Does a Water Protocol Improve the Hydration and Health Status of Individuals with Thin Liquid Aspiration Following Stroke? A Randomized Controlled Trial

Abstract

The benefit of water protocols for individuals with thin-liquid aspiration remains controversial, with mixed findings from a small number of randomized controlled trials (RCTs). This study aimed to contribute to the evidence of the effectiveness of water protocols with a particular emphasis on health outcomes, especiallyhydration. An RCT was conducted with patients with known thin-liquid aspiration post-stroke randomized to receiving thickened liquids only or a water protocol. For the 14 participants in rehabilitation facilities whose data proceeded to analysis, there was no difference in the total amount of beverages consumed between the water protocol group (mean=1103ml per day, SD=215ml) and the thickened liquids only group (mean=1103ml, SD=247ml). Participants in the water protocol group drank on average 299ml (SD 274) of water but offset this by drinking less of the thickened liquids. Their hydration improved over time compared with participants in the thickened liquids only group, but differences between groups were not significant. Twenty-one percent of the total sample was diagnosed with dehydration and no participants in either group were diagnosed with pneumonia. There were significantly more diagnoses of urinary tract infection in the thickened liquids only group compared to the water protocol group (χ 2 =5.091, p=0.024), but no differences between groups with regard to diagnoses of dehydration (χ 2 = 0.884, p=0.347) or constipation (χ 2 =0.117, p=0.733). The findings reinforce evidence about the relative safety of water protocols for patients in rehabilitation post-stroke and provide impetus for future research into the potential benefits for hydration status and minimizing adverse health outcomes.Drinking, deglutition, deglutition disorders, stroke, water, water-electrolyte imbalance [6]. The premise is that thickening a liquid makes it more cohesive and dense, reducing its flow rate. This enables many patients to better control the bolus intra-orally, thereby reducing aspiration risk before and during swallowing [7,8].There has been growing concern, however, about the blanket prescription of thickened liquids for a number of [14,18,19]. By far the greatest concern about thickened liquid prescription is that individuals with dysphagia do not consume enough fluids. Researchers have demonstrated that the bioavailability of water from a quantity of thickened liquids is equivalent to that from the same quantity of thin liquid [20][21][22] confirming that thickened liquids themselves are not the cause of dehydration. Furthermore, it is recognised that, in addition to beverages, food contributes to approximately 20% of overall fluid intake with an even greater percentage if individuals are on pureed food [23,24]. Notably, food was found to be the greatest contributor to oral fluid intake in a cohort of patients with dysphagia in acute settings [25]. However, total fluid intake has consistently been found to be inadequate for individuals with dysphagia on modified diet and liquids, especially if reliant o...

An oral hygiene protocol improves oral health for patients in inpatient stroke rehabilitation

“…The second study was a prospective observational study which collected the same outcome measures of fluid intake, hydration status and rate of adverse events in a sample of patients without dysphagia (n = 86) as illustrated in Figure . The findings from these studies with respect to the primary outcomes have previously been published . A unique aspect of both of these studies was that an oral hygiene protocol was implemented daily for all participants and oral health scores were collected at weekly intervals.…”

“…The findings from these studies with respect to the primary outcomes have previously been published. 29,30 A unique aspect of both of these studies was that an oral hygiene protocol was implemented daily for all participants and oral health scores were collected at weekly intervals. The oral health scores of 12 rehabilitation inpatients with dysphagia and 77 without dysphagia were available from two data points, at commencement of the study (Day 0) and one week after the implementation of the oral hygiene protocol (Day 7).…”

Is IDDSI an Evidence-Based Framework? A Relevant Question for the Frail Older Population

“…Finally, when foods are carefully selected, positive impact on food intakes and weight are observed [22]. Free water protocols can support hydration to improve hydration in well-defined populations [30,31]. To date, research looking at efficacy of the nutritional treatment to circumvent dysphagia is insufficient [20,32,33].…”

Implementation and Analysis of a Free Water Protocol in Acute Trauma and Stroke Patients

“…This result is consistent with previous research on the FWP in the rehabilitation setting. 1,[20][21][22][23][24][25] Participants in the experimental group showed a trend toward decreased days to discharge from the study, but the small number of participants that were followed precluded statistical testing.…”

“…19 To date, 7 studies of the FWP in the rehabilitation setting have been published. 1,[20][21][22][23][24][25] Of these, 6 did not reveal elevated rates of aspiration pneumonia in participants on free water protocols. One study, however, showed lung complications, including aspiration pneumonia, in 6 of 42 participants (14%) randomized to a group with access to water but no lung changes in the control group (n = 34).…”