EVIDENCE BASED PRACTICE

Trial and tribulation

Given prima facie evidence that drink thickness recommendations for clients with learning disabilities and dysphagia are often not followed, Margaret Margerison, Adrienne Fenton, Ros Hunter and a volunteer jury put a portable viscometer on the stand. Although it proves unsuitable, the trial has made the team more aware of the issues they need to address.
THE CHARGE Our small speech and language therapy team in Rotherham has ongoing concerns over the suitability of thickened drinks given to clients with learning difficulties and dysphagia. Despite our recommendations as to the level of modification of drink required for each individual, we have widely observed that the drinks produced by carer or staff quite often bear little resemblance to the suggested description. Moreover, staff and carers have little awareness of the discrepancy or its relevance. In their study Cichero et al. (2000) found that differences in the viscosity of thickened fluids were considered as a source of variability and potential hazard. Goulding and Bakheit (2000) worked with people in Plymouth who were dysphagic following a stroke. They stressed the importance of making drinks to the correct consistency because, if too thin, they may not prevent aspiration and, if too thick, are usually unpalatable and are often rejected by patients. This may lead to dehydration and malnutrition. Their study concluded that there was a striking inverse relationship between the volume of fluid consumed by patients and the viscosity of the thickened fluid. Moreover, they referred to a study by Miller and Watkin (1996) which showed that highly thickened fluids may actively exacerbate swallowing difficulties in some because of the additional force needed by the tongue to move the bolus. Generally speaking, our clients with learning difficulties are not able to speak up for themselves as to their feelings on the subject of thickeners and variability. Some of our carers freely admit that they use a 'rule of thumb' approach to measuring quantities, and this is borne out by observation. THE PRELIMINARY Although we have held basic eating and drinking awareness training in the past, we felt another concerted push was necessary to try to reach as many staff and carers of our clients as possible. We developed a programme of three hours training, the maximum we thought staff would be allowed away from their duties. Included in the three hours is a 20 minute thickener section. We originally offered 12 sessions and a further 6 have followed as a result of demand. Our second strategy was to investigate the use of a portable viscometer, to find out if everyday use would help carers to measure thickness. As its name suggests, a viscometer is an instrument used to measure what is perceived as a liquids resistance to flow. Could this piece of equipment give our carers / staff a reliable, objective measure of thickness so they could be sure to comply with our recommendations?

The first hurdle to overcome was finding an appropriate model. The internet came up with what appeared to be the answer and the company supplying the equipment offered to lend us a viscometer on free loan for one day. As anyone who has ever investigated viscometers knows, they are hugely expensive as a piece of kitchen equipment (over 3000). We approached a London charity for funding and this was found to be a distinct possibility, subject to a clinical trial of the equipment showing its suitability. THE TRIAL The viscometer was larger and heavier than we had anticipated, but we felt this was not an insurmountable difficulty if it proved advantageous in every other respect. The proceedings We posted flyers asking for volunteers to take part in the trial. Those coming forward comprised speech and language therapists, care staff experienced and inexperienced in the use of food thickener - and volunteers from various professional bodies including physiotherapy and nursing staff. Twenty five volunteers took part in the trial. Each was given the same set of instructions: 1. Take 200 ml beaker of water (already measured) 2. Add thickener 3 level tablespoons (measure provided) 3. Whisk until dissolved (whisk and fork provided) 4. Note down the time (clock provided) 5. Wait 5 minutes (timer provided) 6. Take measurement on viscometer 7. Clean viscometer (under cold tap) The evidence We asked the volunteers to say on a scale of 0 -5 1. how easy was the viscometer to read 2. how easy was the viscometer to clean 3. would they be happy using the equipment on an everyday basis? Their responses are in figure 1. Eighteen (72 per cent) of the volunteers said they would not be happy to use the viscometer on an everyday basis. The reasons given included: Too bulky Too heavy Reading fluctuating and erratic Procedure takes too long Not easy to take out and about Backache as a result of holding the equipment upright to try to achieve a regular reading (one volunteer) Instruction lacking as to the exact point when reading to be taken Not known if it was necessary to unplug for cleaning. THE VERDICT The viscometer we trialled would not be suitable for helping carers achieve the correct consistency of drinks. THE DEBRIEFING Although the trial itself could be said to have failed, several significant factors emerged during the day. We were already aware that: 1. Users of thickener in drinks often did not measure the amount of fluid. 2. Users of thickener often did not read the tin to find out the correct quantity.

