Your father has started coughing during dinner. He clears his throat after every sip of coffee, eats more slowly, and has lost weight without trying. He says food "goes down the wrong way" sometimes. That's worth taking seriously.
This guide uses MedlinePlus from the National Library of Medicine and Medicare. It's general information. A clinician, usually with a speech-language pathologist, should evaluate any swallowing problem.
What dysphagia is
Dysphagia is difficulty swallowing: the feeling that food or liquid is stuck in the throat or anywhere before it reaches the stomach2. Some people have trouble with liquids, some with solids, and some with their own saliva. A few can't swallow at all1.
Because eating gets harder, it can be difficult to take in enough calories and fluids1. That's why dysphagia often shows up first as weight loss or dehydration. See when an elderly parent isn't eating and dehydration in the elderly. Problems with teeth or dentures can make chewing hard; see dental care for seniors. If swallowing becomes unsafe, see feeding tubes for the elderly.
Warning signs
MedlinePlus lists these symptoms of swallowing problems2:
- Coughing or choking during or after eating.
- Gurgling sounds from the throat during or after eating.
- Throat clearing after drinking or swallowing.
- Slow chewing or eating.
- Coughing food back up after eating.
- Hiccups after swallowing.
- Chest discomfort during or after swallowing.
- Unexplained weight loss.
Families also notice a parent avoiding certain foods, pocketing food in the cheek, drooling, taking a long time to finish a meal or having a wet-sounding voice after drinking. Symptoms can be mild or severe2.
Common causes in older adults
Dysphagia often happens because of another condition1. Common causes include:
- Stroke. One of the most common causes1. See stroke recovery in the elderly.
- Nervous system disorders. Such as Parkinson's disease1. See Parkinson's care.
- Dementia. In Alzheimer's, swallowing eventually becomes difficult as the disease advances5.
- Esophagus problems. Including GERD1.
- Head and neck cancer and its treatment1.
- Other factors. Dry mouth from medicines, poorly fitting dentures and weakness after a long illness can all make swallowing harder.
A swallowing problem that appears suddenly, especially with facial droop, slurred speech or weakness on one side, can be a sign of stroke. Call 911.
Why aspiration is the big worry
When food, liquid, saliva or vomit is breathed into the lungs, it's called aspiration, and it can cause aspiration pneumonia3. MedlinePlus lists swallowing problems, old age, being less alert from medicines or illness, and eating or being fed while not upright among the risk factors3. Being in the hospital also increases the risk3.
Signs of aspiration pneumonia can include fever, cough with discolored phlegm, shortness of breath, chest pain, fatigue and confusion3. In older adults, new confusion may be the most obvious sign. See pneumonia in the elderly. Some aspiration is "silent," with no cough at all, which is one reason a formal swallow evaluation matters.
Getting a swallowing evaluation
MedlinePlus advises that most people with dysphagia should be checked by a health care provider if symptoms persist or come back2. Ask your parent's doctor for an order for a speech-language pathologist (SLP), the specialist who evaluates and treats swallowing.
An SLP may start with a bedside exam, watching your parent eat and drink different textures. If needed, imaging tests such as a barium swallow, which films swallowing on X-ray, or a scope exam can show where the problem is1.
Medicare Part B covers medically necessary outpatient speech-language pathology services, including evaluation and treatment of swallowing, when a doctor or other provider certifies the need4. There's no annual limit on how much Medicare pays for medically necessary outpatient SLP services, and the usual Part B cost sharing applies4.
Treatment options
Treatment depends on the cause. Medicines help some people, and some need a procedure or surgery1. Swallowing therapy with an SLP can help many people1. It may include:
- Exercises to strengthen the muscles used to swallow.
- Positioning. Holding the head or neck a certain way while eating1.
- Diet changes. Softer foods, chopped or pureed textures, or thickened liquids12.
- Strategies. Such as a double swallow or a chin tuck.
In very serious cases, people may need a feeding tube1. That decision is very different for someone recovering from a stroke than for someone with advanced dementia. Talk it through with the care team and in light of your parent's wishes; see advance directives.
Safer mealtimes at home
These general tips from MedlinePlus help many people, alongside whatever plan the SLP gives2:
- Keep meals relaxed. Turn off the TV and limit distractions.
