Swallowing matters – a guide for care home staff on managing residents with eating and drinking difficulties

Read our guide below on how best to manage residents in care homes with eating and drinking difficulties.

You can also download a PDF version of this patient information by following the link on the right.

Key features of this guide

This includes:

• a flow chart to help decision making and provide guidance as to when assistance should be requested from speech and language therapy
• practical tools which can be photocopied. An electronic version can also be made available to each care home manager.
• an action plan to record outcomes for individual residents.

Frequently asked questions and concerns

Listed below are some topics which come up regularly when discussing concerns regarding residents. The answers may provide you with a solution or signpost you if SLT is not required at this time.

Q: What should you do if the resident is …?

• holding food in their mouth
• chewing food continuously 
• spitting food out 

A: These behaviours are most commonly associated with dementia. Modification of food and drinks will not necessarily resolve this issue.

You can use the ‘mealtime concerns in dementia’ checklist (see below). This helps you to identify some of the issues and suggests some advice to try and make life easier.

Q2. The resident has infrequent/inconsistent difficulties

A2. Please monitor using a ‘swallowing diary.’ (see below).

If your resident shows consistent difficulties for minimum of 3 days, not addressed by the ‘mealtime concerns in dementia’ advice, please refer to SLT.

Refer to the ‘swallowing assessment referral guidance’ flowchart (see above).

Q3. The resident is having difficulty swallowing their tablet medication

A3. Discuss medication with the practice pharmacist or GP. SLT can’t recommend changes in medication.

Q4. The resident isn’t eating/drinking enough and/or losing weight

A4. Encourage food fortification (offer high calorie snacks and fortified milkshakes). Monitor weight weekly. If you have concerns about decreasing weight over a 4 week period, refer to dietitians.

If the resident is eating/drinking small amounts but managing to swallow this safely, they won’t need a swallowing assessment.

If the resident isn’t eating/drinking enough due to suspected swallowing problems, refer to the ‘swallowing assessment referral guidance’ flowchart.

Q5. The resident is having difficulties chewing food

A5. Check there are no issues with oral hygiene or dentition. If the resident wears dentures, ensure the dentures fit and stay in place. A fixative can be useful.

It may be worth trying easy chew foods and avoiding high risk foods. Please refer to high risk foods information (see below).

Consider completing a ‘swallowing diary’ and refer to the ‘swallowing assessment referral guidance’ flowchart if needed.

Q6. The resident is falling asleep/drowsy when eating/drinking

A6. It’s safest to offer food and drink when residents are alert. If you have a resident that is drowsy often, choose the best times for them when they’re most alert. If they fall asleep during meal times please ensure no food remains in their mouth.

Consider the resident’s medical status and prognosis. Is the resident approaching end of life care? If you’re unsure, consider discussion with either the practice pharmacist in relation to the patient’s medication and/or discussion with their GP. Refer to ‘swallowing and end of life care’.

Q7. The resident is having difficulty drinking from a straw/spouted beaker

A7. Has a straw or adapted beaker been recommended by the SLT team? If so, contact the SLT department for assistance.

Otherwise, drinking from an open cup with assistance, is generally recommended. Use a wide or shallow cup or glass if possible. Try teaspoons of fluids if there are difficulties drinking from an open cup.

Monitor for further signs of swallowing difficulties. Consider using the ‘swallowing diary’ and refer to the ‘swallowing assessment referral guidance’ flowchart if needed.

Q8. The resident coughed with their lunch today

A8.  It may be worth keeping a ‘swallowing diary’ to see if this is a one off or if the resident is having more regular difficulties. If they’re having more regular episodes of coughing and/or choking, refer to the ‘swallowing assessment referral guidance’ flowchart as the resident may benefit from an assessment in this instance.

Q9. The resident is vomiting after meals

A9. Concerns about reflux or vomiting should be directed to the GP.

Q10. We have a resident who was seen in hospital in another health board who needs a review. Can you help?

A10. When residents are discharged from hospital they usually have details of their admission and recommendations on their discharge summary. This may include modification of food and drinks to help the resident to swallow safely.

If the resident is managing these recommendations, we don’t necessarily need to review them. If the SLT in the other health board feels they would benefit from review they will usually transfer the resident’s details to our service.

