Most people have never heard of swallowing difficulties, let alone Thickened Drinks. If you, your family member or friend have been diagnosed with a swallowing difficulty (also known as dysphagia), your speech pathologist would have provided some information related to the swallowing difficulty and how it relates to the particular medical circumstances that caused it. Swallowing difficulties can affect people of all ages and some of the more common causes are: stroke, diseases affecting the nervous system, head trauma, cancer of the head or neck, surgery, radiation therapy, and age related changes to the nerves and muscles of the throat that making swallowing difficult for the elderly.
There are different ways to treat dysphagia and the best method is decided on a case by case basis. It can depend on the cause and severity of the dysphagia, and the age and health of the individual. One form of treatment is food and/ or drink modification, which is only recommended after a speech pathologist conducts a full swallowing assessment. Food and drink modification involves the recommendation of optimum food textures (e.g. coarse vs. smooth foods) and the ideal drink thickness that a person can swallow safely. Food and/ or drink modification can result in big changes to the diet and drinks normally consumed by a person with dysphagia. However, it is important to remember that this suggestion is always made in the best interest of the person’s health, with safe swallowing being the priority.
Following, you will find information about thickened drinks that will help answer common questions and will assist with their introduction at home.
If someone you know has been diagnosed with a swallowing difficulty, chances are they have been recommended thickened drinks or thickened fluids. Thickened drinks are basically normal drinks that have had a specially formulated thickener added to them, to make them thicker than regular drinks. They are recommended by Speech Pathologists for people who can no longer swallow normal fluids safely and who are at risk of having drinks go into their lungs. The consequences of drinks going into the lungs can be strong coughing, choking or more serious risks such as a chest infection and aspiration pneumonia.
So what's so special about thickened drinks? One reason they work is because they travel more slowly down the throat than normal fluids- this means they are easier for a person to control when they swallow. Think about the differences between water and a thick shake. Water runs out of a cup very fast and a thick shake moves much more slowly. If someone with dysphagia drinks water, it can travel down the throat so quickly that the muscles and nerves used for swallowing, don't act quickly enough. This can mean that some of the water trickles into the lungs. However, with thickened drinks, the fluid moves more slowly and this gives the body more time to control and direct the fluid away from the lungs and toward the stomach. That is one reason why thickened fluids work.
People with swallowing difficulties typically have difficulty swallowing throughout the day. Therefore, in most cases, they will not be able to drink normal drinks at all. This means that thickened drinks will replace normal drinks. When someone is on thickened drinks they should aim to drink as much of them as is needed to maintain normal hydration (1-2 litres).
After diagnosis of a swallowing difficulty, regular visits to a Speech Pathologist will be required so that a person's swallowing ability can be reviewed, and they can determine if there is any improvement. This means that someone with a swallowing difficulty should continue to have thickened drinks until their speech pathologist conducts a review and potentially advises otherwise. The duration of a swallowing difficulty will depend on the cause, the degree of recovery, and the overall health of the individual. Therefore, it is difficult to predict how long it may last.
When someone is diagnosed with a swallowing difficulty, a Speech Pathologist will recommend one of three different thickness levels. The level of thickness that is recommended varies from person to person. It depends on the severity of a person’s swallowing disorder. Typically, the worse the swallowing disorder, the thicker the drink. Recently, Speech Pathology Australia and the Dietitian’s Association of Australia worked together to create the Australian Standards for Texture Modified Foods and Fluids*. They developed the naming and descriptions for the three recognised thicknesses of thickened drinks. When a speech pathologist recommends thickened drinks, they will always tell the person with dysphagia (or their family member's) which thickness they should have. The three thicknesses are:
Level 150- Mildly Thick
This level is the thinnest of all the thickened fluids. It pours quickly out of a cup (but slower than regular fluids) and has a fast, steady flow. You can drink drinks of this thickness level out of a cup. Other names used to describe this thickness are: Level 1, Nectar Thick, Quarter Thick, Cream or Semi Thick.
