Swallowing Problems in an Elderly Parent: Signs and Safe Meals

The signs of swallowing problems in an elderly parent usually show up at the table: coughing or throat clearing while eating, a wet or gurgly voice after a sip, food left in the cheek, slow meals, weight loss, or chest infections that keep coming back. If you see a pattern, tell their doctor and ask about a referral to a speech-language pathologist, who can test the swallow. Changes to food texture or drink thickness should come from that team, in writing. If your parent is choking and can't cough, speak or breathe, call 911.

The warning signs at mealtime

The medical name is dysphagia, and the National Institute on Deafness and Other Communication Disorders says it "happens most frequently in older adults" (NIDCD, Dysphagia fact sheet). It rarely announces itself. It looks like Dad coughing into his napkin and saying the soup went down the wrong pipe again.

Everyone coughs on a crumb now and then. MedlinePlus says most people with dysphagia should be checked by a provider if the symptoms "persist or come back." A pattern is worth a call. One bad bite of steak usually isn't.

Why a cough at dinner deserves a doctor's visit

The NIDCD explains that with dysphagia, "coughing or throat clearing sometimes cannot remove it," and material left in the airway can reach the lungs and let bacteria grow, "resulting in a lung infection called aspiration pneumonia."

MedlinePlus lists the risk factors, and several will sound familiar: old age, problems with swallowing, medicines that make a person less alert, and one families can do something about, "eating or being fed when not upright" (MedlinePlus, Aspiration pneumonia). Its symptom list includes fever, shortness of breath, chest pain, wheezing, confusion, and coughing up foul-smelling, greenish or dark phlegm.

The NIDCD also notes that someone who can't swallow safely "may not be able to eat enough of the right foods to stay healthy or maintain an ideal weight." MedlinePlus says to call the provider for a cough, fever or shortness of breath, weight loss, or swallowing that's getting worse.

Conditions that raise the risk

The NIDCD says "any condition that weakens or damages the muscles and nerves used for swallowing may cause dysphagia." Three come up often with aging parents:

• Stroke. It "may weaken or affect the coordination of the swallowing muscles or limit sensation in the mouth and throat" (NIDCD). MedlinePlus stroke discharge instructions name "choking or coughing when eating" as the signs to watch for (MedlinePlus, Stroke discharge). For the emergency side, see stroke signs in an elderly parent.
• Parkinson's disease. The NIDCD says people with nervous system diseases such as Parkinson's "often have problems swallowing," and MedlinePlus lists it among the common causes (MedlinePlus, Swallowing Disorders). Pill timing matters a lot here, as we cover in Parkinson's medication during a hospital stay.
• Dementia. "Memory loss and cognitive decline may make it difficult to chew and swallow," per the NIDCD. MedlinePlus adds that in later stages the person "may need a diet of only liquid or soft foods, to prevent choking" (MedlinePlus, Dementia daily care). If the diagnosis is new, start with first steps after a dementia diagnosis.

Don't overlook the dentures. The American Red Cross names "dental problems or poorly fitting dentures" as a choking risk (American Red Cross, Adult and Child Choking), and MedlinePlus agrees (MedlinePlus, Choking). Dentures also tend to vanish in hospitals, as we cover in hearing aids, glasses and dentures in the hospital.

Who checks a swallow, and what the test looks like

Start with your parent's regular doctor. The NIDCD says the physician "may refer you to an otolaryngologist," an ear, nose and throat doctor, "and a speech-language pathologist," or to a neurologist if a stroke or nerve condition is behind it.

Bring notes. "She coughs at almost every meal, mostly with water and coffee, since about August" gives the doctor far more than "she chokes sometimes."

Doctors and speech-language pathologists (SLPs) who treat swallowing problems use tests that look at each stage of the swallow. The NIDCD describes two kinds of test in general terms: an X-ray video taken while the person swallows foods or liquids along with barium, and an exam with a thin lighted scope that shows the mouth and throat during swallowing. Either way, the point is to see where things go wrong.

