You are sitting in a restaurant enjoying your juicy
steak and garlic mashed potatoes. Laughing
and talking, you are not really attending to
what’s in your mouth. Before you swallow, you
begin to laugh. Upon inhale, a large chunk of
un-chewed meat gets sucked into your airway.
You try to scream, only to hear tiny whistles from
your throat and then you begin to panic. Unable to breathe, you
grab your throat in the universal choking sign. Luckily, you are
with someone who is competent at the Heimlich maneuver and
before you turn blue, your offending chunk has been projected
across the room onto a neighboring plate.
You have just aspirated food lodged in your airway. This
is something that happens to many people at some point in
their lives. Perhaps your experience was simply that some water
just “went down the wrong pipe,” causing you to cough and
sputter in violent spasms. Or, worse yet, you could suffer from
dysphagia, the medical term for a swallowing disorder that has
turned your life around, dictating what, when and how you must
Dysphagia is not Uncommon
It is estimated that at least 50 percent of adults over 80
experience some form of dysphagia and the consequences are
far worse than a simple need for the Heimlich every once in a
while. They include violent coughing, habitual throat clearing,
runny nose and watery eyes, malnutrition, dehydration and
ultimately, pneumonia and death.
As a Speech Language Pathologist for the geriatric
population, over 80 percent of my caseload has some form of
dysphagia. When I first evaluate my patients, the most common
thing I hear is, “I had no idea eating was this complicated!”
That’s because swallowing, like breathing, is perfectly natural
and automatic. Nothing to it, right? Well for some people, those
with dysphagia, swallowing can become a lot of work and worse
yet, very scary.
The causes of dysphagia are numerous and can include
neurological disorders, head and neck cancers, structural
damage to the tissues or cartilage and cognitive disorders, such
as dementia. Sometimes dysphagia has no discernable origin.
The Mechanics of Swallowing
So what exactly can go wrong with a simple swallow? For that,
you have to understand a healthy swallow. But first you have to
know that the esophagus, or tube to the stomach, is located
immediately and adjacently behind the trachea, the tube to the
lungs. When you hear that something “went down the wrong
pipe” it means that it went into the trachea instead of the
esophagus. And without a strong or violent cough, the material
will eventually find its way to the lungs. The lungs do not like the
presence of foreign materials and will react by producing fluid
which is like a petri dish for bacteria and may eventually lead to
There are three stages of swallowing:
The first is known as the oral stage. This is the act of chewing
food and directing it toward the back of the mouth. The integrity
of the oral stage is directly related to saliva production, tongue
strength and coordination and the state of dentition.
The second, and most complicated, stage is the pharyngeal
stage. This is the stage of the actual swallow and is extremely
important for our purposes because it is where everything can
go wrong. During stage two the uvula rises, blocking off the
nasal cavity so food doesn’t regurgitate from the nose; the
thyroid cartilage (your Adam’s apple) begins to rise, forcing
the epiglottis to move downward covering your airway; the
vocal cords close, protecting your airway from food and liquid;
and the food or liquid moves through the throat, heading for
The third stage is called the esophageal stage. This is the stage
where the food is propelled into the stomach by a series of
waves. Nothing can really go wrong here...or can it?
The most common swallowing disorders are, in fact, mild and
can be treated very simply. Problems with the oral stage (stage
one) are usually a result of poor dentition, dry mouth, or muscle
weakness associated with a neurological condition like stroke
or Parkinson’s Disease. Most of these cases can be resolved
simply by softening food consistency, increasing effortful
chewing and consciously using the tongue to manipulate food
in the mouth. These modifications are usually needed only
temporarily and can be eliminated once the dental problem
is addressed or the weakness in the muscles of the face and
Stage two problems are often a result of poor timing,
delayed swallow onset due to neurological disease and
decreased strength in the muscles that control swallowing. This
is a dangerous stage to be dysfunctional. When problems in
this stage appear, it means there is a very high risk of getting
food and liquid into the lungs. Regardless of the cause, the
deleterious effect of aspiration must be eliminated or at least
reduced, to protect the lungs from infection. Solutions may
be to soften food, increase the viscosity of liquids by using
a thickening agent, consciously working on the timing and
strength of the swallow (this takes a long time to perfect) and
utilizing compensatory swallowing strategies.