However, if you think your resident is not managing or would benefit from further advice, contact us to discuss.

Q11. Can we get further information on specific neurological conditions and swallowing?

A11. Most neurological conditions have charities which are a great source of information and advice. For example, Parkinson’s UK have an information sheet called ‘eating, swallowing and saliva control’ which may be helpful.

Q12. The resident is approaching end of life care

A12. Refer to the ‘swallowing and end of life care’ section below.

Q13. The resident wants to choose what they eat or drink – this may include food/drink which is outside of existing SLT recommendations

A13. If your resident has capacity to make an informed decision about their food/drink choices, document the discussions and their decision in the care plan. You don’t need to refer to speech and language therapy.

If you resident doesn’t have capacity, or you’re unsure if they have capacity, complete a capacity assessment. This would be a decision specific to eating and/or drinking.

If they’re deemed not to have capacity, a best interest decision would need to be made. This could involve family, advocate, GP or other relevant professionals. It may be appropriate to involve speech and language therapy. Call us on 01494 323440.

Q14. The resident is coughing outside of eating and drinking, for example, after mealtimes at night or on saliva.

A14. If your resident is coughing after meals, this may be indicative of reflux. Please speak to the GP about management.

If your resident coughs at night this is not for speech and language therapy to manage. Speak to the GP.

If your resident has difficulties managing their saliva, see below for advice.

Mealtime concerns in dementia – how to use

This tool has been designed to help guide you in supporting mealtimes for residents with dementia. It can help you recognise when a request for speech and language therapy (SLT) assistance may be appropriate.

People with dementia can have a variety of difficulties at mealtimes and these issues can change and evolve over time. Mealtime concerns in dementia can help you to identify a specific concern or concerns, and then select advice/strategies to try with the person with dementia. This can be developed into a personalised plan for all staff to work towards and can be included in the resident’s care plan.

Many issues can be resolved without assistance from your local SLT. However, some of the concerns may lead to an SLT request for assistance, and these are highlighted in red. If you have used mealtime concerns in dementia before contacting SLT, you may have essential information that could help the SLT in their assessment and when making recommendations.

As dementia is progressive in nature, mealtime concerns in dementia may also help you monitor for changes or deterioration in eating/drinking.

If you have any questions or wish to discuss anything further, contact your local SLT department.

Concern or issue	Advice or potential strategy
Eats too quickly	Prompt the resident to slow down
	Offer meals with a teaspoon rather than knife, fork, spoon
	Offer small portions at a time only
Prolonged chewing without swallowing	Make sure any dentures are in place and fit well
	Give verbal prompts to swallow, for example, “There’s food in your mouth, try to swallow”
	Give small amounts at a time and do not offer more food until the mouth is clear
	Make a note of problematic foods and consider avoiding
Spits out food	Try not to make a fuss and think about personal preference and taste
	Offer another part of the meal, or alternative food if possible

Avoid bitty foods or mixed textures (biscuits, soup with bits, food with skins)

Refuses to open mouth

Leave the resident initially – return in a few minutes

Place food on spoon or cup at lips for taste/texture stimulation

Leave finger foods within reach if the person is able to feed themselves

Give gentle encouragement/verbal description of the food/drink, for example, ‘I’m going to gve you some carrots now/I’m going to give you a sip of your tea.’

Reduced chewing before swallowing

Give verbal prompts to keep chewing for example, ‘Keep chewing that biscuit’

Make a note of problematic foods and look out for a pattern with textures

Contact SLT if there are concerns about choking or a pattern emerges

Holds food in mouth

Encourage self feeding where possible. This may require some direct assistance initially

Give verbal prompts to chew and swallow, for example, “You have food in your mouth, keep chewing and try and swallow it.”

Alternate food and fluids throughout the meal but avoid eating and drinking at the same time

Check that the mouth is clear between each mouthful. Do not offer more until the mouth is clear

Give gentle encouragement/verbal description of the food/drink, for example, ‘I’m going to gve you some carrots now/I’m going to give you a sip of your tea.’

Try placing an empty spoon against the lips. This can be a reminder that there is food in the mouth

Coughing or choking on food at mealtimes

Monitor for patterns with specific foods or difficulties happening more often

Are there any other signs of aspiration – recurrent chest infections, weight loss

Do not thicken fluids unless recommended by SLT

Contact SLT if difficulties are happening frequently and/or other signs of aspiration are present

Outcome

What strategies did you trial and if successful, request for assistance from SLT).

