Mouth holding/spitting out/stopped eating

Q) What are clinical indicators that someone may be aspirating?

A) Refer to Dysphagia (Swallowing Difficulties) Factsheet

Q) What is the SLT role?

A) To carry out a detailed assessment identifying specific level of impairment and to provide a specialist care plan

Assisting with differential medical diagnosis

Detecting, reducing and preventing aspiration

Carrying out intervention and stimulating improved swallow with appropriate exercises and techniques

Assess and refer if appropriate for instrumental investigations

Q) What is the difference between coughing and choking?

A) Choking – this is when the airway becomes blocked and breathing stops or exhibits stridor. This requires intervention from someone else e.g. back slaps and abdominal thrusts, because the individual is unable to cough. Refer to Choking Factsheet.

Coughing – this is a reflexive response when food or drink tries to penetrate the airway. It is not life- threatening at the time. However, if observed to happen regularly when eating and drinking, it may indicate an aspiration risk. Coughing may also occur when the airway is irritated by small particles, strong tastes, mucus and infection. Some people have “habitual coughing” which also occurs when they are not eating or drinking.

Q) What is thickener used for?

A) A key element in reducing the risk of choking and aspiration when drinking is to modify the texture of the fluid consumed by people with dysphagia. Thickened fluids are easier to swallow as they enter the pharynx slowly, allowing time for the pathway to the lungs to be closed off to avoid aspiration and choking.

Q) Our resident is coughing when drinking normal fluids. Can we try them with thickened fluids? Do we still need to refer to SLT for an assessment if they are managing well on the thickened fluids?

A) Refer to Safer Swallowing for Fluids. You can try them on Slightly Thick IDDSI Level 1 fluid and/ or Mildly Thick IDDSI Level 2 fluid to reduce the risk of aspiration. Ensure you document all trials. Then refer to SLT.

Q) Our resident is on thickened fluids but is now coughing on the recommended Level.  Can I increase the level?

A) Yes, as you are taking proactive steps to reduce your residents risk of aspiration eg if on Level 1 move on to Level 2.  Ensure all trials are supervised and documented.  You may find that your resident can return to the previous level if they improve medically.  They may also benefit from being managed on both Levels dependent on factors such as alertness, fatigue, positioning and mood.

Q) Our resident is on modified diet and managing well, can I increase the texture?

A) Check previous SLT reports for mention of silent aspiration or poor cough reflex. If there are none, and no new clinical signs they are an aspiration or a choking risk, you can upgrade their diet. However, you can only upgrade one level at a time. Ensure that trials are supervised and not one- off observations. These trials need to be documented. If you note any medical changes or difficulties such as reduced oral intake, return to their previous consistency. To upgrade:

Q) Our resident is holding food in the mouth/ taking a long time to chew/ spitting out their food/ drink. Do I need to refer to SLT?

A) No, refer to the Referral Flow Chart. Follow the ‘Advice for Managing Challenging Eating and Drinking Behaviour’ and ‘Feeding Safely Routines’ advice sheets. If suggested modifications are not successful, complete the Managing Dysphagia checklist.

Q) If we have made diet modifications to make their swallowing easier and our resident is managing well e.g. moved from IDDSI Level 5 to IDDSI Level 4 diet, do I need to get SLT to confirm what I have done?

A) No – just make sure you clearly document what you have done and why. If the reason for the diet changes was a temporary medical deterioration e.g. UTI, and not general decline, and they have now recovered, trial them on their previous consistency. You do not want to keep them on a less textured diet unnecessarily.

Q) CQC requirements?

A) Refer to ‘CQC and Speech and Language Therapy’ statement in folder.

Q) What qualifies as recurrent chest infections?

A) Three or more chest infections within a year, which may or may not require antibiotics.

If your resident is having recurrent chest infections that are not related to colds and longstanding respiratory issues e.g. COPD/ asthma, this may suggest they are aspirating.

Q) Our resident keeps saying it hurts when they swallow or it feels like food is getting stuck. What should we do?

A) Review the ‘Managing Reflux and Oesophageal Dysmotility’ advice sheet and follow recommendations.

Check for oral thrush, dental decay and/ or other medical conditions – refer the individual to GP if issues are found. If no reason is found, and dietary modification does not help, refer to SLT to rule out oropharyngeal dysphagia.

