by a healthcare professional such as a nurse or registered dietician, and can

be both objective and subjective in nature.

There are subjective examples that a healthcare professional can use to assess for

dehydration (Bryant, 2007). The patient’s skin feeling or appearing dry, loose, or poorly perfused

can be subjective signs of dehydration. Moreover, other bodily signs are dry lips, dry hair, or

abnormal urine output. Other possible associations with dehydration are the presence of diabetes,

heart failure, or the use of diuretic medications.

Another subjective assessment performed is the 24-hour fluid balance chart. However,

caution must be used with this type of assessment for dehydration as mathematical errors and

improper measuring of fluid input and output may compromise accurate readings (Bryant, 2007).

27

Clancy and McVicar (1995) compiled a list of common diagnostic tools that may point to

dehydration in an individual. The most common objective categories used to assess dehydration

are blood analyses and urine analyses. Blood analyses include hematocrit, serum osmolality,

serum sodium concentration, elevated total protein, and elevated red blood cell count (Clancy &

McVicar, 1995). Any abnormal values may be a factor indicating dehydration, but must be used

in conjunction with subjective measurements. Some common urine analyses used to assess for

dehydration include but are not limited to osmolality measures, urine pH measurements, and

electrolyte balances of potassium and sodium in the urine (Clancy & McVicar, 1995). As with

blood analyses, any abnormal values are indicative of potential dehydration, and are used in

conjunction with other subjective measurements and rest on the judgment of the healthcare

professional.

Other physiological markers of dehydration can include increased thirst, decreased

alertness, fatigue, and confusion (Pross et. al., 2013). Among the objective measures, Pross et. al.

(2013) found that urine specific gravity appears to be the best indicator of dehydration, but that

saliva osmolality could also be a potentially useful and accurate indicator in those with consistent

daily activity. This can be effective as a non-invasive test measure; especially in those who are

not able to have other tests administered to them. Moreover, the elderly nursing care facility

population may not be amenable to other tests due to preference or other health concerns, and a

non-invasive measurement may be easier to administer without contest.

If prolonged dehydration occurs, complications from dehydration may result.

Complications can range from seemingly benign to serious and deadly. As Pinto and Schub

(2013) state, dehydration complications can include but are not limited to constipation, urinary

tract infections, cognitive decline, shock and seizures, continuing even to brain damage, falls,

28

hospitalization, and death. In stroke victims (who could also have resultant dysphagia)

dehydration can lead to reduced cerebral blood flow to an affected area, thus reducing healing

and recovery (Bhalla et. al., 2001).

Treatment of Dehydration

While complications from dehydration can result in serious consequences for the affected

individuals, treatments do exist to remedy the existence of dehydration and associated

complications. Although the treatment of dehydration may seem obvious; that is, to administer

fluids to restore one to a hydrated state, delivery and mode of transmission of these treatments

can be a challenge to healthcare staff and to the nursing care facility residents alike. One must

take care to ensure proper administration of fluids through the best vehicle in a timely manner

according to the needs of the resident.

If dehydration becomes serious enough that oral intake may not be sufficient and timely,

other routes of administration for fluids exist. Scales (2011) discusses avenues for fluid intake

other than oral ingestion including nasogastric tube feeding through enteral routing, intravenous

fluid replacement achieved through peripheral venous cannula, and subcutaneous fluid

replacement. Scales (2011) argues that subcutaneous fluid replacement, or hypodermoclysis may

be a valuable route for IV hydration administration for those who are unable to tolerate

cannulation or with poor venous access situations. For individuals with dysphagia, dehydration

can be problematic, and is often treated with thickened beverages tailored specifically to the

needs of the resident.

In order to ensure proper administration of thickened beverages and treatment of

residents, monitoring techniques of the staff involved in resident care must be given attention.