The result is a plan. The NIDCD says SLPs use what they see to work out changes in "food texture, size, head and neck posture, or behavioral maneuvers," and some people get exercises. Let the SLP show you these rather than copying one from a video.

Texture and thickness are an order, not a guess

Dad coughs on water, so someone buys a thickener at the drugstore and stirs some in. Or Mom gets everything pureed "to be safe." Both feel careful. Neither is a plan.

MedlinePlus is direct about it: "Do not drink thin liquids without checking with your provider or therapist first, as thickened liquids may be recommended by the speech pathologist."

The order may use the IDDSI framework from the International Dysphagia Diet Standardisation Initiative. Its page explains that the framework has 8 levels numbered 0 to 7, with drinks described at Levels 0 to 4 and foods at Levels 3 to 7, so everyone uses the same terms (IDDSI, The IDDSI Framework). It says "the clinician has the responsibility to make recommendations for foods or drinks for a particular patient," and warns that errors in diet texture or drink selection "have previously been associated with adverse events including choking and death."

A few habits help:

• Ask for the order in writing, with the level number and the SLP's exact words. "Thickened liquids" alone can mean different things to different people.
• If thickener is part of the plan, ask which kind, how much, and how to check it.
• Ask when it will be rechecked. An old order taped to the fridge after the diet changed is an easy mistake.
• Get a fresh copy after any hospital stay, along with the rest of our hospital discharge checklist.

Pulling this together with the medicines, the doctors and everything else is where many families stall.

Safe eating habits the sources agree on

These general habits from MedlinePlus and an NHS speech therapy leaflet sit alongside whatever the SLP prescribes:

• Sit upright for the meal. MedlinePlus says "sit up as straight as possible." The Wirral leaflet suggests a 90-degree angle at the hips, at a table if possible, and no eating while slouched or lying down. A recliner counts as slouched.
• Stay upright afterward. MedlinePlus says 30 to 45 minutes after eating, which makes the post-lunch nap worth moving.
• Small bites. "Less than 1 teaspoon (5 mL) of food per bite," per MedlinePlus, chewed well and swallowed before the next.
• Small sips. The Wirral leaflet says no gulping and no tipping the head back to drink.
• No rushing. MedlinePlus says keep mealtime relaxed, don't mix solids and liquids in one bite, and don't wash food down unless the therapist says it's fine.
• Talking waits. Don't talk and swallow at the same time, MedlinePlus says. At a family dinner that takes some discipline from everyone else.
• TV off. Both the Wirral leaflet and MedlinePlus's dementia page suggest fewer distractions.
• Ask the SLP about straws. Check before using one. The Wirral leaflet, for its patients, suggests an open cup and no straws "unless advised otherwise."

Choking: the signs and what to do

Choking is different from a swallowing problem: something is blocking the airway. The Red Cross lists the signs that need emergency care right away: a weak or no cough, high-pitched squeaking or no sound, pale or blue skin, being unable to cough, speak or cry, a panicked look, and hands at the throat.

If your parent is coughing hard and can talk, let the cough work. MedlinePlus says not to interfere, and the Red Cross says to encourage coughing, stay with them, and be ready if things change.

If they can't cough, speak or breathe, call 911, or have someone call while you start. For a conscious adult, the Red Cross and MedlinePlus both describe rounds of 5 back blows followed by 5 abdominal thrusts. The Red Cross version:

1. Stand to the side and slightly behind, an arm across their chest, and bend them forward at the waist.
2. Give 5 firm, separate back blows between the shoulder blades with the heel of your hand.
3. If that doesn't work, have them stand up straight, move behind them, and give 5 abdominal thrusts: a fist just above the navel, covered with your other hand, pulling inward and upward.
4. Keep alternating until they can cough, speak or cry, or become unresponsive.
5. If they become unresponsive, lower them to a firm, flat surface and begin CPR according to your training.

If you can't get your arms around your parent, the Red Cross says to give chest thrusts instead. In a wheelchair, kneel behind the chair and give abdominal thrusts as usual, switching to chest thrusts if those are hard and removing the armrests if needed. MedlinePlus warns not to force open a conscious person's mouth to grab the object.