Q) Our resident is having difficulty or refusing to take their medication.  Should I refer?

A) No. Queries regarding medications should be raised with the pharmacist or the resident’s GP.  A review may reduce the number of tablets required and/or consider giving them in a soluble or liquid form.   If your resident is on thickened fluids ensure that tablets are given with thickened fluids, one tablet at a time and ensure they are in an appropriate upright position.

Q) Can we give medication within a carrier such as smooth yoghurt? Is it being covert?

A) Queries regarding medications should be raised with the pharmacist or the resident’s GP. When appropriate, medication can be given within a semi- solid carrier if there is no drug: food interaction. You must inform the resident. If they do not have capacity this becomes a best interest decision which should be made and documented as per your local policy.

Q) Should I refer to SLT regarding issues such as positioning, utensils, alertness etc.?

A) As your first step refer to the Feeding Safely Routines Fact Sheet to help manage these issues. Ensure you document what modifications you have made and why. If suggested modifications are not successful, or if your resident also presents with clinical signs of dysphagia, complete the Managing Dysphagia checklist then refer for a specialist Speech and Language Therapy assessment if necessary.

Q) We are aware of the SLT swallow recommendations for our resident and we are following them but the resident’s family want to bring in or give our resident non recommended items. What should we do?

A) You need to ascertain and document whether your resident has capacity to make a decision to eat and drink against SLT recommendations.

If the resident does have capacity then it is his/her right to choose to eat and drink what he/she chooses, with an understanding of the risks involved.  This discussion needs to be clearly documented and the manager/senior nursing staff should be involved in the discussion.

If the resident does not have capacity to choose to eat and drink at risk then a best interests decision should be made, with senior staff, family and GP as appropriate. The decision should be clearly documented.

Q) Our resident is ‘eating and drinking with acknowledged risk’ What does this mean?

A) This means that despite the fact the resident is on the safest consistencies possible, with strategies in place to manage the risk, there remains a risk of aspiration and/or choking, which is unlikely to change. Advanced care planning should be in place regarding whether the resident should be treated and/or admitted to hospital for a chest infection or other complications ensuing from aspiration. This should be discussed with the resident, GP, family and care staff as appropriate.

The resident may also choose to eat and drink ‘at risk’ against SLT recommendations if he/she can demonstrate capacity to make and communicate this decision. This should be fully discussed and documented, as above.

Please download and use this checklist. 

All health care professionals need to be able to identify dysphagia, to manage coughing and choking (including using first aid for choking) and in the principles of good practice relating to ‘Feeding Safely Routines’.

It is up to you to consider all these routines when managing a resident’s eating and drinking.  Often all it may take is a few adjustments using these strategies to reduce the risk of coughing and/or choking.

Level of alertness – no-one should be given food or drink if not fully alert. 

Distractions – reduce distractions when eating and drinking.

If your resident is easily distracted, consider moving them to a quiet place during mealtimes, reducing background noise and reducing chat.

Re-focus them to eating and doing if they become distracted.

Time – do not rush mealtimes.

Ensure adequate time to support the individual to eat and drink. If they take a long time to eat consider using insulated containers to maintain the temperature of food/ drinks.

Positioning – sit people fully upright (90^o, with head in neutral position) for all snacks, meals and drinks.

If in bed, raise the bed head and use pillows to support an upright position.

People should remain upright for at least 30mins after a meal to avoid reflux.

Oral Hygiene and pneumonia – dental plaque contains many different species of bacteria, some of which can cause pneumonia. People with eating and drinking difficulties may aspirate their oral and throat secretions and excellent oral hygiene will aid in reducing the risk of chest infections and pneumonia. Ensure the mouth is clean and free from residue at the end of the meal. Mouth care should be given at least twice per day.

Position yourself – sit at eye level and facing the person you are assisting.

Utensils – consider if the utensils you are using are appropriate.

Try different sized and adapted cutlery to see what is managed more easily.

Try short, wide- rimmed normal cups/ glasses first as these are more familiar than beakers with spouts.

Straws should not be automatically given. They should only be used if they have been recommended or if there is evidence there is a real need.

Dentition – dentures, if worn, should fit well. If people have limited dentition softer foods may be indicated.

Glasses and hearing aids – should be worn when eating and drinking.

Ensure that you use verbal prompts to inform them food/ drink is about to be presented.