For a downloadable and printable version of the checklist above, follow the link to download the pdf on the right.

Swallowing diary

Monitor swallowing difficulties by recording them using the following information.

• date
• time
• what was the difficulty with? (drink/type of food)
• what happened? (for example, coughed/ choked/had to clear throat/had to take a drink)
• how were they feeling? (for example, tired/unwell/needed medication)
• position (standing/sitting/lying in bed/other)
• equipment used/trialled, for example, straw, adapted beaker.

Outcome

For example, note patterns when tired, only odd occasions, request for assistance from SLT.

You can download and print a table version to use as a swallowing diary by following the link to the pdf on the right.

Swallowing and end of life care

Swallowing deterioration can be part of the normal dying process. The focus of care at this time should be comfort, and it’s important that we follow any eating and drinking wishes that the resident or their family may have expressed.

A direct SLT assessment is not usually the most appropriate management for someone at the end of their life. Supporting residents to be comfortable, and take small amounts of food and fluids as they are able and want to, should be the priority. This can be documented in the Action Plan or in their care plan as required.

The following advice may help you support residents at this time

Q1. You’re not sure if the resident is nearing end of life

A1. Contact the GP to discuss the resident’s condition.

Q2. The resident is in the last days of their life

A2. Discuss eating and drinking with acknowledged risks guideline with the GP. See page 16 of the pdf document (appendix 1, section B). Refer to mouth care matters (see references, page 26).

Q3. The resident is looking for oral intake

A3. Support residents to take small amounts of food and fluids as they are able and want to, where appropriate.

Q4 The resident is coughing or spluttering when eating and drinking

A4. Oral intake should be offered as the person wishes, taking their own comfort into account. Discuss Eating and Drinking with Acknowledged Risks Guideline, with the GP.

Q5. The resident is coughing during oral intake and is distressed

A5. Make sure the resident is sufficiently alert for oral intake. Try to make sure the resident is sitting as upright as they are able and offer small amounts at a time. Trying a teaspoon can be helpful. Stop and try again later as there can be variability in the swallow.

Q6. Staff and/or family are distressed by coughing during oral intake

A6. If the resident isn’t distressed, offer oral intake as they wish. Remember that swallowing deterioration can be part of the normal dying process. The focus of care at the end of life is comfort for the individual. Often talking with families and educating staff about what’s happening can support them during this time.

Q7. The resident is drowsy or has reduced consciousness

A7. This can be normal as someone is nearing the end of their life. Only offer oral intake when the resident is sufficiently alert. Try at regular intervals throughout the day as alertness may be variable.

Q8. The resident isn’t eating or is eating less

A8. A reduced need for food is part of the normal dying process. Try offering preferred flavours. Offer oral intake as the resident wishes.

Q9. The resident has a dry mouth

A9. Regular mouth care is important, particularly in the last few days of life. Refer to mouth care matters (see page 25 of the pdf document on the right)

Contact your local SLT department if you would like any further advice or assistance.

 

 

 

 

 

 

 

 

 

Dysphagia diet descriptors: food

IDDSI Level 7 Regular Foods	Normal everyday foods Variety of textures Biting and chewing required	Includes all food types
IDDSI Level 7 Regular Easy to Chew Foods	Normal everyday foods which are soft or tender Biting and chewing required	Avoid high risk foods
IDDSI Level 6 Soft and Bite Sized Foods	Soft, tender & moist throughout Bite sized (no bigger than 5cm) Can be mashed down with the pressure of a fork, spoon or chopstick No thin liquid leaking or dripping from the food Chewing required	Biting not required Avoid high risk foods Avoid bread unless recommended by SLT
IDDSI Level 5 Minced and Moist Foods	Very soft Small moist lumps (no bigger than 4mm) Lumps should be easy to squash with the tongue Can be eaten with a fork or spoon Can be scooped and shaped on the plate/holds its shape on a spoon and slides off when the spoon is tilted leaving very little residue May be served with thick, smooth gravy/sauce Minimal chewing required	Avoid high risk foods Avoid foods that require biting or any significant chewing No separate thin liquid (liquid can be drained)
IDDSI Level 4 Pureed Foods	Smooth No lumps Pureed and sieved to remove small bits Not sticky Usually eaten with a spoon, a fork is possible Can be piped, layered or moulded Falls off the spoon in a single spoonful when tilted and continues to hold shape on a plate No chewing required A thickener may be added to maintain stability	Avoid textured food Not sticky No lumps (puree or sieve as required to remove small bits) Liquid must not separate from solid Cannot be drunk from a cup Cannot be sucked through a straw Can’t be poured
IDDSI Level 3 Liquidised Foods	Smooth texture with no bits Can be eaten with a spoon Can be drunk from a cup Effort needed to drink it through a straw No chewing required	Cannot be eaten with a fork because it slowly drips through the prongs Cannot be piped, layered or moulded on a plate No mixed textures

