THICKENED FLUIDS FOR PEOPLE WITH DEMENTIA IN RESIDENTIAL AGED CARE FACILITIES: A COMPREHENSIVE SYSTEMATIC REVIEW

EXECUTIVE SUMMARY Background: Dementia is an umbrella term for a large group of conditions that cause a progressive decline in a person's functioning. Dementia is a progressive condition which causes cognitive and functional decline and, as part of this, the ability to swallow diminishes, a condition known as dysphagia1. Aspiration of fluids is a common result of dysphagia and is a significant problem, both in terms of its effect on the patient and its cost to the community. In order to increase the viscosity of drinking fluids and thereby minimise the likelihood of aspiration, people with dementia living in residential aged care facilities (RACFs) are often prescribed thickened fluids. Objectives: The overall objective of this comprehensive systematic review was to establish best practice in relation to thickened fluids for people living in RACFs to: establish factors associated with the prescription and administration of thickened fluid for people with dementia living in RACFs; assess the effectiveness of administering thickened fluids for people with dementia in RACFs in terms of adequate hydration, mortality, morbidity and patient comfort; identify attitudes of people with dementia in RACFs and their family/carers regarding the administration of thickened fluids; and identify attitudes of staff regarding the administration of thickened fluids for people with dementia in RACFs. Search Strategy: English language articles published from 1995 to 2008 were sought in a comprehensive search of an extensive range of databases, online sources and unpublished literature. Selection criteria: The review considered all types of studies which included the oral administration of fluids with the addition of commercial thickening agent to the liquid which may include: energy/nutritional supplements, juice, water, tea, coffee, cordial, milk drinks, etc., for the purpose of increasing the viscosity of the liquid to minimise the chance of aspiration for persons with dementia in residential aged care. Data collection and analysis: Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. Any disagreements were adjudicated by a third reviewer. MAIN FINDINGS Nine papers2–10 recommend the use of thickened fluids as a strategy to maintain adequate fluid intake for demented persons with dysphagia in RACFs. (Level III.c - IV evidence) Four papers1, 4, 8, 9 directly recommend thickened fluids as an effective method of maintaining hydration for persons with dementia. (Level IV evidence) One study11 found that the use of thickened fluids was generally acceptable to older persons in the event of dementia and dysphagia and was more acceptable to the participants than the prospect of enteral feeding. (Level IV evidence) One study found that the practice of adding infant cereals to fluids as a thickening agent cannot be recommended due to concerns over dehydration and folate deficiency12. (Level IV evidence) CONCLUSION There appears to be little specific data on the effectiveness of thickened fluids for people with dementia in residential aged care. Most included studies had mixed populations of demented and non-demented residents, making dementia-specific results impossible to quantify. From the retrieved data, evidence-based best practices cannot be concluded. It may, however, be cautiously inferred that thickened fluids may be effective for residents with dementia if set guidelines are instituted. BACKGROUND Dementia is an umbrella term for a large group of conditions that cause a progressive decline in a person's functioning and cognition. There are different forms of dementia and each has its own causes, including Alzheimer's disease, vascular dementia, fronto-temporal dementia and dementia with Lewy bodies13. Dysphagia, as well as other conditions (e.g. dependence for feeding; dependence for oral care; decayed teeth; number of medications taken) put people with dementia at risk of aspiration pneumonia14. Aspiration of fluids is a common result of dysphagia and is a significant problem, both in terms of its effect on the patient and its cost to the community. US figures cited by Felt15 list common co-morbidities from dysphagia and their cost (2002): Pneumonia: mean hospital stay 5.8 days; mortality 5.56%; national cost $2 345 241 969USD Aspiration pneumonitis: mean stay 8.75 days; mortality 18.3%; national cost $5 737 998 273USD Dehydration: mean stay 4.11 days; mortality 2.87%; national cost $6 672 747 130USD In order to increase the viscosity of drinking fluids (and thereby minimise the likelihood of aspiration and the other adverse events described above), people with dementia living in RACFs are often prescribed thickened fluids. These fluids are either commercially pre-thickened, or else produced by staff at RACFs, by adding a thickening agent to a beverage. There is some evidence that thickened fluids are often not well accepted by patients. One reason is that the thickeners can suppress the flavour of the beverage to which they are added (e.g. juice, milk, water, coffee)16. Another aspect that may make a thickened fluid unpalatable is texture. University student participants in a study by Howarth et al.17 identified negative qualities and described thickened fluids as too lumpy, too gritty, not sweet enough, too smooth or slimy. A study conducted with eight patients with dysphagia found that the majority (six patients) reported that they did not like using a thickener18. A recently completed Australian study19 addressed the considerable variation in how the viscosity levels of thickened fluids are qualitatively described. The joint project between and the of standardised and for and fluids One of the project was that different for thickened fluids were conducted by the identified different that were for different levels of fluid in in the in terms of of beverage (e.g. milk, water, of of the fluid and between and of thickened be and found between language in the to fluids