Modifying Diet – ensure the most appropriate diet consistency is being offered e.g. limited dentition - softer foods; spitting out lumps – smoother textures; oesophageal difficulties - soft moist diet.

If modified diet has been recommended by a Speech and Language Therapist, ensure this is being followed.

Food should be visually appetising and smell appealing to stimulate the appetite.

Independence – individuals should be encouraged to feed themselves.

Don’t assume they require full assistance; they may be able to manage a handled beaker for drinks but not a spoon/ fork or may benefit from hand over hand support or verbal prompts.

Size of mouthful – trial different sized mouthfuls.

It should be sufficient to stimulate chewing and swallowing and avoid over- large mouthfuls.

People feeding themselves may require prompting not too overload their mouths and clear each mouthful before taking the next.

Portion Size – people who are frail or fatigue easily should be given smaller portions. If having small portions, they should be given foods and drinks more frequently to ensure adequate nutrition and hydration.

Documentation – Food and drink charts and should be kept and weights should be recorded. 

Advice on adequate nutrition and hydration can be sought from a dietician.

Reference –

RCSLT Guidance on the Management of Dysphagia in Care Homes ¹ (March, 2018)

(- ¹ care homes refers to both nursing and residential homes) 

The following must be considered if you observe difficulties swallowing fluids and prior to introducing fluid thickeners or increasing the level of thickness already in use. All residents who are started on fluid thickener or whose thickener level is changed by the care home must be assessed by an appropriately trained dysphagia professional. There is some evidence that permanent modification of viscosity of fluids has its own risks and should be avoided unless absolutely necessary for safety.

Cups, glasses, beakers, medicine cups

What kind of cup/ beaker/ glass are they using?

Tall, thin glasses and spouted beakers may cause the person to tilt their head back and lead to fluid flowing into the throat before they are ready to swallow.

Options:

• Try a short, wide-rimmed cup/ glass/ plastic glass
• Try a specialist cup
• Give liquid medications via spoon

Straws

Straws can make swallowing more difficult and should be used with caution. People are often given straws to reduce spilling. Straws require strength to suck the fluids which can be difficult for some people.

Straws change the pressures in the mouth and disrupt normal swallowing. People often take multiple sips at once via straw which overload the mouth and throat, causing coughing.

Options:

• Avoid straws

Resident’s position

Ensure resident is positioned upright, ideally at 90^o, with head in neutral position/ with the chin slightly down towards the chest for all drinks. If in bed, raise the bed head and use pillows to support the whole body as necessary.

Options:

• Seek advice from Physiotherapy or Occupational Therapy regarding positioning if necessary

Helper’s position

A significant number of care home residents are fed with the helper to the side or standing. This is known to increase the risk of aspiration pneumonia. If safe to do so, helper should be seated in front of the resident, at eye- level or below. Helper safety should be considered if the resident is known to be aggressive.

Self-feeding

If the resident has difficulty controlling the speed and volume of the fluid taken per mouthful, supervision and support should be given. Fluids should not be thickened for convenience because supervision is not available.

Speed and amount taken per sip

Encourage the resident to fully swallow one sip before taking the next. Coughing on fluids often occurs because the person takes too much too quickly. For most people, taking fluid one sip at a time is safer than continuous sipping or gulping.

Taste preferences

Ensure the fluids given are as per their personal tastes.

Fluid diaries

If you doubt that your resident is taking enough fluid, keep a fluid diary. This information will also be helpful to SLT if you decide to refer for dysphagia assessment.

Time of day: fatigue

You may identify that your resident has difficulty at certain times of day, e.g. in the afternoon or evening when they are fatigued.

Options:

• Consider extra supervision at these times
• Consider little and often, rather than trying to encourage large volumes of fluid to be taken when someone is tired

Cognition and alertness

It is dangerous for someone to take fluids or food when drowsy or distracted.

Glasses and hearing aids

These should be worn when eating and drinking.