Merriman (2011) gives advice on indicators of high risk situations of malnutrition and

29

dehydration, and advises techniques to ensure proper monitoring of individuals to prevent these

situations. During the first contact with a resident, the staff should assess the person’s dietary

intake using a MUST (Malnutrition Universal Screening Tool) scoring system, in which the

resident is categorized as high, medium or low risk for malnutrition and dehydration. The study

gives specific factors that may indicate a potential risk for malnutrition and dehydration such as

BMI<20, swallowing problems, chewing problems, recent weight loss or poor appetite, or a mid-

upper arm circumference of less than 23.5cm (Care Quality Commission, 2009). Merriman

(2011) gives specific advice to healthcare professionals to encourage fluid replacement not only

during planned meal times, but also in between meal times along with nutrient dense foods and

drinks, such as termed “milky” drinks.

It is critical that the healthcare professional be intentional about reviewing the fluid

intake of each resident under his or her care, and communicating with other professionals and

staff about the potential for dehydration in every individual. This can be a difficult task because

oral fluid intake monitoring is widely known to be inaccurate and not indicative of the residents’

actual hydration statuses (Shepard, 2011). This challenge can be overcome through vigilant

monitoring and increased communication within departments and between departments of a

nursing care facility.

Many challenges exist in treating individuals with dehydration who reside in nursing care

facilities. Many of these individuals may have comorbidities of both physical and cognitive

natures that make treatment of dehydration a significant hurdle to overcome. Concurrently,

individuals with these comorbidities are usually at greater risk for dehydration, and are in greater

need of fluid replacement than those without multiple diagnoses. Shepard (2013) and Parinello

et. al. (2012) observed that those with renal failure or congestive heart failure are commonly

30

prescribed fluid restrictions. Because of fluid restrictions due to serious diseases such as those

listed, dehydration may be more likely.

Other challenges involved in hydration treatment include those on the cognitive spectrum

of disease. Individuals with Alzheimer’s disease and other forms of dementia may have a

reduced fluid intake (Pinto, 2013). A resident affected by a cognitive condition may argue that

the healthcare professional already gave them something to drink, that they do not know the

individual and will not accept the fluid from them, or they could also simply forget to drink the

fluid if not assisted by a staff member.

Besides the challenges associated with the nursing care residents, challenges also exist on

the part of the staff being able to attend to the needs of the residents at all times. Low-staffing

and high census may rush staff into their care processes, and not allow discriminate viewing of

oral fluid intake. Miscalculations of fluid intake and poor communication often present as

challenges to ensuring proper hydration. When a lack of communication exists, the information

may not be directed from one staff member to another; as a result, the resident may suffer from

dehydration. Lack of training to the employees of the nursing care facility may impact their

ability to assess and properly monitor fluid intake, resulting in charting errors and subsequent

potential risk to the resident.

Combating dehydration in elderly individuals in the care of a skilled nursing facility is of

utmost importance to the safety and quality of life of those affected. Comorbidities, fluid route

administration and the skill level of the healthcare professionals should all be taken into account

when considering how to effectively treat for dehydration in this population. By using specific

and predetermined monitoring techniques coupled with competent training, staff involved in

31

patient care can better hope to treat individuals at risk for dehydration, regardless of other

variables such as physical and cognitive factors which may or may not be of their control.

Relationship between Dysphagia and Dehydration

A definitive relationship exist between dysphagia and dehydration in the elderly residing

in nursing care facilities. For example in a study conducted by Vivanti et. al. (2009), none of the

individuals who had dysphagia met their calculated fluid requirements. Because dysphagia puts

an individual at risk for aspiration and subsequent pneumonia and other consequences, thickened

beverage products have been developed to assist the dysphagia resident in fluid intake while

lowering risk of aspiration.

Thickened beverages come in a variety of types (brands), and can vary slightly in

consistency, flavor, and even thickening agent. However, the main purpose of all thickened

beverage products is to bypass the risk of aspiration in individuals with difficulty swallowing,

while also provided adequate hydration through release of the water molecules from the

thickening agent upon entry into the stomach and remaining gastrointestinal tract (Garcia et. al.,

2010).

