Thickened fluids for people with dementia in residential aged care facilities: a comprehensive systematic review

Abstract

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 dysphagia[1]. 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from 1995 to 2008 were sought in a comprehensive search of an extensive range of databases, online sources and unpublished literature.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 papers[2-10] 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 papers[1, 4, 8, 9] directly recommend thickened fluids as an effective method of maintaining hydration for persons with dementia. (Level IV evidence) One study[11] 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 deficiency[12]. (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.