of and was The effectiveness of thickened fluids in aspiration has not well and of the evidence in relation to this is is known that dysphagia the risk of a or aspiration et conducted a systematic review which the effectiveness of for aspiration in older with the administration of thickened fluids. The review found data to the administration of thickened fluids to of aspiration A recently completed the effectiveness of in the of liquid aspiration and aspiration of thickened fluids or and The in which participants had either dementia, or both The the term effectiveness of the in aspiration, by participants a The the effectiveness of the over a in the of aspiration participants in liquid thickened to was often in aspiration, by liquid and fluids in a significant was in the of aspiration between or thickened fluid was found that using in a more than than using was risk factors as dementia or aspiration on all were has that to thickened fluids may increase the likelihood of patients at in the and a that patients to thickened did not aspiration the has large has its et conducted a with of patients to the effectiveness of thickened fluids in patients as the group and thickened fluids The group thickened fluids of the were to There were either group of aspiration or dehydration the study or the of the reported with thickened the thickened fluids did not their and they in the group reported with to or the were that thickened fluid intake was than for patient in this Another study conducted by and that a may be for some patients. study was conducted with residents in an aged care with The was by of residents thickened fluids staff that residents were not fluid and of residents as from a or a The or adverse of thickened fluids in terms of adequate hydration, mortality, morbidity and patient are not to et are prescribed evidence that the patient is on of practice is the that at a that liquid quality of for older as thickened fluids to be to people with dementia living in RACFs, is a to establish an evidence to their prescription and The overall objective of this systematic review was to establish best practice in relation to thickened fluids for people living in residential aged care facilities (RACFs) with the specific establish factors associated with the prescription and administration of thickened fluid for people with dementia living in RACFs. assess the effectiveness of administering thickened fluids for people with dementia in RACFs in terms of adequate hydration, mortality, morbidity and patient identify attitudes of people with dementia in RACFs and their family/carers regarding the administration of thickened fluids. identify attitudes of staff regarding the administration of thickened fluids for people with dementia in RACFs. of participants The review considered studies which included people with dementia living in RACFs were thickened fluids. of The review considered studies that the oral administration of fluids with the addition of commercial thickening agent to the may include: energy/nutritional supplements, juice, water, tea, coffee, cordial, milk drinks, etc., for the purpose of increasing the viscosity of the liquid to minimise the chance of of The review considered studies which included to the effectiveness of thickened number of people with fluid ability to of in (e.g. to the prescription and administration of thickened fluids to people with dementia in associated with the prescription and administration of thickened fluids to residents with dementia and attitudes regarding the administration of thickened fluids attitudes regarding the administration of thickened fluids of studies to the effectiveness of thickened the study types were studies and studies to the prescription and administration of thickened the study types were studies and In the of or that the inclusion were studies in English were considered for The the this to the The search strategy to identify both published and unpublished reported in A strategy was in which the of of the and to establish search an extensive search was using the for each of the the of identified and articles were for are in the in The were from the search strategy using the or dementia, disease, Alzheimer's disease, vascular dementia, intake or oral or agent or liquid or agent or liquid or fluid or or fluid or or or or or for or care or specific care. search are in were conducted from 1995 - The Australian of and The of and and Search and and The search of of included may be the of to to identify or studies and a search the and for on in of on in of of - of Dementia and for in and of the and of Australian for Alzheimer's and and and the on of of was conducted of the that is not on or in and which its to and Dementia of and in in and in and in Data studies identified by the were critically appraised by independent reviewers for to the review on the and studies that to the inclusion the was retrieved and assessed for to the review were to that to be to the were for the review if they the inclusion as that a the inclusion and on the of the was to study inclusion and was to assess the eligibility of all retrieved for and on which quality of studies were assessed studies were assessed by independent reviewers for quality to inclusion in the review using by the and on the of the and for and Data from studies were assessed using the and data by and were appraised using the and and data by Any disagreements between the reviewers were by to a third reviewer. Data Data from included studies were extracted using a data by and Data from studies were extracted using and from as and were extracted using Data to significant was not are in for all study the search in were identified for the of and the were included in the review that did not the inclusion did not (e.g. or systematic sources the or of this or were of quality were The included One study studies One One One mixed method study studies Two studies Two guidelines to significant of all included results are in a study the inclusion for this on factors and fluid in persons with dementia in residential care a a The of a which was to data on overall over between and with a of residents with dementia in care facilities in US Four different types of were residential living and care. The and In addition to the residents, care and were study had the of an for identify the of adequate and fluid intake for care residents with dementia. 