Consistency of thickened beverages will be decided by healthcare professionals; often

dieticians and speech therapists and implemented in conjunction with the rest of the staff at the

facility. Three main types of thickened beverage consistencies exist; pudding-thick consistency,

honey-thick consistency, and nectar-thick consistency, with respect to order of decreasing

consistency. These consistencies are general target viscosities as cited by Nicholson et. al. (2008)

and are measured by Pascal-seconds, a measure of dynamic (shear) viscosity, in which a fluid

covers a certain space in a time period. Pascal seconds for thickened beverage products as

indicated by Nicholson et. al. (2008) are 0.20 Pa/s, 0.42 Pa/s, and 0.87 Pa/s for nectar

32

consistency, honey consistency, and pudding consistency, respectively. Many facilities do not

order pre-thickened beverages manufactured in a separate commercial entity, and instead prepare

thickened beverages in-house with a separately bought thickening agent. This method has the

potential to lead to incorrect viscosity and differing Pascal-second values which could produce

incorrect consistencies, thereby risking aspiration in residents’ if the preparation is not mixed

effectively. Even if prepared to specification in the nursing facility, thickened beverages may not

maintain the same consistency over time, as Nicholson (2008) reports in his study which showed

that over a three hour period the viscosities of all thickened beverage supposed consistencies

increased up to a factor of 20% if left to set after thickening had occurred (Mills, 2008).

Flavors of thickened beverage products may also play a role in effective delivery of

hydration sources. Depending on the preference of the individual, different flavors may be

administered to the nursing care resident in hopes of eliciting a drink response that will favor

increased consumption and subsequent increase in hydration status. Orange juice, apple juice,

cranberry juice, milk, and coffee are just some examples of flavors available to those who have a

need for a thickened beverage choice. With the varied types of thickened beverages, one must

take care to monitor the viscosity of the product to ensure that the resident is receiving the

intended thickened beverage. As Nicholson (2008) finds that milk, tea, and coffee have

viscosities four to five times greater than that of other fluids, and that the viscosity increases in

an exponential growth model, so healthcare professionals must closely monitor the changes in

thickened beverage characteristics.

With each thickening agent, the flavor can change due to its addition into a beverage.

Matta et. al. (2006) found in their results that all thickeners suppressed the main flavors of the

beverages to which they were added. Varying tastes of bitterness, metallic, and sour among

33

others were found to be present in the post-thickened beverage that were prepared on-site. Matta

et. al. (2006) also found that the honey-thick consistency seemed to have a “slickness” texture to

it after thickening agents of a gum-based nature, whereas starch-based thickeners contributed to a

grainy-texture and flavor. In whatever scenario a thickener is used, regardless of type, the

resident must be satisfied with its flavor and consistency, or there may a failure of delivery of

hydration due to disagreeable characteristics of the thickened beverage.

Thickening agents are the main source of the consistency and flavor characteristics that

make a product agreeable to the consumer while maintaining aspiration risk prevention. The two

main thickening agents on the market are gum-based thickeners and starch-based thickeners.

Gum-based thickeners are somewhat more recently being used, and may provide a better

alternative to starch-base thickeners. From Cichero (2013), types of gum-based thickeners can

include xanthan gum, guar gum, and locust bean gum. Cichero (2013) also cites starch

thickening agents as well as carrageenan, a sulphated linear polysaccharide as frequently used

thickening agents. Matta et. al. (2006), Nicholson (2008), and Cichero (2013) all report a type of

“slickness” to the viscosity and consistency of thickened beverages containing a gum-based

thickening agent, which is generally not favorable to the overall taste. It is also reported in these

articles of flavor suppression with increased thickening, which is also undesirable to the

consumer.

Although the chosen thickening agent is determined by the facility, the type of thickening

agent used may influence intake and acceptability of the thickened beverage, and subsequent

hydration status. This is of great importance when reviewing how much dehydration contributes

to the mortality rates of individuals in nursing care facilities, who are at great risk for serious

dehydration.

