Eating, 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 eating, chewing and swallowing difficulties?

Problems with eating, chewing and swallowing (dysphagia) can increase the risk of food or other items getting stuck in the upper airway (causing choking) 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, eating, chewing and swallowing difficulties can lead to malnutrition, dehydration and constipation. They can also affect a person’s quality of life and desire to eat.

Who helps manage eating, chewing and swallowing difficulties in care facilities?

It's important for the entire health care team to be aware of any problems a person in care has when eating, drinking or taking medication. They must be able to help manage the problems.

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 persons 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 health practitioner will complete a care plan when a person is admitted. They will review it regularly afterwards. The health care team works together to develop the care plan to make sure that the person in care is safe and comfortable. Care plans include information about all health conditions.

The nutrition care plan is part of the overall care plan. It includes information related to eating, chewing and swallowing. Chewing and swallowing information includes:

• The type of diet or texture-modified food
• Thickness of liquids
• Seating position
• Adapted eating aids and utensils
• Oral care plans
• Specific mealtime needs, strategies or supervision required for safe eating

Care plans change with age, illness, or when there is an improvement or worsening of a person in care’s health condition. All care plans must be reviewed at least once each year.

What are some signs of difficulties chewing and swallowing?

A member of the health care team may need to see the person in care 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 foods, fluids or medications
• Have lung congestion or a chronic respiratory infection
• Eat very slowly (longer than 30 minutes) or leave meals uneaten
• Avoid or change certain foods to make swallowing easier
• Experience a change in the sound of their speech, such as a gurgly or wet-sounding voice after swallowing
• Force chewing or swallowing, or swallow many times with one 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
• Have recurrent pneumonia
• Do not want to eat in front of other people
• Have lost weight

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

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

People may not always show signs of choking or aspiration when food or liquid enters the airway or lungs. We call this silent aspiration. Silent aspiration could lead to other health problems such as pneumonia. Signs include:

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

What to do to reduce the risk of choking or aspiration?

It is important to make sure that:

• Care staff who prepare and serve food follow the person's care plan
• Oral hygiene is done according to the care plan
• Food service staff have training to make soft or texture-modified foods. Examples include pureed, minced, and moist or soft, bite-sized foods, and thickened fluids. The food texture, fluid thickness and serving method must match the care plan
• Care staff have training in proper techniques to support safe eating and assisting with eating (such as hand-under-hand assisting)
• The facility’s choking response protocol is followed at all times when serving food, beverages or medications
• A person’s adaptive eating aids (such as two-handed cups with lids, rim plates or built-up cutlery) and utensils are used for each meal or snack
• Dentures are checked and fixed in place before meals
• Meals are supervised for someone with a risk of choking
• There are no distractions, such as loud talking or TV during meals
• People are awake and alert during meals
• People are sitting up straight while eating
• People are prompted and reminded to swallow, slow down, or continue eating or drinking
• People are not rushed or force fed
• Eating, 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 one 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 when care is provided off the care facility premises

For more information

• Food and nutrition in care facilities with less than 24 people, see the Meals and More 
  Manual at www.health.gov.bc.ca/library/publications/year/2008/Meals_and_More_Manual.pdf (PDF, 2 MB)
• Food and nutrition in care facilities with 25 or more people, see the Audits and More Manual at www.health.gov.bc.ca/library/publications/year/2008/Audits_and_More_Manual.pdf (PDF, 5.1 MB)
• Best Practices for Nutrition, Food service and Dining in Long Term Care Homes at www.dietitians.ca/DietitiansOfCanada/media/Documents/Resources/2019-Best-Practices-for-Nutrition,-Food-Service-and-Dining-in-Long-Term-Care-LTC-Homes.pdf (PDF, 4.4 MB)
• Standard names and definitions for texture modified foods and thickened liquids, see the International Dysphagia Diet Standardisation Initiative (IDDSI) at www.iddsi.org
• First aid and CPR training, visit St. John Ambulance at https://sja.ca/en/first-aid-training and Canadian Red Cross at www.redcross.ca/training-and-certification