By Howard Rosenberg
At Amsterdam Nursing Home, a long-term care facility located in New York, NY, my staff and I have taken a proactive approach to establish a personalized level of comfort and independence for each resident at mealtime. A significant part of this approach has been to address dehydration and malnutrition issues that have been particularly associated with residents who have a swallowing disorder known as dysphagia.
Our lessons learned by serving many people in a group setting may hopefully shorten the learning curve for family members who are caring for their loved ones at home. When it comes to encouraging participation and promoting enjoyment during mealtimes, all caregivers should consider the important roles that taste, texture, enjoyment, independence and dignity play.
Taste and Variety
It is crucial to remember that before the swallowing disorder arrived, you and your loved one truly enjoyed dining. Dysphagia may complicate mealtimes a bit, but with a little bit of help, it is still possible for them to enjoy food and eating.
We all have our favorite foods, but we also enjoy variety. Since your loved one can no longer enjoy an assortment of textures in their food, different flavors and tastes must be the main source of variety. Take the time to incorporate different flavors and, if they enjoy seasonings, use varying spice profiles to keep things interesting. For example, when thickened to the proper consistency, a basic tomato sauce or soup can serve as a base for numerous Italian, Tex-Mex or Curry flavor profiles with the addition of different herbs and spices. Providing a diverse selection of foods also better ensures that your loved one is getting a wide range of vitamins, nutrients and minerals.
Furthermore, there are several naturally thick items available at the grocery store that can help diversify your home menu, including yogurt, smoothies, applesauce, cream soups and puddings. These options can help alleviate some pressure on you, the caregiver, when it comes to cooking from scratch and/or thickening every meal yourself.
Handling Thickened Liquids
It can be difficult for your loved one to get used to consuming beverages that are not true liquids. It is crucial that they stay hydrated and consume enough water, but thickened drinks are an acquired taste and will take time to get used to. If they are still having trouble with this change in texture, try offering beverage options that will not seem so strange in this new form. For example, fruit juices tend to seem less unusual when thickened because they are similar in taste and texture to applesauce and other fruit purees. Additionally, even though thickened drinks provide fluids and promote hydration, many people find this consistency less satisfying than a normal liquid. It is important for your loved one to continue “drinking,” and providing thickened versions of their favorite refreshing beverages like lemonade or iced tea may help them feel their thirst is quenched.
Keeping Up Appearances
We have learned an important lesson in the group setting: individuals do not want to wait to be served after other diners or watch their meal be thickened! If at all possible, caregivers should try to thicken drinks and meals away from the person with dysphagia. If you are eating as a family or with others, try to serve everyone’s meals at once. This can take some practice when it comes to timing, but it can make a big difference in your loved one’s appetite. They are likely aware that their food and drink need to be thickened for safe consumption. However, watching someone stir a thickening agent into each beverage and meal isn’t exactly appetizing, even if the end result is palatable. Remember, we eat with our eyes, too!
Maintaining Dignity and Independence
Retaining a normal mealtime routine and allowing your loved one to remain as independent as possible also help to preserve their dignity. If they feel they have some control over their food choices and nutrition, they are more likely to look forward to their meals and eat well.
One way to accomplish this is to use a stable thickener that maintains its viscosity over time. Keep in mind that thickeners are not perfect. Many continue to stiffen after being mixed into food and drink, so it may take some trial and error to find the one that works best for certain items and their ideal serving temperatures. Using a stable product allows your loved one to eat at their own pace and help themselves at will without their meal or beverage becoming too thick. Smaller portions also help to prevent this problem, as it can take longer for someone with dysphagia to eat and they are typically unable to consume larger portions. If your loved one has a weak grip or unsteady hands, fill their glass, plate or bowl only half full. This enables them to use traditional dishes and glassware, serve themselves and lessen their risk of spilling.
Thinking Outside of Mealtimes
Helping a loved one consume enough calories, nutrients and fluids doesn’t have to happen only at breakfast, lunch and dinner. Many seniors (especially those with swallowing disorders) tend to be overwhelmed at mealtimes. Smaller, more frequent meals spread out over the course of the day are more easily consumed and put less pressure on your loved one to eat.
Snacks in between meals can be an excellent source of nourishment and can also be cleverly disguised as a treat. A refreshing popsicle on a summer afternoon or a soothing bowl of warm broth before bed can be a nice change of pace for your loved one, and both of these options can be thickened to meet their dietary needs. Get creative with your snack ideas by supplementing some of their favorite foods with healthy ingredients that are nutrient dense, will help them stay hydrated, boost their fiber intake or enhance other areas of their diet that may be lacking.
Thickened textures cover a range of options and are categorized as thin, nectar-like, honey-like and spoon-thick. Your loved one’s doctor or speech-language pathologist will let you know what consistency is best for them, depending on their level of swallowing difficulty. Each of these consistencies can be achieved through the addition of thickening agents. As mentioned earlier, there are also naturally thick items available at your local grocery store and ingredients that can be added to meals in order to thicken them, such as flour, bananas, yogurt, and white and sweet potatoes.