34

A cause and effect relationship exists between dysphagia and the development of

dehydration. Those with dysphagia may develop dehydration because of the lack of fluid intake

due to other factors such as comorbidities, or resistance to the thickened beverage because of

taste issues. Cognitive comorbidities such as dementia, which affect cognitive processes, may

lead to decline in oral fluid intake. Dementia and dysphagia development many times arise

together (Easterling & Robbins, 2008; Kyle, 2011). When one has a cognitive diagnosis that

already predisposes one to reduced activities of daily living, coupled with presence of dysphagia,

dehydration may follow because of the difficulty of not only convincing a resident to first drink

the fluid, but also the physiological obstacles of ingestion associated with dysphagia.

Dehydration can also in turn be a cause of worsening disease, and is associated with a plethora of

diseases and is a significant contribution to mortality in the elderly (Manz, 2005; Maughan,

2012). Therefore, dehydration could contribute to the worsening of diseases that also cause

dysphagia, which in turn can cause dehydration; a cycle of worsening quality of life and

persistence of disease may develop.

Many challenges and obstacles are presented to the residents of nursing care facilities

regarding dysphagia and dehydration. Physical, cognitive, social, and emotional factors all

contribute to the abilities of the resident to overcome dehydration and cope with the effects of

dysphagia in their lives. Many of these factors have already been reviewed and are of utmost

concern when considering how to best provide treatment to individuals in these situations.

The quality of life of nursing care residents rests on the competence and skill of the staff

providing care in the facility. These elderly individuals are completely dependent on the staff for

their basic needs, and the quality of life of these residents may be a reflection of the quality of

work being done by the healthcare professionals directly and indirectly involved in the residents’

35

care. Certainly, multiple diagnoses and disease states play a significant role in the development

of dehydration and management of dysphagia; however, this should not initiate a spirit of defeat

or apathy in either the staff or the resident. Many obstacles may be overcome concerning both

dysphagia and dehydration through treatment of the disease as well as attention to the residents’

needs. A preliminary study conducted by Juk (2013) found that increased registered nurse

staffing hours per resident day were associated with an increase in comfort and enjoyment of the

residents, and the presence of licensed practical nurses (LPN’s) contributed to the autonomy and

spiritual well-being of the residents. The direct role in the quality of life of residents by the

nursing care staff is important to note because hours spent with residents may help lower

symptoms of depression, which is associated with lower quality of life as evidenced by Kim et.

al. (2014).

Conclusion

Many factors must be considered when developing strategies to combat dysphagia and

dehydration in elderly persons residing in skilled nursing care facilities. A host of factors

contribute as cause for both dysphagia and dehydration; moreover, relationships exist between

both conditions that may supplement one another in overall lowering of quality of life.

Dysphagia and concomitant dehydration are a serious challenge to both the residents and

the healthcare team in today’s society. Living with dysphagia and dehydration can be a struggle

for nursing care residents, and treatments that provide relief while maintaining optimal care may

not be always be available to those affected. As a healthcare professional, one must strive to seek

out innovative and updated solutions to the crises surrounding the health conditions of these

individuals. A collated effort between departments involved in the resident care must be

36

established through effective communication in order to ensure that the best quality of life is

provided to those in their care.

As research progresses to find more effective and novel ways to reach dysphagia

residents, thickened beverages currently provide the most realistic and cost-effective measure of

maintaining the quality of life in these individuals concerning preventative measures for

dehydration. Care must be taken in choosing which thickened beverage product will satisfy the

social and emotional needs of the resident, while delivering the required amount of daily

hydration with proper viscosity. As the efforts of the healthcare team become more assertive and

intentional, coupled with innovative solutions made by research and treatment development

programs, one may see the incidences of dehydration and mortality lowered in those affected by

dysphagia and concomitant dehydration and consequent increased quality of life.

37

Chapter III: Methodology

Dysphagia is a common problem in the elderly who reside in a nursing care facility.