Ros Hunter, Adrienne Fenton, Margaret Margerison READ THIS IF YOU WANT TO FOCUS ON PREVENTION OF HARM HAVE YOUR RECOMMENDATIONS UNDERSTOOD TRY OUT DIFFERENT SOLUTIONS

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SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007

EVIDENCE BASED PRACTICE

3. Some users did not leave sufficient time for the drink to reach its level of thickness before offering the drink or adding additional thickener. But we had not realised how widespread were the practices of: 4. Not following the instructions as to how to mix in the thickener (so volunteers added the whole quantity at once rather than slowly adding whilst mixing in at the same time). 5. Under-mixing so that lumps remained. (This was evident in the trial as we used transparent beakers to contain the 200ml cold water.) 6. Overfilling or underfilling the measure supplied with the thickener We also would not have anticipated that 7. The most experienced users of thickener were not necessarily the most able. In view of the variability in the methods used it is perhaps not surprising that the measurements on the viscometer readings were also wide-ranging. As we did not know how significant the range was, we were not able to reach any clear conclusions on the figures in relation to the thickness we were aiming for (Stage 2 National descriptor, BDA, 2002). We were contacted by the suppliers of the viscometer who were interested in the outcome of our trial. The company replicated our procedure to see if their results were comparable. Their single trial concluded that: (a) the mixture needed to be stirred moderately with a fork for a short time (say up to 45 seconds) (b) the mixture should be allowed to stand for at least 10 minutes (c) the probe of the viscometer should be held steady in the mixture (d) if these procedures were followed, then the viscometer would give reasonably reproducible results. This reinforces our results and the conclusion of our volunteers that the viscometer would not be practical in a domestic context. So, how to move on? THE AFTERMATH Some larger services have research projects into viscometers and are in the process of developing much-needed resources to assist staff and carers achieve the thickness of drinks recommended by speech and language therapists. We await the outcome of their research.

In the meantime we set up an afternoon workshop to include four experienced users of thickener care staff who make thickened drinks on a regular basis and three speech and language therapy staff to develop clear guidelines for appropriate use of thickeners (figure 2). These guidelines are now included in Rotherhams Easy Eating and Drinking manual (in progress) which is to be distributed on a pilot basis to 12 homes and Day Centres in the near future. As part of our Eating and Drinking Awareness sessions, more detailed instruction is now given into the practical usage of thickener in drinks. Margaret Margerison, Adrienne Fenton and Ros Hunter are speech and language therapists with the Learning Disabilities Service, Rotherham, e-mail Margaret.Margerison@ RotherhamPCT.nhs.uk. They are supported by speech and language therapists Joanna Howe, Jo Wilman, Louise Bowden and Ceri Robertson.

Figure 1 Volunteers views 1. How easy 0 1 2 was the viscometer to 1 3 9 read? On scale of 0-5 2. How easy was viscometer to clean? 3. Would you be happy to use the viscometer on an everyday basis? 0 3 1

3 31/2 4 5 (easy) TOTAL 4 4 4 25

1 1

13

25

YES 7

NO 18

Figure 2 Guidelines for making a thickened drink Guidelines for a double cream consistency National Descriptor Stage 2 1. Organise equipment: measuring jug clients cup knife thickener scoop measure separate container (eg. a cup) for thickener clean, dry teaspoon / fork / whisk. 2. Measure 200ml water in a measuring jug 3. Pour the water into the clients cup 4. Measure carefully the right amount of thickener powder into a separate container using the back of the knife to ensure level scoopfuls: 23/4 scoops of Thick n Easy 3 scoops of Nutilis 3 scoops (tablespoons) of Resource ThickenUp 5. Commence stirring water in cup, whilst gradually adding thickener, continuously stirring vigorously (for 1 -2 minutes) until all the powder is dissolved and no lumps remain. (NB It is important to use a fork or whisk to stir in Resource ThickenUp) 6. Leave to stand for 2 minutes (NB If Resource ThickenUp is used, there is no need to leave to stand serve immediately) 7. Check the consistency on the back of a teaspoon to ensure the double cream consistency is achieved 8. Offer drink to client.
Developed by Christine Pask, Kate Priestley, Joanna Franklin and Vicky Holding, John Street Nursing Home, Thurcroft, 2006

References
British Dietetic Association (2002) National Descriptors for Texture Modification in Adults. London: Joint Working Party of the British Dietetic Association and the Royal College of Speech & Language Therapists. Cichero, J.A.Y., Jackson, O., Halley, P.J. and Murdoch, B.E. (2000) How thick is thick? Multicenter study of the rheological and material property characteristics of mealtime fluids and videofluoroscopy fluids, Dysphagia 15 (4), pp.188-200. Goulding, R. and Bakheit, A.M.O. (2000) Evaluation of the benefits of monitoring fluid thickness in the dietary management of dysphagic stroke patients, Clinical Rehabilitation 14, pp. 119-124. Miller, J.L. and Watkin, K.L. (1996) The influence of bolus volume and viscosity on anterior lingual force during the oral stage of swallowing, Dysphagia 11, pp. 117-24. SLTP

REFLECTIONS DO I KNOW TO WHAT EXTENT MY RECOMMENDATIONS ARE FOLLOWED? DO I HAVE THE SUPPORT OF A DEPARTMENTAL STRATEGY TO RAISE AWARENESS AND COMPLIANCE? DO I NEGOTIATE WITH COMPANIES TO TRIAL PRODUCTS?

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SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007

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