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The for staff and thickened fluids was by and in their study event a a dysphagia to factors that intake in to this systematic review is the that of all residents were or and of had some of had by a or found that residents were and fluid residents had a order for thickened fluids residents were identified as some of The that dysphagia is and staff for residents with how to et residents from Australian residential and by a from The purpose was to their attitudes regarding for aspiration were to identify their regarding hospital care in terms the use of or for all in the that they were dementia. for cognitive and using the and the participants were with a and a in a dementia. and and are to (e.g. are to are and in all of including feeding. of with and and as a had of to were if in that they to a or a an oral of with the risk of aspiration The majority of participants they hospital and for aspiration than in the A majority with the use of a for did not with or The that some residents for aspiration with a for hospital and than care and that they are more in relation to of of a thickened than of et study a systematic collection of data on thickened fluid administration in residential care a standardised this study data from facilities US in Data was on residents number thickened number of residents of residents on thickened fluids had assessed by and The study the of thickened fluid use with national and There is considerable variation in the administration of thickened fluids and - a effect on of thickened fluid use as well as of a national in the of residents thickened fluids were to dysphagia and considered to be at risk for dehydration and aspiration is data on of The as part of quality and and and language may to the thickened liquid use in their for with and national recommend that if the national may be a to if the is care in relation to dysphagia The number of residents thickened fluids be into the and the to thickened to patients. the for to identify the effective and by which are and et conducted a in a residential aged care to the effectiveness of a dysphagia included thickened to the were residents between had at the more than and an than of their or had a of and for The group with and of thickened fluids - were to the specific The group levels of and and of and as data was at and study found that a of and thickened fluids can a significant in intake in for an group with dysphagia and some cognitive decline to a It that a in thickened fluid and range may be for residents with dementia thickened fluids. for the of this review the study not data hydration, or effectiveness data for thickened fluids. the inclusion and quality for this et reported on the of a to and in care in the of to and in a to the of in The for in of an of and of the with the The results were by a from The of The guidelines were by factors at the of The by the that be to of in or in days; of in the or of on a a of to or than et that and are common residents, which to the for a and These guidelines recommend that as thickened and can be to the of The guidelines that be on assessed and that of fluid viscosity persons the at of fluid The by Felt15 in the on the viscosity of fluids. One of the of the guidelines is to the that fluid viscosity is is evidence the to thickened for persons with other identified factors this be considered in the of and the and of thickened fluids. this the associated with fluid It that both over and of fluids may to adverse for fluids can be and not be which may to may be more to the may to fluid The of this is that thickened be in It that studies that fluids at and to and The Australian of care of older persons in residential aged care that older people with dementia in residential care are of the of people at risk of One strategy this is the use of thickened fluids of fluids and not to or to persons a fluid The by and persons with Alzheimer's and other in terms of their quality of and with to fluid and an of Alzheimer's and factors in a including the of thickened fluids in intake and maintaining The a of levels of for thickening fluids and that for persons with dementia an part in care to and by is that may be to maintain adequate fluid intake in persons with dementia due to of and as and or feeding. recommend the use of thickened fluids at for persons with dementia and using as a thickening agent fluids are an method of increasing maintaining adequate fluid intake in persons with dementia in with an and risk of aspiration are an of Alzheimer's and other to this that thickened fluids are an strategy for residents with Alzheimer's and that a as a swallow is of little in terms of and on older people in residential care in the use of thickened fluids. that commercial thickeners are and to use and to too if for too It that facilities use infant described in and above), and to fluids as a cost and to some this that the fluids be as and not fluids too with the In commercial thickeners and fluids can be as part of hydration in the is a with increasing the of and fluid is that adding or to fluids the fluids for and may to dehydration which may increase and in as well as other The that were included in this review in terms of this and of addressed the review The other included addressed of the review and some of the study the inclusion was the included were quality however, they of data directly to the review to the of the included the of the review the for the establish factors associated with the prescription and administration of thickened fluid for people with dementia living in RACFs. included addressed this at in and The administration of thickened fluids to