The Hydration Equation: How to keep your patients hydrated.
As SLPs, we know that hydration is key to overall health and well-being, but it can be a real challenge for our patients with dysphagia. We often rely on thickened liquids to reduce the risk of aspiration, but let's be honest, they're not exactly the tastiest. And for some patients, thickened liquids can lead to decreased fluid intake and even dehydration.
So, what's the solution? Well, it's not a one-size-fits-all answer. But there are several strategies we can use to help our patients stay hydrated and happy. Kathy Panther, MS, CCC-SLP, CBIST of the Frazier Institute (Yes, THE Frazier Institute behind the Frazier Free Water Protocol) has been studying hydration for much of her career, and her work and research have supported a bulk of the content in this article. Thank you for your work, Kathy!
Dehydration in the Elderly: A Silent Epidemic
Dehydration is a harmful reduction of water in the body, either from vomiting, diarrhea, or insufficient PO intake. Older individuals are particularly vulnerable to dehydration for two main reasons:
They may be more susceptible to the medical conditions that cause vomiting and diarrhea
They may experience a decreased sense of thirst, impaired mobility, or cognitive decline that makes it difficult for them to recognize and respond to their hydration needs.
Imagine the gas gauge in your car was broken. The needle read full whether the tank was filled to the top or completely empty. On top of that, it’s a two-and-a-half-hour drive to the gas station, and the location won’t show up on Google Maps. You’d likely neglect filling up your tank under these circumstances, right? Similarly, people with advanced age may not recognize when they're thirsty, have trouble getting up and accessing water, and may be forgetful about how much water they’ve had and how much they need. It’s the perfect storm.
Why Hydration Matters
Studies have shown that about a third of nursing home residents are dehydrated. This impacts health in some terrifying ways. This study of 200 people admitted to the hospital showed that 37% of hospital admissions were dehydrated, which ultimately led to some serious health complications. We need water, right? So dehydration can lead to a host of health problems, from constipation and fecal impaction to cognitive impairment, functional decline, and death. That's why it's so important to address hydration proactively, especially in patients with dysphagia. But as it turns out, oftentimes we do the opposite.
Thickened Liquids: A Necessary Evil? Or Evilishly unnecessary.
Thickened liquids are our number-one go-to intervention for patients with dysphagia. Before anything else, we go for thickened liquids. And there's a good rationale behind it: They can help reduce the risk of aspiration. However, that benefit comes with a small catch. We have two painfully obvious reasons behind this:
Taste and Texture: Thickened liquids can be unappealing and difficult to swallow, especially for patients accustomed to drinking thin liquids.
Dehydration Risk: No surprise here. We don’t drink what we don’t like. Less drinking = less water in the body. Why yes, I am a scientist. Thank you for asking.
In a review of the literature, Steele et al., 2021 reported that, “There is no conclusive evidence to support thickened fluids to prevent dysphagia-related clinical complications, including aspiration pneumonia.” Making many wonder how and why they’ve become our number one intervention. It’s kind of like voting for a politician who has a track record of making your neighborhood less safe and more expensive. Who’d vote for that?
Of course, the truth is a lot messier than that, and thickened liquids do benefit certain patients, particularly those with significant dysphagia and discomfort during meals and for whom alternative interventions have been proven ineffective. But I’d venture that this is the minority of the patients who are actually prescribed thickened liquids. We’re using a blanket with holes in it to warm up a large group of people, many of whom aren’t even cold.
Overcoming the Challenges of Thickened Liquids
If you find that your patient does require thickened liquids and is open to them, but is still having difficulty drinking a sufficient amount, there are several strategies you can try here:
Offer a Variety of Flavors: Experiment with different flavors and brands to find options that your patients enjoy.
Adjust the Consistency: Thicker liquids are not always better. Sometimes, a slightly thinner consistency can improve tolerance without increasing the risk of aspiration.
Provide Frequent Small Sips: Encourage your patients to take small, frequent sips throughout the day, rather than trying to drink large amounts all at once, an overwhelming task that can be filling and less palatable.
Consider Alternative Hydration Methods: If thickened liquids are not working, consider other options, such as fluid-dense foods or in the event that the dehydration is an emergency, consider intravenous fluids or subcutaneous hydration with the medical team.
