Recognizing dysphagia at meals

Most of us look forward to mealtime. It is, of course, an opportunity to eat, but it is also a chance to socialize with others and relax from the day’s work or routine. However, for many older adults, eating—and swallowing—is a struggle. Swallowing is mostly an involuntary process that is hardly thought about. On average, a person swallows more than 600 times a day—imagine if you experienced pain with every swallow. Mealtime can be an uncomfortable experience for older adults because of poor dentition, ill-fitting dentures, pain, or dysphagia, a term used to describe a swallowing problem. Approximately 15 million Americans are affected by dysphagia1, which can dramatically influence a person’s nutritional status.

Common Eating Problems

Dysphagia is not unusual among older adults living in long-term care facilities. One study2 recorded the presence of mealtime difficulties in nursing home residents and found that nearly 90% had impairments that included dysphagia, poor oral intake, positioning problems, or challenging behaviors. Furthermore, 68% of the residents experienced dysphagia, compromising their ability to enjoy meals, let alone consume the necessary calories to meet nutritional requirements. Dysphagia can lead to aspiration, choking, dehydration, malnutrition, and pneumonia. In fact, aspiration pneumonia is the fifth leading cause of death in people over 60 years of age and the third leading cause of death in people over 80.1 Clearly, food intake is crucial to many residents’ health and quality of life.

Residents with dysphagia often require modified diet consistencies, such as thickened liquids or pureed foods. In addition, nursing assistants must often comply with specialized feeding techniques, such as placing food in the non-impaired side of the mouth, limiting the use of straws, or facilitating the use of adaptive feeding equipment. In the dining room, nursing assistants who provide help to, monitor, or feed residents must follow the techniques for the residents’ safety and nutritional health. Failure to successfully comply with swallowing and feeding recommendations can cause inadequate hydration and nutrition and unsafe feeding.

Through therapy, a speech-language pathologist can help many residents with dysphagia learn compensatory swallowing techniques. Researchers have found that poor staff training and a lack of understanding about feeding recommendations can cause malnutrition and dehydration in long-term care.3,4McGillivray and Marland conducted a review of the literature on assisting people with dementia during meals.5 Their review found that mealtime assistance is often stressful for residents and staff because feeding becomes task centered and staff have not been sufficiently educated or trained.

As part of their general training, nursing assistants receive education on mealtime atmosphere, techniques to help residents maintain independence, therapeutic diets, how to feed residents, how to identify a choking victim, and the importance of adequate hydration and nutrition. If the swallowing process is addressed at all, it is usually covered briefly. Nursing assistants need to have basic knowledge of how swallowing mechanisms work so that charge nurse can be notified and stop feeding assistance if the process goes awry. Educating nursing assistants about the phases of swallowing and the signs and symptoms of dysphagia is clearly in the residents’ best interest.

An in-depth discussion on eating and swallowing should take place after the nursing assistants have had a chance to assist residents with eating and observe those with dysphagia. Then, the staff can apply the new information in a meaningful way to resident care.

The Science of Swallowing

Although swallowing is a complex process that moves food and liquids from the mouth to the stomach (figure 1), it can be simplified and discussed in four phases of activity. Keep in mind that the four phases are not distinct, but rather overlap one another, as many movements occur simultaneously when we chew and swallow. A person can experience a problem during one or all of the phases.

Anatomy of the head and neck

During the oral preparatory phase (figure 2), a person sees, smells, and recognizes the food before opening his or her mouth to take a bite or sip. So before the food even enters the person’s mouth, a potential for difficulty with the process exists. This is crucial to remember when working with residents who have a cognitive deficit or who are unable to feed themselves. If someone is not cognitively prepared for food, it could spill back into an unprotected airway before the person realizes that anything is in his or her mouth. As a result, the resident could choke. Once food is recognized, it is placed in the mouth, chewed, and mixed with saliva in preparation for the swallow. During the chewing process, the tongue scoops up the food and places it back on the teeth. It is amazing that we have such a great feedback process that we don’t bite our tongues while eating.

Oral preparatory phase: Chewed food mixes with saliva to make bolus (ball)

Oral Phase: Tongue moves bolus to back of mouth

Next, during the oral phase (figure 2), the food is formed into a ball called a bolus. As the tongue pushes the food or liquid toward the back of the mouth, the muscles in the pharynx begin moving to receive the food and the pharyngeal phase (figure 3) begins. The top of the larynx begins to lift and move forward, and the vocal folds close to keep food from going into the lungs (this is why breathing briefly stops when we swallow). The epiglottis also moves to help close the entrance to the airway. The soft palate lifts to close off the entrance to the nasal cavity, which prevents food from coming out of the nose during a swallow. The pharyngeal muscles squeeze the food through the pharynx and into the esophagus. This all occurs automatically without thought or control.

Pharyngeal Phase: Larynx rises, vocal folds close to protect airway, epiglottis closes entrance to airway, soft palate separates nasal cavity from pharynx

Finally, during the esophageal phase (figure 4), the food or liquid reaches the esophagus, the muscle at the top (called the upper esophageal sphincter) relaxes, and the food is squeezed by peristalsis through to the stomach. This also occurs involuntarily.