Reading steps is not the same as practicing them. The Red Cross lists first aid and CPR classes on the same page, and for whoever eats most meals with your parent, one is an evening well spent.

Afterward, get a medical exam, even if everyone is laughing with relief. MedlinePlus says "anyone who is choking should have a medical exam," and to call the provider in the following days for a lasting cough, fever, trouble swallowing or speaking, shortness of breath or wheezing.

If your parent lives alone, tell them the Red Cross advice: call 911 from a landline or a GPS-enabled cell phone even if they can't speak, because the open line will cause the dispatcher to send help. The Red Cross also describes giving yourself abdominal thrusts, or bending over and pressing the belly against something firm like the back of a chair, avoiding sharp edges. Our emergency plan for a parent living alone covers the rest.

Pills are part of the swallowing plan

A parent who struggles with soup usually struggles with tablets too. Hold off on the pill crusher in the kitchen drawer. The FDA says: "Do not break, crush, or chew tablets without first asking your health care professional," and suggests asking a doctor, nurse or pharmacist whether a liquid form might work (FDA, As You Age: You and Your Medicines).

The Institute for Safe Medication Practices warned in 2017 that crushing or splitting the wrong tablet can be a deadly error (ISMP, Long-Term Care AdviseERR, April 2017). Crushing an extended-release tablet can release a large dose all at once. ISMP says letters such as ER, XR, XL, SR, CR and LA often mark these, but some carry no such letters, and enteric-coated tablets shouldn't be crushed either. Its advice: "When in doubt, ask your pharmacist," and tell the pharmacy about the swallowing problem.

Take the whole list to the pharmacy counter and go through it one medicine at a time. Our medication list for an elderly parent shows how to set that list up. Any change in how a medicine is taken goes through the prescriber or pharmacist, and no medicine gets dropped because it's hard to swallow without asking them first.

A swallowing page for the binder

One page, kept in the binder with a copy in the kitchen, covers it:

• Date and place of the last swallow evaluation
• Food texture order in the SLP's exact words, with the IDDSI level number if given, and the date
• Liquid consistency order, same format, plus mixing instructions if a thickener is used
• Strategies the SLP taught (position, pacing, cup type), copied from their handout
• Foods or drinks to avoid
• SLP's name, clinic, phone, and next recheck date
• Medicine notes: which pills the pharmacist said can be crushed, which must stay whole, which come as liquid, plus the pharmacist's name and date
• Denture notes, and whether they fit well lately
• Past choking episodes or aspiration pneumonia, with dates

Then add one line to the Emergency Information Sheet for paramedics under conditions, such as "Dysphagia: diet and liquid orders from SLP dated [date], copy attached." Hospital staff will do their own assessment, but a dated order shows what was working at home.

Frequently asked questions

Is it normal for an elderly person to cough while eating?

An occasional cough on a crumb happens to anyone. Coughing or throat clearing at meals that keeps happening is a listed sign of a swallowing problem, and MedlinePlus says symptoms that persist or come back should be checked by a provider.

Can I thicken my parent's drinks myself?

Not without an order. MedlinePlus says to check with the provider or therapist before changing from thin liquids, and IDDSI says the clinician makes the recommendation.

How can you tell if food went into the lungs?

Often you can't at the table. MedlinePlus lists aspiration pneumonia symptoms such as fever, shortness of breath, chest pain, wheezing, confusion and coughing up foul-smelling, greenish or dark phlegm. Call the doctor if those appear.

Getting it written down

You can do all of this yourself: one doctor's visit, a session with the SLP, half an hour at the pharmacy counter, and a sheet of paper with the orders copied out. If you'd rather have help with the rest, Emergency Binder Now turns about 25 minutes of guided questions into a printable binder for your parent, with conditions, medicines, doctors and pharmacy, a one-page Emergency Information Sheet for paramedics and the ER, and a list of what's still missing. The swallowing page slips in right behind the health section. You can see a sample binder first.