Download The efficacy of pre-thickened fluids on total fluid

Age and Ageing 2008; 37: 714–718
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The efficacy of pre-thickened fluids on total
fluid and nutrient consumption among
extended care residents requiring
thickened fluids due to risk of aspiration
SIR—Dysphagia is associated with many neurological and
neuromuscular conditions including stroke and Parkinson’s
disease. Consequently dysphagia is a common condition in
our patient population. Treatment of dysphagia necessitates
the use of thickened fluids, however there are problems with
the use of thickener. Failure to achieve the recommended
consistency can increase the risk of aspiration. Dysphagia
patients who receive thickened fluids frequently fail to meet
their fluid requirements [1] and this can lead to dehydration.
Whelan [1] investigated fluid intake in 24 stroke patients with
dysphagia to evaluate the effect of the disability, and identify
the type of fluid given. The mean thickened fluid intake was
455 ml/day resulting in the use of an extra 742 ml/day of
supplementary parenteral fluids. This still did not result in an
adequate total intake. However, patients not on a specialist
stroke unit who received pre-thickened fluids drank almost
100% more than those on powder-thickened fluids.
In a small, unpublished study on 10 patients in St. Mary’s
Hospital, fibre, fluid and laxative intake was assessed. In this
study, the patients on thickened fluids had a lower total intake
and their fluid intake consisted mainly of poor nutritional
quality beverages such as tea and lemonade.
The use of powder thickener added to fluids relies on
the staff achieving the correct consistency through correct
instruction and adequate guidelines.
Poor hydration can adversely affect a number of physiological processes including the regulation of body temperature, the distribution of nutrients and the excretion and elimination of waste products of metabolism. A study conducted
on a non-specialist stroke unit who received pre-thickened
drinks consumed almost 100% more than those on powderthickened fluids [1]. We conducted a small study at St. Mary’s
Hospital in Dublin on 11 patients to assess whether the use
of pre-thickened, standardised consistency fluids resulted in
an increase in fluid and nutrient intake, reduced constipation
rates and improved hydration status in dysphagic patients.
Methods
Eleven adult patients, resident in a 321-bed geriatric care
facility that provides acute, rehabilitation and long-term care
services in Dublin, took part in our study. These patients
ranged in age from 51 to 109 years; three were male and
eight were female. They had all previously been assessed and
were considered to be at risk of aspiration and to require
thickened fluids. We utilised a cross-over study design, with
patients assigned to two groups. The first group (group A) was
assigned to receive pre-thickened, standardised consistency
fluids, available in a variety of flavours including fruit juices,
milk, orange juice, peppermint and tea for a 6-week period.
The second group (group B) continued on fluids thickened at
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the bedside using ‘usual’ thickener—modified maize starch—
for the same 6-week period. Fluid intakes were recorded
by nursing staff at each drinking occasion using graduated
measuring cups. After 6 weeks, the groups were reversed and
group A received fluids with ‘usual’ thickener while group B
received pre-thickened fluids for the next 6 weeks. In this
way the participants functioned as their own controls.
Data was gathered on Barthel index and MMSE at baseline, week 6 and week 12. Daily fluid, protein, calorie, vitamin
C and vitamin D intakes were recorded on a weekly basis
throughout the study. Fluid requirements were calculated
using the Parenteral and Enteral Nutrition Group (PENG)
guidelines. Fluid was defined as any food that was liquid
at room temperature. Constipation rates were also recorded
using the Bristol Stool Chart.
Ethical approval was not sought for this study as all participants had been previously prescribed thickened fluids following appropriate clinical assessment.
Results
Eleven patients took part in the study. The mean age of the
patients was 76, the mean BMI was 23.3 and the mean Barthel
index was 0.4.
Results from this study showed that patients had significantly higher energy, protein, calcium and vitamin C and D
intake when given pre-thickened fluids as compared to drinks
thickened at the bedside (Table 1). Eight of the eleven patients
in the study had higher fluid intake when taken in the form of
pre-thickened fluids as compared to powder-thickened fluids. The fluids taken in pre-thickened form were found to be
of more nutritional value, whereas patients taking fluids with
thickener added were more likely to be taking their fluid in
the form of less nutritious fluids such as tea or lemonade.
There was no difference in rates of constipation observed.
