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I’m Theresa Richard. I’ve been a medical speech pathologist for 15+ years, I’m a Board Certified Specialist in Swallowing and Swallowing Disorders, and I’m incredibly passionate about evidence-based practice and equally considering patient preferences with clinical experience and research.

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To thicken? or NOT to thicken? (A Compensatory Strategy Review for Swallowing Disorders Part 3)

by | Jun 27, 2017 | A Compensatory Strategy Review for Swallowing Disorders

Don’t have time to get lost in each blog post? CLICK HERE for a PDF of the entire compensatory strategy review.



So here we are with the last and final step in Logemann’s (1993) compensatory strategies ladder. In channeling my inner Dr. Jamie Fisher, let’s yell it one more time for the people in the back!

1. First, we should try postural techniques,  <— (Part 1 of this series!)
2. Then, try techniques to enhance oral sensation, <— (Part 2 of this series!)
3. Next, we should attempt some swallowing maneuvers, <— (Part 2 of this series – continued!)
4. and LASTLY, but certainly not least: Diet modifications!

As I said in the previous post: for ease of read and to lessen the confusion, I’m sticking with the generic nectar, and honey-thick liquids for this post. We should all be working towards transitioning to IDSSI, but I’ll leave that to the amazing Karen Shefflers and Dr. Steeles of the world to teach. I’m just trying to spread the good word that honey-thick liquid is not the magic potion that cures all dysphagia.

So we’ve determined that not a wish nor a prayer will help Gertrude stay consistent with her compensatory strategies, and we’ve got to do something to help keep our dear friend from qualifying for the nursing home’s next beer chugging competition, and help save those little tiny lungs from drowning. She’s also agreed to some diet modifications since she really doesn’t like coughing and hacking all over her BFFs while sipping her champagne at her weekly Red Hat Society meetings.

Ok so lets beep, beep, beep, back the bus up all the way to back to Day 1 of Dysphagia 101. Why do we thicken liquids? (Let’s say it all together now!) “TO REDUCE BOLUS SPEED.” Good, you remembered. Ok, so reducing bolus speed should in the most perfect world lead to improved bolus control, which would lead to decreased premature spillage, which should buy the swallow a few extra milliseconds to trigger. Ok got it? Good.

So lets be crystal clear here (as in Gertrude’s-champagne-flute-crystal-clear), there are very few studies that have looked at thickened liquids in the disordered population, like 4, yeah dude, FOUR studies have investigated the effectiveness of thickened liquids in preventing aspiration! All of the other studies have been done on healthy normal adults. Yet, even with this lack of evidence, we are still handing out thickened liquids Oprah-style, and as our FIRST line of defense!

There has only been 1, (ONE, UNO, UN) study done by none other than the amazing Jeri Logemann (2008, of course), that evaluated the immediate effects of honey-thick, nectar-thick, and thin liquids with a chin tuck in preventing aspiration. Results indicated via videofluoroscopy that honey-thick was more effective than nectar-thick or a chin tuck with thin in preventing aspiration, HOWEVER! The real kicker that I really want to grind in to your thick skull, is that 50% OF THE PATIENTS ASPIRATED ON ALL 3 STRATEGIES! This is why I’ll shout it from the rooftops, until the cows come home, and I’m blue in the face, that we NEED to be ordering a VFSS or FEES for adorable little Gertrude.

“However, an equally important finding was that one-half of the patients aspirated on all three compensatory strategies (honey-thick liquids, nectar- thick liquids, and thin liquids with a chin tuck).”


I’m just going to throw this little one-liner in here while I’m on a roll, “but Gertrude won’t tolerate a VFSS or a FEES!” Are you sure? Have you tried? But can she swallow? Ok great. If she can swallow, she can play! There are plenty of phenomenal clinicians in this field that can perform a comprehensive study on anyone. Just because Gertrude has a cognitive impairment does NOT disqualify her from having an instrumental assessment. In fact, I will argue that Gertrude definitely SHOULD have an instrumental since as we discussed above, she is not able to consistently perform the compensatory strategies so we MUST find out what underlying pathophysiologies we are dealing with.


I also want to say this again: I. Totally. Get. It. I know we’re all off on our own little dysphagia islands, and it can be extremely intimidating when nursing just wants us  to slap Gertrude on an easy diet that doesn’t require staff supervision or cueing. But we HAVE to think of Gertrude!