Dysphagia, or difficulty swallowing, often requires the resident to have a liquid intake of a

thickened beverage product. Some products may be more effective to induce higher intake in the

resident through variance in taste and texture of the thickened beverage. By studying which

thickened beverage that the residents prefer through acceptance and intake factors, one can seek

to understand which product will yield higher average daily CC intake, thereby increasing

hydration status of the resident and overall quality of life.

Subject Selection and Description

The subjects were chosen after IRB approval to participate in the study from five care

facilities around northwestern Wisconsin. Both facilities and individual residents who

participated agreed to try the new thickened beverage product. Subjects had to have dysphagia,

or difficulty swallowing to participate in the study. Care facility residents were also required to

be on some kind of thickened liquid, in either a nectar or honey consistency to satisfy the new

thickened beverage product parameters. Subjects must also be able to participate in the nine

week study and provide data as accurately as possible.

Data Collection Procedures

Data was collected from all five facilities over a period of nine weeks. The study was

split into three main phases over nine weeks; three weeks for each phase. Phase 1 consisted of

collecting total daily CC intake values for the residents on a thickened liquid diet. During phase

1, CC intake values were collected on whichever thickened beverage product that the facility was

currently contracted and using at the time. This was done to establish a baseline average daily

CC intake for each resident at each care facility. Phase 2 consisted of three weeks of data

38

collection for total daily CC intake values of Aquacare Thick-It H20 product provided by Kent

Precision Foods Inc. After the experimental Phase 2, the facilities returned to their original

product and data was collected during Phase 3 concerning daily CC intake values of that product

for a period of three weeks.

Data was provided by the facility without any resident identifiers to comply with HIPPA

regulations concerning healthcare facilities. Print-outs for each patient were given under a coded

system. Each facility was given a code and each patient was given a coded sub-identifier that

correlated with the resident’s identity in the facility. Only the dietician, dietary director, and staff

who work at the facility knew the residents’ legal names. For example, at facility A, four patients

were given identifiers V241, B217, V225, and H210. The staff at the facility would link these

identifiers to the resident to uphold validity and prevent mixing of data pools between individual

subjects. Once obtained, numbers would be entered into an excel spreadsheet to keep accurate

documentation of total daily CC intake, and were further coded. For example, V241 from facility

coding would be transcribed in the excel file as A1. Tag name “A” representing the facility and

“1” representing the sub-identifier of the resident within facility “A.”

Data Analysis

Data analysis was devised using statistical analyses. Dunnett’s t-test and subsequent p

values were found. Mean averages of decrease or increase from phase changes were studied and

explained through p-value with a statistical significance p<.05; 95% confidence limit.

Limitations

Limitations of the methodology are that the quantitative data are derived from the direct

input by the nursing care facility staff into the computer. Any errors or deviations from what

39

actually occurred has the potential to skew data. As the data collection concerned official

medical records, errors under ideal situations should be kept to a minimum.

Summary

Although little research has been done thus far concerning the acceptability and intake of

thickened beverages consumed by dysphagia residents in nursing care facilities, this research

hopes to shed light on any difference that may result as a switch in product. Many factors

contribute to intake and acceptability of beverages in any population. This research study serves

as a foundation which future researchers can build upon to more completely define acceptability

and intake of thickened beverages, and ultimately their effect on quality of life.

40

Chapter IV: Results

Currently little information exists on the daily total CC intakes of dysphagia nursing care

facility residents; furthermore, acceptability and intake of thickened beverage products has

minimal information available for observance. In this nine-week study, dysphagia residents’ total

daily fluid intakes were recorded to obtain a baseline of the current thickened beverage product

being utilized in-facility during the first three weeks. Phase 2 of the study involved switching the

residents to a thickened beverage provided by Precision Foods Inc. entitled “Thick-It Aquacare-

H20.” During the third phase (last three weeks), residents were then again administered their

original thickened beverages. Differences in intake were noted in a quantitative assessment;

overall acceptability of product was given through verbal reasoning of staff employed at nursing

care facilities.