persons with dementia in RACFs appears to on an people at risk of and the use of thickened the of residents thickened fluids may be than the dysphagia on US The administration of thickened fluids is by the of to It has that staff thickened fluids of a viscosity commercial thickening are added to fluids and that the of fluid may be It is recommended that thickened fluids be to the of this fluids may cost they a which may, the of adverse events for residents by aspiration or overall the the data to a of which may some part in the for not or administering thickened fluids to this as and for persons with dementia is an aspect of care in order to and It is that administering fluids of an viscosity can to aspiration, and is that are and to that fluids are prescribed and residents maintain an adequate and and fluid intake may be and the to be to risk and assess the effectiveness of administering thickened fluids for people with dementia in RACFs in terms of adequate hydration, mortality, morbidity and patient Two included and addressed this studies data on morbidity were to studies that data on mortality to thickened fluids. In both participants or that included thickened fluids. Two of the intake data on The data to that persons thickened fluids are at risk of if is not to intake and of It is to that fluid intake may be to in persons with dementia, due to The of persons with dementia may be or in the of the residents may from or than drinking the thickened It that the practice of adding infant or other to fluids in order to both and cannot be recommended on the evidence as may to dehydration and folate deficiency12. studies the inclusion were found that directly addressed the administration of thickened fluids in terms of patient identify attitudes of people with dementia in RACFs and their regarding the administration of thickened fluids included addressed this objective and this study did not directly persons with dementia, non-demented residents of an to assess their attitudes and for care. persons with dementia may not be to their regarding the administration of thickened fluids due to their disease, this study some if evidence on the of thickened fluids as a A majority of participants in this study that they a that included thickened fluids not enteral and not feeding. studies that the attitudes of or regarding thickened fluids or the of the or of thickened fluids were to be identify attitudes of staff regarding the administration of thickened fluids for people with dementia in RACFs. One included and addressed this The for appears to be a common as both the of for staff as a in the administration of thickened fluids to The use of care staff in aged care appears to on both the of dysphagia and the administration of and fluids to this is not a as and often not thickened the of It that for and regarding the prescription and administration of thickened fluids may be SUMMARY associated with the prescription and administration of thickened fluids for people with dementia living in administration of thickened fluids appears to on an staff the facilities thickened fluids of a viscosity residents be assessed by a and language the of thickened fluids of administering thickened fluids for people with dementia in RACFs in terms of adequate hydration, mortality, morbidity and patient persons thickened fluids are at risk of dehydration intake is due to this is in people with dementia the practice of adding infant cereals to fluids as a thickening agent cannot be recommended as may to dehydration and folate studies were found which patient mortality in relation to intake of thickened fluids of people with dementia in RACFs and their family/carers regarding the administration of thickened included found that of the participants in of fluids in to enteral studies were found which the of or in relation to intake of thickened fluids of staff regarding the administration of thickened fluids for people with dementia in is a for and the use of staff and with be assessed by a and language the of thickened fluids. are prescribed thickened fluids their fluid intake by part of persons with dementia are to an aged care be to the viscosity of thickened fluids to residents with dementia - commercially thickened fluids may more viscosity than on in residential aged care facilities on the and administration of thickened fluids to persons with dementia. and other care staff may regarding the administration of thickened to residents with dementia as they may feeding. to be to to fluids and put in to residents are fluids of a and There is a for both and into the effectiveness and of thickened fluids for persons with dementia in RACFs. to the of this from studies of thickened fluid administration to non-demented patients may not be directly persons with dementia at risk from or There is a for into and attitudes regarding the use of thickened fluids for persons with dementia. CONCLUSION A of were of were the for quality articles were included in the review found little specific data on the effectiveness of thickened fluids for people with dementia in the residential aged care Most included studies had mixed populations of demented and non-demented residents, making dementia-specific results impossible to quantify. with dementia are more to feeding. is recommended that and other care staff be specific to the administration of thickened fluids to patients with dementia including specific to fluids that are to be be to residents are fluids of a and may with From the retrieved data, evidence-based best practices cannot be concluded. From the data retrieved may be cautiously inferred that thickened fluids are effective for residents with dementia if set guidelines are instituted. were from this review due to the of the residential aged care in as aged care of may data to the review more systematic review was by the Dementia - and the - a The reviewers and of and and University of The for University of and University for their on the The is for of own

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