Difficulty with swallowing is not that uncommon. According to the College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO), it is likely that more than 200,000 people suffer from dysphagia (swallowing disorders) in Canada at any given time. Swallowing difficulties can impact us in many ways. For example, disappointment or frustration may occur as a result of not being able to eat the foods that an individual has always liked or a fear of choking may create anxiety about eating.
Difficulty with eating and swallowing can impact our nutrition. The foods we eat:
- Provide energy
- Support resistance to illness
- Support wound healing
- Are essential for body functioning
- Reduce nutrient deficiencies (and associated diseases)
- Maintain our body mass
- Support brain health
- Promote optimal health
With an eating or swallowing difficulty, the quantity of our food intake may be limited due to the increased time and effort required to eat.
Approximately 55% of people who have a stroke will have swallowing difficulties during the first days and weeks post-stroke. Many people regain their swallowing ability within the first month after the stroke. However, according to the Canadian Best Practice Recommendations for Stroke Care, as many as 35% of people still have some swallowing difficulties three months after the stroke. Swallowing difficulties are also common in many other medical conditions or diseases (for example, Parkinson’s disease).
Foods come in a variety of textures. Think about the different textures in the following foods:
- Mashed potatoes
- Cereal with milk
Some people may find it easier to swallow certain textures as opposed to others. Swallowing difficulties may worsen with the following foods:
- Bread requires the ability to bite, chew, and move the food around the mouth. It cannot be mashed like a banana.
- Sticky foods like peanut butter, mashed potatoes, and oatmeal increase the risk of choking.
- Pills can be especially hard to swallow for people with swallowing difficulties.
Drinks also come in a variety of textures. Think about the different textures in the following liquids:
- Tomato Juice
Thin liquids, like water, may cause more coughing when swallowing than thicker liquids, although this may not always be the case.
When caring for someone who has difficulty swallowing, it is helpful to understand:
1) The normal swallowing process
2) What happens when swallowing becomes a problem and the potential impact on the health of the person in your care
3) The adjustments that can be made to make swallowing easier and safer
What is the normal swallowing process?
Consider that we have one funnel of entry, our mouth, for both the air we breathe and for the food we eat. From the mouth, both the food and the air must find their correct path.
- The air we breathe enters into our lungs via the trachea (or breathing tube).
- The food and drinks we swallow enter into our stomach via the esophagus (or food tube).
Different textures of foods and drinks will take different amounts of time and effort to chew and swallow. This preparation is necessary before swallowing occurs:
- Our lips prevent food or drinks from slipping out of the mouth and help with the chewing process. Any weakness of the lips may result in food or drinks escaping from the mouth. When the lips are weak, you may notice some drooling.
- Our teeth cut up and grind the food to make it easier to swallow. Absent teeth can make chewing more difficult, especially with foods that have a harder texture such as an apple or steak. This is not much of a problem with soft textured foods like spaghetti or apple sauce.
- The tongue collects the food/liquid from the mouth, shapes it into a single bolus (or ball), and pushes it to the back of the mouth in preparation for swallowing.
Did you know that closing the lips tightly assists with swallowing?
Swallowing is partly a learned process and partly a reflex. The swallowing reflex protects the airway during the swallowing process. During this reflex, the vocal folds close adding further protection to the airway. You cannot talk at the same time as you are swallowing – If you do, you will start to cough and you may choke!
The prepared food bolus or liquid moves safely past the protected airway and into the esophagus (or food tube). That’s it! Those are all of the components of a successful swallow!
What happens when things go wrong?
If the airway is not protected, food or liquid could enter the airway and then the lungs, which is a serious health risk. This is referred to as aspiration. We have all felt food/ liquid going “the wrong way” or “down the wrong tube.” This usually makes us cough which is a reflex to clear the airway. The cough is very important!
However, a person may not always be aware that food has gone down the wrong tube. This is especially true with some illnesses or following a stroke. Aspiration occurs when substances other than air enter the lungs. Some examples may include:
- Stomach contents
- Bacteria from teeth/gums (in plaque, tooth decay, or gingivitis)
*It is therefore very important to keep the mouth cavity clean through good oral hygiene!
When there are swallowing difficulties, it is important to be aware of ways or strategies to protect the airway and reduce or prevent food or liquids from entering the lungs.
What are the potential risks of a swallowing disorder?
1) Choking: this can cause complete blockage of the airway (for example, a chicken bone, a candy, or a piece of unchewed meat can get stuck in the throat.) Of course, this is an emergency because the person will be unable to breathe. You may want to consider becoming certified in both CPR and choking maneuvers so that you are able to assist someone who is choking. Otherwise, call 9-1-1 or your local emergency number as choking is a medical emergency which can lead to death.
2) Aspiration: this is when food, liquids, or other substances enter the lungs which may lead to pneumonia.
3) Malnutrition/dehydration: this can occur when a person is not able to eat or drink enough to meet the body’s requirements and can lead to serious health complications.
If you or the person in your care is experiencing difficulty swallowing, consult with your health care provider as this can lead to severe consequences such as illness, choking, or death.
What happens after the swallow?
After the swallow, the food bolus or liquid moves down the esophagus (or eating tube). If the valve into the esophagus is not working well or if the tube itself is not pliable, this may result in difficulty with food entering into this tube. Have you ever noticed food coming back up immediately after the swallow? Regurgitation of food/ liquids is not a normal process and you should consult with your health care provider if you or the person in your care is experiencing this.
The food bolus or liquid then moves down the esophagus which leads to the stomach through another valve called a sphincter. If this lower valve is not working properly, there is a potential for back-up of stomach contents causing reflux. Again, reflux is not a normal process and you should consult with your health care provider if you or the person in your care is experiencing this.
How can you help a person with swallowing difficulties?
First, it is important for the person in your care to be assessed by a health care provider. Consider requesting a swallowing assessment if you notice a swallowing difficulty. Often, this may involve a referral to a Speech-Language Pathologist, Registered Dietitian, and/or an Occupational Therapist. The health care team may provide assistance with:
- Texture modifications to foods and/or liquids
- Head posture adjustments while eating/swallowing
- Swallowing techniques
- Sensory adjustments
- Feeding devices
- Positioning modifications
- Nutrition recommendations
- Oral care
In general, a person’s body should, ideally, be upright while swallowing. The head should be in a neutral or slightly flexed position. There will always be exceptions but your swallowing health team will provide assistance.
You should consult with a health care provider if you or the person in your care show signs of:
- Recurring chest infections/pneumonias
- Coughing while eating or drinking
- Choking on foods or liquids
- Wet or “gurgly” voice during eating or drinking
- “Wet” breathing
- Frequent “throat clearing” with meals
- Chewing difficulties
- Several swallows to get a “mouthful” down
- Extra effort to get food down
- Drooling or excessive secretions
- Thick saliva
- Pocketing of food in the cheeks
- Significant, unplanned weight loss
- Pain with swallowing
- Difficulty swallowing pills
- Complaints of “something sticking” in the throat
- Taking a long time to swallow or to finish meals