General advice

• Reduce environmental distractions
• Create a calm environment e.g. calm background music
• Ensure resident is alert and sitting upright before eating and drinking
• Promote independence as much as possible, if resident finds cutlery difficult try finger foods or ‘hand over hand’ feeding
• Review Feeding Safely Routines factsheet
• Take to toilet before meal
• If resident is taking a long time at mealtimes, eating small amounts or fatiguing, try smaller meals little and often/ regular snacks between meals and/or consider food fortification
• Be aware that tastes can change with the dementia process and residents may prefer sweeter foods and/ or stronger flavours than they previously did
• Consider visual/ sensory needs, do they have their glasses/ hearing aids and are they the right ones/ working/ switched on/ clean; if they have a visual neglect or hemianopia, sit on their good side and move the plate around during the meal; if they are visually impaired consider referral to sensory team. Use bright contrasting colours of placemat, bowl and cup for residents with visual difficulties
• Ensure mouth is clean and there is no soreness, maintain excellent oral hygiene and dental check-ups, make sure dentures are fitting, regularly cleaned and in situ if resident tolerates them
• If sudden change in behaviour, check for physical and/ or mental health changes or infection.

Eating non-food items

• Ensure everyone is aware of this and lock away all harmful substances
• For residents with a strong bite reflex ensure that crockery is shatterproof, and avoid metal cutlery to protect residents’ mouths and teeth, choose ‘unbreakable’ plastic cutlery instead.

Wandering or not sitting down for mealtimes

• Let them wander until food arrives

• Use simple verbal/ physical prompting to aid understanding
• Give extra helpings/ fortify food when more settled
• Consider finger foods that can be eaten on the move.

Eating small amounts/ refusing food & fluid

• Offer smaller meals little and often
• Offer 2 puddings if they don’t like the main course
• If refusing puree, try naturally puree consistency foods such as custard
• If refusing thicker fluids, try naturally thicker fluids such as smooth thick fruit juices or smoothies
• If they are on a modified diet, find ways that they can enjoy their preferred flavours e.g. chocolate mousse substituted for chocolate bar
• Make sure you are aware of their preferences/ cultural needs.

Mouth Holding/ not opening mouth including ‘washing machine’ effect of continuous chewing

• Use verbal prompts to keep on track, remind to swallow or use indirect prompts: ‘that’s nice’ ‘this is tasty’
• Use gentle physical prompts e.g. put cup/spoon in resident’s hands
• Try ‘hand over hand’ feeding technique
• Touch spoon/ cup lightly to lower lip to remind person to swallow
• Examine if carefully giving the next mouthful helps trigger a swallow (only do this once)
• Try altering mouthful size
• Experiment with different tastes and temperatures, stronger flavours/ colder temperatures may more easily stimulate a response
• If not opening mouth, coax to have a first ‘taste’ or try a small amount on their lips to elicit a ‘lip licking’ response
• Ensure mouth is clear and administer mouth care after meal
• Remain upright after eating.

Spitting out

• Try softer textures, minced moist and/or puree textured diet may reduce the spitting.

Ref: Kindell, J. 2002, Feeding and eating disorders in dementia

Download this document here. 

Dysphagia (swallowing difficulties)

Chewing and swallowing food and drink is a complex process which uses many different muscles and nerves working in a coordinated manner.  Dysphagia is the term used to describe a difficulty with chewing and swallowing food, drink and/or saliva. 

Swallowing problems may occur when a person has had a neurological event, such as brain injury or stroke.  Conditions such as Multiple Sclerosis, Motor Neurone Disease and Parkinson’s Disease can also cause dysphagia.

Problems can occur with:

• Chewing and moving food and drink around the mouth
• Food and drink going down the ‘wrong way’. This may result in food and drink entering the lungs and causing a chest infection.

Signs and Symptoms:

• Difficulty chewing or swallowing
• A delayed or effortful swallow
• Multiple swallows for each mouthful
• Choking or coughing before, during or after swallowing
• A ‘gurgly’ voice after swallowing
• Watery eyes, red face or trying to catch your breath when eating or drinking
• Taking a very long time to eat and becoming tired
• Frequent chest infections
• Unintentional weight loss.

What does a Speech and Language Therapist do?

Speech and Language Therapists are involved because the muscles and nerves used for chewing and swallowing are also those used for speech.

Speech and Language Therapists are trained to:

• Identify the problem
• Establish why it is occurring
• Advise whether it is safe to eat and drink
• Suggest how to make eating and drinking easier.

The Speech and Language Therapist will be able to assess your swallow by observing the swallowing process.  Sometimes an instrumental assessment may also be used.  This may be a Videofluoroscopy (a moving x-ray) or alternatively a Fibreoptic Endoscopic Evaluation of Swallowing (FEES), which involves passing a small camera through your nose.

