Correct Use of Thickened Liquids
Staff In-service

Use
A nutrition staff member should deliver this in-service to nurses, nursing assistants, and kitchen staff.

Introduction
Estimates vary, but one study indicated that somewhere between 0% and 28% of nursing home residents receive thickened liquids. A physician or speech and language pathologist (SLP) can order thickened liquids. Thickened liquids are necessary when a patient has swallowing problems and cannot handle thin liquids without the risk of choking. Liquids are thickened to nectar-like, honey-like, or spoon-thick consistency (sometimes called pudding-thick). Proper consistency is necessary to provide the safest possible diet for each patient.

Objectives
Following the in-service, staff will know:

• The difference between nectar-like, honey-like, and spoon-thick liquids
• How to properly use thickening agents to achieve the proper consistency of liquids
• The health risks that are specific to those on thickened liquids

Outline
I. Reasons why a patient needs thickened liquids:

• Diagnosis of dysphagia
• Aspiration of thin liquids and/or problems with pharyngeal clearance
• Necessary to have aspiration confirmed by speech and language pathologist and/or modified barium swallow study (MBS), videofluoroscopic swallowing study (VFSS), or fiberoptic endoscopic evaluation of swallowing (FEES)

II. Standard consistency of thickened liquids:

• Thin liquids (all regular liquids, including water, milk, coffee, tea, juice, etc; ice cream is considered a thin liquid because it melts to a thin-liquid consistency in the mouth)
• Nectar-like thick liquids (liquids thickened to nectar consistency, such as apricot or peach nectar)
• Honey-like thick liquids (liquids thickened to honey consistency)
• Spoon-thick liquids (liquids thickened to a pudding consistency)

III. Concerns related to use of thickened liquids:

• Dehydration if patient does not drink enough
• Aspiration pneumonia if fluids are not thickened to the correct consistency

IV. Use of thickening agents:

• Prethickened liquids are available in all consistencies from commercial food service suppliers, which takes the guesswork out of thickening liquids to the proper consistency
• Liquids thickened at point of service:
  • Staff must receive training on how to follow the instructions on the thickening container
  • Some companies produce packets for thickening 8 ounces of fluid to a honey or nectar consistency (follow directions on packet)
  • Some facilities use thickener that comes in bulk containers, measuring the thickener into glasses using a measuring device (follow directions on can)
• Thicken liquids as close to consumption as possible to prevent clumping or overthickening of the beverage
• A resident on thickened liquids also must receive thickened water:
  • Make provisions to thicken bedside water or limit availability of thin liquids bedside
• If a resident is receiving liquid nutrition supplements, thicken them to the proper consistency
• Staff should know the volume of the glasses used on meal trays to assure that the proper volume of thickener is used

Activity
Kitchen should provide several 8-ounce glasses filled with a liquid. Staff should follow the directions on the thickener used by the facility and thicken to honey-like, nectar-like, and spoon-thick consistency. Have staff taste each consistency. Discuss challenges in the correct thickening, as well as the acceptability of the thickened product.

References and recommended readings
Castellanos VH, Butler E, Gluch L, Burke B. Use of thickened liquids in skilled nursing facilities. J Am Diet Assoc [serial online]. 2004;104:1222-1226. Available at www.eatright.org to ADA members.

The Ohio State University Medical Center. Thickened liquids for safer swallowing. Available at: http://medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/nut-diet/nut-other/thickened-liquids.pdf. Accessed December 11, 2010.

Correct Use of Thickened Liquids

Pretest and Posttest

Name: _______________________
Date: ________________________
Department: __________________

1. True or false: Spoon-thick liquids are the consistency of pudding.
2. Which of the following is not an accepted consistency of liquids:
   1. Honey-like thickened liquids
   2. Water-thick liquids
   3. Spoon-thick liquids
   4. Nectar-like thick liquids
3. True or false: If on thickened liquids, a resident should not have free access to any liquids unless they are thickened.
4. How can you make sure that thickened liquids are the right consistency?
   1. Purchase and use prethickened liquids
   2. Follow the directions exactly on thickener packets or bulk thickeners
   3. Know the fluid volume of the glasses used in the facility
   4. All of the above
5. True or false: Ice cream is considered a thin liquid.

Answer key

1. True
2. b. Water-thick liquids
3. True
4. d. All of the above
5. True

Review Date 12/10
G-1460