Booklet - 2003

Swallowing Problems by Clare Morris, Speech & Language Therapist, Prion Group, St. Mary’s Hospital London

SWALLOWING PROBLEMS - How to Help

Cough
A cough is the body's response to 'foreign bodies' entering the airway or windpipe. It is our way of protecting our lungs from getting clogged up and interfering with breathing. It is under neurological control and can therefore be affected in dementia. The important thing to understand is that if someone can cough when you ask them to, it doesn't necessarily mean they will cough to clear their windpipe. Likewise, if someone is unable to cough on request, it may be that they will have an adequate 'protective' cough.

Aspiration
Aspiration is when liquids or food do go down the wrong way and are not removed by coughing.

Below are listed some common problems and strategies used to facilitate swallowing. It is, however, recommended that the advice of a speech and language therapist is sought, as strategies recommended will vary according to the stages of the swallow affected and the client. You can obtain a referral through your GP, or if necessary contact your local hospital or the Royal College of Speech and language Therapists for information on services locally. Other professionals, such as a dietician, occupational therapist, physiotherapist, or district nurse, may need to be involved.

Common problems that you may notice:

• being unaware of food when it arrives
• failing to do anything with food in the mouth, just holding it there
• difficulty chewing and/or difficulty moving food to the back of the mouth
• spitting lumps of food out
• eating very fast or putting too much into the mouth
• eating insufficient amounts or refusing food and/or drink
• talking with food or drink in the mouth and forgetting to swallow causing coughing
• coughing/choking on food and /or liquids
• complaints of food not going down or getting stuck in their throat
• a 'wet' or 'gurgly' voice after swallowing
• difficulty swallowing tablets
• dribbling
• chronic chestiness or recurring chest infections

Ways to promote safe eating that may be suggested by a speech and language therapist

Strategies

• Sitting upright, keeping the chin down. If you put your head back to drink, you are opening up the airway more, therefore if the swallow reflex is slow, it is easier for food and drink to go down the wrong way.
• Take small sips of drink, perhaps from a teaspoon. Avoid the use of drinking vessels that encourage the head to tip back (eg feeder beakers)
• Take small mouthfuls of food.
• Alternate food and drink to help clear the mouth of food: this should be discussed with a speech and language therapist.
• Try encouraging the swallowing of each mouthful twice to clear any food or drink that may remain in the mouth or in the throat after the first swallow.
• If the person has not swallowed what is in their mouth, sometimes it helps to present an empty teaspoon rather than more food. This can encourage the second swallow mentioned above.
• Frequent swallows to counteract dribbling.
• Check mouth after finishing eating to ensure no food or fluid remains.
• ou may have to sit with the person to remind them to use these strategies, and you may find that mealtimes take much longer.

Changes to diet

• Special diets (soft or puree), merely avoiding certain foods, or preparing them differently can make a big difference. Foods that may present difficulty for someone with a swallowing problem include:
  a) mixed textures eg food in a lot of fluids like ministrone soup, or cornflakes and milk;
  b) stringy textures eg bacon, cabbage, runner beans
  c) floppy textures eg lettuce, cucumber
  d) small, hard textures such as peanuts, peas, sweet corn and broad beans
  Cooking food longer so it becomes softer; mashing food with the back of a fork; or liquidising it in a blender can help.
• Thickening fluids to yoghurt or sometimes porridge consistencies may help as they are easier to control. There are a number of thickening agents available through your GP or from a dietician. It is important to speak to a speech and language therapist about this, and it can also be helpful to have guidance in using thickeners as the fluids may become lumpy which does not look appealing and may be off putting!
• The use of nutritional supplements if necessary.
• Crushing tablets or using a syrup form may be easier for someone with a swallowing problem but seek advice from your GP as some tablets need to be taken whole.

Equipment

• Specially designed cups which allow drinking whilst keeping the chin down
• cutlery, plates and non slip mats are available. An occupational therapist can advise you on this.

Sometimes these strategies may be insufficient to ensure an adequate dietary intake. After discussion with your doctor it is may be decided to feed via a tube directly into the stomach. This is called a gastrostomy, and it can be used in conjunction with eating small amounts orally, or can be used alone.

Food and eating is central to living in terms of pleasure and socialising as well as survival, therefore eating and swallowing problems have a major impact both on the person directly affected and those caring for them. It is possible to compensate for many difficulties, and support and guidance from a speech and language therapist can make the difference.

Information about dementia and speech and language therapy services is available from:

• C.A.N.D.I.D (Counselling and Diagnosis in Dementia)
  The National Hospital for Neurology and Neurosurgery
  Queen Square
  London WC1N 3BG.
  Tel: 0171 837 3611 ext 3855
  Fax: 0171 209 0182
  E-mail: c.morris@candid.ion.ucl.ac.uk
• The Royal College of Speech and Language Therapists
  7, Bath Place
  Rivington Street
  London EC2A 3DR
  Tel: 0171 613 3855
  Fax: 0171 613 3854

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