Advice for Safe Swallowing:

• Ensure you sit upright to eat and drink
• Your head should be slightly tilted forwards with chin tucked in
• Stay sitting upright for 30 minutes after eating and drinking
• Eat and drink when you are most alert
• Eating and drinking is tiring. Try to eat ‘little and often’ with appropriate snacks between meals
• Ensure you can concentrate on eating and drinking and are not distracted by the television, radio or conversation
• Try not to talk with your mouth full
• Take your time – do not rush
• Take small mouthfuls – a teaspoon may help
• Do not have hard-to-chew foods
• Make sure your mouth is clear of food and drink before taking the next mouthful. You may need to swallow more than once to clear each mouthful
• If one side of your mouth is stronger, place food on that side. Check the weaker side to ensure no food is stuck there
• Contact your Doctor, Speech and Language Therapist or Dietitian if you notice any signs or symptoms of dysphagia

Difficult Foods:

Mixed textures

• Mixing liquids and solids can cause you to choke on the liquids whilst chewing solids e.g. meat in thin gravy, cereal with milk, minestrone soup

Stringy textures

• These can be hard to chew and may result in some bits being left behind in the mouth or throat, causing choking e.g. runner beans, stringy meat

Foods with skins

• Anything with an outside skin or husk can get left in the mouth after the food has been swallowed and can be hard to chew e.g. sweetcorn, peanuts

Floppy textures

• Foods with a floppy texture can be difficult to chew and swallow e.g. cucumber slices, lettuce

Sticky foods

• Sticky foods may stick to the teeth and roof of the mouth. If you have difficulties with tongue movements it may be difficult to remove this residue e.g. toffees, white bread

Crumbly foods

• Crumbly foods may cause choking if the crumbs are inhaled e.g. biscuits, cakes and pastry

Coarse textures

• Coarse textures, such as haddock or tough meat, may be hard to swallow. Try adding a thick sauce

Hard food

• Some food is hard and difficult to chew.  This could lead to choking e.g. nuts, foods with pips or stones, pieces of raw apple

Liquids

• Many people find swallowing liquids more difficult than solids.  This is because liquid does not hold a shape for more than a second, and can trickle over the back of the tongue.  Some people find milkshakes and fruit smoothies easier to drink as they are thicker. Your SLT may also recommend a thickening agent to thicken drinks.

A Speech and Language Therapist may recommend that you take a normal diet, but avoid or take more care with certain high risk foods.

High risk foods are known to be more difficult to swallow and are more likely to cause choking.  They should not be given to anyone on a modified diet.

If you have difficulties with your gullet (oesophagus), high risk foods may not pass through to the stomach quickly or smoothly.  High risk foods may even become stuck in the oesophagus.

Examples of High risk foods 

Stringy, fibrous textures

e.g. runner beans, celery, pineapple, lettuce, mangetout peas, bacon, gammon

Skins and husks

e.g. broad beans, baked beans, peas, grapes, chick peas, sweetcorn, granary bread, seeds, satsumas, sausages with skin

Mixed consistency foods

e.g. cereals which do not blend with milk (eg muesli, cornflakes), mince/meat with then gravy, soup with lumps

Crunchy foods

e.g. toast, flaky pastry, dry biscuits, crisps

Crumbly foods

e.g, bread crusts, pie crusts, crumble, dry biscuits

Hard foods

e.g. boiled and chewy sweets and toffees, nuts and seeds

Chewy foods

e.g. steak, pork chops, Naan bread, marshmallows

As described in Feeding Safely Routines, excellent mouth care is essential for all residents, including those with dysphagia. It can be difficult to carry out mouth care with a person with dysphagia and this aspect of care can be neglected for this reason.

Please adhere to your local mouth care guidance and refer your resident to a Dentist when necessary.

Additional supportive information can be found in the following resources:

1. NHS Health Education England Mouth Care Matters https://mouthcarematters.hee.nhs.uk/

This resource includes toolkits, factsheets and videos to support mouth care.

1. All Wales Mouth Care  Special Interest Group

http://www.sigwales.org/wp-content/uploads/dysphagia-adult-mouthcare-booklet3.pdf

This is a resource giving information specifically to support mouth care for adults with swallowing difficulties.

Download and use here.