Item Analysis

Results were recorded and interpreted on a facility specific basis. A total of five facilities

participated, with the subject count ranging from two residents per facility to four residents per

facility. A total of 17 residents provided quantitative data for assessment, with two individuals

who were unable to complete the study. Of the two residents who did not complete the study,

one resident improved in health status and no longer needed a thickened beverage, while the

other resident was admitted to a hospital and subsequently passed away. Facilities were

identified through letter identification, with number assigned within each letter heading

corresponding to an individual resident. For example A1 correlate to subject 1 under facility A

etc.

Facility G showed significant decrease between Phase 2 and Phase 3 intake values (p-

value<.05) value, decreasing from an average of 1569.61 daily CC to 1445.36 daily CC intake.

41

There was also a significant decrease between baseline Phase 1 and normal return Phase 3. No

significant results were found in Facility H. Facility I had significant increase in average daily

CC intake from Phase 2 to normal return Phase 3; with a significant increase between baseline

Phase 1 and normal return Phase 3. Facility J had a significant decrease from baseline Phase 1 to

experimental phase 2, with a significant increase in daily CC intake from Phase 2 back to normal

return phase 3. Finally, facility K had a significant increase in daily CC intake average between

baseline Phase 1 and experimental Phase 2. Table 1 below organizes all the mean averages per

facility, as well as p-values for interphase relationship dependent on the statistical data obtained

from Dunnett’s T-Test.

Table 1

Thickened Beverage Intake Values (Mean ± SD and p-values)

Facility P1 Average P2 Average P3 Average P1:P2 P2:P3 P1:P3

Facility G: 1700cc ±

368cc

1570cc ±

383cc

1445cc ±

333cc

.2639 NS .0043* .02297*

Facility H: 1125cc ±

254cc

1138cc ±

331cc

1068cc ±

345cc

.4185 NS .1669 NS .1737 NS

Facility I: 774cc ± 308cc 753cc ±

383cc

847cc ±

304cc

.3319 NS .0263* .0328*

Facility J: 834cc ± 315cc 756cc ±

304cc

825cc ±

328cc

.0076* .0203* .3054 NS

Facility K: 549cc ± 231cc 599cc ±

236cc

530cc ±

232cc

.0954 NS .0322* .3106 NS

42

In Table 1 when statistical difference occurred, all facilities had a statistical difference

between Phase 2 and Phase 3 daily CC intake values. A variety of factors contributed to the p-

value results, and correlation may be biased based on criteria other than thickened beverage

product consumed. In facilities where significant difference existed between P1:P2 as well as

P2:P3, one could rationally believe that additional contributing factors had more influence over

daily CC intake value change than the influence of the study, i.e. the switching of thickened

beverage product. Facility H had no significant results, but this may be due to other contributing

factors, and the small sample size (n=2) from this facility.

43

Chapter V: Discussion

Dysphagia is a common problem among nursing home residents, and can be problematic

and interfere with their daily lives. Although acceptability and intake could be derived through

basic quantitative data, many contributing factors will influence the acceptability and intake of a

thickened beverage product that is supposedly displayed through quantitative results. Some of

these factors are on part of the residents’ preferences, but the majority of the results of the study

are based upon the care facility staff actions, the multiple comorbidities of the residents, and a

variety of other influencing factors that may not even be detectable.

Discussion below includes the results of the residents’ intake values and possible

contributing factors or explanations for results other than the simple switching over of thickened

beverage product. Discussion also includes comments from facility staff about the product, and

their willingness or unwillingness to procure said product in the future.

