Improving Patient Compliance With Dysphagia Diagnosis
Thickened liquids are commonly prescribed for patients with dysphagia. However, dissatisfaction with and inaccessibility to thickened liquids frequently results in poor patient compliance. Reduced compliance can lead to dehydration, weight loss, weakness, respiratory illness, and increased risk of falls. In fact, evidence has shown that noncompliance by patients prescribed thickened liquid diets correlated to significantly higher mortality rates compared with those who were compliant. Professionals, caregivers, and patients must be diligent in pursuing options that meet both accessibility and palatability preferences to overcome compliance barriers for patients with swallowing disorders to improve health outcomes and quality of life.
The prevalence of dysphagia in the healthy older adult population ranges between 13.8% and 37.6%.1-5 Cabre et al identified that 55% of 134 community dwelling elderly adults >70 years of age diagnosed with pneumonia demonstrated clinical signs of dysphagia.6 Reduced muscle mass, strength,7 range of motion,8 and sensory awareness that occur due to normal aging can lead to increased oral transit time, delayed swallowing onset, and poor airway protection during swallowing. These symptoms increase the risk of laryngeal penetration and laryngeal aspiration. In addition to normal aging, various neurogenic diagnoses can also result in dysphagia, including the following (percentages represent prevalence rate of dysphagia in people with these diseases): stroke (38% to 51%),9 dementia (45%),10 and four out of five individuals with Parkinson's disease.11
Key factors in reducing the incidence of aspiration pneumonia and other negative health outcomes include early identification, effective and efficient intervention, and patient compliance.
Identification and Effective Intervention
A compelling study by Low et al revealed the serious health consequences of noncompliance. The authors reported that 86% of individuals who made a conscious decision not to comply with speech-language pathologists' thickened liquid recommendations died. This is a significant contrast to the 39.5% who died despite following dietary recommendations.19 In addition, the degree to which recommendations were followed was correlated with the incidence of chest infections, aspiration pneumonia, and readmissions to the hospital. Those who were noncompliant were significantly younger, living at home, and had significantly more hospital admissions and chest infections or aspiration pneumonia than those who complied.
Patients in Medical and Long Term Care Facilities
Studies comparing thickening products have revealed substantial variability between and within thickened liquid products. For example, prethickened beverages have significantly higher viscosity ratings than beverages thickened with instant food thickeners and tend to be more viscous than recommended in the National Dysphagia Diet standards.20 Statistically significant differences in viscosity values among brands of instant food thickeners have been reported.21,22 Leonard et al reported significant reduction in aspiration rate and lower scores on the penetration-aspiration scale with xanthan gum thickener. Although the aspiration rate was reduced with cornstarch thickener, the difference did not reach significance, suggesting xanthan gum may be more effective in reducing aspiration in individuals with dysphagia.23 Interestingly, boluses thickened with cornstarch were more viscous than those thickened with xanthan gum, but they were not more effective in minimizing aspiration.23
Naturally Nectarlike Liquids
In a follow up study, the palatability of these "naturally" nectarlike beverages was significantly higher than cornstarch thickeners across beverage categories (see Table 2).25 Although one might suspect beverages with higher viscosity would be least palatable, there was no correlation between palatability and viscosity values. (See Figure 2 for the beverages tested and their viscosity ratings.) These findings revealed "naturally thick" beverages can be found on supermarket shelves and are more palatable than those thickened with a powder.
While timely identification and intervention are imperative in dysphagia management, more emphasis must be placed on improving patient compliance through continued efforts to make thickened liquids more palatable, accessible, and affordable for individuals with dysphagia. Additionally, medical facilities need to recognize the overall health and economic impact of patient compliance. Continued contributions to this line of research will offer compelling information to reduce the adverse health effects and reduced quality of life in individuals with dysphagia.
— Sharyl A. Samargia, PhD, CCC-SLP, is an associate professor in the department of communication sciences and disorders at the University of Wisconsin at River Falls. Her research interest involves the study of neuroplasticity as it relates to disorders of voice, motor speech, and swallowing.
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24. Samargia SA, Economy K. Alternatives to traditional thickened liquids to improve compliance in patients with dysphagia. Paper presented at: American Speech-Language-Hearing Association Convention; November 14, 2013; Chicago, IL.
25. Samargia SA, Fraser K. Patient compliance in dysphagia management: which thickening agent is most palatable? Paper presented at: The Minnesota Speech-Language-Hearing Association Convention; April 10, 2015; Minnetonka, MN.