The Fear Factor
One of the biggest barriers to hydration is fear. Many patients are afraid of having an accident if they drink too much, especially if they have to wait for assistance. This fear is understandable. We stress to less mobile patients that they need to wait for someone to help them before using the bathroom, right? But there may be significant delays in arriving to provide assistance depending on the time of day, the number of medical emergencies that might be occurring, and potential staffing shortages. Where does this leave the patient? With the choice of venturing out of bed and to the bathroom on their own and risking a fall or forgoing their dignity and going in their bed. Which would you choose?
The third choice is to avoid liquid altogether. Which many find as their best option. That way, frequent visits to the bathroom are no longer a problem. Don’t drink… don’t go. But this is like starving inside your own home because you’re scared of getting into a car accident on the way to the grocery store. You need to eat. And you need to drink. Not drinking should never be an option. It sounds so obvious and even silly, but it shows the level of distress that people are going through that they would forgo one of the most basic of human needs.
The Four Types of Patients
Kathy Panther used four descriptive categories to help determine a path forward for her patients. They include patients who:
Can Drink: These patients are functionally capable of accessing and consuming fluids, but they may be forgetful or not understand the importance of adequate hydration. These individuals may need cognitive support or reminders.
Can't Drink: These patients are physically unable to access or safely consume fluids. They want to drink and know they need to drink, but simply can’t do it on their own.
Won't Drink: These patients may have concerns about reaching the toilet or simply don't like to drink. “I never was a big drinker,” they might say.
End-of-Life Care: These patients may have complex medical situations or be in palliative care, where hydration goals may vary.
Understanding these categories can help us tailor our hydration strategies to each patient's needs. The solution usually lies in some level of education and support so they know why, where, and how to access the water they need.
Fluid-Dense Foods: The Hydration Heroes
One effective strategy is to encourage the consumption of fluid-dense foods between meals. Up to 30% of the water we take into our bodies comes from food. That’s a third. The good news is that it's entirely dependent on what you eat. There’s no rule to say you need to drink your fluids. You most certainly can eat them too. Your body doesn’t care how it got the fluid, it only cares that it did in fact get them.
What types of food should we encourage to increase that 30%? That one’s easy: Fruits and vegetables. It turns out that the same kinds of food your mom forced you to eat for vitamins and minerals are also great for hydration. You can be strategic with choosing the right kinds of fruits and vegetables, too. Many fruits and vegetables are over 90% water, including watermelon, tomatoes, grapes, peppers, lettuce, cucumbers, and strawberries. And yes, we definitely want to test some of these items via an instrumental swallowing evaluation, as the juiciness can increase the risk of aspiration.
Other good options that may be more suitable for patients with dysphagia include:
Thickened Soups
Yogurt
Pudding
Popsicles
Half frozen items (i.e., frozen smoothies)
Dehydration Risk Appraisal Checklist (DRAC)
The DRAC, or Dehydration Risk Appraisal Checklist, is a valuable tool designed to help clinicians assess and manage dehydration risk in individuals and is effective in identifying risk in older adults. It's a simple checklist that guides clinicians through various risk factors associated with dehydration, making it easier to identify those who might be at a higher risk. Don’t downplay the power of checklists. Dr. Atul Gawande informs us that it can save lives.
The DRAC evaluates several categories to identify risk, including age, gender, health conditions, fluid intake behaviors, and laboratory indicators. It can be used by a wide range of individuals, but is particularly helpful for older adults, those with complex medical conditions, and individuals with cognitive or physical impairments that may affect their ability to stay adequately hydrated.
Using the DRAC is straightforward. Clinicians review each indicator on the checklist and determine whether it applies to the individual being assessed. The more risk factors identified, the higher the individual's risk of dehydration. This assessment can then guide interventions and strategies to promote hydration, such as setting fluid goals, encouraging regular fluid intake, and monitoring for signs and symptoms of dehydration.
Big Takeaways
Hydration is essential for all patients, but especially elderly patients and those with dysphagia.
Fear of accidents can be a major barrier to hydration.
Fluid-dense foods are a great way to increase fluid intake when fluid intake is limited.
By staying informed and embracing a patient-centered approach, we can help our patients achieve their hydration goals and improve their overall quality of life.
What are YOUR go-to strategies for managing hydration in patients with dysphagia? Share your experiences and tips in the comments below!
Liked this? Check out Kathy Panther’s course on Northern Speech to learn more.