Five nursing care facilities took part in this study, with four of the five yielding

significant results concerning increase or decrease in totally daily CC intake values. Facility A

yielded significant results concerning a decrease from the baseline product intake numbers to the

experimental Thick-It Aquacare H20. However, there was also a significant decrease yet again

from Phase 2 to Phase 3, as well as a significant decrease between Phase 1 and Phase 3, which

were both phases independent of the product. It is likely, then, that other contributing factors

other than the switching of the thickened beverage product contributed to the results in this

facility. Facility A was a rehabilitation based facility, where residents are not only in the care of

the facility, but have daily therapies and whose goal is to eventually return back to home or a less

intensive assisted living community. Significant decreases in the results could be attributed to the

improvement of the health conditions of these individuals, and less need for thickened beverages.

44

When their health improves, the residents may be eating more solid foods and drinking less

because they are able to do so.

Facility H had no significant results, and both residents were deemed to be cognitively

aware. Facility H was a long-term nursing care facility, and the absence of significant results

could have been due to the small sample size at this nursing care facility.

Facility I had a significant decrease from Phase 1 baseline intake to Phase 2 experimental

intake values. It also had a significant increase from Phase 2 experimental values to the Phase 3

normal beverage return values. As purported by the director of dietary, all of the residents on

dysphagia thickened beverages at this facility had severe cognitive delays and deficits, and were

known to not be aware of their surroundings. The cognitive delays and deficits of these residents

is a contributing factor to the intake values. The residents’ unfamiliarity with the product could

have simply led to changes in intake. Moreover, Facility I had many charting errors, concerning

entire meals not charted, to entire stints of 3-4 days not charted on residents. The inability of the

staff to chart the intake values, along with the mental health status of the individuals in the study

were contributing factors, as well as limitations to the study concerning this facility.

Nursing home J yielding significant results. There was a significant decrease from Phase

1 baseline product to Phase 2 experimental product, with a significant increase in total daily CC

for Phase 2 to Phase 3 return to normal thickened beverage. There was also no significant

difference between Phase 1 and Phase 3 normal thickened beverage intakes. The status of the

nursing home residents in Facility J was not known, other than they were long-term care

residents. A significant contributing factor to the total daily CC intake of the residents in Facility

J is the use of supplements in the diet. Supplements were not recorded separately in the charting

by the nursing staff, and can influence the intake of other thickened beverages. Supplements are

45

known to cause a “full” feeling when consumed and may have led to decreased consumption of

the other thickened beverages, yet the total daily CC intakes could have been skewed because of

the supplements being included in the total daily CC intake of beverages, and not differentiated.

Facility K had significant results for the Phase 2 experimental to Phase 3 return to normal

thickened beverage numbers. There was a significant decrease in the return to normal thickened

beverage. However, the initial switching over to the Thick-It Aquacare H20 yielded no

significant results. The exact cognitive statuses of the residents in this care facility were not

known, but comments from the dietary director alluded to some type of cognitive deficit such as

varied forms of dementia. Facility K also threw out the coffee beverage due to its proposed

unacceptable nature; this could have significantly impacted the results as any coffee given to the

residents during the experimental period would have been provided through the facility, not the

research study, and was not charted separate.

Facility Comments

Many comments were made by the staff working with the researchers when asked about

the overall impression of the Thick It-Aquacare H20 product, and any willingness for trying it in

the future. Facility G claimed that there seemed to be no difference between the acceptability of

their currently used product and the Thick It-Aquacare H20 concerning the juice blends, but that

the water blends seemed to be more acceptable. Facility G expressed interest in potentially

pursuing the thickened water in the future, because of its lack of lemon juice addition and

keeping of consistency over time. No comments were given concerning the thickened coffee.

Facility H contacts claimed that the actual appearance of the product seemed to be more

appealing, but noticed no difference in the intake or acceptability reported from their residents.

46

Facility H liked the idea of a pre-thickened beverage, because it transferred liability of improper

thickened beverages from the facility to the company if any type of instance should occur.

Facility I commented that there was no difference in the acceptability or intake

concerning any verbal cues or reports from the residents, because their cognitive and physical

statuses where diminished the point that they could not accurately judge the product or respond.

Facility J reported that the product seemed to have a better appearance, but that not much

difference existed in the acceptability or taste of the product as they viewed their residents

consuming it.

