Managing Chewing and Swallowing Difficulties in Care Facilities

HealthLinkBC File Number: 
Last Updated: 
February 2018

Chewing and swallowing difficulties can occur in people of any age, but they are more common in older people. These difficulties can start because of normal aging, medications, dental problems, or medical treatments like surgery. They can also start because of health conditions like dementia, Multiple Sclerosis (MS), Parkinson’s disease, Cerebral Palsy and Amyotrophic Lateral Sclerosis (ALS).

Why is it important to manage chewing and swallowing difficulties?

Problems with chewing and swallowing (dysphagia) can increase the risk of food or other items getting stuck in the upper airway (causing choking) and/or entering the lungs (causing aspiration). A blockage of the airway can be life-threatening. Aspiration can cause people to wheeze, have trouble breathing, or have a hoarse voice after eating or drinking. It can also lead to pneumonia. Over time, chewing and swallowing difficulties can lead to malnutrition, dehydration, constipation or increased urinary tract infections from decreased food and fluid intake. They can affect a person’s quality of life and desire to eat.

Who helps manage chewing and swallowing difficulties in care facilities?

It is important for the entire health care team to be aware of, and help manage, any problems a person in care has when eating, drinking, or taking medication. The health care team may include a nurse, occupational therapist, dietitian, pharmacist, physician, speech-language pathologist, dentist, respiratory therapist, and support staff, such as care aides and food service staff. Family, volunteers, friends, and any other caregivers also contribute to the health and safety of people in care.

What is a care plan?

Care plans help to communicate the care needs of persons in care to the entire health care team. A care plan must be completed when a person is admitted to a facility and regularly reviewed afterwards. The health care team works together to develop the care plan to make sure that the person is safe and comfortable. Care plans include information about all health conditions.

As part of the care plan, the nutrition plan includes information related to chewing and swallowing, such as:

  • The type of diet or food texture (e.g. minced or pureed)
  • Thickness of liquids
  • Seating position
  • Adapted eating utensils
  • Oral care plans
  • Specific mealtime needs or supervision for safe eating

If a person is admitted with a special diet or meal plan, it should be followed until they are re-assessed by qualified members of the health care team. Over time, a person’s care plan may change with age, illness, or health condition. All care plans must be reviewed at least once each year.

What are some signs of difficulties chewing and swallowing?

A person in care could be at risk of choking or aspiration and may need to be seen by a member of the health care team if they:

  • Spit out food or pieces of food
  • Cough, choke or excessively drool
  • Pocket food in the cheek, under the tongue, or in the roof of the mouth
  • Say food "gets stuck" or "goes down the wrong way"
  • Have pain when swallowing
  • Clear their throat regularly
  • Refuse certain food(s), fluid(s) or medication(s)
  • Have lung congestion or a chronic respiratory infection
  • Eat very slowly (longer than 30 minutes) or leave meals uneaten
  • Force chewing or swallowing or swallow many times with 1 bite of food
  • Have teary eyes or a runny nose during or after swallowing
  • Have food or liquids coming out of their nose when trying to swallow

All members of the health care team, as well as family, friends and volunteers must be aware of the signs of choking. Signs of choking include:

  • Reddened face
  • Noisy breath
  • Weak or no cough
  • Loss of consciousness
  • Forceful coughing
  • Unable to speak
  • Grayish face or bluish skin
  • Hands clutched to throat and other signs of distress while eating, drinking, or taking medication

People may not always show signs of choking or aspiration when food or liquid enters the airway or lungs. This is called “silent aspiration.” Silent aspiration could lead to other health problems such as pneumonia. Signs of silent aspiration can include:

  • A wet or "gurgly" voice when eating or drinking
  • Increased chest congestion after meals

What can be done to reduce the risk of choking or aspiration?

To reduce the risk of choking or aspiration, all people who prepare and serve food must follow the person's care plan.

It is important to make sure that:

  • Food service staff are trained to make texture-modified foods (such as pureed, minced or bite-sized foods) and thickened fluids. The food texture, fluid consistency and serving method (small pieces, moist foods) must match what is written in the care plan
  • Care staff are trained in proper techniques for safe eating assistance
  • The facility’s Choking Response Protocol is followed at all times when serving food, drink or medications
  • A person’s adaptive eating aids (such as sippy cups, rim plates or built-up cutlery) are used for each meal or snack
  • Oral hygiene is done according to the care plan
  • Dentures are checked and fixed in place before meals
  • All meals are supervised. Eating alone can increase the risk of choking or aspiration
  • There are no distractions such as loud talking or TV during meals
  • People are awake and alert during meals
  • People are sitting appropriately while eating
  • People are reminded or prompted to swallow, slow down or to continue eating or drinking
  • People are not rushed or force fed
  • Chewing and swallowing difficulties are monitored and reported to the health care team

What must care facilities provide to reduce the risk of choking or aspiration?

People living in licensed B.C. care facilities must have immediate access to at least 1 employee who:

  • Has a valid first aid and CPR certificate
  • Is knowledgeable about each person in care’s medical conditions, including their risk of choking and aspiration
  • Is able to communicate with emergency workers
  • Can easily access first aid supplies, including times when care is provided off the care facility premises

For More Information

For more information on food and nutrition in care facilities with less than 24 people, see the Meals and More Manual at (PDF, 2.0 MB).

For more information on food and nutrition in care facilities with 25 or more people, see the Audits and More Manual at (PDF, 5.08 MB).

For information on first aid and CPR training, visit St John Ambulance at and Canadian Red Cross at

Is it an emergency?

If you or someone in your care has chest pains, difficulty breathing, or severe bleeding, it could be a life-threatening emergency. Call 9-1-1 or the local emergency number immediately.
If you are concerned about a possible poisoning or exposure to a toxic substance, call Poison Control now at 1-800-567-8911.

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