Case: An 80-year-old man with advanced Alzheimer’s disease is admitted to the hospital after a fall. He is noted to have coughing spells after drinking liquids. He has a swallowing study done which shows severe slowing of motility in the esophagus.
What do you recommend?
A. Feeding tube
B. Thickened liquids
C. Continue current diet
The correct answer for this patient is to allow them to continue their current diet. They do not need thickened liquids. A feeding tube would not be recommended.1
Dr. Douglas S. Paauw
So are there any data supporting the widespread use of thickened liquid diets for patients with dysphagia and aspiration?
Multiple clinical guidelines for stroke recommend the use of thickened liquids despite minimal to no evidence of efficacy.2 It is a common practice to give patients with advanced dementia thickened liquids, especially in the hospital setting. Does this help?
Makhnevich and colleagues published a cohort study of Alzheimer’s disease patients with dysphagia admitted to the hospital over a 5-year period.3 Almost half of the cohort received a thickened liquid diet; these patients were matched with patients who received a thin liquid diet. There was no significant difference in hospital mortality between the groups that received thick liquids and thin liquids (hazard ratio, 0.92; P = .46). Patients receiving thickened liquids were less likely to be intubated but were more likely to have pulmonary infections.
A 2018 Cochrane review concluded that there was no consensus on immediate and long-term effects of modifying the consistency of fluid for swallowing difficulties in dementia because too few studies have been completed.4 So why is this important information or lack of information?
What is so bad about a thickened liquid diet?
Eric Widera, MD, shared in JAMA Internal Medicine his experience along with his hospice and palliative care team of drinking thickened liquids.5 He drank only thickened liquids for a 12-hour period. “The challenge was eye-opening. It was the first time I experienced the terrible taste and texture of thickened liquids,” he wrote. He shared some of the risks of thickened liquids: dehydration, poor oral intake, and decreased quality of life.
The bottom line is that there is scant evidence for the benefit of thickened liquids, especially for patients with advanced dementia and dysphagia, and giving thickened liquids is not a benign intervention, because of poor tolerability of the diet.
References
1. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. J Am Geriatr Soc. 2014;62(8):1590-3.
2. McCurtin A et al. J Eval Clin Pract. 2020;26:1744-60.
3. Makhnevich A et al. JAMA Intern Med. 2024 Jul 1;184(7):778-85.
4. Flynn E et al. Cochrane Database Syst Rev. 2018 Sep 24;9(9):CD011077.
5. Widera E. JAMA Intern Med. 2024 Jul 1;184(7):786-7.