Given the high prevalence of many medical conditions that can impact on the normal swallowing process in older people, we must observe all older patients for signs of swallowing difficulty.
Screening older people for swallowing difficulties is vital to avoid choking, dehydration, malnutrition and extended hospital stays due to complications with other illnesses. When swallowing difficulties are identified early, we can tailor care and treatment to respond to each person’s biological and medical needs, their abilities and their lifestyle and cultural preferences.
Screening patients who present with a stroke
Prompt screening is particularly important after stroke as no food, drink or oral medications should be given to the patient until it is clear there are no swallowing problems.1
Screen all patients who present with a stroke within 24 hours of hospital admission.
Speech pathologists recommend using the ASSIST (Acute Screening for Swallow in Stroke) screening tool (and training staff in its use), which is the most widely used, thorough, evidence-based dysphagia screen. It is one component of The Victorian Dysphagia Screening Model and consists of five short questions.
Screening patients with certain medical conditions
Many medical conditions can impact on the normal swallowing process. Finding out whether a person has experienced any difficulty is crucial, particularly with the following conditions:
- Parkinson’s disease and other neurological problems
- head strike due to a fall
- dementia (mild, moderate or severe)
- previous surgery to the mouth, throat, nose, spine or brain
- cancer of the mouth, throat, head or neck
- multiple comorbidities
- frailty which is associated with a high risk of dysphagia and malnutrition2.
Oral health should be screened at the same time as swallowing. Poor oral health and dental issues can seriously impact on swallowing and enjoyment of foods and liquids
Signs of swallowing difficulties
Look for signs of:
- difficulty swallowing or lack of swallowing1
- coughing before swallowing1, during meal times, or after eating
- drooling3, 4
- taking a long time to eat and drink, wasting food
- altered level of alertness or reduced response
- speech or voice changes as they may indicate silent aspiration. Look for slurred speech, a weak, hoarse, crackly, gurgling or wet-sounding voice. If in doubt, ask family members if they have noticed any recent vocal changes
- a history of recurrent chest infections5 or suspected aspiration
- tongue, facial or lip weakness or altered appearance
- pocketing food or tablets in the cheeks
- the patient describing food as sticking to the roof of their mouth or throat, or the sensation of a ‘lump’ or discomfort in the throat or chest, or frequent throat clearing during meal times (can indicate GORD)
- unexplained weight loss1
- reluctance to swallow food, water or medication.
“I had difficulty swallowing tablets when I was in hospital. I had to take my teeth out and I didn’t want the staff to see me, but they have to see you swallow. They have to make sure that you take the medication. I don’t know if anything can be done about that. It was just my vanity but… It’s an issue”. Consumer
Gather information from the patient, their family and carers
If we observe any of the signs or symptoms of swallowing difficulties or the patient complains of any of these problems, we should gather further information from the patient and their family and carers, explore the history of these issues, raise the concern with the treating team and work together to mitigate any immediate risks.
As a first step, ask the patient, their family and carer:
- about the severity and duration of their swallowing problem
- if they have been self-managing this issue, and if so, ask them what strategies have been helping them
- to describe the location of the difficulty in swallowing
- about the types of foods or liquids which make swallowing difficult
- whether the swallowing issue is progressive or intermittent1
- if they are experiencing reflux, as it is often associated with dysphagia.
1. Marik, P., Aspiration Pneumonitis and Aspiration Pneumonia. New England Journal of Medicine, 2001. 344(9): p. 4.
2. Liantonio, J., Salzman, B, Snyderman, D, Preventing Aspiration Pneumonia by Addressisng Three key risk Factors: Dysphagia, Poor Oral Hygiene and Medication Use. Annals of Internal Medicine, 2014. 22(10): p. 13.
3. Wieseke, A., Bantz, D, Siktberg, L, Dillard, N, Assessment and Early Disgnosis of Dysphagia. Geriatric Nursing 29(6): p. 8.
4. Daniels, S.K., Brailey, K, Priestly, D.H, Herrington, L.R, Weisberg, L.A, Foumdas, A.L, Aspiration in patients with acute stroke. Archives of Physical Medicine and Rehabilitation 1998. 79: p. 6.
5. Leslie, P., Carding, P.N, Wilson, J.A, Investigation and management of chronic dysphagia. British Medical Journal 2003. 326: p. 3.