Dysphagia Diet Descriptors: Drinks

IDDSI Level 0 Normal Thin Drinks	Thin Flows like water Flows easily through a straw	No thickener Examples include water, diluting juice, tea/coffee with no milk
IDDSI Level 1 Slightly Thick Drinks	Thicker than water A little more effort required to drink than thin liquid Flows through a straw	Examples include full fat milk, thin smoothies, thick fruit juice Thickener may be required for some drinks to achieve this consistency
IDDSI Level 2 Mildly Thick Drinks	Flows off a spoon Can sip from a cup Pours directly from a spoon but slower than thin drinks Effort is required to drink this thickness through a standard straw	Thickener may have to be added to achieve this consistency Some drinks may not need thickener for example, thicker smoothie
IDDSI Level 3 Moderately Thick Drinks	Easily pours from a spoon when tilted, does not stick to spoon Can be taken from a spoon Can be drunk from a cup Some effort is required to suck through a standard straw	Thickener will need to be added to achieve this consistency Cannot be taken with a fork because it drips through the prongs No bits
IDDSI Level 4 Extremely Thick Drinks	Usually eaten with a spoon Shows some very small movement under gravity, but can’t be poured A spoonful must plop off the spoon if the spoon is tilted or turned sideways: a very gentle flick may be needed to dislodge from the spoon	Thickener required Cannot be sucked through a straw Can’t be drunk from a cup

Food and drinks guide based on the IDDSI framework and descriptors 

Handy hints

You could:

• use a fork or shaker to thicken
• add more fluid if the drink becomes over thick

Access advice sheets and audit forms for catering staff 

High risk foods

The following foods may be more difficult to chew and swallow. These may stick in the throat or ‘go down the wrong way’. It can be beneficial to be more cautious with these foods or avoid them if they are particularly difficult.

Mixed consistencies

These include:

• mince with thin gravy
• runny porridge with milk
• orange/grapefruit segments
• dunked biscuits
• cereals which do not blend with milk (for example, muesli)
• soup with lumpy vegetables.

Dry, crunchy, or crumbly foods

These include:

• biscuits
• crisps
• toast
• pastry
• rice
• crackers
• nuts
• popcorn
• cornflakes
• raw vegetables (for example carrot, cauliflower, broccoli)
• dry cakes
• bread
• dry cereal
• pie crusts
• crumble.

Fruit and vegetables with a husk or skin

These include:

• beans
• peas
• grapes
• apples
• sweetcorn
• tomatoes
• rhubarb
• white of an orange.

Pips or seeds

These include:

• apple seeds
• pumpkin seeds

Very chewy foods

These include:

• meat
• fresh fruit
• boiled sweets
• toffee
• crispy vegetables, especially if raw
• crackling
• crispy bacon
• lollies/sweets/toffees
• cheese chunks
• marshmallows
• chewing gum
• sticky mashed potatoes
• dried fruit
• sticky foods

Bone or gristle

This includes:

• chicken bones
• fish bones
• other bones
• meat with gristle.

Sticky or gummy food

These include:

• edible gelatine
• cognac containing jelly
• sticky rice cakes.

If the resident is having difficulty eating or drinking and you’d like further advice, contact Speech and Language Therapy.

For a downloadable action plan, see the pdf on the right (page 21).

Dementia and swallowing

This page gives about swallowing difficulties that can be associated with dementia. It offers practical advice and suggestions that may help support eating and drinking.

