Managing Chewing and Swallowing Difficulties in Care Facilities
Difficulties with chewing and swallowing can occur in people of all ages, but are more common in older people. These difficulties can develop because of normal aging, medications, dental problems, and medical treatments like surgery and health conditions such as dementia, Multiple Sclerosis (MS), Parkinson’s disease, Cerebral Palsy and Amyotrophic Lateral Sclerosis (ALS).
Why is it important to manage chewing and swallowing difficulties?
For a person in care, problems with chewing and swallowing (dysphagia) can increase the risk of food or other items getting stuck in the upper airway (choking) and/or entering the lungs (aspiration).
These difficulties can lead to malnutrition and dehydration. They can also affect a person’s quality of life and social involvement.
Who helps manage chewing and swallowing difficulties?
It is important for the entire health care team, as well as family members, volunteers and friends to know how to manage chewing and swallowing difficulties. It is also important to know how caregivers contribute to the health and safety of people in care.
The health care team may include: a nurse, occupational therapist, dietitian, pharmacist, physician, speech-language pathologist, dentist, respiratory therapist as well as support staff such as care aides and food service staff.
To help manage chewing and swallowing difficulties, a care plan is created for all new residents who come to a care facility.
What is a care plan?
A care plan must be completed when a person is admitted to a facility. The care plan includes information about all health conditions that may affect chewing and swallowing. It also includes information about:
- the type of diet (or food) texture;
- thickness of liquids;
- seating position;
- adapted eating utensils;
- oral care plans; and
- 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.
The care plan is written to reflect a person’s care needs and reduce any risk of choking or aspiration. The care plan may include changes in food texture like softer foods or solids that are minced (finely chopped) or pureed, as well as thickened fluids. The health care team, the staff involved in preparing, serving and assisting with meals, and the person in care need to be a part of developing the care plan to make sure that the person is safe and comfortable.
A person’s care plan may change over time 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 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;
- are sleepy, tired or slump over at meals;
- 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 running nose during or after swallowing; and
- 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 or cough;
- 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.” Certain medical conditions may increase the chance of a person having 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 cut-up foods) and thickened fluids. The food texture, fluid consistency and serving method (small pieces, moist foods) must match with what is written in the care plan.
- All staff involved in preparing food and serving and assisting people with eating must have regular training in proper techniques for preparation and 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.
- There are no distractions such as loud talking or TV sounds during meals.
- People are awake and alert during meals.
- People are sitting properly in the chin-tuck position while eating.
- People are reminded or prompted to swallow, slow down or to continue eating or drinking.
- People are not rushed or force fed.
- Difficulties chewing and swallowing are monitored and reported to the 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; and
- can easily access first aid supplies, including times when care is provided off the community 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 www.health.gov.bc.ca/library/publications/year/2008/Meals_and_More_Manual.pdf (PDF 2.04MB).
For more information on 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 5.08MB).
For information on first aid and CPR training, visit St John Ambulance at sja.ca/English/courses-and-training/Pages/default.aspx and Canadian Red Cross at www.redcross.ca/training-and-certification.