Discussion
Dysphagic patients who receive thickened fluids frequently
fail to meet their fluid requirements [1], resulting in
inadequate nutrient intake. The results of our small study
are interesting as they indicate that pre-thickened fluids may
increase fluid and nutrient intake in vulnerable patients suffering from dysphagia. As this is likely to improve immune
function, depression, fatigue, confusion, constipation [3] and
weakness [2], it is suggested that a larger study may be
worthwhile.
Key points
r Patients with dysphagia commonly receive thickened
fluids.
r Use of traditional powder thickener may be associated
with insufficient fluid and nutrient intake.
r Pre-thickened fluids may offer a beneficial alternative.
Research letters
Table 1. Nutrient intake according to thickener regimen
Average Nutrient Intake According to Thickener Regimen
Median
IQR (25–75%ile)
P≤
.......................................................................................................................................
Fluid (ml)
‘Usual’ thickener
785
202 (701–903)
0.47
Pre-thickened
795
346 (745–1091)
Protein (g)
‘Usual’ thickener
7
3 (4–7)
0.001
Pre-thickened
15
7 (10–17)
Energy (kCal)
‘Usual’ thickener
267
50 (254–304)
0.0001
Pre-thickened
583
241 (543–784)
Calcium (mg)
‘Usual’ thickener
25
8 (22–30)
0.0001
Pre-thickened
544
156 (467–623)
Vitamin C (mg)
‘Usual’ thickener
35
48 (13–61)
0.001
Pre-thickened
170
134 (128–262)
Vitamin D (µg)
‘Usual’ thickener
0
0
0.00001
Pre-thickened
5
2 (4–6)
Mann–Whitney U test was used to calculate the P value. Significant results are highlighted in bold.
r Pre-thickened fluids were associated with significantly im-
proved nutrient intake, and a trend towards improved
fluid intake.
Conflict of interest
Fresenius Kabi partly funded this study through an unrestricted educational grant; however, it was not involved in
the design, execution, analysis, interpretation of data or writing of the study.
SIOBHÁN ERIN MCCORMICK1 ,
KATHLEEN MARY STAFFORD1 ,
2
GHULAM SAQIB , DANNIELLE NI CHRONIN2∗ ,
DERMOT POWER2
1
Department of Nutrition, St. Mary’s Hospital,
Phoenix Park, Dublin 20, Ireland
E-mail: [email protected]
2
Department of Medicine, St. Mary’s Hospital,
Phoenix Park, Dublin 20, Ireland
∗
To whom correspondence should be addressed
Age, comorbidity, treatment decision and
prognosis in lung cancer
SIR—Lung cancer is now the leading cause of cancer-related
death in most developed countries. Approximately 80–85%
of lung cancer subtypes are of non-small cell (NSCLC), twothirds of which are at advanced stages on diagnosis.
Like other solid tumours, lung cancer is predominantly a
disease of the elderly and ∼30–50% of all patients are older
than 70 years when the disease is diagnosed [1, 2]. Despite
the high incidence of lung cancer and its high mortality rate
in elderly patients, the likelihood of receiving active treatment appears to decrease with increasing age [3, 4]. The
presence of comorbid conditions is regarded as an important
factor influencing treatment decisions [5]. In spite of the fact
that comorbid conditions are very common in the elderly
[6], the prognostic impact of age and comorbidity remains
controversial.
With these aspects in mind, we performed an observational study to analyse the influence of age and comorbidity
on choice of treatment and prognosis in advanced NSCLC.
Patients and methods
Patients
References
1. Whelan K. Inadequate fluid intake in dysphagic acute stroke.
Clin Nutr 2001; 20: 423–8.
2. Thomas B, ed. Manual of Dietetic Practice. Blackwell: Oxford,
2007.
3. Powell M, Rigby D. Management of bowel dysfunction: evacuation difficulties. Nurs Stand 2000; 14: 47–54.
doi: 10.1093/ageing/afn204
Patients with cyto-histological diagnosis of NSCLC stages
III-B or IV according to the TNM system [7], between January 1997 and June 2006, were analysed retrospectively.
Exclusion criteria were as follows: performance status
(PS) >2 according to the Eastern Cooperative Oncology
Group (ECOG) or death before treatment due to causes
unrelated to neoplastic disease.
The oncological committee of our hospital (comprising physicians from the oncology, radiotherapeutic oncol-
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