The guide gives general advice only. For specific advice or to discuss any concerns you may have, contact Speech and Language Therapy.

Swallowing difficulties

Eating and drinking are an integral part of our daily life. We often take for granted how automatic this process is. Dementia can interfere with the processes involved in making eating, drinking and swallowing a safe and enjoyable experience.

Mealtimes can become more challenging and it may be hard to work out what is happening and why. This may be particularly difficult if the person also has communication difficulties, as they may be unable to explain what they are experiencing.

It’s good to identify factors which are likely to lead to problems and adapt before complications develop.

Everyone has different experiences in their journey with dementia. However there are often similarities in the problems encountered.

These might include:

• distraction
• not recognising food or drink
• holding food in the mouth
• not opening the mouth
• refusing food or drink
• difficulties with chewing
• coughing and choking when eating and drinking.

There are many practical hints and tips to try and make mealtimes enjoyable. The following information will include advice on:

• preparing for mealtimes
• the environment
• how to identify swallowing problems
• assisting at mealtimes.

Preparing for mealtimes

You should:

• reduce distractions – turn the TV/Radio off, reduce clutter in the surrounding area
• make sure the person doesn’t need the toilet and that they are comfortable
• make sure any pain is addressed well in advance of the mealtime
• ensure the person is wearing their glasses, hearing aid or dentures if required. Sight, smell, hearing and taste have a huge role in stimulating the appetite and the swallowing reflex
• be aware of the effect of medication on eating and drinking and plan medication accordingly
• ensure good mouth care to increase comfort and decrease any pain or discomfort. This can reduce chest infections in the case of people with swallowing problems.

The environment

You should:

• ensure the person is in a good position. For swallowing, the best position is sitting upright
• only put out the essentials, if having soup you only need to put out a spoon;
• if crockery is a different colour from the table or tablecloth it can increase awareness of the crockery
• ensure there’s adequate lighting
• make food look and smell appealing. Use different colours, textures and smells. The aroma of cooking can stimulate someone’s appetite
• explain what the food is and encourage small amounts regularly
• finger foods can be easier for people who are easily distracted or who prefer to be on the move
• make sure the temperature of the food is right as people with dementia can lose the ability to judge the temperature
• provide fluids regularly. The sensation of thirst can change, so people sometimes benefit from encouragement
• use a clear glass so the person can see what’s inside, or a brightly coloured cup to draw attention to it.

Identifying swallowing problems

People with dementia can develop swallowing difficulties and there may be a risk of food or drink going down the wrong way. It’s important that people with dementia and those around them look out for the warning signs.

Everybody coughs on their food occasionally, but if this is happening regularly contact your local SLT service to discuss this further. If you’re concerned get medical advice.

Signs of swallowing difficulties include:

• coughing or choking
• a gurgly or moist sounding voice during or after eating/drinking
• a change in breathing rate after eating/drinking
• throat clearing
• pocketing food in mouth
• reduced chewing, particularly with textured foods. If this is noted the person may benefit from eating softer foods.

Other signs of swallowing difficulties can include:

• recurrent chest infections
• dehydration
• weight loss
• not coping with saliva/secretions.

It may be helpful for you to keep a diary of any swallowing difficulties.

Assisting at mealtimes

You should:

• encourage independence as much as possible
• try and position yourself at eye level as much as possible
• make sure you are in a comfortable position so the mealtime is relaxed
• tell the person what you are giving them
• try not to talk to anybody else whilst giving the person their food as it can be distracting
• ensure the person is being given the appropriate consistencies of food/drink if they require modifications
• allow plenty of time to give the person their food. Do not rush
• ensure they have swallowed before giving them the next mouthful
• offer sips of fluid throughout the meal but avoid eating and drinking at the same time
• consider what may be useful. This could be a teaspoon for someone who overfills their mouth, a smaller plate for someone who doesn’t enjoy a larger portion, or their favourite cup
• a verbal prompt to swallow may be helpful
• softer foods may be easier for some people to manage
• dry, crumbly foods can be more difficult to manage.

Examples of some foods that are more difficult to chew and swallow include:

• mixed consistencies – mince with thin gravy, runny porridge with milk
• dry or crumbly foods – biscuits, crackers, toast
• very chewy foods – meat, toffee
• fruit/vegetables with a husk or skin – beans, peas, apples.

