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Teachable Moment
Less Is More
June 2016

The Horrible Taste of Nectar and Honey—Inappropriate Use of Thickened Liquids in Dementia: A Teachable Moment

Author Affiliations
  • 1Department of Internal Medicine, PRIME Residency Program, University of California and San Francisco Veterans Affairs Medical Center, San Francisco
JAMA Intern Med. 2016;176(6):735-736. doi:10.1001/jamainternmed.2016.1384

A woman in her 90s with advanced dementia was admitted for stage IV pressure ulcers. She lived at home with her son, who was her primary caregiver and surrogate decision maker. After a hip fracture 1 year prior, she became completely dependent on her son. Because of her dementia, she was started on honey-thickened liquids for aspiration prevention.

During the first week of hospitalization, she refused nearly all food and thickened liquids, turning her head when nurses attempted one-on-one feeding. By the end of the week, only her son was able to feed her small amounts of familiar foods. In consultation with the palliative care service, the primary team and son transitioned the patient to inpatient hospice. Her diet was liberalized to regular liquids and her favorite foods. Her intake improved. Two months later, she had gained 8 kg without enduring a clinically significant aspiration event.

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1 Comment for this article
Negative Title Detracts from Real Issue of Decision-Making in Dysphagia Management
Karen Sheffler, MS, CCC-SLP, BCS-S | SwallowStudy.com
Please see my in depth blog in response to Wang, Charlton, and Kohlwes (2016) at SwallowStudy.com: http://www.swallowstudy.com/?p=1819
It has received a lot of attention on Twitter and Facebook (@SwallowstudySLP).

I concluded the article with these calls to action:
1. SLPs need to market their dysphagia services better. We do not reflexively put people on thickened liquids. SLPs are not the bad guys who like to thicken liquids or make people Nil Per Os (NPO or nothing by mouth).
2. SLPs use patient-centered communication. SLPs discuss findings with the patient, caregivers, and medical team and pose recommendations as a spectrum of options from curative to
3. SLPs advocate for instrumental testing, when appropriate, to place people on the least restrictive diet and make sure that safe swallow strategies actually work. How risky are thin liquids? Does thickening the liquid work? SLPs further advocate for repeat testing, in order to return patients to thin liquids as quickly as possible after an acute illness or weakness has resolved.
4. The medical team, starting with the person’s primary care physician, needs to have discussions early on in the person’s degenerative disease regarding goals of care when eating and drinking becomes difficult.
5. The medical team needs to have in-depth and sit-down conversations with the patient and health care proxy (when applicable). The team should involve the Palliative Care service to help delineate the patient’s goals of care, as these conversations can be complex and lengthy. Is it in the patient’s goals of care to prevent aspiration and aspiration pneumonia at all costs? Would small changes make a big difference in the person’s quality of life (e.g., water between meals or having ice cream)?
CONFLICT OF INTEREST: I am a medical Speech-Language Pathologist who works in acute care (adults/geriatrics), and I am the founder of SwallowStudy.com: Dysphagia Resource for Professionals & Patients. <br/>I have not received any financial incentives to write this article. I had a fellow SLP request my writing assistance to respond to the article. <br/>My desire is to raise awareness around the issues people face when they or loved ones have difficulty swallowing. <br/>Disclosure on one link in my blog regarding Product Reviews of Thickened Liquids: I receive a small <3% commission on sales of thickened liquids through one company only (CWI Medical Products). The total amount I have received from this aspect of my website is $10. This information is disclosed on the website within the product review section. I also review products where I receive no commission.