Introduction

Healthcare staff in all settings need to recognise that particular groups of people are at risk of having difficulty with swallowing.

These individuals should be observed and monitored for any signs of dysphagia. If a problem is detected then the ‘Eating and Drinking Safely Routines’ should be used.

Level of alertness

No-one should be given food or drink if unconscious, not fully alert and if they are in and out of sleep.  Reduce environmental distractors e.g. turn TV off, turn down music.

Distraction

Reduce distractions at mealtimes to facilitate concentration and awareness. This should include turning down music and turning off televisions as well as reducing chat.   Ensure residents have been to the toilet before their meal.

Time

Do not rush mealtimes. Allow adequate time to support the individual to eat and drink if required. Consider the use of insulated containers to maintain the temperature of food for those people whose mealtimes may be prolonged.

Positioning

Residents should sit upright (with head in neutral/midline position) for all snacks, meals and drinks and should remain upright for at least 30 minutes after a meal to avoid reflux.

*Please note there may be exceptional circumstances where maintaining this position is not appropriate, this will be stated in the resident’s care plan.

Oral hygiene

People with eating and drinking difficulties often have poor oral hygiene which can lead to a greater incidence of chest infections and pneumonia.

Ensure the residents mouth is clean and free from residue at the end of each meal. Oral care, including teeth cleaning should take place at least twice daily. This includes removing and cleaning dentures overnight.

Position yourself

If assisting a resident with eating and drinking ensure you are at eye level so that you may observe signs of difficulty as well as being able to provide verbal prompts and encouragement.

Positioning yourself above eye level or sitting at the side of individuals to assist them may have a negative impact on the individual’s ability to swallow safely.

Utensils

Consider if the utensils you are using are appropriate. Using adapted cutlery may increase someone independence e.g. large grip cutlery, plate guard etc.

If assisting someone with their food, try using a teaspoon or the end of a fork. Try a short, wide rimmed normal cup/glass first as these are more familiar than beakers with spouts or using straws.

Glasses and hearing aids

Swallowing requires multisensory stimulation. Food should be visually appetising in its presentation and smell appealing in order to stimulate the appetite as well as increasing the amount taken.

Ensuring that the resident can hear the guidance and advice being given e.g. when prompted to slow down. Similarly, an individual’s swallowing will be affected by hearing the crackle and crunch of different food consistencies. Therefore, hearing aids and glasses need to be available and fit comfortably.

Dentition

Dentures, if worn, should fit well. Be aware that some individuals prefer to eat without their dentures.

Modifying diet

If a modified diet has been recommended by a Speech and Language Therapist, ensure these recommendations are being followed.

Independence

Individuals should be encouraged to feed themselves to encourage and maintain functional independence.

Do not assume that every resident requires assistance and/or the same level of assistance.

Through adaptions to utensils, with hand over hand support or verbal or tactile prompts they may be able to achieve some independence.

Portion size

People who are frail or lack stamina should be given small portions which require less energy to eat (e.g. softer and/or more moist foods).

These small portions of food or drink should be given at more frequent intervals in the day. Oral intake charts should be completed to ensure the person receives adequate nutrition and hydration.

Size of mouthful

Experimenting with the preferred size of mouthful is important. It should be sufficient to stimulate chewing and swallowing but it is important to avoid overlarge mouthfuls e.g. avoid using tablespoons.

Documentation

The amount of food and drink that has been consumed should be noted in order to monitor adequate nutrition and hydration.

Other professionals

The following roles all need to be stipulated and agreed in local care plans for dysphagia management:

• The physiotherapist in managing any associated respiratory condition.
• The dietitian in managing nutritional and hydration support.
• The occupational therapist in postural and feeding equipment.
• The nurse in overseeing safe feeding practice.
• The dentist in denture fitting.