How should you position a resident who is at risk of choking when assisting with meals or fluids

• Refer patients with swallowing problems to health professionals who can help them manage and address their problems while in hospital.
• We can get a better understanding of a person’s swallowing issues by observing them at mealtimes and asking them about their eating habits.
• Mealtime management interventions are just as important as prescribed medications. They help make mealtimes safe and conducive to eating.

There are many things we can do to improve a patient’s food and fluid intake and help address and manage swallowing problems. Here are some recommendations.

“Managing dysphagia is a balance between quality of life, dignity and taking small risks.” Senior speech pathologist

Refer to health professionals

When we have identified that a patient may have a swallowing problem, we should refer them to a Speech Pathologist and other health professionals who will work with you, the patient and their family and carers to inform the development of a comprehensive and consistent assessment and intervention plan.

Speech pathologist to:

• outline a plan for safe food, liquid and medication intake for the treating team and the patient and their family to implement
• undertake a comprehensive dysphagia assessment, which may include instrumental assessment such as a Videofluroscopy and Flexible Endoscopic Evaluation of swallowing
• determine the level of food and fluid texture modification required.1

• investigate the patient’s nutrition requirements

• investigate the underlying cause of the patient’s swallowing issue and advise on treatment options and limitations of care (for example in cases of end-stage disease)
• work with the team and the patient’s family to explore the ethical considerations around non-oral feeding options such as a Naso Gastric or Percutaneous Endoscopic Gastrostomy (PEG) which are contra-indicated for people with advanced dementia, can be very uncomfortable for the patient and do not necessarily improve or prolong life.2

Pharmacist to:

• carry out a medication review – many drugs can cause side affects such as nausea, dehydration and confusion, which can all impact on the swallowing process
• recommend an alternative plan for administration, such as crushing medications, where appropriate, to facilitate their intake. Altering a medication’s consistency can have serious side effects.3

Occupational therapist to:

• provide advice on environmental modifications to facilitate eating and drinking, particularly if the person has a cognitive impairment and requires orientation to the task of swallowing.

• work with the speech pathologist to advise on appropriate and safe positioning to facilitate safe swallowing.

Mealtime assessment

Mealtime assessment provides us with the opportunity for ongoing observation and evaluation.

• Ask about the patient’s usual eating habits as these reveal a lot about the swallowing problem and how they are self-managing.
• Determine how much the patient is eating at mealtimes.
• Notice how the patient eats their food. Do they eat slowly or quickly? Are they able to close their teeth after swallowing? Teeth that do not meet or are missing can exacerbate swallowing difficulties, as chewing action is reduced.
• Observe the patient’s behaviour, cognition and communication:
  • poor attention, distractibility and impulsiveness due to cognition changes will significantly influence intervention and mealtime management plans
  • the older person may not recognise or understand they are having difficulties swallowing
  • they may have difficulty in communicating what they are thinking.

Be familiar with the procedures and terminology used to prescribe food and fluid in your health service. We need to be familiar with the specific food and fluid modification terminology and procedures used in our health service.

Follow your health service procedures and policies, which in many cases will include placing an alert on the person’s electronic record, in their medical history and above their bed.

Examples of terminology for food include:

• full ward
• soft diet
• mince diet
• puree diet.

• thin fluids
• mildly thickened fluids
• moderately thickened fluids
• extremely thickened fluids.

Some health services supply pre-packaged modified food and fluids and some add thickeners and modify their meals on site. If we understand our local procedures we are more likely to ensure the patient receives the right meal.

Mealtime interventions

Mealtime management interventions assist us to respond to existing swallowing problems and to prevent them occurring in older patients who are at risk of developing them during hospitalisation. It is essential that all staff, volunteers and family and carers, who play a role in food preparation, delivery and assistance at mealtimes are aware of the risks and signs of dysphagia, and what to do if there is a problem.

Work closely with your team to:

• Ensure the mealtime management intervention plan, prescribed by a speech pathologist, supports the older person to safely consume their food, fluid and medication.
• Stop the patient eating and drinking if there is ongoing coughing, choking, a wet sounding voice, or they are unable to clear food from their mouth. Refer immediately to a speech pathologist.
• Ensure the risks and interventions are clearly communicated to the patient, their family and each member of staff caring for the patient. Provide education on the type of modified diet they have been prescribed and why.
• Offer water, where appropriate, with meals, as keeping hydrated is imperative for recovery and may also make swallowing foods easier; taking small sips can assist the process.
• Exercise caution when placing someone on ‘Nil by mouth’ as it can lead to a further loss of nutrients in malnourished patients even if it is only for a short period due to their multiple co-morbidities.
• Encourage patients to undertake therapy as prescribed by the dietitian or speech pathologist. This starts with ensuring the right meal is delivered to the right patient and ensuring the patient is:
  • eating or drinking when they are alert
  • taking small mouthfuls of food
  • taking sips of fluid between mouthfuls
  • sitting upright during the meal and staying upright for 30 minutes after they have finished
  • focused on the task and environmental distractions are minimised.
• Encourage families and carers to assist the patient at mealtimes and work with them to ensure they understand how they can reduce any risks associated with swallowing food.
• Encourage patients who have lost interest in food to eat small meals regularly and motivate them to keep well.
• Ask the patient if they enjoy how their food tastes, as taste has a very important input into the swallowing reflex and is needed to enjoy our food and safely swallow. A loss of taste as we age should not prevent a patient from eating.

Assess the patient’s oral health

Assess the patient’s oral cavity to see if dentures, poor oral hygiene or loss of dentition is affecting chewing, speech or swallowing. In particular, look for:

• signs of oral thrush and bacteria – which can lead to infection and complications that can impact on swallowing
• signs of gingivitis such as bleeding gums – try to find out the cause, for example, poor oral hygiene or possible nutrient deficiencies
• the solutions the patient uses to clean their dentures – ask about the solution and find out how often the patient cleans their teeth
• dental and oral issues – the patient may have problems with ill-fitting dentures or not like having them removed and put back in
• if the patient is missing any teeth – loss of teeth affects how the patient chews their food.

Encourage patients to keep good dental hygiene while in hospital:

• if necessary, help the patient brush their teeth after meals
• encourage patients to rinse with water if they are not able to brush their teeth following a meal
• offer water, if safe to so do, during and after meal times
• consider if they would benefit from referral to a dentist if they have not seen a dentist in the previous six months or are showing signs of gum disease, ill-fitting dentures or other dental issues.

1. Wieseke, A., Bantz, D, Siktberg, L, Dillard, N, Assessment and Early Disgnosis of Dysphagia. Geriatric Nursing 29(6): p. 8.

2. Parker, M., Power, D, Management of swallowing difficulties in people with advanced dementia Nursing Older People, 2013. 25(2): p. 5.

3. Kelly, J., D'Cruz, G, Wright, D, A Qualitative Study of the Problems Surrounding Medicine Administration to Patients with Dysphagia Dysphagia, 2009. 24: p. 7.

Reviewed 05 October 2015