Things We Do for No Reason: The Use of Thickened Liquids in Treating Hospitalized Adult Patients with Dysphagia

Inspired by the ABIM Foundation's Choosing Wisely campaign, the “Things We Do for No Reason” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A 74-year-old man with Alzheimer’s dementia and chronic dysphagia with a history of aspiration pneumonia presents with urinary tract infection, hypovolemia, and hypernatremia. He has been on thickened liquids at home for the past several months. As his overall condition improves with intravenous fluids and antibiotics, he requests to drink thin liquids.

Dysphagia is defined as difficulty or discomfort with feeding or swallowing¹ and is a common clinical problem facing hospitalists. The prevalence of swallowing difficulties is estimated to affect 13 million people in the United States, which is likely to increase as the population ages.² Dysphagia often results in inadequate fluid consumption, resulting in complications such as dehydration.¹ However, the most dreaded complication is pneumonia from aspiration. Aspiration, the entry of material from the oropharynx or the gastrointestinal tract into the larynx and lungs, can be problematic since it is often colonized with pathogens.^3-5 It constitutes 5%-15% of the four and a half million cases of community-acquired pneumonia per year with a mortality rate as high as 21%.^5,6

Dysphagia is a clinical diagnosis, and assessment tools are available to help establish the mechanism and severity.³ For example, the bedside swallow evaluation uses the administration of water by the clinician to the patient to assess for the presence and severity of dysphagia.^1,7 The evaluation is performed by making the patient sit upright at up at 90° and administering either single sips of ≤20 ml of water, consecutive sips with intake up to 100 ml of water, or progressively increasing volumes of water. The clinician then observes for clinical signs of aspiration such as choking or coughing. This evaluation is inexpensive, noninvasive, and time-efficient with a sensitivity as high as 91%, if conducted using the consecutive sips technique.⁷ A video fluoroscopic swallowing exam (VFSE) includes the administration of various barium consistencies that may be helpful in determining the precise mechanism of dysphagia, particularly in the pharyngeal stage of swallowing.^3,8 VFSE is often considered as the standard for dysphagia evaluation, although it is expensive, time-consuming, exposes the patient to radiation, and its translation to functional ability to safely eat and drink is unproven.⁸