Swallowing Difficulties: Cups, Spoons and Meal Aids

What is dysphagia?

Dysphagia is the medical term for difficulty swallowing. It may involve:

• Oral problems: weak lips and tongue, poor chewing, a dry mouth or ill-fitting dentures, which make it hard to form and move a mouthful.
• Throat (pharyngeal) problems: delayed or weak swallowing reflex, so food or fluid enters the airway.
• Oesophageal problems: food sticks on the way to the stomach, for example due to narrowing or reflux.

Common causes include stroke, Parkinson's disease, dementia, head and neck cancer or its treatment, muscle weakness, frailty, dry mouth from medicines and some lung conditions. See swallowing problems (dysphagia) in older adults for more on causes.

Signs to watch for

• Coughing, choking or throat-clearing during or after eating or drinking.
• A wet or gurgly voice after swallowing.
• Food or drink coming out of the mouth or nose.
• Food pocketing in the cheeks, or remaining in the mouth after the meal.
• Slow eating, taking a long time over meals, or tiring during meals.
• Avoiding certain foods, such as dry or tough foods, or drinks.
• Weight loss, dehydration or poor appetite.
• Repeated chest infections or a persistent cough.
• Drooling.
• A feeling of food stuck in the throat or chest.
• Unexplained fever after meals.

Silent aspiration can occur without any cough. Repeated chest infections or fevers may be the only sign.

Why a professional assessment matters

A speech and language therapist (SLT), sometimes called a speech-language pathologist, assesses swallowing, often watching the person eat and drink different textures, and sometimes arranging an X-ray swallowing study or a camera test. They decide:

• whether swallowing is safe and which foods and drinks are safe;
• what food texture and drink thickness is needed, if any;
• what position and techniques help; and
• what exercises might improve swallowing.

Using thickened drinks or pureed food without an assessment can be wrong or even harmful. Do not guess. Ask the doctor for a referral. See aspiration pneumonia prevention.

Safe positioning and mealtime routine

Good positioning is one of the most effective measures and is often the first advice an SLT gives.

• Upright. Sit as upright as possible, ideally in a chair with arms and good support, with hips well back. In bed, sit fully upright with pillows or the bed raised, not slumped; see backrests and sitting up in bed.
• Head and chin. The head slightly forward, chin gently tucked, not tilted back. The SLT may teach a specific technique.
• Stay upright after meals for 30 to 60 minutes.
• Calm environment. Turn off the television, reduce noise and distractions, and let the person concentrate.
• Take your time. Allow 30 to 45 minutes. Never rush.
• Small mouthfuls, with a teaspoon, and wait until each is swallowed before the next.
• Check the mouth is empty between mouthfuls.
• Alternate foods and sips only if the SLT advises.
• Do not talk or laugh with food in the mouth.
• Supervise if advised; stay with the person.
• Mouth care before and after meals; see oral care for frail older adults.
• Dentures well fitting and in; see teeth, dentures and eating well.
• Rest if tired. Smaller, more frequent meals may suit better.

Cups, spoons and plates

The right equipment makes safe swallowing easier. Ask the SLT before using these.

Cups and mugs:

• Cut-out (nosey) cups with a notch for the nose, so the head does not tilt back to drink.
• Two-handled cups with a lid and a spout, for tremor or weak grip.
• Lidded cups to limit the flow and prevent spills.
• Straws, which suit some people but may increase the flow and risk in others; ask the SLT.
• Weighted or non-slip cups.
• Cups with measured sips.

Spoons:

• Small, shallow teaspoons that deliver small amounts.
• Built-up handles for grip; see easy-grip cutlery and eating aids.
• Angled spoons for easy reach to the mouth.
• Coated or plastic spoons for people who bite on metal.
• Feeding spoons with a long handle for carers.

Plates and bowls:

• Scoop plates and plate guards to keep food on the plate.
• Divided plates to separate foods.
• Non-slip mats.
• Contrasting colours to help people with poor vision or dementia see food.

Food textures and drink thickness

Many SLTs use internationally agreed levels of food texture and drink thickness (the IDDSI framework), from thin drinks and regular food to extremely thick drinks and pureed food. Your parent's level is set by the SLT, based on assessment. Never change it yourself.

General points:

• Thin drinks such as water, tea and juice move fastest and are hardest to control. Some people need thickened fluids.
• Thickened drinks are made with commercial thickeners, added in the right amount; follow the SLT's and maker's instructions exactly. Too thick or too thin is unsafe.
• Texture-modified food: soft and moist, minced and moist, pureed, depending on the level. Foods that are dry, crumbly, stringy, sticky or mixed in texture, such as rice with thin dal, dry chapati, nuts, raw vegetables, toast and sticky sweets, can be hazardous.
• Moist foods: add sauces, gravies or ghee as advised.
• Pureed food should look appealing; use moulds or pipe it, and keep flavours separate.
• Fortify food to increase calories without increasing volume, as advised by a dietician; see soft and pureed diets and protein powder for older adults.
• Avoid mixed consistencies such as soup with lumps or cereal with milk, unless advised.

Medicines

Swallowing tablets can be difficult. Do not crush or break tablets without asking the pharmacist, since some are designed to be swallowed whole. Ask the doctor about liquid or dissolvable forms. Take tablets with a spoonful of puree if advised, sitting upright. See medicine reminders for a forgetful parent.

Dementia and Parkinson's disease

In dementia, a person may forget how to swallow, hold food in the mouth, refuse food or eat too fast. Techniques include a calm routine, cues such as stroking the throat or showing the spoon, prompts, and adjusting textures. In Parkinson's disease, slow, stiff muscles can affect swallowing, so timing meals with medicines helps; see Parkinson's disease at home guide and dementia eating and weight loss. In advanced dementia, tube feeding generally does not prolong life or improve comfort; careful hand feeding is recommended; discuss with the doctor.

Preventing choking

• Know the signs of choking: unable to speak or cough, clutching the throat, a silent struggle.
• If a person is coughing, encourage them to keep coughing and do not slap the back.
• If they cannot breathe, speak or cough, call 112 and begin first aid (back blows and abdominal thrusts or the method taught on a first aid course). Take a first aid course, since this is a life-saving skill.
• Do not leave a person with swallowing problems alone with food.
• Have the right foods. Avoid high-risk foods unless the SLT allows.
• Keep a first aid guide accessible.

Nutrition and hydration

People with swallowing difficulty are at high risk of malnutrition and dehydration. Watch weight, intake and urine colour. Offer small, frequent meals and nourishing foods, and ask a dietician about supplements; see malnutrition in older adults, hydration for older adults and loss of appetite in older adults. Record weight monthly; see weighing scales and weight loss.

Emotional and social aspects

Mealtimes are social and cultural events. Modified diets can be depressing. Make food look and taste appealing, include favourite flavours, and eat together where possible. Respect cultural and religious dietary needs, including fasting; see fasting, festivals and older adults. Avoid embarrassment, and treat the person with dignity.

When to ask a professional

See a doctor for any new swallowing difficulty, coughing with meals, repeated chest infections, unexplained weight loss or fever. Ask for referral to an SLT. A dietician advises on nutrition and fortification. A dentist can check teeth and dentures. Call 112 for choking that does not clear, or sudden difficulty breathing. Our care advisors can arrange an assessment and trained carers.