Level 400- Moderately Thick
This level is the second thickest of all the thickened fluids. It is similar to the thickness of a thick shake (but a thick shake becomes thinner when it melts, so people on this thickness level still can’t drink thick shakes!). Drinks of this thickness pour slowly from a cup and have a slow rate of flow. As it is thick, the best way to have this drink is with a spoon. Other names used to describe this thickness are: Level 2, Honey Thick, Half Thick or Thick.
Level 900- Extremely Thick
This level is the thickest of all the thickened fluids in the new thickness guidelines. Drinks of this thickness cannot be poured from a cup into the mouth as they have a very small flow rate. Drinks of this thickness are so thick that they hold their shape on the spoon and so using a spoon to have them is the best method. Other names used to describe this drink thickness are: Level 3, Pudding Thick, Full Thick, Mousse or Extra Thick.
You have two options, you can purchase pre-made thickened drinks or you can make your own thickened drinks with a powder thickener. Many people also use a combination of both- so they get the benefits of both options.
Pre-mixed thickened drinks
These are available in single serve cups (sold individually or in cartons) or large bottles. Here are some advantages:
they don't require preparation and are ready to drink,
they don't need refrigeration until they are opened
they have a long shelf life (6+ months)
You can be assured that the drinks have been prepared to the right thickness and they are not too runny or overly thick
These products are particularly appealing to people who are elderly or have a disability and are not able to prepare the drinks for themselves or do not have someone who they can rely on to do it correctly and regularly (drinks made at home with thickening powder only last 1-2 days in the fridge). The down side of pre-packaged drinks are that they cost more than thickening powder and some brands manufacture only a limited number of flavours. In Australia, we are lucky to have manufacturers that have over 20 flavours on their menu.
The second option is that you can make thickened fluids using a specialised powder thickener that can come in small tins up to large, economical boxes. These thickeners are specially formulated for people with swallowing disorders. Thickeners like cornflour, gelatin or Karicare are not recommended for thickening drinks. The reasons for this are:
It is hard to get drinks to the correct thickness with these products
They often dramatically change the taste of the drinks they are put into
They can be difficult to mix in completely
The drinks may change in consistency (get thicker or thinner) over time or as the surrounding temperature changes. This could result in the drink thinning down or becoming too thick or gluggy and therefore being unsuitable to drink.
A benefit to using specialised thickening powder is that it is cheaper and more economical than buying pre-mixed drinks and you can add it to whatever flavoured drink you choose (including beer and wine!!). A disadvantage of using a powder thickener is that many people, especially the elderly or those with a disability may have difficulty mixing the drink to the correct thickness level. If a drink is too runny it puts a person at risk of having the drink spill down the throat and then go into the lungs. If the drink is too thick, it may not be appetizing and a person may drink less of it and therefore be at risk of dehydration. Also, drinks that have been pre-mixed using a powder thickener only last a very short time in the fridge- typically 1-2 days.
As not all powder thickeners can be used to thicken hot drinks (and you think you might like to thicken hot drinks such as tea), remember to look for this information when you are choosing a powder thickener.
You will find the instructions on the back of the container that you buy. They are quite easy to follow. Each pack normally has three recipes describing how to make up the drink to each of the three recommended thickness levels. For example, if you are on Level 150- Mildly thick, the recipe might instruct you to add 1 teaspoon of powder to 200 mLs of liquid- then stir for 1-2 minutes with a spoon or fork. For hot drinks, some manufacturers recommend letting the drink stand for 5-10 minutes after you have mixed the thickener in. This is so that the drink gets to the right thickness and all the lumps disappear.
If you are mixing larger quantities, the recipe may also suggest that you use a stick mixer to get a better consistency and to further ensure there are no lumps in the drinks. As the instructions for each product can be slightly different, please remember to read and follow the instructions on the product that you have purchased.
As you can see, there are some things to understand about using and making thickened drinks, however you have a number of options and it becomes a matter of finding solutions that meet your budget, your tastes and the amount of preparation you are willing to do.
Just remember, if you are unsure about which thickness level applies to you, your relative or friend, don't guess, it could be risky for the person drinking it- especially if the drink is too thin. Just ask your speech pathologist and they will be happy to tell you.
*Dietitian's Association of Australia; The Speech Pathology Association of Australia Limited (2007).Texture-modified food and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition & Dietetics, 64 (Suppl.2): p553-576