Recently I discovered the book, Dysphagia Following Stroke (Daniels & Huckabee, 2014), and I literally read the entire thing in less than 48 hours (nerd alert!). It’s a fantastic and extremely easy read. The authors detailed two key points when deciding to recommend thickened liquids, and again I really want to shove those concepts down your throat (pun intended):

1. Patient Satisfaction/quality of life: Your patient’s lack of compliance with a recommended diet (puree, thickened) is directly related to the dissatisfaction of the food/liquid preparation. (Colony, 2005)

2. The Risk/benefit ratio:

  • Aspiration
    • There is an INCREASED incidence of pneumonia in patients receiving honey-thick liquid compared to nectar-thick or thin with a chin tuck. (Robbins et al., 2008)
    • Dependency for feeding and oral care, the number of decayed teeth, and tube feedings are more predictive of aspiration pneumonia (Langmore et al., 1998) <— (This “Predictors of Aspiration” paper is a must-read for anyone working in SNFs and struggling with the ultimatum to thicken or not to thicken)
  • Dehydration
    • The issue is not with the actual thickening agent causing dehydration, rather it is a palatability issue with the patient drinking less than they would if it weren’t thickened.
      • The free water protocol may be your best bet if dehydration is a concern.

So let’s review these scenarios:

“Gertrude is not being compliant with the recommended diet” Correct. She hates it. Is it worth disrupting her entire lifestyle if she (and her family) are aware of the risks?

Do you know for a fact that the honey-thick liquids that you are putting Gertrude on are PREVENTING or INCREASING her risk of aspiration?

Do you know if the honey-thick liquids are causing dehydration, or a possible electrolyte imbalance which can put her at potential risk for a re-hospitalization and cost the SNF upwards of $35,000?

“Since Gertrude is a slow eater and seems to get fatigued easily, we should put her on honey-thick liquids,” wait wuuut? NO! Do you know if she is she aspirating?

Neither do I, your guess is as good as mine. The only way to find out the answer to all of these questions is by ordering a VFSS or a FEES. Again, no patient ever complained about making their own decisions. Your job is to be the informant and the educator, not the judge and the jury.

Ok, so now that I’ve completely ruffled your feathers, but have gotten your attention at least, when should thickened liquids be used? Again, no hard and fast rule here, but here are some guidelines to help you.

Thickened liquids may be most beneficial if the patient has:

  • difficulty chewing
  • prolonged oral prep
  • delay in pharyngeal swallow
  • laryngeal penetration
  • aspiration
  • nasal regurgitation

Thin liquids may be your better bet if your patient presents with:

  • reduced tongue base retraction to the posterior pharyngeal wall
  • reduced laryngeal elevation
  • poor cricopharyngeal opening

People ask me all the time, so are you totally against thickened liquids? Is that what I said? Didn’t think so. I am all for using them appropriately and with an end game, such as exercises to improve the swallow, a follow up FEES/MBSS in 4 weeks, another re-eval if Gertrude starts showing signs of dehydration, malnutrition, and/or electrolyte imbalance, and/or total open communication with the patient and their family about the risk/benefit ratio. What I am against is the reckless procedure of putting someone on puree, and honey-thick without doing a complete CSE, FEES, and/or VFSS, and acting as a foolish, unethical mess, by telling Gertrude that she will die if she doesn’t drink her honey-thick liquids. You do not know that, you do not have a magic eight ball.

Hopefully this post makes you think a little more critically before slapping someone on honey-thick liquids. Again, IF they are necessary, they are a very valuable tool in our toolbox, but you have to consider all of the angles. Just remember that we all may be in this position someday, and some of us have already dealt with this with a family member, I just ask that you treat your patients (or Gertrude) as if she were your own mother!

Did you miss Part 1 or Part 2 of this series? Go check it out!

If this entire post is completely greek to you, or if you would just like some additional support while trying to stay afloat on dysphagia island, please consider joining us for the Medical SLP Collective. We provide brand new weekly resources in the form of handouts and videos, a panel of experts to answer ALL of your Medical SLP questions (anonymously, and not limited to dysphagia) and monthly webinars for ASHA CEUs.