Saliva management advice

Some people, particularly those who have a neurological condition such as Parkinson’s or stroke, may have trouble managing their saliva. This may result in saliva escaping from the mouth, excess saliva within the mouth, and/or saliva pooling in the throat.

These problems can sometimes be improved by one, or a combination, of the following approaches:

Dry swallow

Encourage a dry swallow before eating/drinking.

Head/body positioning

Whenever possible the head should be maintained in a central position, and should not be allowed to fall forward or to the side.

Medication

Medication may be prescribed to dry out saliva. Information can be obtained from your GP as to whether this is an appropriate option and which medication is suitable.  There are often side effects from taking these medications.

Steam inhalation

Carry out steam inhalation twice a day for 15 minutes as this will help to reduce thick mucus and phlegm.

Natural products

Drink papaya, pineapple or other citrus drinks before a meal to help break down phlegm and mucus.

General information

Some products, particularly dairy products such as milk, may thicken the saliva and make it harder to swallow. It may be advisable to avoid these whilst you’re experiencing difficulty.

Eating and drinking will stimulate saliva production. Some foods, such as very sweet or very sour foods, may increase the amount of saliva.

Maintaining good oral hygiene is very important for people who are having difficulty managing their saliva and/or difficulty swallowing.

To help to prevent soreness developing around the mouth it is advisable to ‘dab’ rather than wipe the saliva away. Wiping can also stimulate the production of more saliva.

It’s also a good idea to dab the area with vaseline or a barrier cream (such as lip balms).

Speech and language therapy referral criteria

Inclusion criteria

Referral to Speech and Language Therapy is appropriate when clients:

• have difficulty swallowing food/ drink or saliva
• coughs/chokes when eating or drinking
• have repeated chest infections
• deteriorate suddenly or have sudden onset of swallowing difficulty
• area already on a modified diet due to swallowing difficulties but there’s been a change in swallowing function.
• have difficulty communicating as a result of a neurological condition.

Client / carers need advice on alternative communication systems, for example, communication aids.

Exclusion criteria

Referral to Speech and Language Therapy can happen when a client:

• has difficulties chewing food due to poor dentition but no other swallowing difficulty
• holds food in their mouth due to cognitive changes but no other swallowing difficulty
• is declining
• won’t eat or drink.
• has problems swallowing tablets but no other swallowing difficulty
• is too drowsy to manage sufficient oral intake
• has a small appetite
• has lost weight with no apparent swallowing difficulties
• has vomiting or gastro-oesophageal problems only, including crico-pharyngeal spasm
• is feeding ‘at risk’, this has been documented and there have been no changes since documentation.

Referral can also happen when a GP considers a client is in the last few days of life.

References and resources

International Dysphagia Diet Standardisation Initiative Framework (IDDSI) 2019

Management of patients with stroke: identification and management of dysphagia (SIGN Guidelines, 2010)

Parkinsons UK, Eating, Swallowing & Saliva Control Information Leaflet (2018)

Resuscitation guidelines (Resuscitation Council UK, 2021

Guidance on the management of dysphagia in RCSLT/care homes

Motor Neurone Association

Stroke Association – swallowing problems

MS Society – managing MS swallowing difficulties

Mouthcare matters

Mental capacity

Nestle NT Hub – Training videos/webinars/information

Dementia UK

Alzheimer’s Society

Eating and drinking with acknowledged risks

Local hospital speech and language therapy contacts

Amersham Hospital

01494 323440

Wexham Park

0300 615 4619

Oxford

01865 743133

Milton Keynes

01908 725292

 

About this guide

Swallowing Matters was developed by the NHS Lanarkshire Speech & Language Therapy (SLT) Adult Service in consultation with care home staff in both North and South Lanarkshire and the first version was published in 2018. The SLT Team have agreed we can use this resource in Buckinghamshire.

This resource assists care home staff to identify how best to manage residents with eating and drinking difficulties.

Heather Edwards AHP Consultant at the Care Inspectorate welcomes this revised version of Swallowing Matters,

“Swallowing Matters is an excellent resource for social care staff, giving practical guidance that can be used in everyday situations to ensure that people experiencing care have positive mealtime experiences”.