Stage three dysfunction is a result of poor esophageal
response or integrity. Signs of esophageal swallowing
dysfunction can include an earlier than usual feeling of fullness,
a feeling that something is constantly stuck in the throat,
frequent regurgitation of undigested food and coughing and
choking from the food and liquid that comes back up from the
stomach and ends up in the airway. Treatment at this stage can
include softening of the food and most importantly, utilizing a
swallowing strategy called “cyclic ingestion” – the act of taking a
sip after every single bite of food. This is the simplest and most
effective treatment option for someone with esophageal stage
dysphagia. Recommendations will most likely include sitting at
a 90 degree angle during all meals and remaining upright after
all meals for 45 minutes or so to let the esophagus empty into
Sometimes the esophagus functions so poorly that it must
be surgically stretched in order for the food to pass into the
If you are suffering from dysphagia, your doctor will most likely
refer you to a Speech Language Pathologist (SLP or ST) who will
evaluate the severity and nature of the impairment and prepare
a treatment plan.
Patients and Caregivers are often scared and overwhelmed
when faced with dysphagia because it affects such a core daily
function and the risk of dire consequences is so great.
Home Care and Self Care for Dysphagia
The following is a guide that can help you better understand
how to deal with dysphagia.
- Prepare the correct consistency of food and liquid recommended by your SLP. This is extremely important. The consistency of food and liquid are carefully selected by your SLP to compensate for a variety of factors. It is often unrealistic to expect the swallow to improve quickly so the diet and liquid modifications can compensate for the immediate swallowing difficulties, reducing the risk of further illness. If you are unsure of how to prepare the desired consistencies, work with your SLP and ask questions. You may be surprised how easy it can be when you have someone to help you.
- Always encourage eating in an upright position at the table. Never eat or allow your loved one to eat lying down or reclining. This allows for optimum transport of food and liquid to the stomach and decreases the risk of food and liquid lodging in the airway or lungs.
- If you have a loved one who requires feeding assistance, always wait until their mouth is empty before introducing a new bite or sip. They may want you to serve another bite or drink, but to do this places your loved one in more risk of washing food or liquid into the lungs.
- If your SLP provided a swallowing sequence, such as alternating solids and liquids or double swallow with chin tuck, stick to it as much as possible. These are recommended to decrease risk of further illness.
- You are the eyes and ears for the SLP. Report any coughing, choking, wet voice sounds or changes in behavior to your speech therapist. Record which consistencies you were eating or feeding when these behaviors occurred.
Special Considerations for Caregivers of Patients with Dementia
Dementia is the cognitive decline often demonstrated with
advanced aging, Alzheimer’s disease, brain injury, severe stroke
and other advanced neurological diseases.
People with dementia often have three intact stages of
swallowing. However, poor attention and awareness impacts
on the ability to persist with the task of eating. This can result
in oral holding and pocketing of food and liquids, failure to
recognize food as something to eat, inability to manipulate
eating utensils, poor appetite and changes in food preferences.
Here are some suggestions when feeding or helping an adult
with a diagnosis of dementia.
- Start the meal with liquids. This will help “whet the whistle” and make the swallowing process more automatic.
- Place a utensil in a restless hand, even if you are providing the feeding assistance. This provides the appropriate feedback and normalcy of the process.
- Decrease distractions as much as possible. Quiet your family members and turn off the television during feeding.
- Provide one item at a time for the highly distractible selffeeder.
- Provide finger foods to aid in self-feeding.
- If your family member has difficulty swallowing food once it is in the mouth, try patting the lips with a napkin, introducing a new empty spoon, bring a drink to the mouth or even add a bit of ice cream between bites.
Dysphagia can be life threatening and it can also gravely
impact quality of life. Often, people with dysphagia are afraid
of eating in public. They avoid social situations, family events
and celebrations because they are embarrassed by coughing or
afraid of choking. But a speech pathologist can help return your
life to normal, bringing the joy of eating back into you and your
family member’s lives.