- Sit up straight. As upright as possible, in a chair rather than a bed when you can.
- Take small bites. Less than a teaspoon per bite.
- Chew well and swallow fully before the next bite.
- Use the stronger side. If one side of the face is weaker, chew on the stronger side.
- Don't mix solids and liquids in one bite, and don't wash food down with drinks unless the therapist says it's okay.
- Don't talk while swallowing. Ask family not to ask questions mid-bite.
- Stay upright after eating. For 30 to 45 minutes.
- Check before thin liquids. Thickened liquids may be recommended.
Making modified food appealing
A diet of soft or pureed food can feel like a punishment, and people who dislike their meals eat less. A few ideas help keep food appealing while following the SLP's plan:
- Puree foods separately. Keep colors and flavors distinct instead of blending a whole plate together.
- Season well. Herbs, sauces and gravies add flavor and can help moisten foods if the texture plan allows.
- Choose naturally soft foods. Scrambled eggs, yogurt, mashed vegetables, soft fish and well-cooked cereals often fit softer textures.
- Watch mixed textures. Foods that are both liquid and solid, like cereal in milk or soup with chunks, can be harder to swallow safely. Ask the SLP.
- Plan for snacks and fluids. Smaller, more frequent meals and regular drinks in the approved consistency help prevent weight loss and dehydration.
Ask the SLP or a registered dietitian for a written list of safe foods and drinks. Post it in the kitchen so every helper follows the same plan.
Mouth care matters too
A clean mouth matters for people with swallowing problems, because bacteria in the mouth can be carried into the lungs along with saliva. Brushing teeth or dentures twice a day, cleaning the tongue and gums, and keeping dentures well fitted are simple steps. Ask the dentist about dry mouth, which makes chewing and swallowing harder and can be a side effect of medicines. If your parent can't brush alone, a caregiver can help with a soft brush while your parent sits upright.
When a parent resists the changes
Many older adults hate thickened drinks or feel embarrassed eating differently. Explain the reason in terms of what your parent cares about, such as avoiding another hospital stay. Let them choose flavors and foods within the plan, eat with them, and avoid policing every bite. If your parent fully understands the risks and still chooses to eat certain foods, talk with the care team about honoring that choice as safely as possible. See when a parent refuses help.
Pills and dysphagia
Swallowing pills can be harder than swallowing food. Never crush pills or open capsules without asking the pharmacist, since some medicines are dangerous or don't work when crushed. Ask whether a liquid, smaller tablet or different form is available. A pharmacist can also check whether any medicine is causing dry mouth or drowsiness that makes swallowing harder. See medication management.
Swallowing problems in dementia
As dementia advances, swallowing often becomes difficult5. A person may forget to chew or swallow, hold food in the mouth or be distracted at meals. MedlinePlus notes that some people need someone to remind them to finish swallowing2. Simple steps help: one food at a time, calm surroundings, verbal cues like "swallow," and enough time.
In late-stage dementia, swallowing changes can be part of the end of life. See end-of-life signs in dementia and hospice for dementia for how families and care teams approach comfort feeding and other choices.
When to call the doctor
MedlinePlus advises contacting the provider if your parent coughs or has a fever or shortness of breath, is losing weight, or if swallowing problems are getting worse2. Call 911 for choking that doesn't clear, trouble breathing, or signs of stroke.
Swallowing and care settings
If your parent lives in assisted living or a nursing home, ask how the kitchen prepares modified textures and thickened liquids, who supervises meals, and how staff learn each resident's swallowing plan. In a nursing home, the plan should be part of the care plan; see care plan meetings. After a hospital stay, make sure the SLP's recommendations travel with your parent; see discharge planning.
Next steps
Write down what you've noticed at meals, ask the doctor for a speech-language pathology evaluation, and follow the plan the SLP gives. If meals and daily care are becoming more than home can manage, our home care guide and the care quiz can help you think about the level of support your parent needs.
An example
After a small stroke, Ruth, 83, coughed whenever she drank water. Her daughter asked the doctor for a swallow evaluation. The SLP found that thin liquids were going toward her airway and recommended mildly thickened drinks, a chin tuck when swallowing and exercises. Within a couple of months Ruth could manage thin liquids again with care. This is an illustration; each person's plan comes from their own evaluation.