Facility K reported the coffee product to be unacceptable, smelling and tasting stale and

burnt. Facility K threw out the product and resorted to using their own coffee thickened beverage

if any of the residents wanted coffee. Facility K did state that the thickened water seemed to have

a better appearance and that it “set better” on the shelf prior to use. Facility K also reported that

the residents reported a “creaminess” concerning the thickened beverage product, and that this

texture was also unacceptable as stated from the residents.

All facilities seemed to have a positive response concerning the thickened water, a neutral

response concerning all of the thickened juice products, and either no response or a negative

response concerning the thickened coffee. One facility questioned why there was no prune juice

available, and the majority of the facilities would have liked to see some type of thickened dairy

product available for the research study. The only facility that expressed potential willingness in

switching to Thick-It Aquacare H20 was Facility G; moreover, only using the thickened water

and not any of the other products.

Facilities had a general positive overall impression of the product, but had no desire to

switch to the product even after the study. Many factors influence the decision of which

47

thickened beverage product to use. The biggest factor according to all of the facilities was cost.

The Thick-It Aquacare H20 was deemed to be far too expensive to warrant a switchover, when

competitor thickened beverage products were far less expensive and performed the same task as

the Thick-It Aquacare brand. Many facilities expressed disinterest in the product because the

residents may not have all faculties, and are unable to tell a difference in taste and texture of the

products, so there would be no benefit to using a Xanthan gum thickened product versus a

starch-based product because the residents would have the same daily intake CC values,

regardless of type of liquid thickener. Another reasoning is that miscommunication between

dietary and nursing staff leads to waste of product. Many dietary staff believe that the nursing

staff will often not use all of the product, and instead of labeling for future use, will dispose of it

down the drain. This leads to an unwillingness to purchase more expensive thickened beverage,

because it will result in a net loss for the department due to individual actions of other

department staff.

Conclusions

Results showed that the daily intake of thickened beverage products based on facility

charting is unreliable. Acceptability and intake of thickened beverage products is almost

indeterminable due to a host of variables including comorbidities, staff actions, charting errors,

daily emotional and social changes in the lives of residents, miscommunication between

departments, and many other factors. This agrees with Shepard (2011) that monitoring of oral

fluid intake is widely known to be inaccurate. In this study not only monitoring of oral fluid

intake appeared to be inaccurate, but also charting of the oral intake was at times intermittent and

incomplete. A plethora of variables that influence the decision or ability of a resident to consume

a thickened beverage are widespread and present among all nursing care facilities. As long as the

48

residents are consuming the appropriate amount of thickened beverage to meet fluid

recommendations and maintain hydration, the thickened beverage is an acceptable viscosity to

allow for low risk of aspiration, and ability of water molecules to separate from thickener--

thickened beverage product type appears to not be a significant factor concerning intake and

acceptability of a thickened beverage by nursing care residents with dysphagia.

Indeed, the very causes of dysphagia and need for a thickened beverage that can lead to

dehydration (dementia, stroke, TBI, etc.) are also the reasons for the inaccuracy of daily intake

CC values concerning nursing care residents. Because of the highly differentiated diagnoses that

are intertwined with dysphagia, one may find it challenging to accurately portray one product as

being superior to another when considering acceptability and intake.

Recommendations

Further research into which product and thickening agent will precipitate in increased

hydration status should be conducted. However, the sample population must be refined to

include those without cognitive issues to better ensure a more accurate understanding of the

acceptability and intake of the thickened beverage. This may prove difficult given the array of

diseases are associated with dysphagia, and the severity and type of dysphagia that is highly

individualized. This research should serve as a basis for dysphagia research concerning

thickened beverages used in nursing care facilities.

It is also recommended that additional studies on communication between departments

and its effect on the reported intake values of the residents. It may be beneficial to run a staff-

training seminar on administration and proper quantification of thickened beverage consumed,

and study whether the seminar has an effect on the accuracy of medical records and reported

intake values.

49

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57

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