Many people living in care homes have swallowing difficulties, also known as dysphagia, due to conditions such as dementia, stroke and Parkinson’s disease. Frailty, weakness and general poor health can also make swallowing less safe and efficient.

The Adult Community Speech and Language Therapy Service (SLT) offers specialist assessment and management of swallowing problems to:

• help the person with dysphagia to eat and drink as safely and normally as possible
• involve the person with dysphagia in decision-making about their eating and drinking as much as possible
• advise care home staff about how to best meet the care needs of the person with dysphagia
• involve family and friends in the care provided where possible and according to the patient’s wishes.

Referrals

The service receives a very high number of referrals for people with dysphagia. This number is increasing each year. It is important that referrals are appropriate so that time is not lost seeing patients who will not benefit.

It is also very important that staff making a referral give us enough information so that we can decide which patients need to be seen first and respond as quickly as possible.

Referral criteria

Speech and language therapists (SLTs) are specialists in oropharyngeal dysphagia, which means a swallowing problem within the mouth or throat area.

Many people have dysphagia and are able to manage well with some adjustments to their food, drinks or the way that they take them. We do not need to see every care home resident with dysphagia and many will have recommendations in place from past SLT assessments which are working well.

Referral to SLT is needed when there is concern that someone is not able to eat and drink safely and effectively. There may be a new problem or swallowing problems which seem to be getting worse.

Please refer anyone who presents with signs of dysphagia such as:

• coughing or choking on food or drink
• wet gurgly voice during or after eating or drinking
• unable to clear food from their mouth
• suspected aspiration and recurring chest infections
• drooling, dribbling food or drink from the side of the mouth.

Referral forms can be emailed to our central access point. Please make sure that you give us as much information as possible about the swallowing concerns so that we can decide how urgently they need to be seen. If the referral is incomplete it will delay the assessment.

We will contact you to arrange an appointment once the referral has been triaged according to clinical risk.

Speech and Language therapy will not work for: 

• people with symptoms such as vomiting or regurgitation, or with oesophageal swallowing problems. For example, due to an oesophageal stricture, achalasia or cancer of the oesophagus etc
• swallowing problems lower down, for example in the oesophagus (gullet) or stomach
• people whose problems with eating are due only to loose dentures or dental issues. Please seek dental advice. If there are chewing problems due to dental issues then a soft or puree diet may be needed but this does not require referral to SLT
• when the problem is refusal to eat, a poor appetite or taking a long time to eat and there are no other specific signs of a swallowing problem.
• food refusal and poor appetite are not often due to physical swallowing problems
• anyone who has difficulty only when swallowing tablets but is able to eat and drink without difficulty
• difficulty swallowing tablets is often a longstanding problem and does not mean that swallowing is unsafe. It may be helpful to discuss alternative medication routes with the GP or pharmacist, such as syrups
• anyone who is currently too drowsy to eat and drink. People need to be awake and alert to swallow safely. Unfortunately we cannot assess the swallow function adequately if the person is too drowsy for food and drink
• if the problem is pain when swallowing and/or oral thrush or other painful conditions of the mouth or throat
• this is a medical problem and should be referred to the person’s GP for examination and treatment
• anyone who has a one-off event of swallowing difficulty but no other signs of dysphagia, for example a single coughing or choking episode
• anybody can experience a one-off event when eating (perhaps if distracted or talking) and this does not mean that they have dysphagia. It is advised that staff should supervise eating and drinking for anyone who has had a one-off coughing or choking incident to look out for any further difficulty

Please phone us if you are unsure whether or not to refer a resident to us. We are happy to talk it through with you.

What can you do?

When you have concerns about a resident’s swallowing and are waiting for us to come and carry out our specialist assessment, we advise the following for safer swallowing.

Make sure that:

• the person is fully alert and awake for any oral intake (food, fluid or medication)
• the person is sitting as upright as possible
• you have checked that any previous SLT swallowing advice for this resident is being followed
• good oral hygiene is maintained by regular mouth care
• mouthfuls or sips are not too big
• eating and drinking is at a steady rate and not too fast. Watch for a swallow and a clear mouth before the next spoonful or sip is taken
• check that utensils such as straws or spouted cups are really needed as often they make it harder for the person to control the drink, leading to difficulty. Sips from an ordinary cup with assistance can often be safest
• help is available for the person to feed themselves. This often makes the swallow safer and more efficient, especially for people with dementia. Hand over hand feeding is where the patient holds the utensil, for example a cup, and you put your hand over theirs to help with steadiness, support etc
• when the patient is actively involved in bringing the food or drink to their mouth, their body knows that they need to be ready to swallow and the swallow is often better co-ordinated.

Please note:

People often try thickened drinks with residents when they start to have difficulty such as coughing on normal fluids. The SLTs cannot recommend thickened fluids without having completed a swallowing assessment face to face with the patient. This is because thickened fluids are not safer for every patient and it is against professional guidance to give advice when we have not seen the patient.

We encourage care home staff to use their own observations and professional judgement to decide the best way to help the resident with their swallowing until we are able to see them, and this may include thickening drinks in some cases. You should document your assessment and the reasons for any changes in the resident’s notes.

After SLT assessment

After our assessment, we will give our clinical opinion and written recommendations to the resident, care home staff and family where possible. The GP and any other relevant professionals will receive a written report.

Care home staff need to follow SLT swallow recommendations in order to meet the resident’s care needs around eating and drinking.
We will continue to review and treat someone for as long as there is a clinical need, for example:

• if the nature of the swallowing problem is not clear
• to make sure that SLT recommendations are put in place successfully
• to support the resident and family to understand the risks of not following SLT swallow recommendations
• if further recovery or deterioration of swallow function is anticipated
• it is very important to contact SLT if you notice any change in the resident’s swallowing, especially if it is getting worse and you have concerns about swallow safety. Please also let us know if the problems improve or if there are any problems with following our safer swallowing advice.

Discharge from SLT

Patients will be discharged from SLT when further assessment will not be able to help, for example:

• treatment goals have been achieved
• SLT swallow recommendations are in place and effective
• Swallow function is not expected to change for the foreseeable future
• a risk feeding plan is in place for someone where it is not possible to stop aspiration happening (food and drink going down the wrong way and into the lungs) and the patient is on the safest possible swallow recommendations in the circumstances.