Esophageal Phase: Food travels to stomach

Because so many parts of the mouth and neck are involved in swallowing, residents presenting with dysphagia might display different signs. One person may drool during meals, another may have trouble chewing, and someone else could cough after the swallow. These are important indications that something is wrong. Ask your staff if they are familiar with the four phases of the swallow. Can they describe a sign or symptom of dysphagia? If not, they may need more training to ensure residents are able to safely and comfortably enjoy their meals.

Dysphagia Awareness Training Techniques

Through funding from The Mt. Sinai Health Care Foundation, IDEAS Institute examined the education needs of nursing assistants related to mealtime. As a result, Meal Time Matters was developed. The program includes interactive exercises to help nursing assistants mix thickened liquids properly, actually feel a classmate swallow by learning proper hand placement on the throat, taste different consistencies of liquid, and learn the value of providing liquids to someone before feeding him or her a meal. The classroom discussion includes information about the phases of the swallow, signs and symptoms of dysphagia, diet and liquid consistencies, solutions to common mealtime challenges, safe feeding guidelines, and assistive eating devices. An eight-minute DVD presents common mealtime challenges and prompts discussion by asking the participants questions. The trainer’s text has additional questions and information about the video’s content.

IDEAS Institute field-tested the program in two different situations. First, 18 nursing assistants in three different nursing homes in Cleveland, Ohio, attended a free Meal Time Matters in-service at their facilities. All nursing assistants were given a pretest before the class and a posttest and course evaluation at the end of the program. Second, every Cleveland-area nursing home was invited to one of two free Meal Time Matters train-the-trainer sessions. Fifty-three people, including nurses, nursing assistants, dietitians, speech-language pathologists, and occupational therapists, attended the train-the-trainer workshop and more than 90% of the attendees indicated that they would definitely recommend the program to others.

One goal of the field testing was to measure knowledge gain. Results indicated statistically significant changes in scores from pretest to posttest. A paired t-test was run for all students (n = 71). Mean scores were 6.0 and 8.6 for the pretest and posttest respectively, which was significant (p < 0.000). The results were analyzed for all students together, as well as for the nursing assistants and professional trainers separately. The results were similarly positive. For the nursing assistants (n = 18) mean scores were 4.4 and 7.3 for the pretest and posttest respectively, (p < 0.000). For the professional staff (n = 53), not surprisingly, the pretest scores were higher (6.6) and the posttest scores were quite high (9.1), also a significant difference (p < 0.000). Thus, Meal Time Matters clearly presents new information to both professional trainers and nursing assistants in an understandable format.

Jennifer Brush, MA, CCC/SLP, Executive Director, IDEAS Institute, is a speech-language pathologist, educator, and researcher in the area of dementia and geriatric care. For more information about Meal Time Matters, phone (440) 256-1883 or visit

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  1. Dorner B. It’s Tough to Swallow: Nutrition and Dining for Dysphagia. Akron Ohio:Becky Dorner & Associates, 2002.
  2. Steele CM, Greenwood C, Ens I, et al. Mealtime difficulties in a home for the aged: Not just dysphagia. Dysphagia 1997; 12 (1): 43-50; discussion 51.
  3. Colodny N. Construction and validation of the mealtime dysphagia questionnaire: An instrument designed to assess nursing staff reasons for noncompliance with SLP dysphagia and feeding recommendations. Dysphagia 2001; 16 (4): 263-71.
  4. Burger SG, Kayser-Jones J, Bell JP. Malnutrition and dehydration in nursing homes: Key issues in prevention and treatment. National Citizens’ Coalition for Nursing Home Reform; The Commonwealth Fund; June 2000.
  5. McGillivray T, Marland GR. Assisting demented patients with feeding: Problems in a ward environment. A review of the literature. Journal of Advance Nursing 1999; 29 (3): 608-14.


Did You Know?

We produce about 10,000 gallons of saliva in our lifetimes. Saliva is necessary to help break down food when we chew. Many older adults have reduced salivary production because of their medications. Reduced salivary production can lead to dysphagia. Care staff should be made aware if a resident has xerostomia (dry mouth), which may improve with an adjusted dosage or new prescription.


Signs and Symptoms of Dysphagia

Some signs and symptoms of dysphagia are not commonly known. For example, did you know that a persistent low-grade fever might be a sign of dysphagia? Did you know that if a resident is spitting food at meals, he or she might have oral phase dysphagia and might be unable to chew properly? Review the list below with your staff. Residents displaying the following signs and symptoms of dysphagia should be seen by a speech-language pathologist:

  • Having trouble recognizing food

  • Difficulty placing food in mouth

  • Drooling or spitting

  • Food falling out of mouth

  • Pocketing of food in mouth

  • Rocking tongue back and forth while chewing

  • Food left in mouth after the swallow

  • Chewing for a long time

  • Coughing before, during, or after the swallow

  • Delayed or absent rise of the larynx during the swallow

  • Requiring 3–4 swallows after each bite

  • Continuous throat clearing during or after the meal

  • Wet or hoarse voice

  • Complaining of something caught in throat

  • Refusing to eat or very slow eater

  • Lasting low-grade fever

  • Unplanned weight loss or unexplained loss of appetite

  • Pneumonia

  • Malnutrition or dehydration

Topics: Articles , Clinical , Nutrition , Rehabilitation