Feeding, 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 feeding, chewing and swallowing difficulties?

Problems with feeding, 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, feeding, chewing and swallowing difficulties can lead to malnutrition, dehydration and constipation. They can affect a person’s quality of life and desire to eat.

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

It is 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 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. Your health practitioner will complete your careplan when they admit you. They will review it regularly 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.

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

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

If you have a special diet or meal plan during care admission, follow the care plan until qualified members of the health care team re-assess you. Over time, your 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. A member of the health care team may need to see them 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:

• 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
• Grayish 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 of silent aspiration can 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?

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 have training to make soft or texture-modified foods. Examples include pureed, minced and moist or soft and bite-sized foods) and thickened fluids. The food texture, fluid consistency and serving method must match the care plan
• Care staff have training in proper techniques for safe eating and helping with feeding
• Follow the facility’s Choking Response Protocol at all times when serving food, drink or medications
• Use a person’s adaptive eating and feeding aids and utensils (such as sippy cups, rim plates or built-up cutlery) for each meal or snack
• Practice oral hygiene according to the care plan
• Check dentures and fix them in place before meals
• Supervise meals. 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
• Remind or prompt people to swallow, slow down or to continue eating or drinking
• People are not rushed or force fed
• Monitor and report feeding, chewing and swallowing difficulties 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 when care is provided off the care facility premises

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).

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).

Standard names and definitions for texture modified foods and thickened liquids, see the International Dysphagia Diet Standardisation Initiative (IDDSI) at: https://iddsi.org/.

First aid and CPR training, visit St John Ambulance at: www.sja.ca/en/first-aid-training?CookieCheck=cookieVerification&Redirect=https%3A//www.sja.ca/English/courses-and-training/Pages/default.aspx and Canadian Red Cross at: www.redcross.ca/training-and-certification.