If your loved one has additional dietary restrictions for personal or religious reasons or due to a health condition, such as diabetes or a food allergy, be sure to look closely at the labels of all thickeners you are considering for purchase. Most product labels will list values for use in a diabetic exchange diet, state whether or not they contain gluten, lactose or other allergens, and display any kosher certifications, if applicable.
Thankfully, the selection of available thickeners is increasing all the time. Below are a few most popular options on the market. They are typically divided into powders and gels, but the thickening ingredients in each are classified either as starch-based or gum-based. Powders tend to be more difficult to blend into food and drink compared to gel varieties.
Starch has been available for a number of years and is easily accessible and affordable. The primary ingredient used is maltodextrin or modified cornstarch. These products can cause fluids to appear cloudy, have a gritty texture, taste “starchy,” and they may produce lumps when mixed. After mixing, it can take anywhere from 30 seconds to a few minutes to set up and reach the desired consistency, but the final product will also continue to thicken over time. Foods thickened with starch-based powder must be served right after being mixed. Hot foods must typically cool slightly for easier mixing with these products and then be reheated before serving. When mixing with sodas or other carbonated beverages, starch powders often cause drinks to fizz up and lose their bubbles.
These products typically consist of xanthan gum or cellulose gum and maltodextrin. Gum powders are newer to the market, so you may need to check with your pharmacist for assistance in ordering it. Gums thicken fluids without added flavor, cloudiness or grit, and they maintain viscosity across temperature and time. After about 5 minutes of setting time, gum-based powders should not continue to thicken. Xanthan gum is the only thickening agent that can be frozen or heated and maintain its viscosity. This is essential for safe swallowing. Use this option, either in powder or gel form (see below) to make thickened popsicles, ice cubes or other food items that you intend to freeze. Do not use regular ice in thickened beverages, as it will change their overall consistency and pose a swallowing hazard!
Gel and Liquid Thickeners
Gel options are also gum-based and much easier to mix into foods and beverages than powders. They also tend to blend easily in more difficult items such as soda, hot foods, alcoholic beverages and protein-rich supplement drinks like Ensure or Boost. This product does not lump up, but it must still be mixed in thoroughly.
Other Convenient Thickening Options
In recent years, companies have tried to make their thickening agents easier to use both at home and on the go. This includes the creation of individual serving size packets and pre-thickened beverages, such as water, juices, coffee, tea, and even prepared pureed meals and food items. These ready-to-drink products are available in nectar and honey consistencies, so make sure you buy the right texture for your loved one.
Once again, you may need to check with your pharmacist for assistance in locating these ready-to-use products. They offer great versatility and can be used in conjunction with other unthickened ingredients to achieve a safe consistency. Pre-thickened products have been the preferred base for many recipes at Amsterdam Nursing Home. We have found that, while they are initially more expensive, we have much less waste and see improved intake for our residents, so the investment has been worth it for us.
Will Insurance Cover Thickening Products?
Some thickening products are covered by Medicare, Medicaid or private health insurance companies. While you do not need a prescription to purchase these products, having a doctor document your loved one’s medical need for these products both in their chart notes and with a prescription will help you get them approved for coverage. Of course, private insurance policies and Medicaid can vary significantly, so check with your loved one’s provider to see what information you will need to provide in order have these products considered for coverage.
Thickened Recipes Our Residents Love
These recipes use pre-thickened beverages and are quick and easy to assemble for loved ones with difficulty swallowing.
Your Cup of Tea
- 1 teabag of choice
- 2 Tbsp. boiling hot regular water
- 6 oz. of hot Thick-It AquaCare H2O thickened water
Instructions: Steep the teabag with the regular boiling water in a teacup, creating a highly concentrated tea. Pour the hot thickened water into the concentrated tea, stir thoroughly, check for consistency and serve. Stir in powdered sweetener as desired.
Iced tea variation: Chill the thickened tea in the refrigerator and serve over a glass of thickened ice cubes.
Your Favorite Flavored Water
- 1 packet of water flavoring powder or desired amount of liquid water enhancer
- 8 oz. of Thick-It AquaCare H2O thickened water
Instructions: Pour the thickened water into an 8 oz. drinking glass. Slowly add the flavoring to the thickened water, stirring briskly until the mixture has dissolved fully dissolved. Serve over thickened ice cubes.
Thickened Ice Pops
Beverage of your choice thickened with a gum-based product (Try ready-t0-use Thick-It AquaCare H2O in apple, cranberry, or orange juice varieties, or use the Your Favorite Flavored Water recipe above.)
Instructions: Pour thickened juice or water into an ice pop mold. Freeze and serve.
Howard Rosenberg is the Director of Dining Services at the Amsterdam Nursing Home in New York City.